Dealing with EHR difficulties
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Growing dissatisfaction highlights need for strong client/vendor relationships

With more physicians than ever using electronic health records (EHRs), it’s no wonder that there are more looking to switch their EHR systems than there are physicians buying new ones. Switching to a new EHR, however, comes with its own headaches. Moreover, there are only a handful of systems that address dermatologists’ needs. Consequently, it behooves dermatologists to build a long-lasting relationship with their EHR vendors so they won’t have to contemplate switching in the future.

Common reasons among dermatologists for switching EHR vendors are a lack of easily customizable templates, training, and support, including timely upgrades for the Medicare and Medicaid EHR Incentive Programs for Meaningful Use (MU) of certified EHR technology, Physician Quality Reporting System (PQRS), and ICD-10. Then there is the inability to electronically import lab work/reports or connect to pharmacies for e-prescribing. Also on the list are additional costs associated with addressing any and all of the above.

Custom templates

Office visit templates are one of the biggest EHR-related problems about which dermatologists complain, noted Gilly Munavalli, MD, MHS, medical director at Dermatology, Laser and Vein Specialists of the Carolinas in Charlotte, North Carolina. Many vendors say that their templates are easily customizable and offer a pool from which to choose. But the reality is that customizing templates is not such an easy task, often taking more time and money than anticipated, he said. “You can take an inordinate amount of time trying to customize a template and it still won’t be what you want, and you’re paying for that time.” Most EHR vendors offer a period of template customization. “But as your practice grows, you add new procedures, and documentation requirements can change or increase; with these ever-present modifications, your templates must be kept current to reflect them precisely,” Dr. Munavalli added. 

The week that Central Dermatology Center in Chapel Hill, North Carolina, went live with its first EHR system, the practice hired a consultant from the vendor to design a basic office visit, said David Todd DeVries, MD. The vendor neither offered standard office visit/procedure templates nor responded to a request to provide templates from other dermatology practices that had successfully implemented the EHR. After numerous redesigns failed, the practice ended up having to build the templates themselves. “We had to learn the software language and spend extraordinary amounts of time building a customized office visit template,” said Dr. DeVries, whose practice consists of five board-certified dermatologists and four physician assistants. In addition, elements of the visit note had to be accessed by means of a tab system, which was cumbersome and impractical, and increased the possibility of missing vital information, he added.

Having switched EHR vendors 11 months later, Dr. DeVries and his colleagues find the format of an office visit easier to navigate. “The current EHR involves a visit template that is standardized across all of the users. The interface allows rapid movement from section to section. The visit note is then rendered in a style that is recognizable to physicians regardless of their specialty,” he said.” The practice is in an area fairly saturated with dermatologists and two major medical systems, he explained. In order to continue to draw patients, they have to effectively communicate with their referring providers in a format that is instantly legible.[pagebreak]

The current EHR allows customization of specific elements, such as counseling. However, Dr. DeVries has found it frustrating that customization is provider- and problem-specific. For instance, where previously the practice had a handout for counseling on cryotherapy that could be provided with any of the many indications for cryotherapy, he must now import the text of counseling into every problem for which cryotherapy is an appropriate treatment. But he appreciates the importance of having an EHR that is not so practice-specific that it loses its applicability for the majority of dermatology practices. Dr. DeVries is also optimistic that if enough users request a specific feature the vendor will consider adding it as the company has been responsive to specific issues that they have raised.

Training, support, upgrades

Initially, his EHR vendor offered some on-site training, Dr. Munavalli said. Then it switched to online training due to a lack of manpower. “That was disappointing because some things are harder to figure out online,” he said. Overall, the quality of support isn’t as good as dermatologists think it should be given the associated cost, said Dr. Munavalli, who practices with three other dermatologists, one physician assistant, and two aestheticians. Furthermore, there is a lot of on-the-job training that isn’t included in the initial training, noted Mark Kaufmann, MD, an associate clinical professor at Mount Sinai School of Medicine.

Dr. DeVries understands the frustration. His practice’s first EHR was a server-based system purchased for hundreds of thousands of dollars. There were ongoing additional costs associated with adding licenses for new users and continuing support. When the server went down or a server-related problem occurred, the EHR system was down for hours at a time. Initially, they hired an information technology consultant who was paid by the hour to address these crises, but they occurred so frequently that they eventually had to bring someone in-house.

Nowadays, when the periodic issue arises with the new EHR, the vendor addresses it with a sense of urgency, Dr. DeVries said. Furthermore, upgrades are routinely performed on the new cloud-based EHR system. Typically, upgrades with cloud computing require the vendor to simply flip a switch to update all of its clients whereas upgrades for server-based EHRs require a site visit.

