The Cure for the Fatally Flawed EMR Software Model

Jonathan Bush is cofounder and CEO of athenahealth Inc., in Watertown, Mass. Contact him at jbush@athenahealth.com

The EMR horse is out of the stable and galloping full speed ahead, and it could race right over the industry if we don’t take a hard look at the current EMR software model presently being offered to providers. With the departure of Dr. David Brailer as National Coordinator for Health Information Technology in May, our industry finds itself at a critical juncture. The current software-based EMR solution being touted does not address the massive process breakdown that exists in healthcare and will ultimately prevent any widespread adoption of clinical solutions by physicians.

While providers are starting to feel pressure to adopt some kind of EMR solution as new performance-based reimbursement programs emerge, still they struggle with increasing concerns about the impact EMR implementation will have on their financial viability. A few very large physician groups have emerged as the super-successful poster children for software-based EMRs, often with the benefit of intensive hand-holding from EMR vendors hoping to use them as success stories. Others have experienced the frustration of very long implementation cycles, high up-front costs and elusive tangible benefits.

As the bulk of the market watches these dramas play out, waiting for standards and best-practice approaches to emerge, the time is now or never to examine the current packaged software approach to EMR, make sure we understand why the market is heading down the current path, and dare to ask if there might not be other, less toilsome routes to achieving the benefits of data-driven clinical workflows and accessible, accurate electronic
health information.

Follow the Money
A frequently successful strategy for understanding market conditions is to follow the money. As we look at the government initiatives and funding to establish regional health information organizations (RHIOs) and to drive adoption of national standards for EMRs, where is the money? Who is pushing for RHIOs and standards? Who is framing the debates and who will benefit?

Clearly, every major EMR software vendor stands to benefit in a world where everyone must have an EMR, and they are deeply invested in shaping the standards and perpetuating their approach to sustain business models, which are founded on selling packaged software at large or significant profit margins.

EMR software vendors need to take responsibility for delivering tangible and sustainable results for their software, which presents significant and inherent challenges. These are challenges the industry should be talking about today, but we are not because once again, solutions that deliver true ROI for both the provider and patient are not easily delivered using packaged software.
Given this status-quo ante, a question which has, not surprisingly, been absent from the current industry debate is: Will packaged software solve the EMR problem? The answer is no.

If Not Software, Then What?
Software alone is not suited to manage the enormous variability, paperwork and intensive human effort required to make an EMR system work effectively. The business of healthcare is broken; software, combined with intelligent processes and a service-oriented architecture, is the solution.

Clearly, every major EMR software vendor stands to benefit in a world where everyone must have an EMR, and they are deeply invested in shaping the standards.

We need to build an EMR model where the vendor is not paid for software; that would be free. They are paid for getting the grunt work done, and the more accurately, cheaply and efficiently they get it done, the more profit they make. This idea amounts to a radical new take on the pay-for-performance (P4P) craze we see emerging in healthcare.

This would be a model where doctors pay the EMR industry for results, not software and hardware. Instead of asking physicians to be at risk for outcomes and process all by themselves, the EMR industry would share risk with them, and be rewarded by them for limiting that risk with correct and timely data and repeatable best-practice process that they build into the clinical workflow.

The EMR industry has been working hard to develop software that will meet the unique needs of the thousands of small physician groups in the U.S. that most agree is the critical market segment for making the NHIN (national health information network) a reality. Small practices don’t have the financial bandwidth required for the traditional EMR software and hardware needed for implementation while also dealing with the continuous challenges of the billing and collections aspect of practice management.

Software vendors have gone to great lengths to develop exhaustive pick lists to click from, and wizards to guide the provider through the process of populating an EMR. Dozens of EMR vendors have wrought marvelously elegant approaches to streamline tasks and make data entry as natural a part of the patient-doctor experience as possible. In their efforts, they have missed the core driver of adoption; medical groups need EMR solutions that allow them to improve quality while also becoming profitable. Essential is a healthcare infrastructure that provides an automated service backbone that will ensure that doctors are fiscally fit, that insurers and government pay doctors, and there is motivation to adopt technology.

Knowledge and Service Are the Cures
A service-based, automated EMR solution that injects knowledge into a practice is what will correct the current EMR model in this country. This service-based EMR model would act as a proactive knowledge utility, providing updated payer coding and documentation requirements, technology, quality and P4P specific knowledge, and collections and billing services that would give doctors guaranteed financial and clinical performance. This kind of infrastructure would help physicians afford automated EMR solutions by providing core services and the scale to manage them, combined with aggregated system knowledge, which, in turn, will produce consistent and sustainable results for the provider.

The service-based EMR would create a network effect that would allow physicians to stay independent but still have all the benefits of being part of a sophisticated organization that can get sustainable results using an EMR solution. The model is self-sustaining, funded by getting physicians paid for the care they are delivering while reducing the overall operational expenses of their practice. Quality and efficiency will naturally follow.