The Current State of the EMR Economy

This is an audio-interview with Mark Anderson discussing The Current State of the EMR Economy. Due to severe damage to the Houston coastal infrastructure from Hurricane Ike, our interview is interupted as we re-establish contact from a call-wipeout. However, nothing can stop either a Texan or our intrepid blogging reporter Robert "ever-ready" Gleeman.

Click the Play button above to listen to this interview.

This is the transcript from our interview, for those who prefer the written word.

Robert Gleeman:  This is Robert Gleeman with emrupdate. I am talking today on "Casual Friday," on audio‑only with Mark Anderson, from the AC Group. Mark, thank you for being with me again today.

Mark Anderson:  Well, I'm glad to be with you from lovely Houston, where there is no electricity anywhere to be found.

Robert:  Well, we did try using our OOGL video interview technology and, for the first time, we were not able to get a usable signal. I hope that you will make it through this outage OK.

Mark:  It's kind of interesting. If you think about the doctors that are around the Houston area who have had no electricity now for over a week, how do they see patients? And how do they keep their practice management EMR system going, especially when there is no cable connection?

The wireless is very poor now in the Houston area since most of the lines are down. It would be interesting to go back and see how physicians can handle using technology in a situation like we are having here in the Galveston‑Houston area.

Robert:  This is a time of a real emergency, and I hope that things will get back to normal. How do you run your ranch with no power?

Mark:  Luckily, I have a generator from before which I had bought a couple of years ago. We are running off of that.

Just last night, seven days after the hurricane hit, the stores now are starting to open up, and they are selling additional generators. Right now, I have three generators at the house running the basic stuff. No air conditioning here in lovely Houston, but at least I can have the refrigerator and lights and the fan running to keep us going.

Robert:  We are pretty cool here right now in northern California. I think it is about 56 degrees. It is like fall here, now.

Mark:  That would be nice!

Robert:  I want to talk to you about something, Mark, that is going on in emrupdate right now. We have some very vocal and very verbose nay‑sayers, who are very quick to point out the problems with EMR and the problems with EMR vendors. But I want to talk to you about some of the positive reasons that people come to you as an EMR and EHR consultant. What do they have in mind? Why are they coming to you? And what are they looking for with EMR, Mark?

Mark:  I think the big thing that we are seeing with physician practices today is that there has been so much talk about EMR that the doctors have been coming in and saying, "I know PQRI is coming. Now there are some bonuses. I know that the new e‑prescribing initiative is out there. We need to do something."

They are coming in and saying, "I want to get an EMR, because people are saying that I should have it. Now that I am looking, will it save me time and make me more money?" This is what they are really...

Robert:  What they are really saying? It looks like we may have a poor connection on this line, too.

Man 1:  We are on again, Robert.

Robert:  Is it mostly what people are telling them they need to do, or is it the problems they are encountering with paper files?

Mark:  No, I think if you look at the average physician out there, realistically they are not having a problem with the paper files. At least, it is not a big enough of a problem to switch over. Remember, most of the physicians can still hand write out their charts. It saves them time, right now, to hand write than it does to go in and click a thousand buttons to do everything.

A lot of doctors are saying, "Paper is faster." Now, if they have to dictate their notes... That is where the operational savings comes, if you can get rid of the dictation. But most of the physicians I talk to are not happy with the output that comes out of the EMR. It is not in the same format that they do today.

We have to find a way of making sure we save them time, help them to make more money, and to make sure that the note at the end comes out that clearly looks like something that they would have written or dictated... not a computer‑generated list of problems.

Robert:  In other words, what is driving doctors to EMR is not so much the problems with paper or cardboard files as it is what they are hearing about pay for performance, better follow‑up on chronic illness, some of the different ways of keeping track of diabetes and so on. That is what is driving them more so than problems with paper.

Sorry, Mark. We had another drop out there...

Houston, we have a problem! Let me try to make that call back. [phone ringing] ...other types of utility problems. Mark? [phone ringing] We will try it once again.

Mark:  I am moving to another section of the house. Maybe, I will have better reception.

Robert:  [laughter] Well, we are certainly live here. I did not stop the interview, Mark. I just redialed you. I guess we are having some real utility problems here.

Mark:  Yeah.

Robert:  Folks, please remember that we are talking to Mark Anderson from the AC Group in Houston, several days after a major hurricane storm. There is no power in Houston. Mark is running on generator power, and we are trying to find a location where we can continue the interview.

Mark:  OK. Let's try this.

Robert:  OK. I can hear you pretty well at that location, Mark.

