For doctors, the pressure is on to computerize
From the January ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
Electronic medical record resources
Tips for considering an EMR
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This month marks the beginning of a new year for the eight physicians at Johnson County Internal Medicine Associates in Franklin, Ind. It is also the "go-live" debut of the group's new $100,000-plus electronic medical record (EMR) software system.
Johnson County is just one of many groups taking a new look at EMR software. As the federal government prepares to roll out new regulations dictating how health care information is processed and stored, the pressure is on physicians to invest in new software that will help them comply.
Some practices are deciding that the time is right to take the plunge. "With all the new confidentiality regulations coming up, we thought the writing was on the wall," explained Johnson County general internist G. Mitch Cornett, MD, who pushed for the EMR system.
While EMR vendors say there has never been a better time to buy, not everyone is convinced. Physicians remain leery about putting big money into technology that has been hyped for years. Most physicians concede that a shift to electronic clinical records is inevitable, but they remain sharply divided over whether now is the time to invest.
To see just how far EMR systems have come in the last few years—and whether they are ready for prime time—we talked to physicians who have jumped on the bandwagon and computerized their medical records. While some are convinced that now is the time to computerize your practice, critics are just as certain that it's not.
A push from new laws
While physicians are increasingly turning to tools like electronic billing programs and handheld computers, most still have not embraced computerized medical records. According to industry analysts, fewer than 5% of practicing physicians now use electronic clinical information systems.
Conventional wisdom says that figure will grow due to regulatory pressure. A big push may be coming from the Health Insurance Portability and Accountability Act (HIPAA), a complex law that will require physicians to protect the privacy and security of clinical information. (For more on HIPAA, see "New rules for computerized data: What will they mean for physicians?" in the December 2000 ACP-ASIM Observer.)
Even before the HIPAA regulations are finalized, some groups like Dr. Cornett's have decided to get a jump on HIPAA compliance. "With all the HIPAA regulations coming down, we figured there might be a mad rush for EMRs in a year or two," Dr. Cornett said.
By taking the plunge now, he added, the group hoped to get a better price before demand increases. They also figured that avoiding the rush would mean better service for training and installation.
But HIPAA wasn't his group's only concern, Dr. Cornett said. The Johnson County physicians also wanted to end the hassle of tracking more than 20,000 patient charts among eight physicians in a 5,000 square-foot space. The group's administrators estimate that the practice spends more than $70,000 in staff and physician time looking for charts each year. The new EMR system will help them eliminate that wasted time, they hope, and let the practice cut at least two staff positions.
Other groups say they're taking the EMR route to solve mounting problems not just with costs, but also documentation and liability. In San Angelo, Texas, the 50-plus physicians at the multispecialty group West Texas Medical Associates were shelling out $65,000 a month in medical record and transcription costs—a financial hemorrhage they wanted to stanch.
Since they installed an EMR system in 2000, those monthly costs have dropped to $30,000. In addition, said Ross M. Carmichael, FACP, a general internist with the group, the new system has helped him bring up his coding levels by 10% to 15%, meaning more revenue for the group.
The EMR also helped the practice solve another looming nightmare: the group's growing reliance on "dummy" charts. As paper charts piled up in transcription or were misfiled, physicians would start new pages for patient visits or refills. This system frustrated physicians, who were worried about liability and allegations of fraud and abuse.
For other groups, patient safety concerns tipped the scales. "When the physician puts in an order for a prothrombin test or a nuclear scan, does the test actually get done?" asked Judah Friedman, chief executive officer of the 17-physician South Broward Cardiology Consultants in Hollywood, Fla. The group installed an EMR system just two months ago.
"We've had a hard time keeping track of that with paper charts," Mr. Friedman continued. "We hope that the EMR's automatic flags will take care of the problem."
Still others say new technology addresses physicians' standard complaint: "I didn't go to med school to learn how to type." Within the last few years, EMR fans say, technology has begun to give physicians many more feasible data-entry options—including wireless applications and improved handwriting and voice recognition programs. (For more information, see "Tips for considering an EMR," online at www.acponline.org/journals/news/jan02/computerize.htm#tips.)
Ready for prime time?
Despite such glowing reports, many physicians have major reservations about EMR software. Some say it imposes unwanted uniformity on the way physicians practice, such as forcing everyone to conduct patient exams in a certain order. This could rub a lot of physicians the wrong way.
"EMRs can force a group to conform to a certain practice style that all the members may not agree with," said Mark E. Frisse, FACP, a medical informatics expert in St. Louis and chief medical officer of pharmacy benefits management company Express Scripts Inc. "Information systems often inappropriately amplify minor practice differences because of all the money and emotion committed to these systems."
In addition, some say that the EMR learning curve may still be too steep for most physicians. General internist Daniel C. Davis Jr., FACP, medical director of clinical informatics at Queens Medical Center in Honolulu, uses voice recognition with his EMR system. He said he creates notes much faster now than he used to by hand.
