Don’t ever believe EHR uptake is slow only because it costs too much

The latest numbers from the CDC’s National Center for Health Statistics affirm that a majority of small practices do not have an EHR. Why is that?

One big reason is because small practices don’t have the management or technical infrastructure available to prepare for and handle the biggest challenges facing medical practices today.

What are those challenges and what’s that got to do with EHR implementation? According to the Medical Group Management Association’s 2011 “Medical Practice Today: What Members Have to Say,” the top five challenges of running a practice are:

  1. Preparing for reimbursement models that place a greater share of financial risk on the practice
  2. Participating in the Centers for Medicare & Medicaid Services’ EHR Meaningful Use incentive program
  3. Dealing with rising operating costs
  4. Selecting and implementing a new EHR system
  5. Implementing and/or optimizing an accountable care organization

Two of the top five specify the EHR, and another two are indirectly dependent upon EHR implementation.

In a small practice, who is going to drive the EHR selection process? One or more of the physicians may have a high desire to get an EHR, but a physician’s day is already full. If the physician transfers time away from patient care to spend time on a thorough EHR search, that practice immediately loses revenue from that nonperforming physician.

And there are other questions to ask:

Is there anyone in the practice who has any expertise in a system selection process? Identifying appropriate vendors from a marketplace of hundreds for the evaluation process requires at least a base knowledge of available solutions along with some understanding of how they align with the practice’s needs.

The practice must also vet the vendors’ viability to assure that the product and support will be in place for the next 3 to 5 years. The practice needs to be able to evaluate references and negotiate implementation services (not just price). And, then there is the actual implementation of the EHR, which is more critical to the practice’s successful use than the system itself.

Does the practice have the management expertise to analyze the current operational costs and productivity benchmarks compared with projected operational costs and productivity during go-live and post go-live? Physicians expect a return on investment (ROI) from the implementation of a new system. It is necessary to know the practice’s current operating costs to determine if savings can be achieved with the acquisition and implementation of any technology.

Key performance indicators such as total support staff per FTE physician, square feet per FTE physician, medical revenue after operating and NPP (nonphysician provider) costs per FTE physician, physician work RVUs per FTE physician, percent of accounts receivable over 90 days old, and the adjusted fee-for-service collection percentage should all be trended prior to the EHR implementation and benchmarked post-EHR implementation.

Often in a small practice one physician or the office manager may be the one and only IT resource for the practice. Sometimes a small practice will call in a local computer networking/support company to install a new server or to trouble shoot problems that exceed the expertise in the practice. The challenge in a small practice is the limited knowledge base and lack of time to stay current with the ever-developing world of technology.

Does the practice have the human resource capacity to manage a new project? Implementing and optimizing an EHR in a practice is not something you can just add on to an already overburdened manager or nurse, or physician.

Implementing an EHR is a full-time position for at least three to six months even in a small practice. And, after that, the ongoing support (optimizing, implementing new releases and features, managing incentive program participation, etc.) will require about .20 or .25 FTE for the system guru in the practice.

The EHR guru will interact with the vendor, maintain knowledge and understanding of incentive and pay-for-quality programs, and be the go-to person for providers and staff using the application.

So, given the challenges facing medical practices of all sizes, is it any wonder that it’s a daunting task to select and implement a PM/EHR system in a small practice.

Securing outside help from experienced and knowledgeable consultants can supplement the practice’s infrastructure and improve the likelihood of a successful system implementation. But don’t ever believe EHR uptake is slow only because it costs too much.

Rosemarie Nelson is a principal with the MGMA Health Care Consulting Group.

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  • Margalit Gur-Arie

    It does cost too much. Maybe not the EHR itself, which can range in price from $0 to about $500 per physician per month, but all the mythological expertise supposedly required around making this purchase.
    People buy cars and homes every day without paying expensive consultants, and I don’t see a reason why they can’t buy an EHR on their own as well. Yes, there are things you should know and there are better ways to go about it, but you shouldn’t have to pay for this knowledge. ONC has a lovely knowledge base at that can help, and you can get (my) free expertise (without government kool aid) in the form of whitepapers and recorded webinars at
    It’s not rocket science and it should not take more than a few hours of anybody’s time.
    Finally, the reason small practices don’t buy EHRs as fast as large ones, is that there really is no compelling business case for an EHR in a small and already efficient practice. Maybe when interoperability becomes a reality, there will be….