“We used to keep our fingers crossed every time we heard that a new update was coming’ from our old vendor, hoping that this upgrade would be the one that would significantly change the software and make it easier to use,” said Sonia Badreshia-Bansal, MD, a clinical instructor at the University of California, San Francisco and chief executive officer of Elite MD — Advanced Dermatology, Laser, and Plastic Surgery Institute of Danville, California, with five offices in northern California. “Unfortunately, after five years of waiting, we realized that the type of changes we needed to be made would require the entire software to be rewritten from the ground up, and that was never going to happen.”

Additionally, not all vendors provide adequate upgrades for MU attestation, PQRS, and ICD-10 in a timely fashion. Both of Dr. DeVries’ EHR vendors made MU attestation for Stage 1 possible, although he noted that the current one is far more straightforward. Furthermore, the vendor continues to educate practices on how to meet MU through a series of webinars. He plans to start reporting PQRS measures this year and understands that his EHR system is considered a certified registry as of 2014. Dr. DeVries is confident that the vendor will be well-positioned for the transition to ICD-10, which has been postponed until Oct. 1, 2015.[pagebreak]

Electronically importing lab reports

Another issue for many dermatologists in private practice is that they can’t import lab work/reports into their EHRs. (This is typically less of a problem in hospital systems.) Often large labs are able to interface with EHRs, however, smaller ones commonly do not. That means a bridge using Health Level Seven, or HL-7, language must be built to enable the lab and EHR to communicate — an expensive undertaking.

The dermatologists at Boynton Beach Skin in Florida use two laboratories; the outside one is able to electronically report lab results, but its own lab cannot, noted Andrew Weinstein, MD, who works with five dermatologists and one dermatopathologist. “Right now, it’s not a big issue. We scan results in,” he said.

Similarly, Indianapolis-based Dermatology, Inc. has its own lab and is working on an interface between it and the EHR system, said Chris Bohyer, MD, who practices with eight other dermatologists. “The lab report can be imported, but it’s very cumbersome,” he said. “It would be nice if it could be more streamlined.”

Central Dermatology Center’s first EHR offered interfaces with the outside laboratory and dermatopathology vendors, Dr. DeVries said, but they were incredibly clunky and time-consuming, lengthening the process of triaging a result from seconds to minutes. “You want to be able to scan a lab sheet within seconds to see the normal values, but that was impossible,” he said. They were doing double work to try to meet Stage 1 MU. They were happy to return to a paper tracking system with the second EHR. Now, they are patiently waiting on their current vendor to develop interfaces for both their in-house dermatopathology lab and larger outside lab, which will enable the practice to meet Stage 2 MU. “We are looking forward to the day when it’s all integrated,” he said.

An independent pathology lab paid to have a bridge made between it and Dr. Munavalli’s EHR. However, it was never utilized because the reports it generated looked so bad. “Even if you bridge the data across, there’s no guarantee that you’ll get a nice-looking report,” he said. He is faxing reports as PDFs, which is not conducive to easily analyzing the data. Plus, scanned documents take up a lot more space in the EHR than importing a set of lab values as numbers. That slows down the EHR system, makes it more difficult for the software to run, and adds storage costs.

When lab reporting and the EHR truly work together it can improve the ability of dermatologists to provide optimal care, according to Julie Mermilliod, MD, chair of dermatology at Ochsner Medical Center, which adopted an EHR system in 2012. “As part of making our workflow more efficient, we have created favorites lists from which to order labs with one-click. Once labs are drawn, the result comes to our results-review inbox. From here, our docs can easily message the nurses with instructions to carry out, i.e., call patient to schedule appt, update Ipledge, etc.,” she said. “This note will be attached to the lab, so we can reference back and know exactly how we handled the normal or abnormal lab. Because our entire system is connected on the same system, any lab ordered by any other physician is easily found, therefore eliminating redundant lab work that leads to unnecessary health care spending and patient inconvenience. One can also easily look at trends of labs in the EHR. We can see any particular lab result for a time period in both numeric and graph format. This is invaluable for managing patients on long-term immunosuppressant or other systemic medications.”

Switching EHR systems

Gaining access to your data is probably the most significant issue involved in switching EHR systems. Converting the data from the first EHR to their current one has proven to be enormously difficult, Dr. DeVries said. Unable to obtain access to the first vendor’s proprietary software, a third-party vendor can’t adequately convert the data. The current vendor is unable to identify an alternative third-party vendor to assist. Manually converting the data into PDFs and sending them to the current EHR seems to be the only option, he explained. “The price tag will no doubt run into the tens of thousands of dollars, but it is necessary to ensure the integrity of our patients’ medical records,” Dr. DeVries said.

When Dr. Kaufmann switched, his old vendor offered to transfer his data in a PDF format for a fee of $5,000. Instead, he hired college students to do the same and then scan the PDFs into the new EHR.

