Surviving an Unsuccessful EMR Implementation: Lessons from the Field Date: August 6, 2013

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Erika Spencer
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1 Surviving an Unsuccessful EMR Implementation: Lessons from the Field Date: August 6, 2013 This paper is being submitted in partial fulfillment of the requirements for ACMPE Fellowship Darryl K. Hull, MPH, FACMPE

2 Introduction Prior to his arrival, the administrator s new practice group selected and began implementing a new electronic medical record (EMR) system in late The practice was already accustomed to technology and innovation. In 2001, the group began using a proprietary software package that became the precursor to the EMR system deployed in That system needed to undergo an expansive and costly upgrade to meet the rigors set forth in the Affordable Care Act legislation of However, the developer had no interest in continuing its support of the product and the practice had to purchase a new EMR system. They selected a system, defined a training timeline, and secured a go- live date. As the administrator was acclimated to the project during the first two months in his new role, the implementation and EMR consultants continued their work as the launch period approached. When the practice started to use the system during the scheduled go- live period, the providers became completely disengaged amid a number of system- related issues and training concerns. As a result, the board quickly decided to halt the implementation and returned to the former charting system. Although presented as an initial alternative, to do nothing in addressing the group s concerns was deemed unacceptable. The physicians and management had an immediate sense of urgency to move forward decisively, given the economic implications of not adopting a system that supported the tenets of the Affordable Care Act. An EMR committee that included the administrator was then formed and tasked with selecting and presenting alternative solutions to the recent EMR predicament. The committee sought to learn what exactly had gone wrong 2

3 during the go- live and the challenges and opportunity costs of staying with the current system. After several discussions, they identified two alternatives for the clinic to pursue. Alternatives Considered The first alternative was to stay with the current vendor and challenge the company to remedy the disclosed issues identified by the board and physician group (Figure 1). An immediate benefit to this option was that the expenses in remaining with the system were low compared to finding a new product. Given that the balance of the system components were installed, challenging the vendor to repair the issues seemed financially more viable than vetting and purchasing another system outright (a new system was estimated to cost between $300,000 and $400,000). Remaining with the current vendor had a number of other benefits including the continued use of resources already acquired in converting demographic and clinical data. As for the negatives related to this alternative, the most significant, if not pressing, concern was that the system was extremely unpopular with the provider group. Although the administrator was not present during the product selection, he knew that the bulk of the physician group was not involved in the selection and vetting of the new system. Provider input is a key to any system deployment, and previous leadership failed in this regard. Another concern was that the vendor could not guarantee that they could remedy the performance- related matters in a timely manner, if at all. With this lack of assurance and follow- up from the vendor, the committee worried about a second launch of the product. 3

4 The second alternative the committee considered revolved around identifying and selecting a different EMR product. The immediate and most striking barrier to choosing this alternative was cost. Despite the expense of re- training and the technology demands of repairing the current system, the committee knew those costs would be far less than implementing an entirely new product. In addition to cost, designing and implementing a new system would prolong efforts to adopt an EMR within the prescribed time frame. The board and committee were hoping to be using a licensed and configured system in six to seven months. Adopting a new system would ultimately double that time frame, impacting the maximum government award for achieving meaningful use (Figure 2). However, the committee identified a number of positive outcomes. One of particular significance was having physician input from the onset of choosing a product and project implementation. This had been a failure of the original selection process, and the committee would remedy this concern if this option were pursued. Decision and Chosen Solution The decision process was slated to occur over a two- to four- month period. The timeline here was purposeful and succinct; this was a key decision with significant financial implications, and the shareholders wanted to give the committee every opportunity to formulate a well- informed resolution. The committee met with each shareholder and physician accordingly as the team reviewed both alternatives and continued to vet an itemized punch list. This list would detail the options and functionality the provider group desired in the EMR 4

5 product (Figure 3). With input from the entire group, the committee finalized this list and presented it to the shareholders for ratification. With the shareholders approval, the committee began to meet with several vendors including the current vendor responsible for the failed implementation. At the meetings, the committee shared the punch list and collected bids to determine the financial impact of each vendor s option. This was key in developing a defensible position for each alternative. The committee formulated a pros/cons analysis to aid the decision process (Figure 4). With the punch list in hand, the vendors were challenged to provide product demos to the physician group. Once these demos were completed, the committee collected feedback from each provider and retained final bids from each prospective vendor. The final bids painted a striking picture, specifically, the opportunity costs associated with moving to a completely new system. If the group decided to purchase a new system, the clinic stood to lose about 62 cents for every dollar spent on a new system (Figure 5). The potential loss was significant, and, before a making a formal decision, the committee communicated this concern to the shareholder group. To the surprise of the committee, the board urged the group to still include this second alternative. The financial loss would be justified if it led to a functional system that maintained their clinical efficiency. Armed with this knowledge, and the aid of the other comparative analyses, the selection committee decided to pursue a semblance of the second option that worked from both a cost and implementation standpoint. 5