  • azmd

    Has anyone considered the possibility that EHR uptake is slow because physicians, although trained to be very compliant, have their limits on what hoops they will jump through when told to do so?

    Many of us who use EHR are very well aware that it does very little to improve patient safety or efficiency of care, and quite a lot to facilitate governmental micromanagement of physicians.
    At my hospital, the billing software for our EMR system is not being used, and we are still required to submit paper contact sheets every day, because the system is not considered accurate or reliable enough to support such an important function as billing. Ironic, no?

  • azmd

    Hi, Amy–

    I apologize, I think perhaps I did not communicate clearly what I intended to.

    I am not particularly frustrated by our EMR’s billing function not being adopted yet. I am merely pointing out that it hasn’t been adopted because it, like the rest of the system, appears to have some flaws. Those flaws are felt to be acceptable when the system is being used to provide patient care, but not acceptable for something as “critical” as billing.

    I could go on and provide a very long list of ways in which our EMR makes patient care more cumbersome for the providers, but I think the general problem is that once the system was put in place, the subsequent process of “optimizing” the system, or customizing it so that it actually syncs well with the workflows of the providers, is apparently an additional expense for which our facility doesn’t have quite as big an appetite as the initial adoption. This is really the frustrating part for most of us.

    As for easy access to patient medical history and treatment details, I agree that is critical to good care. However, it does not require a complete EMR system At our facility all old records have been available electronically as scanned documents for quite some time, and actually, for my purposes, the records are easier to review in that older format rather than the one offered by our new EMR system.

    • ninguem

      And Rosemarie Nelson is in a business consulting organization?

      Did it never occur to her that all the IT people, all the support staff, all the time lost………IT ALL COSTS MONEY.

  • buzzkillersmith

    Huh? If it works in the VA, then it must work in a small practice. Can you say non sequitur?

  • southerndoc1

    When was the last time anyone needed stent information from 10 years ago during an office visit to guide clinical decision making?
    I think most docs are more concerned about being able to efficiently handle a patient with nine problems during a 15 minute visit.
    Not a good trade-off.

  • John Henry

    EHR to the small practice is more burden than benefit. Cost of equipment, software, transfer of soem or all of the established paper record, upgrades, service calls to IT professionals, all of it imposing costs and not really reaping any efficiencies. Large comprehensive care entities like the VA are useless comparisons and really represent something entirely different that a small non-government outpatient practice. The records end up in server silos, onsite or in the “cloud,” the latter of which is a concept held hostage to outdated broadband technologies to which, in many communities in the USA, there is absolutely no alternative.

    Unless there is a need to provide access to records between multiple offices, paper charts are generally secured onsite and so lost/misplaced charts are really not that much of a problem, not at least enough of a problem to warrant spending tens of thousands of dollars on a network and system that make daily work less rather than more efficient.

    The real reason so many are buckling in and buying is partly fear, fear first of losing an opportunity to get stimulus money to offset the costs of the system and fear of suffering revenue loss in fines from CMS (as if the threatened reductions that by far dwarf any of the “fines” have suddenly become moot.) No one is expecting to profit by buying these systems. Worse, anyone looking forward has to realize that when the stimulus money dries up, and equipment has to be replaced in the inevitable requirement to accommodate either some new version of operating systems or chart software or both, the real cost of these systems will become obvious, as they substantially and permanently introduce a new operating cost on medical practices, literally forever. Oh, and as with any industry, there will be failures, and those left with a dead-end product will find either no further support and will need to start over with some other product, or their vendor will be bought out and more likely than not, they will be offered the product of the acquiring company, not continuing support for their legacy product. Either way, a real crapshoot. Pick well, my friend.

    Any wonder why there isn’t more enthusiasm for EHR?

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