Now, we were talking about some of the reasons that drive doctors to look into EMR. You were telling me that it was not so much the problems with paper, because that is what they are trained on, as it is the things that people tell them about pay for performance and better response to chronic illnesses. Is that pretty much the case?

Mark:  It depends on the specialty. For instance, primary care physicians that are your family physicians, internal medicine and even pediatrics... They are reimbursed, and they are trying to take care of more problems of the patient. In other words, diabetes with CHF... They are trying to help those patients stay a little bit healthier.

The issue is, again, that the majority of the physicians out there are specialists. They are really not taking care of all of those other issues. So, having an EMR that helps document diabetes and get people back in for health maintenance alerts really does not benefit many of the specialists that are out there.

For example, orthopedic doctors... They don't really do that many lab tests. Traditionally they are taking care of a broken bone or a sprain or a torn rotator cuff. They are not treating the health of the patient as much as the family physician would. Therefore, the requirements for EMRs are so different between the specialists and the family practice doctors out there today.

Robert:  Do the specialists have a lot less requirements? Are they easier to work with and satisfy?

Mark:  They have a couple of requirements. One of them is a lot less data entry, because they are traditionally not doing as detailed a review of systems. The HPI is related to the one issue that they are looking at.

And their order sets are a lot easier. They do not order as many lab tests. Their x‑rays are pretty simple. Their medications are typically limited to eight to ten primary medications that they recommend.

Their requirements are a lot less. But, their requirements for replacing the transcription are very high. They want that note to look like something that they would have transcribed. Most of the EMR vendors do not really provide a nice‑looking note that comes out that looks like what a physician would have dictated.

Robert:  What would you say are some of the happiest customers of EMR and EHR? Are they the specialists, or are they the general practitioners? Who seems to do the best, in your opinion?

Mark:  We have done a number of studies on both the family physician side and the specialists.

We have found that there are extremely happy specialists out there if they can get rid of their transcription and, specifically, when they allow the patient... their nurse or MA, to really enter in a lot of the information. The basic family history, social history... to get all of that information... and then have the nurse or the MA do the review of the systems and HPI.

The specialists really like the product when all they have to do is review the information, walk in, talk to the patient, do their physical exam and then they put their information in. That is what seems to work with the specialists out there... when they do their first data entry after the physical exam. They are happy with that. It does save them time, and it does help them replace their transcription.

I would say that I have about, probably, 60 percent of the specialists are still using Dragon for portions of the dictation. They are basically dictating right into the EMR their final assessment. So, they are still getting all of the E&M coding ‑ you know the clicks and buttons ‑ because someone else is putting that in. And they are still making the note look like something they would have dictated, because they are using Dragon to get part of that out.

For the family physicians and internal medicine doctors, typically we see that they are happier with the product if they are growing in size. For instance, SETMA, which is a large physician group out here in Beaumont, Texas, has been extremely successful with their EMR, but they started with five doctors and now they have 26 doctors. They have grown and they have not had to add cost on. They went from a staffing ratio of 6.5 staff per doctor; five years after implementing the EMR, they are now at two staff per doctor. So they have actually cut their staff in half by growing.

Very hard for a family physician of one or two to put an EMR in and actually save any time, because, you have to have all of that staff. There is a minimum staff no matter what. In SETMA's case, they were able to grow their practice through the use of the EMR. And, because they are doing a lot more work on health maintenance alerts in keeping people healthier, they have won a number of awards.

They are getting paid more now, because they actually have a good EMR that is driving the health of the population in their community.

Robert Gleeman:  How are you spelling that, SETMA?

Mark:  S‑E‑T‑M‑A.

Robert:  I see.

So, it sounds like there are many, many doctors using the EMR happily and with good effect and good results. I guess what I'm asking you, Mark is: in your opinion, what are some of the things that make for a happy EMR customer?

Mark:  I think if we can get a way of getting the EMR to work around the workflow of the physician practice, instead of the physician changing everything they do to work around the software product, that is where we see success.

Robert:  Yeah.

Mark:  Because the EMR is just the tool. What we are doing with all of this training and everything that everyone is offering, is that we are showing people how to use the tool only.

But, it is like building a house. We are showing them how to use a hammer without building a house. We have got to get a lot more as far as, how do we really use this to save time and make money? They vendors are not spending the time. Or, more likely, the doctors are not willing to spend the money to make sure that they look at what we call "clinical and operational transformation." How do we get the software and office workflow to work together to save time and make the doctor more money?

No one is doing that. They are only installing software and going, "Doctor, you are on your own. You figure it out from here."

Robert:  [laughter] It is a very difficult product for a vendor to sell, isn't it?

