Going Electronic
Easier to use and more affordable than
ever, electronic medical record systems still present a
challenge for most practices. Careful planning and
implementation are key to a smooth transition and realizing
their full potential.
By Gina Rollins Published
May/June 2003
This year may turn out to be the year of
the electronic medical record (EMR). EMR systems in ambulatory
care settings are finally in vogue after going through a long
period of limited adoption, and the convergence of several
important factors is further propelling implementation. The
systems, which cover the gamut from basic stand-alone units to
highly sophisticated integrated products, hold the promise of
both improved patient care and long-term—if not
immediate—productivity gains and cost reductions.
The downside is that many of the
systems still have hefty price tags at a time when physicians
are facing difficult economic challenges. Knowing what you need
from an EMR, selecting a vendor that meets those requirements,
and carefully planning and implementing the system will help
you realize its full potential with the fewest headaches.
A strategic decision
“It’s a strategic decision
based on improving patient service, cost structure, and
physician productivity. You shouldn’t be doing it simply
to get rid of a piece of paper,” says Ron Sterling, the
president of Sterling Solutions,
a Silver Spring, Maryland-based health information system
consulting firm. “It needs to reflect what your business
is about and what it’s evolving to.”
One of the main reasons physicians
are climbing on the EMR bandwagon is the desire to improve
patient care. The ability to have information available the
moment it’s needed holds the potential of reducing
errors, speeding diagnosis and treatment cycles, and greatly
enhancing the ability to manage patients with chronic disease.
It also dovetails with rising consumer expectations and
computer-literacy.
As a practical matter, EMR systems also
facilitate compliance with privacy standards of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). Another factor
is that EMR applications are more robust and less costly than
ever before. “The early systems strived to do everything
and they were very complicated and difficult to use,”
says David Winn, MD, the chief executive officer of e-MDs, an EMR company based in Cedar Point, Texas.
“The capabilities and ease-of-use have improved.”
At the same time, prices have dropped by as much as 50 percent
in the past 18 months, according to Sterling.
Finally, as early adopters have
demonstrated success with EMR systems, more and more practices
are willing to make the digital leap. “I think it’s
just part of the product acceptance curve. When we opened two
years ago, people were cheering us on, but privately they were
doubting that [our system] would work. Now, we have people
visiting us all the time to see how it works,” says Barth
Doroshuk, the chief executive officer of the Washington
ENT Group, a five-physician
otolaryngology practice in Washington, DC. The practice, which
opened in March 2001, uses the A4
Health Systems EMR.
Taking a another look
With those kinds of forces in play,
physicians are looking anew at the benefits, economic hurdles,
and implementation challenges of EMR systems. What they
discover depends largely on the type of system under
consideration. At the low end of function are stand-alone
document scanning systems, which make transcribed records
available for on-screen viewing. At the opposite end:
fully integrated products that do everything from
automating documentation and clinical work flow to providing
decision support and electronic charge capture and coding. Less
sophisticated systems generally help reduce the burden of paper
and are less costly and easier to implement than more complex
applications. However, they also lack power to accomplish
activities like clinical decision support and outcomes
monitoring.
The way EMR databases are structured
and maintained also varies. Application service provider (ASP)
models run over the Internet. Practices “rent” the
software and have the option of downloading and running it on
their own systems or interacting with it through a browser. In
either case, data is stored remotely and maintained by the
vendor rather than on a file server at the practice’s
office. Client-server models are based in the practice, where
data is maintained on a file server. Providers pay licensing
fees to operate the software and also purchase back-up systems
and other hardware. Affordability and easy implementation and
usage are the main advantages of ASP systems, but they have
some distinct shortcomings, most notably the speed,
reliability, and security of data and communications.
Understandably, ASP models are much
less expensive than client-server systems. Some cost less than
$1,000. In contrast, depending on the level of sophistication
and implementation support, client-server applications can cost
anywhere from $15,000 to $50,000 per physician.
Finding benefits
Virtually no one disputes that EMRs
enhance patient care. For many people, however, the jury is
still out as to whether the systems do anything to improve an
income statement. The ability to improve patient care is the
only compelling reason to implement an EMR, according to Scott
Yates, MD, the president of North Texas
Medical Group, a six-physician
internal medicine practice in The Colony. “We don’t
make more money because of an EMR, and it didn’t lower
our overhead at all,” he says. However, the EMR makes it
possible to follow and track outcomes for patients with chronic
diseases such as diabetes. These outcomes may lead to
reimbursement improvements down the road. “If we provide
better care and can prove it’s better, we may eventually
get support for higher contract rates,” he says. Yates
opened the practice three years ago using the GE
Medical Systems Logician product.
