There is virtually no physician that has not had at least some exposure to Electronic Medical Records (EMR). With that exposure there is the natural progression to the consideration of implementing such a program into their practice. For the Technologically-savvy (techie) physician this transition may offer an exciting time in life, as there is the opportunity to incorporate a private passion into their work. For the rest of us, though, the decision to go with EMR may be considered a painful necessity, an ordeal that may surpass even the studying and testing to maintain board certification that is required of all younger physicians in the United States and other countries, as well. For the non-techie physician, the barrier to implement EMR can be quite high both financially, and emotionally/professionally as a care-giver with pride in work, and in the record of that work. Practice Management (PM) is already being done electronically by the vast majority of physicians, and their comfort with their current PM program can lead to potentially costly bias in the decision to transition to EMR.
The Costs of EMR
Decreases in reimbursement for patient care within the United States make the investment into EMR a bitter pill to swallow. Worse yet, many physicians that have already made the leap describe no savings, or Return On Investment (ROI), even years after implementation into their practices. And there is the immediate recognition that EMR notes depersonalize the interaction with the patient, and the understanding that the creating of such notes are very likely, at least temporarily, to negatively affect the interaction with the patient. Some physicians do not value receiving EMR-assisted notes from another physician, as the information that needs to be gleaned can be hidden in an unfamiliar format. The sub-specialist could perceive that his practice might suffer decreases in referrals if his notes back to providers are too oblique to help the referring physician.
The Returns of EMR
On the other hand, most doctors have already been exposed to the benefits of having an EMR, or at least have been told of the theoretical benefits. The following list is by no means inclusive, but certainly are major factors that will influence the physician, or physician’s group to seek out an EMR for their system.
The first factor is the most obvious for the large institution that can no longer be kept within a single geographic site, and will have caregivers spread out over a large geographic area. In the past, access to the medical chart would require complex planning to make sure that the chart would be carried to the appropriate office on the correct date of the patient encounter. It doesn’t take much imagination to see the terrible inconveniences and costs to an institution with that system in place. And the problem will be magnified in the patient with multiple system disease who will be seeing physicians at multiple sites in the same day. Giving the record to the patient to carry to the next site would be fraught with risk of loss, damage, or even misinterpretation of the record by the curious patient. Because of the inconvenience of medical record handling many clinics had, or continue to have, their growth stunted.
Unfortunately, the EMR’s that have been used in these situations have not always been physician friendly, and yet these were often the first EMR’s implemented. The case for EMR for the small practice was only worsened by the stories coming from the physicians of those institutions. But even within the small practice the moving about of medical records is cumbersome, and expensive. And in any group practice there is the occasional (or not) occurrence of a record damaged in a physician’s trunk, where it was stored after carrying the chart to the hospital to admit a patient, or after taking the chart home to catch up on work after putting the kids to bed. And even within a single geographic site, the amount of chart movement will not just be the number of patients to be seen, but some multiple, as well, of charts being carried to the nurse or physician because of phone encounters that need to be documented. It is not unusual in the primary care office for as many charts to be moving because of phone calls as there are for face-to-face encounters. An electronic record is as accessible as a computer and a modem, and can follow the physician around. The limitations of the reliability of the computer systems have been greatly reduced in the recent years, and the benefits now seem to outweigh the effort of carrying the physical chart around.
Of course, there will not be as much medical records personnel needed, once an EMR is functioning. There will be less labor required for medical record movement, and the potential for savings, as well, in space. Fewer employees, and the eventual elimination of charts sitting on racks, within a doctor’s office that incidentally might be situated in an expensive part of the city. The resulting economy of space could be utilized in downsizing (and has been) or used for the expansion of the practice with a new physician or physicians invited in to work in the original plant, even as overhead has been decreased.
And the savings of space is not only related to medical records, as many physicians groups do their own billing. A good EMR has the ability to simplify the billing by allowing the physician, during the course of his visit, to automatically attach a billing code to not just the visit itself, but every procedure done during that visit. The learning curve for this process prevents many physicians from investing the time to learn. But EMR’s often claim to pay for themselves just with improved capture of reimbursement, a plague in some medical offices that will allow billable services to go unpaid. What’s more, the number of billing people within an office can be often be decreased over time, as the remaining workers are left to correct minor errors, or to help with the more complicated billing procedures that have not been learned. The key to understanding this benefit is that once the physician has become facile at understanding the process, it adds very little time to his visit, but has the potential of great savings. The linking of diagnoses to billing codes is already being done by most physicians on paper. The leap to doing it electronically is nearly automatic once the foundation work is done.
