Electronic Medical Records: The Promise and the Reality
By Steve Goodman
A patient walks into your office, even for the first time, and instead of being handed reams of forms to fill out – your receptionist glances at her computer, smiles and says “Hello Mr. Jones, the doctor will be right with you…” For more than 10 years that has been the promise of EMR – electronic medical records. The technology exists, and many practitioners have systems in place and are reaping the benefits – but how close are we to universal acceptance and ubiquitous use of EMRs throughout the medical community?
At the most basic level an EMR is an electronic record of a patient’s health information generated by all of his or her encounters with any healthcare practitioner or setting.
An EMR is not only a record of past medical history. Included are patient demographics, progress notes, specific problems, medications, immunization records, all laboratory data radiology and other diagnostic reports. EMR has been shown to streamline the clinician’s workflow. A recent study published in BMJ, The Journal of the British Medical Association, concluded that when compared with paper based records paperless records were more often fully understandable and fully legible. Paperless records were found to be significantly more likely to have at least one diagnosis recorded, to have recorded the advice that had been given to the patient, and when a prescription had been issued, paperless records were more likely to specify the drug dose. The study also found that doctors using paperless records were able to recall more of the advice they had given to their patients. According to a University of California report prepared for the California Healthcare Foundation that surveyed 20 small physician practices that had implemented EMR, “Almost all users reported increased patient care quality due to such improvements as better data legibility, accessibility and organization, prescription ordering, and prevention and disease management care decision support”
Tragic events like 9/11, Hurricane Katrina, and the California wildfires have showcased the benefits of electronic record keeping. With large scale EMR systems in place, many of the medical records that were lost in such tragedies would have been preserved, leading to more efficient care and better patient outcomes for those injured or displaced in such events.
Despite the seeming advantages of EMRs, hospitals across the country are evaluating if, when, and how they will subsidize electronic medical record technology.
“I see a lot of hospitals still trying to figure out what to do,” says Mark R. Anderson, CEO of healthcare technology advisory firm AC Group, Inc. of Montgomery, Texas. “Hospitals need to learn about the different advantages and disadvantages of [an EMR] project before offering a service.
In the meantime Congress is poised to put forth a multi-billion dollar stimulus package that calls for $19 billion to implement electronic health records and other information technology. The Senate version of the package was supported by Pennsylvania’s own Arlen Specter, one of only three Republican senators to support the bill. The others were Susan Collins and Olympia Snowe, both of Maine. According to the Senate bill, hospitals would be eligible for incentives for using electronic medical records beginning in 2011 and would be penalized if they haven’t switched over from paper records by 2015.
In the compromised bill between the House and Senate versions it was Specter, a cancer survivor, who argued for an additional $6.5 billion for medical research. “I think it is an important component of putting America back on its feet,” Mr. Specter said.
The federal government already supports and operates a practical EMR model. Veterans’ hospitals across the country share an electronic system, called VistA, which allows for sharing of records for veterans in its health system. With VistA, a VA facility anywhere in the country has the same access to an eligible patient’s records as his or her local hospital.
Time and again EMRs have been shown to enhance the quality of patient care by minimizing errors and improving efficiency and coordination. With all of the apparent positive benefits to implementing EMR, why have so many physicians still been slow to add an EMR solution to their practices? Initial cost still seems to be the biggest hurdle. According to Robert Miller, Ph.D., one of the authors of the California Healthcare Foundation study, “The initial costs can be substantial. We came up with about $44,000 per billing provider on average. We found providers paid for their initial costs and cumulative ongoing costs in 2.5 years. After that, it was $23,000 per billing provider per year in net gains, on average ‘. However, Miller was quick to point out “But that’s the average. There were three practices that, at the rate they were generating benefits, would take over nine years to pay for EMRs. One practice almost went bankrupt due to billing problems associated with implementation. So, while the average payback period is 2.5 years, there’s also risk in making the move.”
Mike Davis executive vice president of analytics for the Healthcare Information and Management Systems Society (HIMSS) says,“We found that cost continues to be a significant barrier to technology implementation, despite the benefits of improved patient care and fewer medical errors attributed to the EMR.”
That is why Miller, among others, is in favor of subsidies for doctors who implement EMR. These subsidies to community physicians could possibly be paid for out of the $19 billion in the Obama stimulus package to upgrade hospitals’ electronic records systems. “Physicians should be paid for using EMRs well” said Miller, “and that’s where pay-for-performance comes in. Practices with EMRs are very well situated to gain from pay-for-quality performance because they are in a better position to capture and report on data than are paper-based practices, and have more tools to improve quality.”
Mark R. Anderson believes that even with financial and support staff assistance many physicians may still resist hospital offerings. “The initial reaction might be that they don’t necessarily want an EMR or they want their own,” says Anderson. “Most doctors just don’t trust hospitals.” Regardless of physician resistance, Anderson is convinced hospitals need to develop programs to help provide community physicians with EMR technology. “It is a great use of their money if they think it all the way through,” says Anderson. “There are some great financial benefits to the hospital and it bonds the doctor to the hospital. And, it can improve the quality of care.”
