Cookie Cutter vs. Customizable EMR

Honestly, this is one of my favorite discussions to have about an EMR system. The only hard part is that it’s an endless debate with no clear resolution. However, the choices that an EMR vendor makes in regards to their cookie cutter vs. customizable approach is really important.

For those who aren’t as familiar with the issue, the challenge lies mainly in out of the box utility vs. ongoing improvement.

The first part of that challenge is that most doctors think that when they spend their hard earned money on an EMR software, that it should be able to just work out of the box. I think many of the other software programs and other things we buy have created this culture of things just working. For example, it’s amazing how few things you have to do to setup a new computer when you buy it. The computer manufacturers have done a great job making it dead simple to get your computer and be using it shortly after pulling it out of the box.

Most people want this same type of thing to happen with an EMR. Sure, they realize that there will be some customization and entry of their clinic specific data. It’s understandable to have to create some users, add in your address and phone number and a few things like that. However, there’s this expectation that I should be able to just start using the system. Many are surprised when they start documenting their first patient to realize that there are no templates (or insert other EMR feature) available to them for that patient.

Of course, in the EMR vendors defense it’s a challenge to pre-load the information in a way that it just works out of the box. Certainly an EMR vendor could load it up with every template imaginable. However, then they’d hear the complaint that the pediatric doctor had no need for those GYN templates and what kind of silly EMR vendor would make that simple mistake. Of course the EMR vendor knows this fact, but how do you build a software that can take this into account. Much easier said than done.

Of course, some EMR vendors have approached these challenges by providing a real cookie cutter approach to EMR. The complaints then come that the EMR system isn’t customizable enough for the doctor. Of course, these are the same people that would have complained about all the customization they would have had to do if they were just given a really bare bones EMR software install.

The reality is that every practice is different and so it’s a major challenge for EMR vendors to balance these two competing interests.

At its core, the EMR software needs to be as setup as possible right out of the box. However, it also needs to provide as much customization as possible so that when the out of the box features aren’t right for a particular practice it can be changed to fit their needs. It’s a funny little balancing act that has more basis in art than science. However, when done right it makes a huge difference.

What types of things do you do or have you seen to solve these challenges?

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

10 Comments

  • John, I think you hit in on the nail when you wrote: “The reality is that every practice is different and so it’s a major challenge for EMR vendors to balance these two competing interests.”

    No two practices are the same and thus there is no “standard” on how someone does charting, records an encounter, or even writes a prescription!

    Thus, making it extremely difficult to offer a “cookie cutter” approach as you mentioned. I don’t think it is analogous to other software and devices like computers, phones, word processing software, etc. because those things are made for the general masses and not for a specific audience (health care providers).

    I think adoption will really make the biggest difference in standardization. When computers, cell phones, and other commonly used software/devices first came out, they were cumbersome and hard to figure out for users, but as more and more people started using them, they had to make them simple and easy to use thus creating a standard. Once more providers start using EHRs, we will see better approaches on the software side.

  • My computer’s browser has a “View > Customize Toolbar …” option which allows me to set things the way I want to view them. Likewise in my initial computer set-up. Following this logic, and EMR would only have one “template”, but allow the user to select or deselect from a menu of small checkbox items that together “tailor” the EMR to a degree. I’d be surprised if some EMRs don’t do this already.

  • David,
    I think that all of the EMR vendors do this type of thing. The challenge is finding the balance between a completely customizable experience and an out of the box friendly experience that limits how much customization you actually have to do to enjoy the software. Some do it better than others.

  • Sadly, the status of IT in healthcare is so far behind other sectors that the end users will accept substandard products. The vendors are slowly coming on board in response to pressure, but many have depended on a lucrative consulting/implementation business for years and have not had the motivation to create a “standard” set of configuration data. For example, I am all in favor of customization, but when a vendor ships a product that requires you to define all values for a Gender field, we are missing something critical. There is a standard set to start from (ISO 5218) and while some practices will have a need to add values such as “Male and Female,” “Male from Female,” and “Female from Male” at least the standard four options should be included with an EMR purchase. Even if the vendors wish to offer separate “Starter Packs” for the various segments (Family Practice, Assisted Living, Hospital, etc), some form of initial configuration should always be negotiated into the purchase agreement – without the need for hundreds of hours of contract time. We need those hours to address things that truly distinguish one practice from another.

    Medicine is both art and science.

  • Brett,
    The male/female example is a good one. Sure, it’s easy to add the options for it and easy for a provider to define, but why should they? That’s something that EMR vendors can reasonably have populated for a provider. Then, the EMR provider can make it possible to edit those fields if a doctor feels like it should be documented a little bit different.

  • The choice we really face is between products that totally destroy workflow and products that mostly destroy workflow. There is no advantage to customizing lousy software.

  • The EMR vendors need to get their act together and offer templates with user-friendly, pick & choose options. This should be the same for the software. One thing many people may be forgetting is the motivation for why the software is built the way it is now. The cost for the software is a drop in the bucket compared to the huge profits the EMR vendors earn over the lifetime of the software for implementation costs, maintenance, upgrades, licenses, etc.

    So, if EMR vendors delivered their software as easy to install and customize they’d be giving up their largest revenue streams.

  • I think there’s an even larger revenue stream available to an EMR vendor who makes a usable software and just collects the small monthly fee for their software. Much better than angering your customers with crappy software that requires high priced consulting.

  • According to one vendor’s web site they can get providers up and running in five minutes with a “free” EHR (paid for by putting pharma ads on each screen).

    They also claim to be the fastest growing and largest “free” EHR in the country. (Epic with 1 in 4 docs is clearly the largest but not in the small group market).

    Oh and you get a nice check from the government as well.

  • Asuzus,
    I can guess the company you’re talking about is Practice Fusion.

    I’ve written about them when they were just starting and you might read what I wrote then: https://www.healthcareittoday.com/2008/07/14/when-emr-software-became-freeor-does-it-cost/ Some things have changed, but it’s worth considering.

    I think that post puts in perspective the 5 minute thing. I also talk about that type of install: https://www.healthcareittoday.com/2009/01/25/5-minute-emr-install/

    I’m going to be trying out the 5 minute install myself in the next week before I attend the Practice Fusion user group meeting. So, watch for a post about my experience. It will be fun to start the clock and see what happens.

    I don’t think it’s quite the right characterization that they pay for the “Free EHR” with pharma ads on each screen. That’s one possible revenue stream they’ll use, but they have a few others like selling aggregate data to Pharma or things like that. They have a page somewhere on their site that describes all the ways they make money. I’m just too lazy to find it right now.

    I’ve never seen them claim to be the largest. Just the fastest growing one. Of course, that’s a bit of marketing spin since it’s easy to have a bunch of doctors sign up for free. Would be interesting to know how many use it for every patient they see. I guess I might learn more about this next week at their user group meeting. I’ll be sure to ask.

    Full Disclosure: Practice Fusion is an advertiser on this site which is why I know so much. Plus, they were one of the first (if not the first) to do the Free EMR model and I found it intriguing then and now.

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