EHR Transition: Take Two
July 9, 2019 | Frontline Stories
In 2017, Susanne Madden sat down with Dr. George Rogu of RBK Pediatrics to discuss how he and his team, integrated different software applications (i.e., EMR, Practice Management, Scheduling, et al.) into his practice. Watch the 2017 interview here: www.verdenviewpoint.com
During the interview, Dr. Rogu demonstrated the functionality of each software and how each application helped the practice be more effective and efficient. Moreover, he emphasized how each software application was configured to operate seamlessly with each other.
Dr. Rogu also shared with Susanne that an all-inclusive software solution (i.e., one vendor that offers the EMR and Practice Management system) was not a good fit for their practice. Although Dr. Rogu acknowledged the challenges of working with multiple vendors, ultimately, he was confident that a hybrid model was the best option for his medical practice.
Shortly after the interview in 2017 with Verden’s ViewPoint, Dr. Rogu received a call that would change everything. We recently caught up with Dr. Rogu to get an update and see what had changed since the 2017 interview.
Brandon B: Dr. Rogu, thank you for taking the time to have a chat with us again.
Dr. Rogu: Always happy to chat with you, Brandon.
Brandon B: In 2017, Susanne Madden and you sat down for Verden’s ViewPoint technology issue to get a glimpse of your practice’s technology set up. I’d like to do a quick recap and briefly revisit the interview. Can you talk about the EMR and practice management system you had and how all the pieces came together?
George Rogu: We started with a practice management system in 1996. Then, in 2008 EHR systems were in vogue. Back then, there weren’t any all-inclusive computer systems. No one had it. So we found an EHR that was relatively good and interfaced well with our practice management system. Then we implemented a practice portal that integrated with our EHR system.
Brandon B: Was the portal a different vendor than the EHR company?
George Rogu: Third party, yes. And then we had a physician scheduler system that was integrated with the practice management system.
Brandon B: Sounds like you had a lot of moving parts. What were some of the challenges of dealing with multiple vendors?
George Rogu: One of the challenges is that only a few people know how everything works. Then if it breaks, nobody knows what happens, and vendors always blame somebody else. However, our vendors were outstanding. They always tried to resolve our problems.
Brandon B: You were a big proponent of your hybrid approach to technology. What were some of the things that led you to believe that this was the way to go for your practice?
George Rogu: Because it worked. I keep saying, if it works, do not change it. Why would I change my practice management if it’s worked since ’96 perfectly? As I said in the interview with Susanne, I am a big believer that if your system works, do not change it. I had a hybrid system where one company had the EHR, another company had the practice management, and the interface worked. 98% of the time, it worked well.
Brandon B: Some could argue that an all-inclusive system would work even better because everything is in under one umbrella, as opposed to working with multiple vendors.
George Rogu: I agree with that. If you’re starting out, an all-inclusive would probably be the way to go. However, we were not just starting. We were adding on. It was like a house. You bought a home, you built, and then you built it more, and so on.
Brandon B: Let’s turn the corner. About two years ago, the hybrid system — or as you put it, the house that you built — was turned upside down. Tell us about what happened?
George Rogu: The way I look at the industry changes for technology companies (i.e., EHRs), in general, is just like the private practice industry. You have the small, solo private practice that cannot keep up with all the transitions, and the regulations, and all the new things and then they get taken over by a big hospital system. This is what happened with our EHR company. Our EHR vendor was a small private shop that made a reliable product. However, it got bought by Athena, a prominent EHR company.
Brandon B: In the interview with Susanne, you specifically addressed how a change in your technology would cause significant disruption, not only to the practice and the employees but patient care would suffer as well. Tell me about what went through your mind. How did you approach this significant disruption?
George Rogu: Moving to Athena meant we had to outsource billing entirely because Athena doesn’t sell you an EHR. They sell you a billing service, and they let you borrow their EHR. So, we did not want to do that.
I knew of an EHR that interfaced with our practice management system. Since I was the hybrid guy, I said, okay, we’re just going to replace the EHR and connect it with the practice management system. It shouldn’t be that big of a deal. The change will only disrupt the doctors and not the staff. I was confident that was the way we were going to go.
Brandon B: You planned to take this other EHR (not Athena, but another vendor) and attach it to the practice management system which would allow you exchange a piece of the puzzle as opposed to replacing everything?
George Rogu: Correct, but that didn’t happen.
Brandon B: Sounds like it was a great idea. Why were you not able to make that happen?
George Rogu: I found out that our vendors were phasing out the hybrid model as we knew it. EHR and practice management software companies are moving away from hybrid models and focusing on all-inclusive solutions. My understanding is that this is an industry-wide shift. It makes sense. There is a significant upside to managing the entire user experience, and I’m sure it’s less expensive than maintaining hybrid models.