So EMR has the theoretical ability to improve the speed of collections, as billing will more likely be correct the first time submitted, and there can be a decrease in personnel, and the work space required, once the system is effective.
So far, then, we have discussed the increased convenience of medical record access, and the diminution of space and personnel in medical records and billing possible with EMR.
The next savings is seemingly obvious, but does not apply to all practices, and that is the cessation or vast diminution of use of transcription. Anyone using a paid transcription service has had to notice how much it costs. If it weren’t for the costs of transcription, most people would use a very simple digital EMR with notes dictated into memory. Indeed, many people have created their own EMR doing exactly that. But the reason that has not become the standard for EMR is multifold. A good EMR system with information entered into discreet folders will allow information to be “mined” after the fact. This is becoming increasingly important with recent “Pay For Performance” features to be implemented by multiple insurance carriers in the United States, including Medicare. Such mining would be difficult in a simple digitally dictated note. THIS IS THE SINGLE MOST IMPORTANT REASON that EMR’s are not just dictated, though such record keeping would be the most intuitive to use. However, it is not yet a given that data mining will become the standard of care in medical care. The value of that capacity is left to the purchaser to assign.
But almost as importantly, the segmentation of information packets into folders will allow the building of [wikipedia:Macro], or [wikipedia:Template word processing] that will allow descriptions of problems, or findings with just a few keystrokes, with improved detail requiring less time to create.
Of course, generating the note at the time of seeing the patient has other obvious benefits. You can send the note to the next physician the patient is seeing the moment you are done with the visit. Information from your note can be printed off and given to the patient as reinforcement. With a good EMR system, the previous social history, allergies, medical history, family history, surgical history will be brought forward with the click of a button, allowing a much more thorough note to be generated with just some (relatively) simple updating at the time of the visit. And typically the paper- bound physician would not likely re-dictate the entire history every visit, because of time and cost constraints. Most physicians know how much they are spending on transcription, and so the savings available is immediately apparent. Though the amount of information in the note may “muddle” the message to another physician, this problem is being improved with better formats that separate the bloat of repetition from the new findings and decision making done at that most recent visit. If there is elimination of a transcriptionist working “in-house” there is the collateral space savings to be noted as well.
Finally, the EMR record has the potential, presuming a good program and reasonable diligence, to be a far better record of patient care than could be achieved with paper, able to reduce a patient’s entire history to just a few pages that is automatically updated with every visit to the physician. The holy grail of medical records available to anyone around the country, when a patient presents ill, becomes achievable. And, yes, this availability will threaten privacy, but there will be an associated improvement in access to efficient care. I will leave it to others to discuss this compromise.
Choosing an EMR
No one knows a medical practice better than the physicians themselves. There may be a good reason to pay a consultant to screen EMR’s for the group, but that decision in itself may indicate that the group is not ready for EMR. The most expensive EMR you can purchase is the one that you will not use. And there can be INCREASES IN COSTS long term if the failure of one or more physicians to invest in the learning and implementation of the EMR leads to duplicate systems of EMR and traditional paper records. There will be exceptions to this suggestion, but physicians themselves should be involved in the decision as to which EMR would be best for the practice. This invites discussion amongst the physicians as to whether they are ready to make the leap, and allows the group to assure that every single doctor is ready to commit to the incipient increase in workload involved with the transition. For most groups there will be individuals fraught with fear over the transition, and those fears have to be allayed well enough before going forward. In large clinics there are physicians that choose to retire early or move on rather than adopt the EMR that was chosen for them. Clearly no one starts an EMR with the plan of destroying a group, and yet that risk exists, and best prevented by having as many physicians as possible participating in the learning about EMR’s. There will be the physician in a practice, perhaps the greatest earner, that will feel too busy to attend the meetings regarding EMR implementation, and yet they are the most important ones to be there, as they have the most to lose by an implementation gone bad. They have often maximized the efficiency of the old paper system, and may have the most difficulty getting back to that kind of efficiency with the new system. However these individuals are usually very motivated, and if they come to understand the long-term benefits of EMR, they may become a promoter of the idea, rather than a potential land mine in its implementation once purchased.
