Shhhh! (10 Secrets the EHR Companies Don't Want You to Know)

Getting physicians to use an Electronic Health Record (EHR) is not an easy task. Getting them to fork over thousands of dollars for one is even harder—and yet EHR companies have demonstrated an astounding ability to convince many physicians to spend ridiculous amounts of money for software that all too often actually decreases efficiency and increases frustration. How do they do it? Before I expose the secrets of how EHR companies get the unwary to sign on th dotted line, full disclosure is in order: I own an EHR company, and many of the issues discussed below could be construed as being self-serving (indeed, many are). Thus, keep in mind that these are my own opinions based on years in the field as both a vendor and a practicing physician, and may not reflect the opinions of the publisher of this magazine or anybody else.In 2001, as a family physician wishing to use an EHR in my practice, I researched a number of solutions and found them to be overly complex and well outside my price range. Eventually, I gave up and decided to develop my own software, Amazing Charts. Since that time, in addition to running a private family practice, I’ve sold my EHR to more than 1,500 practices. Yet, I’m a Birkenstock-wearing family doctor first, and a salesman second, so I felt it was time to expose the seedy marketing and sales techniques that continue to fool so many physicians into adopting over-priced and overly complex EHRs.Physicians tend to learn from the experience of others, either anecdotally or from peer-reviewed sources. We assume the information presented to us by reputable institutions, experts, and our colleagues is unbiased and that potential conflicts of interest are fully disclosed. When it comes to the EHR industry, this assumption is incorrect.

Secret #1: (EHR awards have been bought!)

What first provoked me to explore the dirty secrets of the industry was discovering that most of the coveted awards prominently displayed by EHR companies are judged by people who are getting paid by them. Although this may be reasonable under some circumstances (eg, the expert judge is also providing legitimate consulting services to the EHR company), it is completely unethical if it isn’t openly disclosed—and in the case of EHR awards, the judges’ monetary relationships are not disclosed.

If one can’t trust an EHR award, perhaps it is safe to get advice from an expert lecturing at a conference or a consultant you pay to evaluate your practice and make recommendations?

Secret #2: (That “non-biased” expert recommending an EHR to you may have been paid off too!)

A significant number of the leading “experts” and practice consultants also earn money from the same vendors they recommend. Again, this situation is not necessarily a bad thing, unless a prospective buyer isn’t clearly informed of the relationship. Whereas the FDA oversees drug company-sponsored meals and requires full disclosure of speakers’ affiliations and relationships, there is no similar protection from the unscrupulous EHR expert/consultant. I’ve attended many lectures by consultants who had been paid by one or more EHR companies without any sort of disclosure before, during, or after the lecture. Similarly, many consultants, in addition to charging you for their “objective” advice, also quietly collect money directly from some EHR vendors for their referrals. So, perhaps it is safe to get advice from another physician who uses one of the EHRs you’re considering?

Secret #3: (Even that EHR-using physician you’ve been referred to may have been paid off!)

Clearly—and reasonably—an EHR company would try to avoid giving you the contact information of an unhappy client. But might the doctor to whom you are referred be getting compensated? Surprisingly, a number of EHR companies actually pay referring physicians to “compensate them for their time” in speaking with you. This can take the form of a direct cash payment or free/discounted software and services. Again, this is not necessarily unreasonable so long as the relationship is disclosed.

Secret #4: (The respected physician leader of your local society may also be receiving compensation!)

Remarkably, I’ve even learned of physicians in leadership positions (such as your local medical society, IPA, etc) entering into financial relationships with EHR companies and not clearly informing the membership about the connection. Without clear disclosure, any of these examples at best is unethical, and at worst, is fraud. In the end, it is the EHR buyer who foots the bill for this insidious marketing. Determining the true cost of this deception is difficult. In fact, simply figuring out the real cost of an EHR can be surprisingly hard, since most vendors won’t provide this information.

Secret #5: (Determining how much a specific EHR costs is going to be difficult, and you are going to be nickel-and-dimed every step of the way!)