Brandon B: Did you end up evaluating Athena even though you weren’t fond of their business model?
George Rogu: I gave it a chance, an honest try. I looked at it, and after the demo, I said, “This is so complicated it’ll kill my productivity. I cannot figure out how to order a simple rapid strep; how am I going to do anything more than that?” I just gave up on it.
Brandon B: Was it the interface, the functionality, or something else you didn’t like?
George Rogu: Doctors should be able to open the application and have it work. They should not have to figure it out. I’m pretty good at figuring stuff out, and I couldn’t even start. I couldn’t find the beginning. That was the reason we didn’t like it. It wasn’t intuitive enough.
Brandon B: Do you think the difficulty you experienced navigating the application had to with your practice’s culture and being accustomed to the old EHR, or was it inherent in the design of the system?
George Rogu: No, no. It’s the culture of EHR companies in general. You see this in the hospital. Everything is made for internal medicine. Also, they think that pediatrics is just like treating a little adult, so they try to squeeze pediatrics into a template that’s built for adult medicine. Athena is for adult medicine. It doesn’t work for pediatrics. However, that is what a lot of these prominent vendors do. They say, “Okay, it’s just an HPI. It’s just a patient history. We’ll throw in some ear infections and some strep throat templates and make it pediatrics.” That’s not it. PCC and OP just do pediatrics. There’s a difference between a hospital that has a pediatrics department and a dedicated children’s hospital — OP and PCC are like a children’s hospital.
Brandon B: You mentioned PCC and OP. Tell me about your experience with these two pediatric-centric EHR/PM systems.
George Rogu: I needed to develop a clinically integrated network (CIN) out in Long Island, which we did. That meant I needed a system that was able to be connected with regional extension centers. I also needed a product that had a large footprint in our area, and Office Practicum did. On Long Island, there was only one practice that used PCC’s EHR. Half of our clinically integrated system practices have Office Practicum; which simplified the data aggregation process that is critical to the CIN.
Brandon B: EHR companies like OP and PCC have an excellent reputation. They are also pediatric-centric which makes them appealing to the pediatric community, naturally. However, they are small companies when you compare them to a company like Epic, for example.
George Rogu: We also looked at Epic. As you know, there are subsidies opportunities from hospitals. Choosing Epic would probably have been cheaper upfront, but you know what? That was going to be another problem in the future.
Brandon B: What do you mean?
George Rogu: It can be a problem down the road because the hospitals subsidize the software for just a few years. Those funds reduce the upfront cost, but after several years, you’re on your own, and the ticket on that was astronomical.
Brandon B: What you are saying is, just because there’s some initial financial incentive, it doesn’t mean it is a good long term strategy.
George Rogu: If you want to stay in private practice, you have to invest money into your private practice. If you don’t have money to put into your practice and you’re going to have to be subsidized, then you shouldn’t be in private practice, you know? Simple as that.
Brandon B: Any other long term considerations physicians ought to consider when looking at Epic?
George Rogu: I think many people get trapped with these types of deals. For example, they sign up for a subsidy from a hospital to use Epic. The practice data goes into the hospital’s database platform, and as time goes on, the practice is stuck because they can’t pull out the data. And then they have no other option but to sell out to the hospitals.
Brandon B: If the cost of the EHR should not be the priority, then what should be important when considering an EHR?
George Rogu: You have to pick software solutions that are good for your specialty; that is simple and intuitive. You also have to touch it; you have to look at it. You can’t just make a decision based on what somebody else said. They could be wrong. They’re giving you bias, their bias. The software has to feel good.
Brandon B: What about the clinical staff? Does it have to feel good for them too or only the physicians’ opinions matter?
George Rogu: It has to be suitable for the staff and the physicians, because, if whatever you do in the system puts a roadblock for the team, eventually that roadblock is going to block the physicians as well. It’s going to slow things down, so it has to be moldable, adaptable, changeable, and easy to use.
Brandon B: I want to go back to when you found out about the impending transition. What was the reaction of your physicians and staff when you told them the news?
George Rogu: Well, at first they were shocked. They couldn’t believe it. Then they were depressed. Then they accepted it, and they moved on. It was like the grieving process, you know.
Brandon B: When making significant transitions, experts recommend designating a cheerleader, a project champion so to speak. Did you have someone in that role and if so, what was their approach to get everyone on board?
George Rogu: I guess you can say I assumed that role. I tried to be the physician leader in the organization, and every day I’d send out a message to encourage the physicians and staff: “We’re doing great!”