As important as providing better
care is, it usually doesn’t translate into bottom-line
benefits. Although some practices have yet to find economic
gains from EMR systems, others insist the switch has produced
cost savings and increased productivity. According to Doroshuk,
the Washington ENT Group has about one-third the support
positions per physician of a typical otolaryngology practice,
and it has virtually no transcription expense, which would run
several thousand dollars a month for a similar-sized practice
operating in a paper-based environment.
EMRs also improve physician
productivity by enabling them to see more patients in the same
amount of time, argues Tom Landholt, MD, a solo family
practitioner in Springfield, Missouri, who also is a consultant
to GE Medical Systems. For example, a doctor might spend three
to five minutes diagnosing a case of strep throat, but have 10
to 15 minutes allotted for the visit on his schedule. “If
you do that through the course of the day, you just scheduled
an hour you didn’t use,” he contends. EMRs improve
work flow by minimizing the amount of time spent in repetitive
tasks outside the exam room, he says. “In a typical
outpatient practice, most of the tasks are done by others. The
doctors are not the people delivering care; they direct care.
And it’s all the systems surrounding the
doctor—like pulling charts and faxing records—that
are inefficient.”
Exactly how much time EMRs can shave from
office visits is debatable, according to Michael Mytych, the
president of Health Information Consulting in Menomonee Falls, Wisconsin. He estimates that
while EMR products save at least 30 minutes each day on
established patient visits, they add 10 minutes to new patient
visits because symptom- or system-driven templates lead to the
collection of more thorough information. However, the extra
time for initial visits “can be mitigated with a
pre-visit survey that the patient completes and is uploaded
into the system,” he says.
One practice that has seen financial
savings is the Colorado division of
the Kaiser Permanente Federation, which experienced an eight
percent drop in visits after implementing an EMR. “We
weren’t trying to do that. It was a result of having
information available when it was needed, so that we could
address problems during a single office visit, or handle issues
over the phone. With those visit slots made available, we were
able to see eight percent more people with the same staff as
before,” says Andrew W. Wiesenthal, MD, the associate
executive director for clinical information support.
The division also saw its Medicare HMO
rates increase. “Our reimbursement is based on risk
adjustment that’s triggered by the disease burden
measured by the diagnostic complexity of our Medicare patients.
To do that, we collect management codes. The difference in
having the machine do it [versus manually] is staggering. The
system pays for itself right there,” says Wiesenthal.
Kaiser was on the forefront of the EMR wave, initially
developing a homegrown product in collaboration with IBM that
was implemented in its Colorado and Hawaii divisions. However,
in February 2003, it announced plans to complete implementation
in other divisions using the Epic
Systems EMR.
Providers operating in primarily
fee-for-service environments are struggling to see how an EMR
can produce similar economic benefits. An example is Austin Regional Clinic, a 140-physician multi-specialty practice in Austin,
Texas. “Those are great arguments for managed care, but
in fee-for-service, time spent on the phone is an expense; it
doesn’t generate revenue, and we’re already above
the norms for productivity, so there’s probably not that
much to be gained,” explains Russell Krienke, MD, the
group’s medical director. Austin Regional Clinic is in
the throes of deciding how to proceed with an EMR
implementation.
Compounding the financial picture is
that while EMRs enable reductions in the number of medical
records staff, they often require new, more expensive outlays.
“The staff you don’t have to have, who are pulling
charts and locating documents, are fairly inexpensive and
part-time. But if you have a sophisticated system, you have to
have maintenance and network support. So instead of $5,000 per
month for medical records staff, you may pay $12,000 per month
for computer data specialists,” says Yates, the internist
from North Texas Medical Group.
The Washington ENT Group, of Washington,
DC opened in March 2001 using the A4 Health Systems EMR. “When
we opened two years ago, people were cheering us on, but
privately they were doubting that [our system] would work. Now,
we have people visiting us all the time to see how it
works,” says Barth Doroshuk, seated, the chief executive
officer of the practice. Physicians Catherine Picken and
Thomas Troost, behind Doroshuk, own the practice and employ
three other physicians.
photo/ © 2003 CHRIS USHER