But Dr. Davis, who is also part of a four-physician primary care group, was quick to add that he spent between 50 and 100 hours over a three-month period to train the system to an acceptable level of accuracy. (That time included creating dictating shortcuts and learning how to correct transcribed text.) Advances in processor speeds mean that voice recognition software has improved, Dr. Davis said, but "most doctors in the general medicine setting still don't want to put in that kind of time."
Even without speech or handwriting recognition, critics say, doctors should expect to invest a significant amount of time. James D. Lakin, FACP, medical director of Fairview Health Services, an integrated delivery system in Bloomington, Minn., and member of an independent three-physician allergy practice within the system, said that he used to be a physician champion of EMRs, but he's "now a contrarian borne of experience." He claimed EMRs are still far from ready for most physicians, an opinion that grew from seeing different sectors of the Fairview system try to adopt them.
Implementation is still so tough, Dr. Lakin said, that many physicians watch their productivity plummet when they first go live. Moreover, he said, computer logic is still far from a physician's.
"I deeply resent those iterative pathways you have to click through," he said. "You take a very human experience—the subtleties and nuances of diagnosis in internal medicine—and force it through a cyber-sieve that takes the guts out of the clinical experience."
Dr. Lakin also offered this caveat: "An EMR is hideously intrusive in the doctor-patient relationship," he said. "One colleague likened it to a squalling infant in the exam room: Either you become preoccupied with it because you like it so much, or you're distracted by it because it's raising Cain."
His conclusion? "Right now, the EMR is a grossly oversold piece of software that fails to meet expectations in most clinical practice situations."
Time, patients and culture
EMR proponents loudly disagree and justify the time it takes physicians to get up to speed, pointing to other important dividends. Dr. Carmichael from West Texas Medical Associates, for instance, who types in patient information himself, admitted that his productivity dropped 15% during the first three months he used the system. Now, a year later, he said his patient load has returned to normal, but he "spends a little longer doing patient records than when I was just dictating notes."
He was quick to point out, however, that the extra time has produced some big payoffs in improved workflow. "When patients call and say, 'I need my little blue pill refilled,' we're able to pull their medications up in a matter of seconds, rather than starting a round of chart pulls and phone calls," he explained. "I spend a bit more time putting data in, but that saves much more time down the line."
As far as EMR systems imposing uniformity, some physicians say they actually welcomed the opportunity to standardize their practice. "Deciding how to design the electronic chart made the doctors define which elements should be included in every encounter," said South Broward Cardiology's Mr. Friedman. "It gave us the opportunity to examine in detail every single process, to see which steps made sense and what could be streamlined."
While South Broward's system is still too new to have a track record, Mr. Friedman said the group's physicians don't think the system will be an intrusion. "Our doctors already routinely dictate their notes in the exam room in front of patients, and for good reason," he said. "They want patients to point out if something is going into their record that isn't exact." He expects that level of patient interaction to increase with the new system.
Analysts point out that the public has grown increasingly accustomed to the presence of computers in all professional encounters. And Keith W. Michl, FACP, former Governor for the Vermont Chapter who has used an EMR in his solo practice in Dorset, Vt., since 1998, said he can count on one hand the number of patients he believes the EMR has cost him. Many more, he said, appreciate the system's advantages.
"Many of my patients spend winters in warmer climates and want a printout of all their medical records and prescriptions. Before they'd have to wait a week, but now I just print records out and hand them over."
Integration issues
When considering an EMR, doctors should weigh another big variable: the informatics plans of local hospitals. Are hospitals in your community installing clinical information systems, and does their software have ambulatory care components?
According to Barry R. Hieb, MD, research director at Gartner Inc., an information technology analysis company, only about 10% of hospitals in the country have invested in electronic clinical information systems. But sales of electronic systems to hospitals are rising 25% every year, driven in part by patient safety concerns, he said. And hospitals are increasingly insisting that vendors roll out compatible office-based components for their employed and affiliated physician practices.
Groups closely tied to one hospital system might do well to wait until they can "piggyback" onto their hospital's clinical information system. Honolulu's Dr. Davis, for instance, maintains an electronic record for his own patients in his private practice—but the other three physicians in his group do not. They are waiting until their medical center helps underwrite an EMR for its affiliated groups, a process that should start within the next two years. While the group will have to pay for its own software and licenses, the medical center will cover some hardware costs and provide support personnel.
However, that decision becomes complicated if you admit to several different hospitals; independent groups may then want to consider buying their own stand-alone EMR. Choosing to electronically integrate with only one hospital's system might align physicians too closely with that institution—a strategic position many groups may not want to be in.