Most EHR companies continue to avoid transparent pricing and will not openly provide an actual cost for their software and required services. Like a car salesman, even when asked, the majority of EHR vendors won’t give you a straight answer on price. Instead, they will try to obscure the issue with questions about how your office is set up, what interfaces are required, and the training needed to use their software.

Also, hidden charges are the norm in the EHR industry. Features you would reasonably expect to be covered by the base price often are not. For example, most vendors charge extra for “optional” modules we all use every day, such as ICD, CPT, and medication databases; spell-checking; document management capability; and scheduling. These add-on modules will dramatically increase the EHR’s price, which may not become clear until after you have started using the product in your practice.

Charging for “training” to teach you how to document a note is simply ridiculous. You’ve already paid a lot of money to your medical school and residency for this training, and you learned quite well how to document an encounter. If you must be taught how to use software that isn’t intuitively designed to flow like your own office, surely the price of that training should be included.

Secret #6: (Your patient data will be a bargaining chip to prevent you from leaving an EHR company!)

Perhaps the most egregious hidden cost (often apparent only well after you’ve signed a contract) is the fee charged by some EHR companies to practices when they try to get their data back from the company. It is the rare EHR vendor that actually provides a mechanism within its software to export your patient demographics and notes en masse without having to contact the vendor. Although many salespeople tell you the data is yours, when you actually ask for the data, you’ll be charged thousands in an attempt to hold your data hostage and discourage you from switching to another EHR system. Without that data, you would have to reconstitute your electronic notes.

In justifying hundreds or even thousands of dollars a month just to use their software, many companies will rely on theoretical calculations that prove you can make money by spending money.

Secret #7: (The return on investment (ROI) argument is another way of saying “this solution is overpriced!”)

If a company has to bombard you with white papers and intricate examples of how its EHR system will save you money by eliminating the need for your secretary to pull a paper chart 30 times a day, then they are looking for every theoretical penny of savings in an attempt to justify a price that is obviously too high. Companies that resort tothe ROI argument as a way of convincing a practice to pay thousands of dollars up-front in order to save theoretical money are selling only theoretical savings. If you can’t immediately appreciate the potential benefits of purchasing an EHR system, the software isn’t designed well enough, the price point is too high, or both.

Secret #8: (EHRs don’t improve quality of care and often make you less efficient. And since you won’t figure this out until you are actually using the product, EHR vendors won’t let you try-before-you-buy, and there is no return policy!)

This is the biggest secret of the EHR industry. The products’ abilities to produce accurate, improved, and rapid documentation—what should be the most important features of any EHR—are often woefully inadequate. Navigating through window after window, clicking multiple checkboxes, and inaccurate documenting by exception are all-too-common features of the overpriced EHR. To make matters worse, all this window-hopping and clicking may well distract you from providing high-quality care.

In fact, two recent studies have shown that using an EHR might actually hamper your ability to meet quality guidelines! Publishing their results in the July 9 issue of Archives of Internal Medicine, the authors of a Harvard/Stanford EHR study reported that “EHRs were not associated with better quality ambulatory care.” For example, their results indicated that, for one of the quality indicators studied (statin prescribing to patients with hypercholesterolemia), “visits to practices using EHRs had significantly worse quality.” A study of the relationship between EMR usage and diabetes care quality published in the May/June 2007 issue of Annals of Family Medicine found that practices not using an EHR were more likely to meet guidelines than those using an EHR.

So, if EHR software doesn’t really work well, why is it that so many of us are buying it? Th e answer is simply that EHR companies are good at selling, and that—combined with the misplaced market hype that EHRs are the solution to our healthcare crisis—has been enough to cajole many physicians to quickly adopt a solution that isn’t affordable, usable, or proven. Many vendors tout CCHIT (Certification Commission for Healthcare Information Technology) certification as the answer to these issues. Ironically, it may be CCHIT that is causing much of the problems.

Secret #9: (A CCHIT-certified product, by definition, is often more expensive and less usable than non-certified products.)

