Ditch, Switch and Migrate!

This article has many interesting statistics on the demand of the provider to find an EHR that works for them.  When and if you switch-we advise you have a "Migration Plan" carefully created with your new vendor to avoid starting from ground zero. 

 

EHR users ditching systems, trading up - Dissatisfaction with current EHR systems have many providers turning to new vendors 

Erin McCann is Associate Editor at Healthcare IT News. She covers physician practices, ambulatory care and social media in healthcare. Follow Erin on Twitter @EMcCannHITN

2013 has been billed as the year of EHR dissatisfaction, with up to 23 percent of physician practices reporting they were trading in their current EHR system for a new brand altogether, and, according to a new Black Book Rankings report, there were only a handful of vendors that came out on top. 

 

The survey finds that providers switching to new EHR systems were turning to Practice Fusion, Care360 Quest, Vitera, Cerner, Greenway, ChartLogic, GE Healthcare and athenahealth — all vendors who have risen to the top of the replacement market satisfaction polls, officials note.  

 

"Regularly, at least two of these eight vendors were on the short lists of 88 percent of the current replacement market buyers surveyed," said Doug Brown, managing Partner of Black Book, in a news release. 

Seven others — Allscripts, AmazingCharts, eClinicalWorks, Kareo, McKesson and NextGen — also received top rankings in six of seven 2013 Black Book client experience surveys, Black Book officials note. 

 

"EHR system shifters now position to reallocate more than $5 billion in sales as the unstable vendor marketplace begins to get agitated," said Doug Brown, managing partner of Black Book, in a news release. 

 

Eighty-one percent of survey respondents who indicated they were ditching their current systems said they were on track to replace their EHR within the next year; some 11 percent said they were unsure, according to the report. 

 

The study is a follow-up assessment on the status of electronic health record users, all of which indicated deal-breaking dissatisfaction with the current vendors.

 

EHR users polled in the original survey had cited numerous cases of software vendors underperforming enough to lose crucial market share, with vendor solutions often struggling to keep up.

 

Most concerning to current EHR users were unmet requests for sophisticated interfaces with other practice programs, complex connectivity and networking schemes, pacing with accountable care progresses and the rapid EHR adoption of mobile devices, the original survey found.

 

Out of those EHR users considering a system switch, 80 percent said the solution does not meet the practices' individual needs; 79 percent indicated that the medical practice had not adequately assessed the group's needs before choosing the EHR; 77 percent of respondents cited solution design as ill-fitted for their medical practice or specialty; and 44 percent said vendors have been unresponsive to requests. 

RVU’S ‐ Successes, Perils and Pitfalls

RVU Components

The RVU (Relative Value Unit) is becoming an important consideration for ED physicians. Its original intent was to become a standard measuring tool for incentivizing clinicians toward increased productivity.

CMS assigns an RVU value to every CPT code, using 3 components:

1. Work –55% ‐ with five sub‐components:
• Time
• Mental effort and judgement
• Technical skill
• Physical effort
• Stress
2. Practice expense ‐ 42% ‐to account for overhead to run the practice / manage the entity to which the CPT code refers (does not include the EMTALA effect)
3. Professional liability‐ 3% ‐ allotted to “address” the cost of malpractice insurance.  Applied at 3%, even if actual PL costs are 1%, 10%, or 50%.

Rationale for RVU Incentivized Programs

 

The rationale for an RVU incentivized program is to increase the overall efficiency of the provider staff by rewarding efficiency. In theory this tool will stimulate clinicians who are marginally efficient, or less than optimally efficient, to improve by linking rewards to performance.

Again in theory, CMS hopes to decrease its (endangered) costs for services by stimulating efficiency. Physician groups would correspondingly hope to gain profitably by improving patient flow.

In an ideal world, this would be a win‐win situation for both CMS and clinicians.

RVU Implementation Systems

There are essentially two ways to implement an RVU system.

The first uses 100% RVU reimbursement, also known as “eat what you kill.”

The second guarantees a base salary; to that base is added a “piece” of the group’s overall RVU pie; the size of each piece is determined by the individual’s percentage contribution to the total RVU pie. Other factors may be given value in either methodology, so that RVU credits can additionally be offered for positive patient satisfaction scores, meeting attendance, night shift differentials, absence of complaints, participation on committees, etc. RVU credits may be subtracted for such things as above average number of complaints, failure to complete charts in a timely fashion, lateness, or other negatives that impact the group’s image or performance.

RVU Program Pitfalls

The unintended (and therefore problematic) consequences of an RVU program are especially evident in three areas:   

1. Competition between physicians
2. Potential for some to game the system
3. Invisible impact on departmental workflow

Competition occurs when clinicians attempt to sequester certain types of (higher RVU) chief complaints, and maintain control of their progress principally for the benefit of their own bottom line. Such activities may become evident as general attitude changes, cherry‐picking of chief complaints, evading of opportunities to pitch‐in and help when these do not directly impact one’s RVU tally, chart hoarding, and others.

Gaming the system has various forms, including uneven use of practice assets (PAs, NPs, scribes), requisition of choice shifts, buffing critical of care charges, working unpaid hours, and others.

Impact on ED Workflow may be unapparent but significant. When the analytic focus is on just RVUs, they become a somewhat distorted numerical representation of efficiency. Other major factors may be hidden by the dominance of the RVU process. Such hiddenness may be of greater consequence in a big department, where some physicians may perform non‐RVU activities that facilitate and support essential ED functionality.

For example a “fast” ED physician who can clear out the waiting room and the incoming queue by seeing a load of “lower value” RVU patients, opens up the department in key ways that enable the influx of higher RVU value patients. In the final calculation, in this case, the clearing physician is of inestimable value, while it is the other physician who gets the RVU credit, creating an imbalance that does not represent true value.

The Solution

Ultimately, it takes sophisticated analysis and constant adjustment to make such a system work. It will not be a walk in the park. Attention should be paid to the cumulative acquisition of know‐how about RVUs and applying them most appropriately for your particular ED and its physician staff.

The best solution might be a combination of equal shares of:

1.  Base Salary
2. "Eat what you kill" - minus practice expense of PA's,NP's, and scribes
3. Rewards for intangibles
• performance metrics (door-to doctor/door to balloon/LOS etc
• patient satisfaction scores
• complaints and compliments
• meeting attendance/committee participation
• risk management CME's
• quality measures (how to measure?)
• resource utilization and consumption

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