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A Day at the Office: The MACRA-sized Headache—Part 2

Lundy, Douglas W. MD, MBA

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Clinical Orthopaedics and Related Research: October 2018 - Volume 476 - Issue 10 - p 1931-1932
doi: 10.1097/CORR.0000000000000453
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In my last column, I shared the steps my practice took in order to qualify for Medicare’s Quality Payment Program, including the acquisition of a new electronic medical records (EMR) system to comply with a host of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requirements [1]. While this hardly seems an enticing opening to a column meant to be good reading, those who have ever been in practice—or tried to change EMRs—know how disruptive this can be, and how challenging major changes to a staff’s workflow are for a practice. Changing a practice’s EMR is certainly at the top of the list of issues that can disrupt the practice of medicine. It was not an easy decision.

We asked ourselves a series of questions: Is the expense and hassle of adopting a new EMR worth the cost of the MACRA penalty? Is the trouble of manually collecting and submitting performance measures tolerable, or should we adopt an EMR that can handle this task for us? What if the private payers decide to adopt this new system and we are not ready? How far behind would we be?

Ultimately, we decided to purchase and implement a new EMR system. In this column, I will detail how we implemented our new EMR system, what we did well, and how we could have better served our practice.

The Decision

After our group’s physician Board of Directors agreed to start our MACRA adventure in the Merit-based Incentive Payment System (MIPS) pathway, we researched the capabilities of our existing EMR and determined that the current system was inadequate to meet our needs. As we understood our options under the MIPS pathway, we could complete the Performance Measures documentation and submit the data ourselves, contract with a third-party vendor to do this task for us, or switch to an EMR that would handle the whole process.

Doing the work ourselves was not an option since we didn’t have the workforce to submit all of our documentation on time, and we did not have the finances to go on a hiring spree. Third-party vendors charged high fees that would have minimized or offset any financial benefits gained from complying with MACRA. A new EMR system, we reasoned, would perform the required daily functions, report our data to the Centers for Medicare & Medicaid Services, and hopefully gain some practice efficiencies to justify the cost and hassle associated with switching systems. Two overwhelming issues dominated the discussion: The capability of the system to do what we needed and the expense that the new system would add to our practice. We did not have a set budget for the new EMR, but the overall cost needed to be revenue positive after the benefits of MACRA were realized. We believed a fully integrated system with parallel incentives (the EMR company does well when we do well) should be a positive lift for the practice’s finances.

What Did We Do Well?

Our group’s leadership team considered the various EMR options and visited with trusted colleagues who were using those platforms. We did not want to have to trust vendors’ sales pitches; instead, we developed critical and well-researched questions we required vendors to answer in clear, specific terms. We hosted multiple demonstrations of the products with affected stakeholders (clinical staff, revenue cycle, appointment schedulers, physicians, physical therapists) and actively sought their feedback throughout the process. We knew that a new EMR system would affect the entire office, and the opinions of the staff were very important to us. Critically, we analyzed the effect of the new EMR on existing third-party applications and the associated cost to get these products to work in the new environment. These third-party applications include all of the “add-ons” you have to make the practice run better such as financial and accounting programs, patient-reported outcomes tools, online scheduling application, etc. This was a tedious process that required us to coordinate the interoperability of these familiar systems with the unknown receptiveness of the new EMR. Our leadership team anticipated EMR vendors selling us on the promise that their product would be compatible with every system—but we knew that wouldn’t be the case. For this reason, we sought advice from the experience of current users to ensure the programs would work together. We empowered our own IT staff as well as hiring outside consultants to ensure that the products were compatible in the live environment.

Our private practice employs more than 100 orthopaedic surgeons and physiatrists, so we were large enough to hire a project manager who led the implementation process. We developed a command center so that there was a central hub for communication among our staff before the new EMR system went live. We had multiple mock go-live events to determine where the implementation could potentially fail or not perform as smoothly as we expected. Although I do see the value in MACRA, do not underestimate the impact that participation in MIPS has on office workflows. While some physicians will enthusiastically welcome the change, others will vehemently oppose it. We trained the new workflow to our staff rather than trying to force the new EMR into our existing workflows. I know peers who have done the opposite with poor results.

What Could We Have Done Better?

Admittedly, I have a few physicians in my group who are still angry at the new EMR processes, and if asked, they would share their dissatisfaction about the new system and the transition in plain terms. To be fair, the number of these dissatisfied physicians is decreasing with time, and a substantial number see the value in the new system and appreciate the new efficiencies and opportunities. Unfortunately for us as leaders, the angry naysayers are far more vocal than their satisfied partners, which is something all private practicing orthopaedic surgeons in leadership positions should anticipate. We communicated the rationale and benefits of the conversion extensively throughout the enterprise; we were convinced that we had overcommunicated. In retrospect, however, there were pockets (some large) of personnel with whom we failed to adequately communicate. Achieving and maintaining physician engagement in EMR conversion is a monumental task, and I would grade our success in this metric as “average”. This was not for a lack of effort on our part, and we made communication our primary objective. But orthopaedic surgeons are busy people, making it sometimes challenging to engage. Still, the responsibility is on the leader, and an effective leader must successfully convey the message.

To some degree, MACRA has placed private practice leaders in a “no-win” scenario. To comply with the law requires workflow disruptions and changes to the way physicians and staff use technology that not all will be happy with. On the other hand, the leader will be criticized for the loss in revenue if the practice decides not to comply. If I had to do it again, I would still execute our chosen plan, but I would try to emphasize more effectively its benefits, rationale, and process to my group.


1. Lundy DW. A Day at the Office: The MACRA-sized headache—Part 1. Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000000418.
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