Anyone who knows even a little bit about behavior modification theory intuitively understands that offering rewards and/or punishments is an effective way to encourage people to do what you want them to do. The government clearly understands this principle and has been using incentives and penalties to motivate physicians to participate in its programs—PQRS, ePrescribing, and, most recently, the EHR incentives.

The EHR incentives have already prompted a great deal of EHR activity, but the program is too new to quantify cause and effect yet. A direct correlation between government policy and provider behavior, however, is evidenced by the history of my company’s ePrescribing license purchases, so I thought EMR Straight Talk readers would find the analysis of my company’s experience interesting.

As illustrated above, ePrescribing sales tracked the MIPPA legislation as follows:

• 2009 was the first year of ePrescribing bonuses, and the requirements (a 50% threshold) made it important to start ePrescribing early in the year. As you can see, this created a huge demand for ePrescribing licenses during the first half of 2009.
• Sales continued in late 2009 and early 2010—although at a more moderate rate—as later adopters decided to take advantage of the last year of 2% bonuses and as the easier-to-meet threshold of 25 ePrescribing encounters was introduced.
• Imminent penalties caused a spike in sales in the beginning of 2011, when providers first learned that 2012 penalties would be based on ePrescribing activity—or lack thereof—in the first 6 months of 2011.

Another interesting observation that can be made is that, for some providers, penalties are a much more effective behavior modification tool than incentives, regardless of the relative amounts of money at stake. My experience with ePrescribing—illustrated by the 2011 surge in licenses—was that many physicians who had not been persuaded by the 2% bonuses in 2009 and 2010 felt compelled to move ahead when faced with a 1% penalty for 2012. Regardless of whether a particular physician attributes more weight to the carrot or to the stick, the data above—although not unexpected—confirms the effectiveness of the government’s strategy.

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Like the dot-com bubble, the EHR bubble—nurtured by the government incentives—will not last. As I look at what’s happening in the market, it becomes apparent that at some point in the not-too-distant future, the EHR bubble will pop and many vendors will face financial challenges that will lead to their demise.

Several market factors will come into play, including:

• Physician dissatisfaction with their choice of EHR, which likely was selected in haste to meet the government’s incentive timetable and was delivered by an overwhelmed vendor;
• Physician disenchantment with the EHR Incentives Program, as financial rewards decrease while requirements intensify;
• An overabundance of EHR vendors  competing in a market dominated by a small number of major players. (Currently there are 472 EHR vendors offering certified “Complete EHRs”)

To understand how these factors will affect EHR vendors, it is important to understand how such companies typically raise money and what kind of “hockey-stick” growth projections they made to attract investors.

Missed growth projections; continued expenses for implementation, support, and ongoing upgrades; and diminishing government incentives will leave many companies unable to find investors willing to fund their future growth.

There will be market consolidation, and financially strong companies will acquire distressed companies for pennies on the dollar.

…To read the full story, see HIStalk Readers Write.

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HHS has made it official—Stage 2 of meaningful use will be pushed back to 2014. The announcement by HHS Secretary Sebelius came as no surprise, following as it did the recommendation made by the HIT Policy Committee and the endorsement by ONC head Farzad Mostashari. The change only affects providers whose first incentive payment year is 2011, since they are the only providers who would be subject to Stage 2 regulations in 2013 had the delay not been implemented—everyone was already entitled to 2 years of meaningful use at Stage 1.

What I find interesting about all the hoopla that has accompanied the announcement is the spin the government put on the decision. According to the press release from HHS, “To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.”

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Last week’s EMR Straight Talk post, “Are EHRs Being Oversold,” hit a nerve, judging by the number of readers and the volume and intensity of comments submitted by physicians. Sadly, for every one of the physicians who took the time to write, there are scores of others enduring similar experiences. The following excerpts from their comments are reflective of their frustrations:

• We are a year into [EHR] implementation and it has been horrible and costly. What little efficiencies gained have been lost to a decrease in productivity.
• I now require a scribe to maintain the [same] patient flow that was seen four years ago we began using the system.
• The trouble with most EMRs is the horrible user interfaces that are designed by committees who have no concept of ease of use for ophthalmologists.
• The programs are user unfriendly in the extreme, cumbersome and inflexible. The learning curve is seriously long and even when mastered takes a terrific amount of time away from the patient.
• The joy-killer was encountering the endless barriers to putting my own ideas to work.
• Training is lengthy, expensive, and markedly disruptive in an office.

Every one of these stories breaks my heart as a staunch EHR proponent—particularly since the situations could have been easily avoided.

The Root of the Problem

The problem lies in the EHR selection process. When it comes to dispensing medications, for example, no physician prescribes without knowing the success rate for that particular drug for that particular type of patient and problem being addressed. Yet, typically, physicians do not make EHR purchase decisions in the same way that they make clinical decisions—using empirical evidence and data to predict outcomes.

I’d wager that for each of the disillusioned physicians above, the EHR selection process was nearly identical:

1. The group chose 5 to 7 vendors for consideration;
2. Each vendor demoed their product in front of an EHR selection committee whose task was to narrow down the field to 2 or 3 finalists;
3. The finalists performed one or more demos to a wider group of physicians and staff;
4. The vendors each provided 2 or 3 practices as references, with specific contact names;
5. One or two physicians and staff members spent a day visiting one reference site for each of the vendor finalists; and
6. They selected an EHR.

