Emergency department physicians who use "best of breed" (BoB) electronic health record systems rated their experience 59% higher than did ED physicians who have EHRs that are part of enterprise systems, a new KLAS Research report reveals. But many healthcare organizations still impose enterprise EHRs on their EDs because it's simpler to have a single integrated system.

The top-rated EHRs in the KLAS survey -- all BoB products -- were Wellsoft, Picis, T-System and Medhost. Epic, the top-selling enterprise system, was next in order behind the BoB leaders. Enterprise solutions from Cerner and Allscripts fell far below Epic, and Meditech came in dead last, with a 29% approval rating.

Documentation accuracy was reported to be greater in best-of-breed EHRs than in enterprise systems. BoB systems also outperformed enterprise products in their ability to improve patient care because of intuitive layouts that reduce order entry errors and physician prompts to ask patients more targeted questions and alert caregivers to adverse drug events.

[ Why specialists crave best of breed EHRs. Read EHRs Aren't Specialist-Friendly Enough. ]

Physicians rated Picis, T-System and Wellsoft highest in areas affecting patient safety, and Picis the highest for improving patient care. Clinicians especially appreciated Picis' customizable alerts, which help reduce "alert fatigue." Physicians wanted better clinical decision support features from all vendors.

Erik Burmedez, KLAS' research director and the report's author, told InformationWeek Healthcare that the BoB vendors came out ahead because they focused more on the specific needs of ED clinicians. "They're simply better able to meet the needs of the physicians in terms of workflow and all the modules that are physician-facing," including documentation, order entry and medication reconciliation, he said.

Based on his interviews with ED doctors, he added, "anything that takes you more than three clicks is too many" because of the extreme time pressure in the ED.

Sunny Sanyal, CEO of T-System, explained in an interview, "Generally, the best of breed solutions are fine tuned for the ED as an environment. In contrast, the enterprise solutions are generic solutions that use generic methodologies in their workflows, and they force fit the generic workflow into the specialized care setting."

The ED is a very intense, high-velocity environment, he pointed out. A physician is seeing five or six patients at a time, is constantly being interrupted and can't perform tasks sequentially, so he or she needs a specialized documentation approach. In the case of T-System, that includes a series of back slashes and circles on electronic screens much like the paper forms that many T-System customers use.

Two-thirds of BoB physician users said their systems provided them with most of the data they need to be effective in the ED, Bermudez said. That includes lab and imaging results and pharmacy orders. However, many doctors said it was difficult for them to send ED information to the inpatient EHR when patients were admitted.

Bermudez said that was less a failing of BoB EHRs than a reflection of enterprise vendors' reluctance to interface with them. "A lot of the enterprise vendors are less willing or less apt to step forward and work with the best of breed vendor. They tell the healthcare organization that they'd prefer if you went with Cerner, Epic or Meditech in the ED, and let's make it simpler for all of us and replace that best of breed solution."

Sanyal has encountered the same problem, especially with Epic. Organizations that adopt Epic, he said, want a "seamless flow of data," which they equate with a single enterprise system that includes the ED. Although evolving standards are making it easier to integrate disparate systems, he said, healthcare systems that use Epic "are not willing to listen to suggestions that they use a more tailored system in the ED, even if they lose money as a result. They acknowledge it may not be good for every department, but they say they have other needs."

Bermudez agrees. "Once Epic enters, it's all or nothing," he said, because organizations look at how a single integrated system can help them in the "big picture of accountable care." As for Meditech, which has the lowest-rated ED system, some hospitals insist that ED doctors use it, even if it slows them down, he noted.

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