That consideration underscores an ongoing hurdle the EMR industry still faces: the lack of technological integration. While physicians can achieve considerable cost savings and benefits from an EMR system within their own practice, different systems still can't "talk" to one another, a major obstacle to the free flow of electronic information.
That integration should take place within the next two to three years, experts say, because HIPAA is mandating electronic formatting standards, and clinical medical vocabulary standards are going to emerge. While those standards will one day allow different systems to communicate, for now physicians will have to wait.
Electronic medical record resources
- To order a copy of "Electronic Medical Records: A Guide for Clinicians and Administrators," by Jerome H. Carter, FACP, go to http://www.acponline.org/catalog/books/emr.htm.
- For a list of electronic medical record vendors, go to http://www.electronic-medical-records.com/.
- For a copy of the January 2001 EMR vendor survey from the American Academy of Family Physicians, got to http://www.aafp.org/fpm/20010100/45elec.html.
If you are considering going paperless, here are some tips to help decision-making and implementation:
- Identify your problems. While electronic medical record software can lead to savings related to chart pulls, refills and transcriptions, it can have a steep learning curve for both physicians and staff. Before pricing different systems, said Daniel C. Davis Jr., FACP, a clinical informatics medical director in Honolulu, ask what you want the EMR to do.
"Be very explicit about defining the value of the EMR to your group and patients," Dr. Davis suggested. For example, do you want to reduce chart pulls or transcription costs? Do you need to eliminate chronic problems with illegibility or downcoding? If those are your objectives, an EMR might be the way to go.
But depending on what you want to change, "a medical record system may not be the answer," said medical informatics expert Mark E. Frisse, FACP. "Maybe a better phone system or photocopier would be the right way to spend money right now." - Buyer beware. Analysts say there is a lot of "churn" in the EMR market: Many companies fail, while others emerge to take their place.
In such a volatile market, physicians need to choose a vendor with a stable history and business model. That's particularly true with the changing Health Insurance Portability and Accountability Act (HIPAA) landscape: You need a vendor who will be around to supply you with HIPAA compliant software updates.
"You want a company that sticks by its products, that doesn't keep sunsetting products to rush on to the next new gizmo," said Mindi K. McKenna, PhD, publisher of the monthly newsletter, eHealth Coach (www.ehealthcoach.com). You also want to negotiate a digital exit path so you have access to your records if the vendor (or your practice) switches ownership, or if you decide to use another system.
"Some vendors say that they can't guarantee that they will export the data out of their system into someone else's," Dr. McKenna said. "At the minimum, you want to have all your digital records provided on disk or as electronic back-up files." - Kick the tires and shop around. Take the time to see EMR systems in action. Ask potential vendors to set up site visits with clients who use the system, and consider bringing physicians from user groups in to talk to your physicians.
When pricing systems, don't accept blanket hardware packages. You can often get components more cheaply by unbundling a vendor's package, said Thomas Ryan, RN, director of clinical services at Johnson County Internal Medicine Associates in Indiana. He was able to buy a scanner (same model and warranty) for $4,500 that his EMR vendor was charging $8,000 for. - Cut back on bells and whistles. Vermont internist Keith W. Michl, FACP, was determined to go paperless when he went into solo practice in 1998, but he had to watch the bottom line. He has kept the cost of his system down (he said he has invested a total of $20,000) by learning to live without some fancy features.
For instance, drug interaction software packages at the time were expensive and "tedious to use," Dr. Michl said, particularly for an internist with patients taking 20 different medications. Instead of buying drug interaction software for his electronic clinical system, Dr. Michl uses his handheld's interaction program. - Try a gradual rollout. "I'm starting out with, 'Here is the mouse, and this is how you right- and left-click,' " Johnson County's Mr. Ryan said. "The different literacy levels are going to be a big hurdle."
At West Texas Medical Associates in San Angelo, Texas, several physicians suffered a 25% cut in productivity during their first few months of EMR use. That's why chief operating officer Dorma Kohler suggested that physicians steer clear of full and immediate implementation. Instead, use the EMR initially for one or two patients every hour—or even every day, giving yourself time to ease into the system. - Stay flexible. The system should be flexible enough to allow for differences in practice styles and comfort levels. At West Texas Medical Associates, Ms. Kohler said, some physicians use voice recognition software while others type in their patient information. Physicians can also choose to have a computer (or laptop) either inside or outside the exam room, depending on how comfortable they feel entering data during a patient visit.
According to Ms. Kohler, about 40% of the group's 50-plus physicians keep computers in the exam rooms, while another 40% want the hardware outside. The remaining 20% enter data the old-fashioned way, she said: They dictate notes that are transcribed and entered by staff into the electronic record.
She added, however, that those physicians now pay transcription costs as a direct overhead expense. With transcription costs shifting from a shared to a direct expense, Ms. Kohler said, physicians who enter data directly into the EMR now get $1,000 to $1,200 more income every month.
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