6 The committee learned that the vendor of the clinic s former practice management (PM) system already had an EMR product that was viable and could be customized to fit the needs of the provider group. Given the comfort level that the billing and clerical staff had with the PM product already, training was truly needed only for the provider group and the clinical team members who would use the EMR product daily. Also, while still significant, the opportunity costs with this decision were much lower than with moving to a completely new system about.41 cents loss on the dollar versus the previously mentioned.62 cents (Figure 6). The lower cost here was partly because the PM system still existed on the servers (alleviating the need to reinstall), and the required data conversion would impact only new patients seen during the implementation of the failed system. The committee informed the current vendor that they would forego their agreement and move toward an alternate solution. Although there was no immediate cost in terminating its agreement with the vendor, as described earlier, the group did have a financial loss related to the resources and time already spent on the failed product. The committee firmly believed they could recoup some of these costs through arbitration, a task left to clinic counsel. The committee also formally engaged a third party to help with the new pending implementation to provide not only a local, experienced resource for deployment but also a crutch if any customization or changes were desired outside of the capabilities of the EMR vendor and clinic staff. All that remained for the committee was identifying a timeline for training, implementation, and scheduling a go- live date amenable to both the vendor and provider group. 6

7 Once the alternative was selected, the committee began the process of adapting and deploying the new EMR system. First, the administrator identified an internal project manager who acted on behalf of the clinic. This individual was the glue throughout system deployment and ensured communication and timelines were adhered to. Next, the EMR selection committee was repurposed and became the EMR core committee. This group was now tasked with being the leading change agent for the clinic with respect to project oversight, template development, and the development of training protocols for the clinical staff and providers. This key group was comprised of physicians, staff, and leadership from the third- party support vendor. Next, a super- user group was created. Several key staff members were selected through an application and vetting process. These individuals would be the front- line leads throughout training and go- live. In addition to these groups, using the previously comprised punch list, subcommittees were created to work in developing and customizing the EMR product. Each subcommittee was responsible for developing and supporting a particular part of the EMR environment. For instance, one subcommittee was responsible for building clinical workflows. The subcommittees included a trainer from the EMR vendor as well as a member from the third- party support group. These subcommittees were significant in that they represented key points of collaboration for the project as a whole. Biweekly meetings kept all involved parties in the loop regarding project progress and hurdles if any became apparent. The core committee also traveled to the EMR vendor s national user conference to engage other providers and groups in similar, pre- deployment 7

8 situations. The national user conference was also an opportunity to see where the product was going in terms of future updates and to get a sense of industry trends related to clinical charting. This represented a strategic and informative opportunity for the clinic and core committee. With everything set in terms of resource gathering and product development, they scheduled and dated a go- live period. Lessons Learned/Outcomes Close to a year later, the administrator was satisfied with the clinic s position within the new product and the selected alternative. Physician engagement at the start of the go- live period improved dramatically. By including clinical leadership and the provider group at the onset, the committee was able to select a product that met the needs of their day- to- day clinical practice. Staff involvement helped to transform the training process. Including key clinical staff members proved to be an integral part of the training and development needed during both go- live and the implementation period. Third- party involvement was also critical and helped ease the transition, quell any misgivings about the viability of the product, and ensure the providers would enter an EMR environment that was accessible and easy to navigate. Recommendations 1) Include physician input in any EMR system deployment as it is key. The predecessor failed to identify this, which led to the major issues present during the initial go- live period. 8

9 2) Engage the staff and self- train them. A group should not rely solely on the resources presented by the EMR vendor. 3) Employ local resources. The third- party support group the administrator identified had experience building, customizing, and deploying the product on several levels. This was an important find for the group. 4) Review contracts with each vendor to identify what processes, if any, are in place to remedy or dissolve a relationship if needed. Although cost is a barrier to changing systems midstream, this should not deter a group from making a necessary change. A group must decide if remaining with the failed product makes sense given the overall performance challenges. If the providers of a group cannot see patients in an efficient and meaningful manner, the costs related to switching products can become easier to justify. 1 Office of Population Affairs (OPA). Affordable Care Act. U.S. Department of Health and Human Services, 01 Mar Web. 06 Aug < care- act/index.html>. 9