Brandon B: So, not only were you the designated project champion and informing staff about what is going to happen, but you also embraced a leadership role to keep motivation and morale high, because you knew it was going to be a difficult transition.
George Rogu: Correct. RBK [Pediatrics] was like the Titanic. We were going to hit an iceberg. So we did everything in our power to steer away from that iceberg. All those positive messages and words of encouragement helped people get through the transition.
Brandon B: In my experience, one of the biggest challenges with software transitions in particular is dealing with and managing generational gaps. Did you have issues?
George Rogu: Most of the younger generation, they had no problems. The mid-career people, found it a bit more challenging, but eventually they came through it.
Brandon B: What would you say was the breakthrough?
George Rogu: As long as you believed in it, it worked. If you were one of those naysayers, those negative Nancy kind of people, nothing that you say would work. I had to try to change the culture into a positive culture, not, “Oh my God, what are they doing to us? What are we going to do?” That doesn’t help anybody. It just makes for a negative culture, and you’re not going to succeed.
Brandon B: You mentioned negative Nancy. I want to explore that a bit. Did you have a complete buy-in, or was there some resistance?
George Rogu: The interesting thing is that we had complete buy-in from the clinical staff. The leadership, the physicians, that was difficult.
Brandon B: Why do you think the partners and physicians had issues with the transition?
George Rogu: I think what happened with them is they got numb to the whole thing because they couldn’t do anything about it. It’s like learned helplessness, so they didn’t do anything.
Brandon B: How did you handle it?
George Rogu: Those guys needed a lot of hand-holding and encouragement, “Come on! You can do it! It’s going to be fine. It’s just another EHR. It’s not that big of a deal. It’s easier to transition from an EHR to an EHR than it was from paper to EHR.”
Once I got through to them, then it was a little bit easier. If the leadership is not positive about the project and they shut down, then there’s a trickle-down effect to the nursing staff, to the secretarial staff, to the administrative staff. So, getting the partners and physicians on board was key.
Brandon B: You mentioned earlier that the younger generation adapted quickly. Did you rely on some of the younger physicians that embraced the new transition to help you with moving others along?
George Rogu: I did have some help from the younger staff. I divvied out jobs and projects to different people in the organization. “You’re going to be in charge of this piece. You’re going to be in charge of templates. You’re going to be in charge of medications.” I also had to report to Office Practicum on what we completed.
Brandon B: It sounds like you had a robust project management system with deliverables and task assignments. Was this vendor driven, or was this a practice driven initiative?
George Rogu: It started as a vendor-led initiative. They provided spreadsheets with tasks that had to be accomplished by X date. That gave me the homework list that I had to assign to the team. I guess the vendors were better at figuring this out. We just realized how to implement what they already thought up at the practice level.
Brandon B: What you have now is virtually the opposite of what you had before. What are your thoughts on having an all-inclusive software solution (i.e., EHR, PM, Patient Portal)?
George Rogu: If I were to start from paper charts today, I would do an all-inclusive cloud model. It’s much easier — no servers in the office, no security risks and things like that.
Brandon B: So you’ve changed your mind. That’s undoubtedly a big pivot from two years ago.
George Rogu: Yes. But again, if your operations are working, don’t change it. Change it only when something makes you change. Just ride it out as long as you can ride it out. I think in five years, technology is going to be even easier, so maybe in five years, change will be more straightforward. Who knows?
Brandon B: Is there anything else you’d like to add as a final thought?
George Rogu: Yes, I do. The old EHR was good for the time. Doctors were able to write their exam notes, push it to the billing, and the bills went out. Everything was hunky dory, the work plans, the ordering of vaccines, everything. What they didn’t do well, and I think this was their downfall, is that they did not prepare for the future, which is the population health side.
EHRs contain so much data, but if you can’t pull it out, it’s useless to you. It’s a glorified typewriter. That’s what I like about our EHR, it’s like one monster spreadsheet. Every little box, every small cell, means something. You can then extract the data, and you can share it with all these different entities.
For example, our clinical dashboard took our Excel spreadsheets and put them into pretty charts, and merged it with other EHRs. Unfortunately, they did not continue to develop; whereas PCC and Office Practicum, they do develop, and they move on for the future, and they’re adjusting. That’s why they’re still around.
Brandon B: You mentioned earlier that small vendors are vulnerable to more prominent companies. One could argue that Office Practicum and PCC are relatively small when you compare them to Epic or Athena, but what you’re suggesting is that companies like OP and PCC continuing to push, think about the future, and adapt to the changes.
George Rogu: I believe so. You know, I look at it this way; They’re big enough to matter in the marketplace, but they’re small enough to be able to change.