Simple and Effective EMRs will Solve So Many Problems

I just read Ryan Rick’s guest post on Phoenix, Arizona EHR Uninstalls and I remembered a New York City Health Department’s project called Primary Care Information Project (PCIP) headed by Dr. Farzad Mostashari. I see big problems for Dr. Mostashari’s project. I predict many uninstalls and ultimately a low successful implementation rate. They have good intentions but are making classic mistakes which will ultimately prove to be their undoing. I hope what they are doing will work (because I am a big fan of EMRs), but let me outline a couple of critical weaknesses in their plan and then we will see how things work out for them over time. I think all “top down” EMR implementation organizations will take note of this experiment.

I think Dr. Mostashari has bought into the notion that implementation has to be daunting and hard. “Our experience here is that it’s just hard,“ Dr. Mostarshari said. He thinks like Dr. Middleton, “A crucial bridge to success, according to experts, will be how local organizations help doctors in small offices adopt and use electronic records. The new legislation calls for creation of “regional health IT extension centers”. In a letter to the White House and Congress last month, Dr. Blackford Middleton, chairman of the Center for Information Technology Leadership, a research arm of Partners Healthcare in Boston, and 50 other experts emphasized the importance of these centers and pointed to the Primary Care Information Project in New York City as a model.” — Steve Lohr, How to Make Electronic Medical Records a Reality, New York Times, March 1, 2009.

Implementation is daunting and hard if you pick systems which are NOT simple, NOT easy to install, NOT easy to learn, and NOT easy to use. PCIP in New York City is using eClinicalWorks which has a good reputation, but I am NOT sure it is simple, easy to install, easy to learn and easy to use. If eClinicalWorks had all the “simple and easy” characteristics, then I don’t see why the implementation would be so difficult and daunting.

Dr. Mostarshari is also moving very aggressively and fast. Not a good idea in my opinion! He is rolling things out to the whole system before seeing what works and what does not work. “The city Health Department’s Primary Care Information Project (PCIP) has already converted over 1,300 physicians and 226 medical practices to EHRs”. Record Recovery, Center for an Urban Future, page 5, June 2009. I think the project is only a couple years old.

Ryan Ricks, of XLEMR, makes a series of suggestions in his post which I believe are extremely important. “It seems that Arizona physicians are scrambing to remove unusable systems due to poor selection or botched implementations.”. “Physicians need to be careful and not rush into a decision they may regret.”. “Physicians should focus on their needs … and select the simplest system that fulfills their requirements”. “Simple systems are easy to install, easy to learn, and easy to use.” “Ease of use is critical; complex and difficult systems can lead to spiraling maintenance and training costs, and may ultimately be discarded”. “They should take their time to find a simple, user friendly system that meets their needs.” — Ryan Ricks, XLEMR Update Newsletter, July 2009, Mr. Ricks makes some excellent points. Water flows downhill very nicely, but it takes a lot of energy to pump it to the top of the mountain!

It is my feeling that implementations would be less daunting and more successful if the EMR systems were less complex, easier to install, easier to use and easier to learn. Doctors are smart people who can learn to do stuff without handholding and constant supervision and oversight. The fact that the New York City PCIP Project needs all this hard work and all this effort and all this money makes me suspect that they have made major mistake in choosing an EMR system that is too complex, too hard to learn and too hard to use. Their second mistake is moving very rapidly to roll it out to the whole system before removing the bugs (the bug may be eClinicalWorks).

This top down approach is doomed to fail. Doctors must be able to choose the systems which works for them. If you have to ram it down our throats, it will be regurgitated at some point when we just get fed up. This happened in Pheonix Arizona, is going to happen in New York City and, if we are not careful, may happen in the whole country if things are not managed in a smarter manner. This is also a warning to Hospital Systems which are working in a similar “top down” manner to provide EMRs to their employed physicians and their private physicians (via the 85% rebate model). We don’t need Regional Health IT Extension Centers and we don’t need large organizations forcing us to use THEIR preferred EMR. We need to be using EMRs which are easy to install, easy to use and easy to learn! We need to identify those EMRs and promote them aggressively.

About the author


Dr. Jeff


  • An effective EHR that is easy to use, easy to install, easy to learn and low cost without mind boggling maintenance costs? There is no such animal.

  • There are over 400 EMRs!

    I have seen at least two that are easy to use, easy to install and easy to learn!

    I have looked at over 15 EMRs and so far I have found two, but you have to know where to look and how to find them!

  • Bobby B. – which two? 🙂

    Clearly, there’s need for a “Quicken/Quickbooks” of EMR systems.

    Dr. Jeff – your post got me to thinking about interoperability (everyone will *not* choose the same EMR/EHR system). Would love to hear your thoughts on interoperability. Perhaps a comment here?

  • MIke, check out SOAPware and SRSsoft.

    XLEMR uses Excel as their EMR platform. You may want to check this out as well.

  • Hey Mike,
    This is Dr. Jeff from
    I have lots of thoughts on interoperability.
    Maybe I could put your post on my site as a guest post and I can do the same on your site.
    Basically, I think this interoperability thing is “much to do about nothing”. We can use CCD and CCR to accomplish everything we need to accomplish with interoperability.
    If you think about it, only certain data needs to be shared and this can be done with CCR. You can use CCD to share text and reports. If you share the Patient’s Summary Information (Allergies, Meds, Past Medical History, etc) and you share their consultation and hospital reports, you have shared all you need to share.
    Mike are you interested in doing a conversation on our blogs about this?

  • Also makes you an interesting acquisition target Daniel by Intuit if you integrate with Quickbooks.

  • From a billing perspective, eCW is a very difficult system for a common medical biller to learn how to use efficiently. Many practices that implement this EMR loose a tremendous amount of revenue. Physicians are sold on the idea that it is so simple to use that they will be able to handle their own billing. This is not true at all. There are far more efficient EMRs for billing than eCW.

  • Apparently, the PCIP program referenced above has been declared a success with only 1% of providers reverting back to paper – see:

    It is ludicrous to utilize the number of providers that did not return to paper as a measure of success. Who would return to paper after being introduced to EMR’s (and penalties for failure to adopt). In the case eClinicalWorks ( used by the PCIP providers), user, I know how extremely difficult the exit plan out of eCW is, meaning it is extremely disruptive and expensive.

  • Apparently, the PCIP program referenced above has been declared a success with only 1% of providers reverting back to paper – see:

    I am not convinced. To Mr. Singh, who authored the above report, it is ludicrous to utilize the number of providers that did not return to paper as a measure of success. Who would return to paper after being introduced to an EMR (and the government payor penalties for failure to adopt)? It is important to note that, in the case eClinicalWorks (used by the PCIP providers), switching to different EMR’s is almost as unlikely. Why? It is very hard. As a long time user, I know how extremely difficult the exit plan out of eCW is, meaning it is extremely disruptive and expensive. Obviously, eCW doesn’t benefit from making it easy. Everyone wants EMR implementation to work. Be sceptical of those that declare “mission accomplished.”

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