10 Figure 1: Chart of Issues with Failed Go- Live Surviving an Unsuccessful EMR Implementation: Lessons from the Field Appendix Issues%with%Failed%Go0Live System'Stability'concerns'and'slow'performance'within'chart'templates Inoperable'medication'and'E*Prescribe'module Lack'of'accounting'and'business'office'reports Incorrect'mapping'of'imported'data'from'former'system

11 Figure 2: Meaningful Use Incentive Payments Medicare Incentive Payments Payments Total Eligible Providers (EPs) Total Payments for Clinic Year 1 $18, $414,000 Year 2 $12, $276,000 Year 3 $8, $184,000 Year 4 $4, $92,000 Year 5 $2, $46,000 Total $44,000 $1,012,000 Meaningful'Use'Incen5ve'Payments' Dollars'($)' $450,000## $400,000## $350,000## $300,000## $250,000## $200,000## $150,000## $100,000## $50,000## $0## Year#1#Year#2#Year#3#Year#4#Year#5# Payments#per#Eligible# Provider# Total#Payments#for# Clinic#

12 Figure 3: Punch List EMR$System$Punch$List Templates(for(Rheumatology,(Internal(Medicine,(Dermatology,( General(Surgery Working(interface(with(current(lab(orders(system Dictation(with(the(ability(to(import(from(third(party(scribe Working(interface(with(current(imaging(orders(system Online(Training(Modules/Resources Accounting(Reports((i.e.(A/R,(Outstanding(Balances,(etc.) Support(a(large(document(and(data(import(from(former(clinical( system;(data(to(be(mapped(correctly

13 Figure 4: Pros/Cons Analysis Alternatives Pros Cons Alternative*#1:*Continue*with*the* same*emr*product*and*challenge* vendor*to*repair*and*remedy*disclosed* issues. *Low*cost*to*clinic*when*compared*to*adopting*a*new* EMR*system.***Training*already*complete*with*repsect* to*the*practice*management*piece*of*the*software. *Unpopular*system*with*physicians*(including* clinical*leadership).**no*guarantee*that*the* performance*of*said*system*would*improve*and* that*all*issues*would*be*addressed*in*a*time*fram* amenable*to*the*practice.**timeline*for*new*system* would*prevent*group*from*receving*full*meaningful* use*incentive*payment(s). Alternative*#2:*Choose*a*Different* Product *Opportunity*for*physician*involvement*and* engagement*as*it*relates*to*a*new*system.***a*chance* to*start*"anew"*and*from*an*informed*standpoint*in* negotiating*with*new*vendor(s). *Cost***Implementation*timeline*length*as*it*relates* to*additional*training*and*new*resources.

14 Figure 5: Opportunity Costs Opportunity*Cost(s) Failed*System*Expenditure New*System*Expense* (Average) Alternative*#1 $695,037 $290,000 Alternative*#2* $565,037 $350,000 *Note:*The*total*opportunity*cost*in*selecting*the*second*alternative*is* $565,037;*in*other*words,*the*clinic*would*lose*.62*cents*for*every*dollar* spent*on*a*new*product*installation.

15 Figure 6: Opportunity Costs (Revised) Opportunity*Cost(s)*(Revised) EMR*w/*PM*system* Failed*System*Expenditure already*installed Alternative*#1 $695,037 $180,000 Alternative*#2*(Revised)* $565,037 $230,000 *Note:*The*total*opportunity*cost*in*selecting*the*second*alternative* (revised)*is*still*$565,037;*however,*the*clinic*would*lose*.41*cents*for*every* dollar*spent*on*the*installation*compared*to*.62*cents*in*figure*5.

RELIEF FOR ELIGIBLE PROFESSIONALS? PROPOSED STAGE 2 MEANINGFUL USE RULE INCLUDES IMPORTANT (POTENTIAL) EXCEPTIONS [OBER KALER]

RELIEF FOR ELIGIBLE PROFESSIONALS? PROPOSED STAGE 2 MEANINGFUL USE RULE INCLUDES IMPORTANT (POTENTIAL) EXCEPTIONS Publication RELIEF FOR ELIGIBLE PROFESSIONALS? PROPOSED STAGE 2 MEANINGFUL USE RULE INCLUDES