Then there is the bridge that will need to be built to enable the lab reports to be sent to the new EHR system.

On a positive note, switching from a server-based system to a cloud-based one did not require a significant initial investment in server technology for Dr. DeVries’ practice. The practice pays for actual use on a monthly basis with additional costs for storage and faxing, an easier option from a cash-flow standpoint. Also, responsibility for data integrity rests with others who are better trained to maintain it, which is an enormous relief, he said.[pagebreak]

Fostering success

Building a successful client/vendor relationship could keep dermatologists from wanting to switch EHR systems. What does that entail?

“Probably the most essential piece to a good relationship is an acute understanding that both parties share the responsibility of fostering user success,” noted David Henriksen, President and CEO of Nextech. To that point, training should not stop after implementation has concluded. In today’s digital age, technology is ever-changing and it’s essential for dermatologists to keep pace with the health information technology trends, he said. Henriksen encourages dermatologists to participate in training and usability webinars, attend user conferences, or simply stop by the vendor booth at meetings to ask for a rundown of the latest software capabilities. “Our most successful clients are those who immediately hit the ground running, working to learn the system inside and out,” he added. “By taking the time to ensure that everyone has been adequately and thoroughly trained from the beginning, physicians are setting their practice up for long-term EHR success that will grow their practice through enhanced efficiencies and improved workflows.”

Dr. Badreshia-Bansal concurs. “An EHR is only as good as the time you put into understanding it, setting it up, and learning it,” she said. At her practice, an operations team spent countless hours planning and training staff before going live with the new system. “We closed the doors at all five locations for 40-plus staff to dedicate the necessary training time,” Dr. Badreshia-Bansal said. In return for the initial time spent on training, the practice now runs more efficiently on a daily basis.

Following several weeks of “excellent training” and a few weeks after going live with the new EHR system, Dr. DeVries’ practice paid to bring in one of vendor’s trainers to assess their utilization and recommend strategies for improvement.

The practice’s assigned account manager serves as a direct link to the EHR provider, Henriksen points out. “Many of our most proficient software users regularly leverage the insight of their account manager, using them as a trusted advisor to help overcome challenges that practices can sometimes face with health care technology,” he said. “When both parties regularly communicate and work to ensure the entire team is on the same page at all times, the odds of success are dramatically increased.”

Dr. DeVries, for one, appreciates having an open dialogue with his EHR vendor. “If you have a question or concern about the system, you can submit a request on the vendor’s support site and you will get a response,” he said. “It may not be we will do this tomorrow,’ but it will be acknowledged.”

Just as a vendor will provide a project lead, an implementation consultant, a technical resource, and application trainers, the practice needs a project lead, a clinical lead, a technical lead, and identification of super users on their side as early as possible, said Henriksen, adding that it could be the same person from the practice. At Dr. Weinstein’s practice, the clinical manager serves that role. “Whenever possible, we work through the clinical manager to communicate with the vendor,” he said.

Ask a lot of questions

Finally, set realistic expectations. In order to do that, dermatologists will likely have to ask a lot of detailed questions and make sure they get satisfactory answers.

As an example, software vendors will no doubt be touting their methodology for ICD-10 codes. But it’s not enough to ask if the EHR vendor is ICD-10 ready because there’s no certification board to explain what that means, Dr. Kaufmann said. Ask the vendor how it is tackling ICD-10. Is it going to use a crosswalk? How long will it take to fill out the billing when using ICD-10? Will the EHR generate the ICD-10 code or will it ask the dermatologist what it should be? In either case, how long will it take for the EHR to generate the codes?

Another area to ask about is the training for implementing the EHR system. “The vendor may say it takes most doctors a couple of days,” Dr. Bohyer noted. Find out specifically how many hours it will take to set up the system, transition to it, and return to a normal patient load.

Ask about the support. How much is typically needed, what does it cover, what form does it come in (e.g., in-house, online, phone), and what is the price tag for the different types of support offered? Make sure that the support lines are not being manned by people for whom English is not their native language or who are not in this country because support is being outsourced across the industry as associated costs continue to rise, Dr. Munavalli said. “But it doesn’t help if the vendor offers you 24/7 support if, in reality, a lot of that support won’t be helpful,” he said. Other issues to be clear on are upgrades and accessing the data.

Of course, all of these issues among others should be clarified in the written contract, which Dr. Weinstein urges every dermatologist to read as it is binding.

It’s hard to predict the issues that will come up with any EHR system over time. That’s why it’s so important to maintain a good client/vendor relationship, which will allow dermatologists to address concerns as they arise. Lastly, as Dr. Weinstein put it, “Don’t sweat the small things that don’t have a big impact on patient care.”

Editor’s note: Dr. Kaufmann serves on the advisory board for Modernizing Medicine.