On Sept. 10, 2009, the New York Times Business section ran an article by Steve Lohr headlined “A Healthy Dose of Digital”, describing the marketing campaigns of IT giants to push into the electronic health record business by promising low cost software and services. I dashed off the following letter to the editor, which may or may not be published there:
As an independent consultant offering assistance to small medical practices in the selection and implementation of electronic medical record systems, I have had many conversations with physicians devoted to their reservations about “going digital”. When ranking the issues, cost is not near the top. The real issue is usability. While the push by IBM, Dell and others to address the cost of the technology is admirable, the technology itself is, first of all, disruptive, and second, ergonomically inadequate.
You cannot simply drop an electronic health record system into a medical practice and expect everything to run smoothly. Many tasks and responsibilities in the practice workflow will become redundant, while new opportunities will not be realized because the practice model has not adapted to take advantage of them. Dealing with these issues requires suitable planning and due diligence, as outlined in publications from the American Medical Association and others. Doing it right will take considerable time away from the practice of medicine to deal with business and technical issues, as described by Robert Miller and Ida Sim in a paper published in Health Affairs in April, 2004.
The man-machine interface offers another challenge, as working with a computer in the consulting room requires a very different set of skills from using pencil and paper to take notes. Physicians fifty years old and more are highly resistant to this, and because they are likely to retire by 2015 are unwilling to make the transition or the investment. But even younger practitioners find the computer in the consulting room highly distracting, and an impediment to all-important patient communication. Making the switch requires extensive training and a redesign of work methods.
Consultants like me offer assistance in planning for change and in identifying and implementing the electronic medical record system that is the best fit for the practice. We believe doctors will be best served by following a disciplined process of goal-setting, analysis and re-design of work flows, and solicitation of competitive bids from all the technology providers, including IBM and Dell.
Now, some might understandably take me to task on the issue of cost, not least because I often point out the sizeable costs incurred over and above that for the system hardware and software. If a practitioner does a comprehensive ROI analysis that includes the opportunity cost incurred for training and system management issues, then yes, cost will be the most significant hurdle to investing in EMR. On the other hand, it is not this total cost of implementation and ownership on which the big vendors are competing or seeking to leverage for market penetration.
The fact is, these opportunity costs will be incurred no matter whose software a practice adopts. They can be somewhat mitigated by following a rigorous process of product and vendor selection:
- articulate a vision for the practice after five, ten, and fifteen years;
- set goals and objectives to be realized by adopting EMR;
- document and understand the practice workflow as it is today and as it will be after implementing EMR, and how the change will be managed;
- evaluate EMR product offerings based on the vision of the practice and the demands of the specialty;
- select a vendor in competitive bidding in which they are asked and must explain how they will address the key concerns of the practice.
In the process of articulating the vision for the practice, the practitioner should consider how he wants the practice to be perceived by both new and long-time patients, and how this perception should be encouraged by the experiences of making appointments, seeing the doctor, learning test results, asking questions in person, on the phone or by email. And consider how administering the practice could be made less onerous. What can an EMR do to help reduce the effort and issues involved in getting paid by patients and insurers? Then approach vendors and ask them how they will help meet these goals and address these concerns.
I am all for the big vendors making a real effort to make their products affordable. But I caution practitioners to file this away for future reference. You have a lot of work to do before you can even decide which vendors to consider.