Until federal funding becomes available it has fallen on States and individual municipalities to develop such subsidy programs. New York City for example has begun a $60 million project to heavily subsidize EMRs for 1,000 primary care physicians, mainly those with 10 or fewer doctors, and largely in lower income neighborhoods. The EMR system has been designed for the city by eClinicalWorks. The system usually costs approximatly $45,000 to implement for a typical small pratice. However, New York is cutting that cost down to $24,000 through subsidies for practices that qualify by having at least 10 percent of their patients who are on Medicaid or without any insurance. In addition to financial subsidies, the city is also providing teams of trainers to assist with the transition.
eClinicalWorks projects that 100,000 healthcare providers will be using the company’s software within the next 10 years, impacting patient care for 100 million patients.
Real World Experiences
There are roughly 200 vendors who provide some sort of EMR to the physician’s office. Obviously we are not dealing with a “one size fits all solution”. In addition to eClinicalWorks, some of the other well-known names are SpringCharts, Massachusetts based Meditech, Allscripts, headquartered in Chicago, and NextGen Healthcare with offices in Horsham, Pennsylvania.
The Reagan Eye Center in Waxahachie, Texas has had NextGen’s system in place since August of 2007. According to Paige Pollard, OD, EMR administrator for Reagan, the key to launching a successful EMR initiative is giving the staff plenty of time to familiarize themselves with the EMR and offering enough training, practice, and support. Explains Pollard, “It’s important to be as comfortable with it as possible.” She adds, “I basically spent one day a week in training or manipulating the system, which worked well because I knew what our exams were like and could configure the EMR to match the way we work.” The Center has four facilities within Waxahachie. Since the system “went live” there has been increased efficiency across the four now networked sites, where they no longer have to fax charts or other paper records between locations. Pollard explains that the system also automatically supplies the coding for services performed during exams, which has improved revenue. “When I first saw the increase in revenue, I was a bit worried but then realized that the EMR captures codes more accurately and gives you more than you might typically give yourself”
Excela Health, a network of medical practices representing a variety of specialties located throughout Westmoreland County Pennsylvania, turned to Allscripts to implement an electronic health record system for its more than 115 physicians. “Our strategy calls for finding ways to enable physicians to improve the quality of the services they deliver, simplify their lives, and to improve their bottom line, and we believe Allscripts will help us accomplish those objectives,” said Otto Salguero, chief information officer of Excela Health. “Electronic health records eliminate the inefficiencies of the paper chart and provide ‘best practice’ guidelines, automated safety alerts, health management plans and other critical information where it’s needed most, at the point of care.”
Those who have been through the process of implementing EMRs agree that due diligence and having the proper information and support before, during, and after implementation is critical to its success or failure. As the old saying goes “fail to plan – plan to fail.”
IT experts agree it is important to think through all the steps in an EMR project from one end to the other. Organizations such as HIMSS provide information and valuable resources to healthcare professionals considering an EMR solution. According to an HIMSS report available on their website, among the first steps physicians need to take before implementation of an EMR solution is to “Develop an implementation budget and create a project plan to guide your process”. The report states that practices all too often underestimate the amount of work required to prepare an EMR product to go live. Small practices should expect staff to put in many additional man-hours, or hire additional staff during implementation -an expenditure many offices fail to plan for. No matter the size of your office or clinic, the EMR vendor you have selected should provide you with a Project Plan – if they have not – be sure to ask for one.
Robert Miller’s research found that most small practices greatly underestimated the learning curve required to reap the full benefits of an EMR system after initial launch. Most of those in the California Healthcare Foundation study reported an increase in the length of time necessary for documentation, and found they were working longer hours on average, once they had put in EMRs. It is difficult to predict length of learning curves and the impact of learning curves on productivity, but most vendors of EMRs say that typically within 6 months to one year, healthcare providers are leaving their offices at their normal times.
Researchers have found two other important pitfalls practices often run into is not having the right hardware to support the EMR system, and not anticipating the level of the staff’s reluctance to adopt the new procedures. The first can be avoided, say the experts, by working with the vendor and following their “recommended” system requirements and not the “minimum” system requirements. According to HIMSS, avoid the second by “appointing a physicians champion” -a person who can reassure staff, ask for their input and be motivating and enthusiastic about the specific benefits that the EMR will provide.
According to results from the most recent HIMSS Ambulatory Healthcare IT Survey, market growth of electronic medical record implementations in settings such as private medical practices or specialty clinics, continues at a slow but steady pace. “Our survey results indicate that medical practices and clinics recognize both the value of, and the barriers to, implementation of the electronic medical record,” said Mary Griskewicz, MS, FHIMSS, senior director, ambulatory information systems, HIMSS. “While this transition from paper to digital health records slowly moves ahead in ambulatory healthcare settings, HIMSS will continue to monitor the needs of, and provide educational resources, for this important sector of healthcare.”
Over the next few years, deciding to adopt an EMR will likely be one of the most important decisions made by any clinical practice. The transition to an EMR from a paper system can be challenging, but with extensive planning and proper support many of the pitfalls can be avoided, leading to a successful implementation.