Buying and implementing an electronic health record (EHR) system is the biggest decision a practice will ever make. EHR systems can have both positive and negative impacts on a practice’s operations depending on the vendor’s qualifications and how the system is implemented. Keep in mind that vendors are not responsible for all failures, however. Some practices find it extremely difficult to implement change, while others have buyer’s remorse and regret their decision to purchase an EHR system altogether. Practices can also find it difficult to adjust to an EHR system when it does not meet their own unique needs and requirements. This is especially true for ophthalmology practices, given their specific complexities. Some vendors avoid the specialty altogether or partner with vendors that focus exclusively on ophthalmology practices.
Anatomy of an Ophthalmology Practice
One reason that both ophthalmology practices and vendors struggle with EHR systems is the complexity of the practice itself. Let’s examine the “anatomy” of one ophthalmology practice by reviewing its possible services:
- Professional services
- Surgical services
- Optical services
- Laser services
- Retina services
- Cornea services
- Cosmetic services
- Revenue cycle management services
And when you look inside the basic practice structure, the systems get even more complicated. The composition consists of the following:
- Device integration
- Image management, storage and retrieval
- Exam-room instruments
- Physician Quality Reporting System and e-prescribing programs
- Clinical integration
- External integration
- Practice management integration
- And on and on …
Why Do EHRs Fail?
To understand why some EHR systems fail involves first determining if the solution was ever capable of meeting the requirements of a typical ophthalmology practice, as outlined above. For example, an ophthalmology practice with an ASC likely operates under two tax ID numbers, which typically requires two databases to keep the financials separate. Not all systems can support multiple databases within a single application. A purchaser who discovers this limitation only after the system is in place faces major problems. The outcome can be difficult to accept after the fact, especially if the vendor promised a much different result. To ignore the problem or to delay taking action to remedy it can have several unintended consequences, including, but not limited to:
- Cost overruns;
- Loss of confidence;
- Failure to comply with EHR incentives; and
- Future penalties for not adopting an EHR system.
So why do EHR systems fail to live up to expectations or not perform satisfactorily? There are a myriad of reasons. Having consulted with several practices trying to reinvigorate their EHR systems, here are my top 10 reasons (in no particular order):
- The system created a prolonged (more than six weeks) threat to physician productivity.
- The system was defective from the beginning.
- The system did not have specialty-specific content or workflow built into it.
- The trainer was ineffective and unqualified.
- The implementation was flawed and did not consider workflow.
- The practice did not commit the necessary resources to the project.
- The infrastructure, network and hardware were inadequate.
- The vendor misled by overpromising and underdelivering.
- The system was incomplete or was missing critical modules such as portal, e-prescribing, practice management and so on.
- The vendor discontinued the product and stopped supporting the system.
When Should You Replace Your EHR?
So the big question for practices that are dissatisfied with their EHR system is this: When is it practical to replace your system — and when is it not?
Start by asking yourself the following questions about the system:
Can the issues be resolved through remediation and/or some type of new approach?
More often than not, the failure can be corrected, or some reasonable compromises and workarounds can resolve the issue. The last thing that vendors want is for their customers to fail in using their software. Most responsible vendors take complaints very seriously and will do what is necessary to correct the issues. Before considering uninstalling the product, first exhaust all efforts to work with the vendor to correct the problems.
Can the issues be resolved through development and/or technical improvements?
No software is perfect. Most vendor improvements involve input from users who are experiencing issues. A good vendor considers an issue an opportunity to enhance or improve the product. It can take time for the vendor to make needed improvements, but the wait will be worthwhile when you begin to see progress.
Is the vendor responsive and concerned about the issues?
Vendor responsiveness is one of the more important elements to consider because much of the outcome depends on the vendor’s willingness to take responsibility for ensuring your success with the system. It will be very difficult to remediate the problems if the vendor fails to lead the charge. If that is the case, an alternative course of action (discussed later) may be needed.
Does the practice bear some responsibility for the failure?
In fairness to vendors, not all EHR failures are their fault. Some practices are just not prepared to undergo an EHR transformation. Some practices have even discovered saboteurs who feel the EHR system threatens their job security. Others may have failed to fully train clinicians on use of the software, thus creating inefficiencies and challenges. If you feel the practice has not done all it can do, you owe it to yourself to address these internal issues before abandoning your EHR system.
Has the product (or version) been commercially discontinued?
Often, the failure is due to the product becoming obsolete or outdated. The practice must keep its software up to date. The current version generally incorporates all necessary improvements. Continuing to use an outdated version of an EHR system is one of the fastest ways to fall behind, experience unwanted threats or limit the practice’s ability to attest to meaningful use of an EHR system.
What Are Your Options?
