Hate Your EHR? Was It a Big Mistake? Here's What to Do

; Ron Sterling, MBA


November 29, 2012

Editorial Collaboration

Medscape &

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Leslie Kane, MA: Hi. I'm Leslie Kane. I'm Executive Editor of Medscape Business of Medicine. By now most physicians are using electronic health records (EHRs), but there is a big problem: Many of them hate their EHRs. In a recent Medscape survey, more than 28% of users said they dislike their EHRs but feel stuck with them. What do you do if you are in that position? To give us some advice, we are here today with Ron Sterling, who is an EHR [or EMR, electronic medical record] expert from Silver Spring, Maryland, and author of Keys to EMR Success. Thanks so much for being here with us, Ron.

Ron Sterling, MBA: Thanks for inviting me, Leslie.

Ms. Kane: We have had feedback that many physicians have chosen an EHR and now they can't stand it. What leads to that situation?

Mr. Sterling: A number of issues can lead to that situation. They might not get the right product, for different reasons. For example, they might have outside influences who tell them to use a particular product. Another situation is that physicians are not completely engaged in the selection of the product. In some cases, people buy the right product but they are just not using it effectively.

Ms. Kane: How can a physician tell which of those situations is the problem?

Mr. Sterling: Go back and look at how you made the decision and how engaged you were in making that decision. In some cases, doctors literally say to staff, "Go find an EHR product for me and I will use it." Or, when looking at a product, they don't invest the time in understanding it. Or they don't make site visits to see how they can use this product successfully.

The bottom line is, when the physician is making the decision about which EHR to buy, they have to buy into it. Even if it is a multiphysician practice, we have to come to the bottom-line questions, which are: Are you going to use this system? Are you willing to put in the time and the effort and adjust to adopting this tool into the style of how you practice medicine? If we can't answer those questions in a positive way, we are putting a lot of risk on the table about our entire EHR project.

Ms. Kane: Can you tell me more about why doctors would not be using the EHR the right way?

Mr. Sterling: There are many different reasons. For example, when you are looking to adopt an EHR, you have to make decisions about redesigning how your practice is going to operate. I tell people that they have to take the whole practice apart and put it back together again, no matter how big or how small the practice is, because everything we do right now is tethered to that paper record. If that tether no longer exists, they have to figure out how they will operate in their environment without this piece of paper. For example, if the chart is in the door this way, it means that the patient needs to see a doctor. If it's in the door that way, a nurse is supposed to go in. If a paper record doesn't exist, how will I know which it is? I have been flipping through this chart for years, I know all the visual cues, and now I have to sit there and flip around in this computer system. In many cases, I have to go and literally redesign the system from a workflow perspective. I also have to consider how doctors interact with patients so that they get the information they need and put it into the EHR. That's a lot of change that somebody has to engage in. It's not such an easy thing.

Ms. Kane: What about lack of training? Could that be a reason why they dislike the EHR?

Mr. Sterling: Absolutely. The lack-of-training issue falls into 2 categories. First, the reality is that the practice must become independent from the vendor. Nobody has enough money in their pockets to pay the vendor to be there for months. The vendors come in, they train everybody on the EHR, and then the vendors pull their people. You may not be willing -- or have the resources -- to pay for them to stay. Even if you have those resources, you will come to a point where they will leave your practice, go back home, and you will have to run it yourselves.

From a training perspective, you need to assign a couple of your practice employees to become in-house experts on the various aspects of using EHRs, which includes understanding the clinical content as well as the work in your environment. You have to protect that to make sure that you use the system on a consistent basis. When doctors become disillusioned with the EHR, it could be because they don't know how to use it correctly, or in some cases they are not maintaining it correctly. If they are not sitting down on a daily basis and saying, "Have I done all the work, have I documented all the information I need into my EHR?" then the EHR will become problematic. They will almost be undermining the efficacy and the accuracy of the EHR records.

Ms. Kane: If that is the problem, what can they do to fix it?

Mr. Sterling: They have to invest the time up front for the doctors and the staff to become knowledgeable and comfortable enough with the EHR so they can get in front of a patient and use it. In some cases we say to the doctors, "Here is your EHR, here are a few hours of training; go treat a patient." Then we are surprised when the doctor’s focus becomes the EHR. They are not looking at the patient. Or they will turn their backs on patients so they can document something on a workstation in the corner of the room. All of these things undermine the connection with the patient. It's not a pleasant experience for the doctor, either, because the doctor thinks, "I've become a data-entry clerk." If people put in enough effort up front to become knowledgeable about how the EHR works, if they become comfortable with it so they can integrate it into their style of interacting with patients, it's going to be a very good experience.