The inevitability of EMR becoming the standard of health care record keeping is accepted by almost every physician, right now. But the question being raised most often as a reason not to go with EMR immediately is the cost, and the potential that EMR’s will soon be offered free to the private practice physician groups. As you may have gleaned from the discussion above, the benefits of EMR to the physician can only be achieved with the successful implementation of the program, with the group wholly invested in the success of the new system. The risks of accepting an EMR that is more convenient for the hospital or insurance group paying for the EMR, then, is obvious. They will not be choosing an EMR with the best interests of the physician group in mind. I could raise paranoid issues about insurance companies supplying an EMR to the doctor so as to mine the records for the information they will use to lower costs, or even judge the competence of the physician group. How many physicians feel that insurance companies are really competent to make that judgement? But the main reason for a physician group to choose their own EMR is opportunity costs.
The Hidden Costs of EMR
No EMR supplier can predict how long it is going to take for a group to get up and running fully on EMR. Some groups choose to ease into EMR with some physicians adopting the program earlier than others, with the hopes that the energetic early adopters will work out the bugs for the practice while the cash flow continues from the rest of the group. Other groups will train hard together, and set a start date after which all records will be done in the EMR. What has to be understood is that no matter how much is paid for an EMR, there is almost certainly going to be a decrease in the productivity of the physicians as they learn the system. There is no system to date so intuitive that will allow a physician to start at the efficiency that they had gained with paper records. There should be suspicion of any EMR company that would try to claim differently, at least of this date. For those who choose a start date for implementation for everyone in the practice, that loss of productivity while learning is easier to estimate. This loss is called the opportunity cost. More simply, it is the money not earned because of the patients that couldn’t be seen because the physicians and caregivers could not function as quickly. Some groups compensate by working longer hours, so that cash flow is maintained, but there is still the cost in overtime for support staff, and there is the value of the physician’s time, however unquantifiable. The opportunity costs can easily surpass the cost of the EMR. Indeed, a FREE EMR THAT IS DIFFICULT TO LEARN AND/OR LIMITS EVENTUAL SPEED AND FUNCTION CAN PROVE MORE EXPENSIVE. This is NOT an admonition to buy an expensive EMR. However this is a caution that choosing ease of implementation and longterm efficiency be factors in the selection of an EMR system.
The Other Costs of EMR
Of course there will be the cost of software and hardware, as well as training with the purchase of any EMR. Trying to compare prices from each vendor will prove challenging. Most vendors will offer a package price, with cost of the software, recommended hardware, and training included in the price. However the amount of training, and where the training occurs, is always variable. And you will see that the hardware needs recommended by one vendor will not match the needs suggested by another. Sometimes there are apparent savings from a vendor if they do not supply the hardware, but rather recommend what is needed and have the practice purchase the hardware and have a privately contracted Information Technology (I.T.) group install the system. The training quoted by some vendors will be 3 days in your office. By other vendors the training included could be 5 days. It would be naïve to suggest that the vendor offering 3 days of training has a system that is easier to learn. Skimping on training may be one of the costliest mistakes made by a group. (See Hidden Costs, above). Finally, some systems require that the physician travel to a training site for intensive education. Such concentration of effort might be worthwhile, even cost effective, but it is always during weekdays and therefore the physician’s loss of productivity during those days is far greater.
There are benefits in having a single vendor responsible for all work on the EMR, as there is only one person to call for any problem. There is less theoretical fingerpointing as to the source of problems when there is only one responsible party. Realistically, though, some of that same fingerpointing occurs even within the vendor’s company. Obtaining references that confirm the accountability of the vendor will prove invaluable. Remember, failed hardware and glitchy software add to the opportunity costs as much as a slow learning curve.
Then there are maintenance costs and licensing fees. If a vendor’s program, for example, includes a lot of Microsoft licensed products, you must expect to pay the licensing fees going forward, and the vendor does not have control over those costs. Microsoft software is familiar even to non techies, and so there is some comfort in have Word, for example, incorporated into the EMR program. Having to learn a new word processing program may not seem worth the bother to some practices. But some practices will change their minds when they see how the monthly fees add up. As of this writing there is no source that will allow an estimate of the costs of inefficiency of NOT having Microsoft, or other familiar, licensed products incorporated into the programs. Suffice to say, there are a few programs that avoid the high cost of the proprietary licensing fees, and most others bear the cost so as to yield a simpler to learn program. The ongoing cost of an EMR doesn’t go away, and there are endless permutations of low or high initial cost, high or low maintenance costs. There are also vendors with high initial costs and high maintenance costs.