Why does such an exhaustive and time-consuming selection process so often lead to failed EHR implementations?

Preventing an EHR Failure in Your Practice

To prevent an EHR failure in your practice, the flawed selection process must be altered. The first thing to understand is that the rosy experience of one or two handpicked vendor references will not guarantee a similar experience for you and your colleagues. If a vendor has sold its EHR to 100 practices and has as few as 5 successful implementations, you will be referred to one of these 5 practices. A visit to 1 or 2 of these 5 successful practices may leave you with a warm and fuzzy feeling and the expectation that, because they were successful, your success is virtually assured. In this case, however, your real probability of success would only be 5%.

Separating the Wheat from the Chaff

So how do you quickly eliminate vendors with lackluster success records before you and your staff waste hours watching slick sales demonstrations of sexy software with “must-have” features? Separating the wheat from the chaff is simple—just ask all your initial set of EHR vendors for lots of references. If a vendor cannot produce at least 2 references for each year they have been in business, run the other way. Do not accept any excuses for being unable to provide you with the number of references that you seek. (A common excuse is that the vendor wishes to protect the privacy of its clients.) If they had lots of references, they would give them to you in a heartbeat—happy customers are always willing to show their successes to others.

Many of the initial vendors chosen will not be able to produce a satisfactory number of references. This should narrow down the number left for you to consider, and it will save a tremendous amount of valuable physician and staff time.

Statistically Significant Reference Checking

At this point, your list of vendors will likely include just the one or two that have provided you with a meaningful reference list. You may have to accept the bias created by the fact that the references are carefully handpicked by the vendor(s), but it is imperative that you do not limit your inquiries to the specific physicians identified by the vendor. Typically, these are the practice administrator and one or two physicians who had spearheaded the EHR purchase for the practice; as a matter of pride, they are more likely to paint a rosy picture of the EHR than to acknowledge its shortcomings. The only way to avoid this trap is to speak with other physicians at the reference practices. This is easy to do. When you get the reference list from an EHR vendor, ask them to include the practice websites, then randomly choose physicians to call from the physicians’ bio pages. These physician-to-physician calls should be short (only 10 minutes each) and you should ask specific questions about cost, efficiency, and number of patients seen. The American Society of Cataract and Refractive Surgery (ASCRS) has an excellent set of questions on page 5 of their EMR selection guide .

1. When did you install your EMR?
2. How long was the installation/implementation process?
3. How would you describe the installation/implementation process?
4. Was the system as user friendly as the demonstration by the salesperson?
5. How many patients per hour/per day did you (and your partners) see before the installation/implementation of your EMR?
6. How many did you see after?
7. Approximately how much more time do you devote to entering exam data into your EMR now compared to how you documented exams before you began using an EMR?
8. How do you like the quality of the EMR-generated exam notes?
9. Have you had to hire scribes to enter data for you? If so, how many and what is their annual cost?
10. Has your EMR completely eliminated the paper charts in your practice?
11. Given your practice’s experience with your EMR, would you recommend it to a similar practice?

How much of your time should this type of random reference checking take? Not much! Ten 10-minute calls (less than 2 hours of time) to randomly chosen physicians will yield more valuable data on your chances of success than having a slew of vendors demo their products to your doctors and staff for hours on end. Only after having conducted the due diligence described above will you be able to derive real value from spending your time seeing demos—because you will only be seeing demos of the one or two EHRs that you now know are likely to deliver success.

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I am a firm believer in the tremendous value that the right EHR can deliver to physicians, so the historic dissatisfaction with the EHR industry—as reported in studies and anecdotal conversations—has long disturbed me. The alarming intensity of this dissatisfaction was brought home by visitors to my company’s booth during the recent AAO (American Academy of Ophthalmology) meeting.

I was truly appalled by the abject frustration and anger expressed by numerous physicians about their EHRs. One visitor described his experience by saying, “It has taken the joy out of practicing medicine.” Another said that he felt like he should put a picture of his face on the back of his head so that his patients could see him—because he was forced to focus on the computer and enter data while the patient provided information. Physicians universally complained about the “productivity-killing” impact.

Why is this so? I know there are good EHR products in the market that physicians enjoy using and that enhance, rather than reduce, their productivity. Why are physicians not more successful in finding these?

The answer is that EHRs are being oversold. There are many EHRs that are marvels of software, capable of doing incredible things, but the selection process that physicians typically employ is flawed, and the sales process capitalizes on this shortcoming. The salesperson dazzles them with a demo, or they take prospective purchasers to see a physician—typically just one or two—who adeptly uses the software. This creates a false sense of ease-of-use, and the physician prospect leaves the site visit expecting that he or she will be able to use the EHR just as successfully. But not all physicians are alike—they may all be very intelligent and have tremendous medical expertise, but they are not all equal in technological inclination or skills. Their success—or lack thereof—with a particular EHR will vary significantly.

This brings us back to the importance of doing due diligence—something I have talked about before. Call and/or visit a variety of physicians who represent a wide spectrum of proficiency. Go to the reference practice’s website and select physicians on your own—don’t rely on the vendor’s selection. Ask the kind of questions listed in the last EMR Straight Talk. This is the only way to increase the odds of a successful EHR experience, and to avoid making a painful and costly mistake.

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