Coker Connection Newsletter

When and How to Convert to Another EHR

• January 1, 2016

Is your EHR not working? Is your EHR at the end of its useful life? Are you experiencing a vendor merger or practice merger?

Buying and implementing an EHR is one of the biggest decision a practice will ever make. EHRs can have both positive and negative impact on the operations of a practice, depending on the qualifications of the vendor and the methods of implementing the system. Further, not all failures are caused by vendors. Some practices find it difficult to implement change; other’s just have buyer’s remorse and regret their decision to purchase EHR. It can also be difficult to adjust to an EHR when the system does not meet the unique needs and requirements of the practice.

Why do EHRs fail?

To understand why some EHRs fail is first to determine if the solution was even capable or qualified to meet the requirements in the first place. This answer is sometimes difficult to accept after the fact, especially if the system did not perform as promised. To ignore a failing EHR or delay taking action can have several unintentional consequences. Some of the concerns are:

• Excess cost overruns
• Loss of confidence
• Failure to comply with EHR incentives
• Future penalties for delays in adopting
• Loss of opportunity cost and added workaround expenses

Although EHRs may fail for myriad reasons, our experiences from consulting with practices reveal the top 10 reasons failures occur:

1. The system creates a prolonged threat to the physicians’ productivity in excess of 6 week.
2. The system was defective.
3. The system did not have specialty-specific content or workflow built into it.
4. The trainer was inadequate and unqualified.
5. The implementation was flawed and did not consider workflow.
6. The practice did not commit the proper resources to the initiative.
7. The infrastructure, network, and hardware were inadequate.
8. The vendor misled the buyer by over promising and under delivering.
9. The system was incomplete or missing critical modules such as portal, eRX, practice management, etc.
10. The vendor discontinued the product and stopped supporting the system. (The vendor may have merged with another vendor and will be forcing a conversion to the most modern platform.)

When should you Replace Your EHR?

So the big question is: When should you replace your EHR? What is practical? What is impractical?

Before you consider replacing your EHR, ask yourself the following:

• Can the issues be resolved through remediation and/or with some new approach? Usually, the failure can be corrected, or there can be some reasonable compromises and workarounds to address the issue. The last thing a vendor wants is to have a customer fail using their software. Most responsible vendors take complaints very seriously and will do what is necessary to correct the issue. A practice should first exhaust all efforts to fix the issue before considering a de-installation.
• Can the issue be resolved through developmental and/or technical improvements? No software is perfect, and most improvements will come from user experiencing issues. A good vendor will consider an issue an opportunity to enhance or improve the product. It can take extensive time for the vendor to make these improvements, but if progress occurs, it is worth the wait.
• Is the vendor responsive and concerned about the issues at hand? This question is one of the most important because so much of the outcome depends on the responsiveness of the vendor and their ability to take responsibility for your success. If the vendor has become non-responsive or attempts to brush off the issues, it could be tough to remediate the problems. Under this situation, an alternative course of action may be needed, which we present later in this article.
• Does the practice bear some responsibility for the failure? In fairness to vendors, not all failures are their fault. Some practices are just not prepared to undergo an EHR transformation. Some practices have discovered incidences ofsabotage fromthose who feel EHRs threaten their job security. If you feel the practice has not done all it can do, you owe it to yourself to address these issues within before pulling out your EHR.
• Has the product (or version) been discontinuedcommercially? Often, failure is due to the product becoming obsolete or outdated. The practice MUST stay up-to-date on the current version, which has the improvements written into the software. Staying on an older version of the EHR is one of the fastest ways to fall behind and create unwanted threats.

What are your Options for Resolution?

Using the questionsabove, can you determine if the problemrelates to the “product” or the “process”? If you are unsure of whether the problem is with the technology or the user, here is an easy test: Are you the only organization experiencing these problems? Are most other practices/hospitals using this same system satisfied with the product? If the vendor can prove or provide examples of where and how their product is overcoming these same challenges successfully, then the issue may be related to the process and not the product. If the vendor avoids the problem or is unable to demonstrate ways to solve the issue, then the matter is likely product related.

 Another test is to examine how the system performs compared to what was promised. While the intent of the vendor was not to mislead, it is not uncommon for expectations to be miscommunicated. Further, it is common to assume products come delivered as plug and play and with all the bells and whistles. Often, the demo was a presentation of what is possible, but it requires extra modules and customization for the system to perform a certain way. It is critical, therefore, to document expectations and deliverables before committing to a vendor of choice. 

Options for Problem(s) Related to the PRODUCT

Ask yourself the following questions:

• Can it 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 the answer is YES to these questions, then consider giving the vendor an opportunity to remediate the issues. In most cases, this should be done at the vendor’s expense, not the practice’s. Before agreeing to this arrangement, be sure to document expectations, set a timeline for delivery, and have a contingency plan, if the problem is not resolved.

If the answer is NO, the product is likely defective, and there could be a breach of contract. Most vendors do provide a warranty that their product will perform as promised. While it’s still best to work towards a resolution, if the problem cannot be corrected, you may be entitled to a refund. Coker provides FREE contract inspectionsif you are unsure about how to interpret the language.

Options for Problem(s) Related to the PROCESS

Consider these aspects about the processes in place in your practice:

• Was there proper training?
• Was the implementation based on the requirements of the practice?
• Was the workflow reengineered around the EHR?
• Was the practice committed to making the necessary changes to be successful with EHR?

If the answer is YES to all of the above questions, then you may want to reexamine the issues and determine if the problems are product related or due to lack of responsiveness from the vendor.

If the answer is NO, we have good news for you: most failures related to process can be corrected. It’s not always easy, especially if the staff and physicians have lost confidence, but not having the right process is never a good justification for de-installing an EHR. If several other practices have been successful using the same system, then the practice should look internally for the answers. It may be helpful to engage a thirdparty who can provide an objective assessment of the practice. Some failures only relate to 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 resources because they are too busy. Again, external resources are available to augment these projects if time or expertise to do it yourself is insufficient.

Summary

EHR failures are never pleasant, and they are almost always very costly. It’s best to exhaust all efforts and remediation options before de-installing an EHR. Also, you should read your contract carefully because there could be some financial obligations for terminating your vendor’s contract early. In cases where you feel the product is defective, or the vendor failed to deliver as promised, there could be a breach in services/contract, which would give the practice some legal grounds for resolving the issue. In any case, it’s best to keep proper documentation of all communications demonstrating your efforts to remediate the problem. It is wise to talk with customers of the vendor to see if others are experiencing the same problems. Finally,you may have a third party conduct an assessment/audit of your situation to determine the cause of the problems. As stated, most vendors will do whatever is necessary to avoid having an unsuccessful client, as dissatisfaction will severely hurt their marketing and can be embarrassing if the problem becomes widespread. Never delay or put off confronting issues, as it will become more difficult and challenging if you wait. Most vendor warranties are for 90 days, so this is another reason to be prompt and to keep good documentation. If, ultimately, you have to replace your EHR, please consider these terms before signing your next vendor contract.

• Your system warranty should not start until the system successfully goes live.
• Require the vendor to agree to an acceptance policy/language before deciding to purchase the system. The acceptance language allows you to enter into an agreement with the vendor, but the contact is not fully accepted until the system works as promised.
• Make sure to tie your financial obligations to favorable outcomes. Here is an example of payment terms to protect your investment:
  • Pay 20% when you sign the contract.
  • Pay 20% once the vendor successfully installs the software.
  • Pay 20% once the vendor successfully trains the staff.
  • Pay 20% once the practice successfully goes live using the product at the point of care.
  • Pay 20% thirty days after going live.