Frankly, the biggest erosion of savings with EMR is the not the cost of the program and maintenance, but rather lack of use. If an expensive program is to suit a practice, and offers a recognizably higher chance of having the group use the program, it could prove the wisest investment, with excellent return.
Some groups choose their EMR based on the Practice Management (PM) program already in place. The risks of making the decision in EMR based on the PM program should now be obvious. And yet, it seems to be the major determining factor for many groups. Of course the EMR associated with the PM program should be evaluated along with other vendors. But the learning curve for PM programs is much less than that of EMR.
Styles of EMR
There are groups that maintain separate EMR and PM. This may allow them to use an inexpensive EMR that suits them nicely. A system like this will require that information be entered independently into each system which is, of course, inefficient. So to solve that problem, many companies have combined individually excellent EMR and PM products with a [wikipedia:Computer Science Interface]
Those companies that have combined the two excellent products will tout the invisibility of the interface, and the benefit of having tried and true products with known customer satisfaction as the basis of the their product. Competitors will point out that the presence of two programs will eventually show up in inefficiencies of scheduling, having to switch screens, and the like. There are arguments for both, and excellent products that are interfaced, and other EMR/PM that are all just a single program that handles it all. For a long time, the PM aspect of the single programs were NOT the equivalent of the PM programs in the interfaced systems. Recently that gap has been narrowed.
There are EMR’s that may shorten the learning curve by using handwriting recognition in ways that are new and unique, and will allow data mining even out of hand written material. There are others that allow the basics of EMR, at very low cost, with such few features to learn, and easy ones at that, that savings will occur much more quickly, but there exists the risk of hitting a ceiling in functionality that may be regretted later. There are increasing numbers of EMR programs with variant ways of Templating that can even learn from repeated use patterns. There are reasons why these learning programs can be considered annoying, as they require the physician to slow down and read a new template, rather than clicking quickly in a well known template, much as a virtuoso pianist will play the piano without looking at the keyboard. If the orientation of the keys were to change, then hours of practice at the keyboard would be lost.
Then there are permutations of how and where the major data is stored, whether on site on a local server with local responsibility to back up the system, or on an offsite computer system maintained by the vendor, called an ASP system ([wikipedia:Application Service Provider]).
Recently there has been standardization ([wikipedia:CCHIT]) recommended by the United States Government, at great cost to those companies wishing to comply. These costs will be passed on to the consumer. Unfortunately, some very good and simple EMR’s will not have the resources to achieve certification. Even among the larger companies that are effecting certification there is no consensus that these mandated changes are going to greatly improve the functionality of EMR’s.
The biggest disappointment in EMR’s is that there is little motivation to make them intercompatible. In other words, it may be difficult or impossible to transfer records already created on one EMR to another if there is a falling out with a vendor (or if a vendor is to fail), and a change is desired. This speaks to how important it is to choose a vendor with great care, as it is more likely to be long term relationship.
How To Tell Which EMR is Best
There have been attempts to “measure” the quality of an EMR by various competitions, and by survey. Since few people are facile in multiple EMR’s the surveys allow no direct comparison. And since the competitions are often manned by hyperskilled operators supplied by the vendors themselves, the usefulness of these competitions is uncertain. It would seem much easier to get objective comparative data regarding a new car than an EMR. References to successful implementations, and efforts to assess the stability of the company will be mandatory for the judicious buyer.
Going with an EMR is not the easy route to take. But if implemented effectively there are examples of great savings in cost, and certainly almost all will claim increased convenience. In the motivated practice, there will be an Opportunity Cost for DELAYING the transition to EMR, as the financial benefits and the benefits to care can be startling, and the long term savings should surpass the initial investment relatively rapidly and by multiples if the proper system for that group is chosen.
Erick Bournigal
(rheumdoc)
Posted
Sep 06 2007, 09:40 AM
by
rheumdoc