If I go in and give them a very short timeframe, they won't be familiar with it, they won't be comfortable with it; and to top it off, when I make them use it when they see every single patient, it's not going to be a very pleasant experience. You have to glide into using the EHR. Make it a positive experience throughout the implementation process. Make sure that you are monitoring it so you can measure your success. You don't want to turn around and say, " We were not successful because we made all these mistakes." And then you made it even worse by going to all the other doctors in the practice and saying, "Okay, we are all going to use this, and this is how we are going to use it." You have set up these very specific mechanisms but have never really verified whether they were going to work in your situation.

Ms. Kane: Are there situations in which it is neither the lack of training nor the lack of incorporation into the practice, but some other factor?

Mr. Sterling: The main reason is that they didn't pick the right product. Or, in some cases, over time the product or the practice has changed, and it doesn't work for them anymore, so they have a failure on their hands. Suppose you had a practice and you went out and bought an EHR geared for that practice. Suppose it is a specialty practice -- orthopedics or cardiology. And now, all of a sudden, you want to start branching out to become a multispecialty practice. Maybe the product isn't right for that. Maybe the practice started out as a 2- or 3-doctor practice and now it has become a 10-doctor practice. Ten-doctor practices have different EHR issues and problems than smaller practices.

Another scenario is a vendor who becomes nonresponsive. Suppose you start out with a vendor because they dealt with your area of medicine, and now all their business is in primary care, which is not your area. All the toys that are coming out in the EHR are geared toward primary care, but you are trying to deal with surgery scheduling, and it doesn't work anymore. You can grow away from the product or the product can grow away from you. At the end of the day, it's just not a good strategic fit. You will have to make a move to something that is more appropriate for your situation.

Ms. Kane: What are the steps a doctor takes from the point of saying, "I hate this EHR" to solving the problem?

Mr. Sterling: If you hate the EHR even though the EHR is competent and effective but you just don’t use it correctly, maybe you need to go back and do an assessment to find out why it isn't working for you. Do you need to go back and redesign the system? Do you need to adjust how you use it so that you can be more successful? After you go through that, then you might have to go through a retraining process to get everybody trained to use it effectively inside the practice. Once you have done that retraining, you are reimplementing it.

I have to warn you that some of that reimplementation might mean that you have to go back and fix a patient's medical record going forward. Suppose, for example, that people were entering medications as notes instead of putting them into the medications module. Everybody says, "We are doing drug utilization review -- can we get our meaningful use points to collect our money?" You have to go back and say, "Wait a second -- the product works; we are just not using it correctly." That’s very different from being in a situation in which the product itself is bad. If the product is really inappropriate for you, then that is going to be a completely different effort.

Ms. Kane: At what point does a doctor cry "Uncle!" and say, "This is not the right system for us"?

Mr. Sterling: You have to soul-search, make sure that the product that you are buying is going to solve the problem, and make sure it's not about your practice. If you have to go to another product, that's a different effort. There are cost issues associated with that. There is also the problem that it's extremely difficult to take information from one EHR and move it to another environment. They have very different structures. Some are textual, with long text fragments that make up your medical record. Some of them have little labeled fields. If you are a cardiologist and you are taking the patient's medical history, in some systems you will be checking off boxes, whereas in other systems you will be dictating notes through Dragon, or a similar product, using voice recognition. Those are very different products, and to move from one to the other or back again is very difficult.

The features of some systems are very different. For example, consider a scanned image. If you scan in an ER report from the hospital, or maybe you scanned in some information from a patient, such as a previous medical record or a document the patient brought in, some EHRs track whether the doctor looked at this document. Some EHRs don't track this. When you are trying to convert from one to another, how are you going to bring that information over correctly and where are you going to put it? There are many examples of trying to map and figure out, "Okay, I have this information here in this old medical record. Here's where I want it to go. How do I get there?" It's very difficult.

If you have a failing EHR because the vendor is failing, that is a different situation. That means that the product isn't working for you anymore. You might have lots of workarounds. In some cases, you end up with many pieces of paper that you are using to document things and the system is scanning them in. Sometimes the vendor is abandoning the product and moving to a different product. They might have stopped maintaining it and fixing it. They are not investing their money into it -- we have seen that in some cases. We have vendors who have said, "We sold a product that we put in your office, and now we want to sell you a service out of the Cloud." They make it impossible for you to continue to use that product in your office. These are things that can happen and you are subject to them.

Another situation that I have seen is when the EHR is no longer being actively sold. The manufacturer says, "No new practices are implementing this system." That is a really serious problem strategically. So, practices really have to keep an eye on what’s going on with the product. Is it moving forward? Are there signs that this product is no longer a viable option to maintain your records?

Remember that the punchline to all of this is, it's the practice that is responsible for maintaining patients' records, not the EHR vendor. HIPAA security is the responsibility of the practice, not the vendor.

Ms. Kane: Very good advice; that is definitely something that physicians need to keep control of and stay aware of. Thanks very much for taking the time to speak with us today. We have been speaking with Ron Sterling, an EHR expert from Silver Spring, Maryland. I'm Leslie Kane from Medscape. Thank you for joining us.