Mark:  The sale cycle is so long. I have talked to practices that have been looking for two years for a software product. But, I am working with a family physician out of Kentucky who called me last Friday. He said that he wanted to buy an EMR and a practice management system and get it installed by November 1st. We spent four days in a row doing webcast demos, and today he is signing the contract.

So, within seven days, he went from "Gee, I would like to get something," to signing a contract... within seven days. It can happen! You can sell quickly. But you have to have a doctor who is motivated. In this case, the doctor had all of the information he wanted. He looked at six really good products and made his decision relatively quickly. So it can occur.

Now the next question, how successful will he be using the product, will really depend, not on the product but how well the product integrated into his workflow and the process going forward.

Robert:  I wanted to ask you a question. You don't have to answer this if you don't want to, but these are very tough times in the stock market, and there is an election going on which is very heated. How are times for EMR sales right now?

Mark:  Well, when I talk... they claim that sales are the best they have ever been. Then I go back and look at the results. I would say that EMR sales are down about 35 percent from the last year. I think what ends up happening is that every vendor wants to keep a glorified story out there. Everything is great. We are selling like [audio cuts out].

I talk to a lot of doctors, and a lot of them are just putting off their buying power. Partly because they are still saying, "Hey, I am going to wait and see what the hospital does. I am going to wait to see what the MSO or the IPA in my community does, because they are looking at EMRs.

I think that there are still a lot of potential clients out there who are looking. But we are finding that a lot more of the bigger doctor groups are looking instead of the individual physicians.

So, I think business is really hurting most of the vendors today.

Robert:  I think that this is showing that the economy affects everybody: doctors, EMR vendors, EMR consultants...

Mark:  Yeah.

Robert:  As a parting shot to the doctors in "emrupdate," that read "emrupdate, "what can you tell us about now, in this time, at this moment in the economy and in the country? Is it a better time to go to a consultant than ever?

Mark:  If I was small physician practice looking for an EMR, I would not call a consultant. I would sit back and wait to see what the community is going to do first. No sense in going out and spending money, buying EMR that may or may not be connected to the rest of the community in the near future.

I would go to the hospital administrator, your MSO, your IPA, whatever you belong to, and start talking to them about them putting together a community EMR. That way, we can start sharing data. So, the patient goes to the primary care doctor and they collect the information. That information goes directly into the specialist's EMR. So we don't have duplicate data entry.

I think, realistically, we have to stop buying individual silos of computers and get more of a community‑based EMR going. That is where I think the market is really going to go, and that is where the government has been talking about. If you look about the whole CCHIT stuff now, it is all about creating standards for community systems. That is the new one they are working on today. That is where we everything going.

Wait until your community does something and get connected into the community.

Robert:  Are you geared up to be involved in that and to help with that process?

Mark:  Right now, I would say that 90 percent of our business has switched away from helping physicians to really working with these larger communities. Because, the communities... With the change of the Stark Law, there are some major changes going on, where communities are starting to say, "Maybe we should start looking at bringing together a community."

Maybe in our next session we can talk about the financial benefits for the patient, the employer, the healthcare plan, the hospital and the doctor, by going to more of a community‑based EMR versus silos of information.

It is kind of like here in Houston... We all don't have our own electrical plants. We all share the same electrical service. But, then again, it is good to have a back‑up system, like a back‑up generator for when the whole community goes down. Even though I keep promoting community‑based EMRs going forward, every individual physician still has to have a back‑up procedure in case the community is not working. ...like we have here in Houston, with 2.5 million people without electricity seven days after the hurricane hit.

Robert:  I hope you recover well from that. It sounds like you are pretty self‑sufficient with generators and all. We did get our connection. It wasn't easy, but we did get it [laughter].

Thank you very much, Mark. I appreciate the extra effort to communicate with me today.

Any final thoughts for our readers?

Mark:  I think the main thing is for doctors to continue to be vocal. If you don't like what you are seeing, tell people about it. We need to make sure that the message is getting out there, that some EMRs are working well and the lousy EMRs are not working well for the physicians. It is up to the physicians, who are the users of these systems, to be more vocal and to let people know where it works and where it doesn't work.

Robert:  Well it is good to hear that you are pro‑physician, and that is the position that we take at "emrupdate."

Thank you very much, Mark Anderson with the AC Group for talking with me again on "Casual Friday." Thanks, Mark.

Mark:  Thank you.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here and more Interview here.

Mark R. Anderson CPHIMS, FHIMSS
CEO and Healthcare IT Futurist 
AC Group, Inc.
118 Lyndsey Drive
Montgomery, TX  77316
(c) 281-413-5572
(f)  832-550-2338
email: mra@acgroup.org
web: www.acgroup.org