Answering the questions above can help you determine if your problems with the EHR system are related to the “product” or to the “process.” If you are still unsure, take this easy test:
Are you the only practice experiencing these problems? Are most other practices using this same system happy with the product?
If the vendor can give you examples of where and how the product is successfully overcoming the same challenges you are experiencing, then the issue may be related to the process, not the product. If the vendor denies that there is a problem or is unable to demonstrate ways to solve the problem, then you are likely experiencing a product-related issue.
Product-Related Problems — Questions and Options
Can the problem(s) be corrected through development or system tweaks?
Can the system be redesigned?
Can the vendor provide a reasonable workaround until the problem is officially resolved?
If you answered “yes” to the above questions, then consider giving the vendor an opportunity to remediate the issues. In most cases, any fixes should be at the vendor’s expense. Before agreeing to vendor remediation, be sure to document expectations, set a timeline for delivery and have a contingency plan if the problem does not get resolved.
If you answered “no” to the above questions, the product is likely defective and the vendor could be in breach of the contract. Most vendors provide a warranty designating that their product will perform as promised. While it is better to work with the vendor toward a resolution, if the problem cannot be corrected, you may be entitled to a refund. (If you are unsure how to interpret the language in your contract, Coker Group provides free contract inspections for members of the American Academy of Ophthalmic Executives (AAOE).)
Process-Related Problems — Questions and Options
Was the training received sufficient and effective?
Was the implementation based on the practice’s requirements?
Was the workflow re-engineered around the EHR system?
Was the practice committed to making the changes necessary for success with the EHR system?
If you answered “yes” to all of the questions above, you may want to reexamine the issues to determine whether the problems are related to the product or involve a lack of responsiveness on the vendor’s part.
If you answered “no” to the questions above, we have good news for you: Most failures related to process can be corrected. Making corrections is not always easy, especially if the staff and physicians have lost confidence in the system. However, not having the right process is never a good justification for uninstalling an EHR system. If several other practices are successfully using the same system, then your practice needs to look internally for answers. It may be helpful to engage a third party to provide an objective assessment of the practice. Some failures simply involve “not knowing what you don’t know.” Implementing an EHR requires a lot of attention, time and effort. Some practices find it difficult to commit the necessary resources because they are simply too busy. There are external resources that can be enlisted to implement these projects if the practice does not have the time or expertise to do it itself.
EHR failures are never pleasant and almost always very costly. It is always better to exhaust all efforts and remediation options before uninstalling an EHR system. Further, you should carefully read your contract; there could be some financial penalties for early termination. If you feel the product is defective or the vendor failed to deliver as promised, the vendor could be in breach of the contract, which would give the practice legal grounds for resolving the issue. In any case, it is essential to closely document all communications and record your efforts to remediate the problem. It would also be wise to talk with some of the vendor’s other customers to see if anyone else is experiencing the same problems or to have a third party conduct an assessment/audit of the situation to help determine what is causing the problems. Most vendors will do whatever is necessary to avoid having an unsuccessful client, as dissatisfied customers can severely hurt their marketing efforts and cause embarrassment if knowledge of problems becomes widespread. Never delay confronting issues; it will only become more difficult and challenging over time to address them. Most vendor warranties are for 90 days, which is another reason to address problems promptly and to keep good documentation. If you do ultimately have to replace your EHR system, consider including these terms before signing your next vendor contract:
- Be sure that the system warranty starts only after the system successfully goes live.
- Require the vendor to agree to an acceptance policy/language before you agree to purchase the system. The acceptance language allows you to enter into an agreement with the vendor, but specifies that the contract is not fully accepted until the system works as promised.
- Tie your financial obligations to successful outcomes. Consider these sample payment terms to protect your investment:
- Pay 20 percent when you sign the contract.
- Pay 20 percent once the vendor successfully installs the software.
- Pay 20 percent once the vendor successfully trains the staff.
- Pay 20 percent once the practice successfully goes live using the product at the point of care.
- Pay 20 percent 30 days after going live.
AAOE is planning an instruction course on EHR conversion challenges during this year’s Joint Meeting in Chicago. Stay tuned for more details. And be sure to visit www.aao.org/aaoe for additional practice management resources.
NOTE: AAOE members may receive a complimentary EHR contract review and inspection by emailing firstname.lastname@example.org or by calling 770.597.0590.
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About the author: Jeffery Daigrepont, senior vice president of Coker Group, specializes in health care automation, strategic planning, operations and deployment of fully integrated information systems for medical practices and hospitals. A popular program speaker, he is frequently engaged by highly respected organizations across the nation. He co-authored Complete Guide and Toolkit to Successful EHR Adoption, published by the Healthcare Information and Management Systems Society in 2011.