Th e theory of a standard certifi cation process makes a lot of sense. CCHIT certification had the potential to markedly improve the industry and speed EHR adoption by requiring interoperability and reasonable functionality. Instead, CCHIT has allowed overpriced vendors to hide their poor usability behind the guise of being a “certified solution.” Alas, when one examines the certification requirements, it is evident that the very nature of this certification actually increases product cost, discourages EHR technology advancement, and—most concerning—worsens usability.

CCHIT certification is unjustifiably expensive ($28,000 to apply, then $4,800 annually), and this expense is most certainly passed on to the users. Whereas overpriced EHR companies can absorb this cost easily, requiring such a large application fee makes it difficult for reasonably priced vendors to compete and may prevent a small start-up company, which might have the ultimate solution that does actually improve care and efficiency, from ever entering the fray.

Because CCHIT certification has hundreds and hundreds of specific criteria defining how an EHR must work, and since every one of these criteria is required for certification, a CCHIT-certified EHR ends up being bogged down by all the required features. Simply put, the bells and whistles mandated by CCHIT certification result in programs so complex with menus, buttons, and options, they make Microsoft Word look simple. Some examples of their onerous requirements include criteria #71a, which mandates the EHR be capable of recording comments by the patient or patient’s representative regarding the veracity of information in the patient record. Sure, it may be good to have this ability, but should it be required?

Similarly, criteria #238 requires an EHR to be able to display medical eligibility obtained from a patient’s insurance carrier. Again, potentially a nice feature for some users, but must every EHR have this, along with the associated complexity, cost, and loss of valuable window real estate? Multiply this requirement a few hundred times, and you have an unusable and expensive product. (Okay, since this secret might land me in hot water, I should disclose that my EHR isn’t CCHIT-certified, and while I may be forced to become certified to continue to compete with other EHRs, I have avoided it thus far for the reasons noted above.)

With the myriad of EHR companies hawking their wares, how can you get through the background noise of paid-off experts, certification nonsense, and glossy marketing campaigns?

Secret #10: (There are alternate ways to determine if an EHR, and the company selling you the product, will work for you.)

Thankfully, there are a number of less-biased forums where compensated and non-compensated users can freely voice their opinions on the software they’ve purchased, as well as the company selling it. The AAFP’s (American Academy of Family Physicians) Center for Health IT has a wealth of information, including a rating system scored by actual physician users. And although the AAFP does have some partnerships with various vendors and accepts advertising dollars, it is one of the more objective places to compare EHRs. The AAFP also has an e-mail listserv for AAFP members that provides a daily Electronic Medical Record Digest, where anybody can comment on their experiences, opinions, and problems.

Another place to find uncensored information is the online board, where users, vendors, and experts voice their frank opinions on the industry and all it encompasses. A relatively new and refreshing concept called the Ideal Micropractice also provides a forum that promotes open and uncensored discussion on running an affordable, high-quality medical practice. Among other things, actual EHR usability and pricing is frequently addressed.

Finally, a number of more progressive venues are beginning to arrange “document challenges” where various EHRs can run through a standardized patient, thus demonstrating how each deals with the same patient data. The Medical Records Institute is one such group pushing this competition. Although this is a promising development because it allows a more objective comparison of EHR software, it still is not optimal, since a significant payment from EHR vendors is required to participate.

Today’s EHR industry remains a sea of unrealized dreams. Although it seems obvious that adopting technology in your practice should improve efficiency and decrease costs, unscrupulous marketing campaigns, unabashed corporate greed, and pseudo-public certification have all played a role in obscuring our ability to separate the wheat from the chaff . Until we cease to accept the party line and choose EHR technology in the same way we pick other technology—on usability and price—many of us will end up paying money we can’t afford for products that actually impair our practice. The solution, as it is in most industries, is understanding the deceptive marketing techniques, demanding transparent pricing, and encouraging head-to-head EHR competition. The results are predictable: decreasing EHR prices and an overhaul of overly complicated EHR designs, the secrets that haunt today’s EHR companies the most.

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of Electronic Health Record (EHR) software. He also is the founder and of president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI