Embracing EMRs

Physicians Who Have Done So Say Change Is Worth the Cost  

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Symposium on Health Information Technology - July 2006   

By  Erin Prather
Associate Editor  

Dr. X is tired. She's been at the office since 6 am with only a lunch break between 40 or so patients. It is now 8 pm and she's no closer to going home than when the office closed three hours ago. Her computer blinks as she rubs her eyes. On its screen is an electronic medical record (EMR). The system has a bug, causing it to malfunction. If she can't solve the problem, she can't view her patients' charts. Dr. X drops her head on the desk, wondering how spending $22,000 to improve her practice caused such a mess.

Dr. X is fictional, but physicians' fears of ending up like her are real. They have to overcome those fears. Texas Medical Association's Healthy Vision 2010 says Texas must devise a plan to bring interoperable EMR systems to all physician practices to save lives and money. It's time for physicians to plug into the EMR phenomenon. To read Healthy Vision 2010 , go online to www.texmed.org/Template.aspx?id=4535.

Since publication of the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System , politicians and health care officials have touted EMRs as a way to increase quality, encourage savings, and reduce errors. In 2004, President George W. Bush launched a federal initiative to make electronic health records available to most Americans by 2014.

Last December, the Texas Statewide Health Coordinating Council (SHCC) named an advisory committee to develop a long-range plan for using health care information technology in Texas. Mandated by Senate Bill 45, the committee's plan will cover the use of EMRs, computerized clinical support systems, computerized physician order entry, regional data sharing, and other methods of incorporation.

Those outside efforts to implement health information technology (HIT) are the core reason Denton obstetrician-gynecologist Christina Ann Dooley, MD, elected to have an EMR system in her new practice.

"As a new physician, I was forced to decide upfront whether I wanted paper charts or an electronic format. Since everything will eventually go electronic, I decided it was a better choice, even though it was more of an investment upfront," she said.

Physicians often cite cost as the No. 1 obstacle to implementing EMR systems. The fall 2005 report FasterCures , by the Center for Accelerating Medical Solutions, says other barriers include security and privacy concerns, acceptance and training, infrastructure development, and technical issues. 

Cost Effective  

Martin Garza, MD, an Edinburg pediatrician, has used an EMR system for more than two years. Dr. Garza says his billing is streamlined to where he needs only one billing coordinator. That reduces his overhead because he needs fewer employees than if he was still using paper. It also saves time.

"The costs for a paper office are there, physicians just have to add them up. In the long run, EMRs are probably less expensive. If you go electronic and the costs come out even, think about the time you saved. At the day's end, I don't have to ask someone to run around and retrieve charts for me. I don't have to go searching through a pile on my desk. It's just point, click, and find," he said.

Barbara Fogiel, MD, who started her own obstetrics and gynecology practice in Houston, agrees (see " Practice 911," April 2005 Texas Medicine , pages 55-57).

"I save in terms of staff costs and reduced aggravation," she said. "Reduced aggravation is better in my mind. Plus my patients love that I'm paperless and have confidence that my practice is up with the times."

Dr. Dooley says her patients appreciate electronic prescriptions, as do pharmacists. She saves time because her office doesn't have to answer calls from pharmacists trying to interpret her handwriting, as the prescriptions are clearly printed. It also reduces the risk of medication error.

She points out that her system's mainframe is actually in North Carolina. Should something happen to her office, Dr. Dooley's patients' records would be backed up. Last year's hurricanes proved that such a precaution can be extremely beneficial.

The October 2005 Health Data Management says effective EMR systems make physicians more efficient and productive, allowing them to see more patients by "eliminating time lost waiting for charts, lab results, and other paper-based data." Patients also spend less time in the waiting room.

Both Drs. Garza and Dooley say using EMRs has helped ensure proper payment for their services. Their systems require them to know billing codes in order to fill out charts.

"I definitely have a better understand of coding and billing," Dr. Dooley explained. "It's improved reimbursements because I'm personally billing what I do. Essentially, the coding is more correct than if someone was reading my chart, trying to figure out what the heck I'm telling them."

Added Dr. Garza, "I know what an item is coded for and can literally see the electronic paper trail on the computer. I can track from the moment I see a patient to when the insurance company pays me."

FasterCures also says the increasing use of the Internet in recent years has cut the cost of adopting EMRs and made it easier for physicians to connect with specialists, hospitals, and insurers.

Don't be penny-wise and pound-foolish in keeping an electronic system updated. Dr. Garza warns physicians not to cut corners by failing to upgrade a system or attempt to combine old and new systems. Trying to save money this way can give you a headache like that of our fictional Dr. X.

"It's important that physicians have a complete program, not bits and pieces," he said. "You have to be careful when putting two programs together; it may not work out well. If the charting program cannot talk to the billing one, then the physician is risking not getting paid. I've seen it over and over again with colleagues. Thousands of dollars are lost because their technology programs cannot communicate. It would have been more cost effective to go ahead and purchase one complete system." 

Who Is Doing What  

TMA conducted a survey online and by mail in fall 2005 to see how many physicians were using EMRs. Invitations to participate were mailed to members of TMA and the Texas Medical Group Management Association (see " Ignoring Technology.")

Only 27 percent of the 1,772 physicians who responded are using electronic records. Younger physicians are more likely to be in this group, which includes 37 percent of doctors younger than 40.

By specialty, family physicians are most likely to have implemented EMR systems, while otolaryngologists are the least likely. In 2005, the Center for Health Information Technology (CHIT) reported that EMR implementation by members of the American Academy of Family Physicians increased from about 12 percent to nearly 30 percent in the past two years.

That statistic does not surprise Dr. Dooley.

"A lot of the EMR systems are geared toward family practice," she explained. "It took me a while to find a system that worked. Many EMR companies have not invested the time or money to make their systems pertinent to the OB profession. An OB chart has labs, flow sheets, and other things that many systems don't have the capability to do."

Whereas older physicians often complain about having to transfer their paper charts to an electronic system, frustration for younger physicians lies in their system's inability to perform simple tasks.

"Based on what computers can do these days," Dr. Dooley said, "physicians do become frustrated when their system can't perform a simple procedure. My system cannot calculate a patient's due date. It's the simple action of adding a number of days to the date of their last period, but my system just can't do it. That will have to be something added into the later version."

According to the TMA survey, access to medical records was the most important feature of the physicians' EMR systems. Second was improved workflow, followed by reduced medication errors. Other valued features include reduction in medical records storage and transportation costs.

Half of the respondents who do not have EMR systems plan to implement one eventually. Older physicians are almost as likely as younger physicians to go electronic; a third of the respondents older than 70 are planning to implement an EMR system.

When asked what they liked least about EMRs, physicians surveyed said at times it was difficult, awkward, or time consuming to enter data in the system. They also mentioned that there is no interface with hospital or ancillary provider systems, that new kinds of errors are possible, and that productivity is lost during implementation.

To make the transition smoother, Dr. Garza recommends physicians contract only with computer professionals who have HIT experience. He says physicians too often enlist friends or family members to set up an EMR system.

"You need to make sure the person is knowledgeable not only about computers, but also about medical billing software. Physicians should investigate the software and the person who is setting up the system. Otherwise, you have a potential disaster."

As more benefits of EMR systems are realized, physicians will shake off their fears and doubts of the HIT system. When it comes down to it, they are responsible for the results produced by EMR systems.

"Physicians need to be involved in their systems," Dr. Garza said." This task can't be delegated to an office manager. As involved as physicians are with their patients, they need to also be involved with their EMR systems."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at  Erin Prather.


TMA and TMF Services

Texas physicians needing a consultant's expertise during the process of adopting an electronic medical record (EMR) system can turn to TMA Physician Services or the TMF Health Quality Institute.

TMA Physician Services has offered full-service practice management consulting to TMA members since 1999. In addition to new practice setups, operational and billing assessments, and coding audits, Physician Services provides comprehensive technology consulting for new and existing practices.

TMF Health Quality Institute (TMF) offers EMR consulting services through the Doctor's Office Quality - Information Technology (DOQ-IT) program. DOQ-IT is a national initiative funded by the Centers for Medicare & Medicaid Services (CMS) to help physicians successfully adopt EMR systems. CMS has contracted with TMF to assist practices through October 2007.

Denton obstetrician-gynecologist Christina Ann Dooley, MD, advises her colleagues to contact TMA Physicians Services or the TMF Health Quality Institute when they wish to set up an EMR system. She also recommends physicians seek out colleagues locally or regionally who are using programs in which they are interested.

Houston obstetrician-gynecologist Barbara Fogiel, MD, agrees. She warns that physicians should never rely solely on a salesperson's demonstration and that it's important to double-check that a system can do the things the provider promises. In essence, physicians should take the same precautions needed in buying a car.        

"When purchasing an EMR system, I would get opinions from other users. Take references, talk to colleagues, and get their feedback about what the system does. I ran into a problem because my provider promised me a system could do XYZ. The version I got could only do ABC, not XYZ. That was going to be included in a later version. I didn't realize that when I purchased the system.

"Physicians should write down the goals they have for the system," she added. "They also should make sure the company selling the system will be around for a long time and will not simply fold."

Recently, the Physicians' Foundation for Health Systems Excellence awarded TMA a $1 million grant to improve patient safety by increasing Texas physicians' understanding, adoption, and appropriate utilization of vital information technologies. The first funding check was received on Jan. 1.

As a result, TMA formed the Health Information Technology Department to create and coalesce existing and planned TMA health information technology activities (both grant and non-grant funded).

For both in-office support and interoperability development, TMA plans to partner with organizations such as the Healthcare Information and Management Systems Society to utilize tools and resources that others have developed and to explore potential sponsorship opportunities with vendors to further offset expenses of the project.

TMA has developed a helpline to assist physicians and their office staff with issues related to health information technology. Call (800) 880-5720 or email  HIT@texmed.org


Ignoring Technology: Texas Doctors Not as Wired as They Should Be

Editor ' s Note: The following story originally was published in the May  2006issue of Texas Medicine . We are republishing it in case you missed it.  

Barely a quarter of Texas physicians recently surveyed by the Texas Medical Association have taken the first steps to implement a vital new lifesaving and money-saving technology in their practices.

"Texas must devise a plan to bring interoperable electronic health records (EMRs) to all physicians' practices to save lives and save money," said TMA Immediate Past President Robert T. Gunby Jr., MD. "TMA has launched a new program to guide doctors through the decision-making process. But the overwhelming value of EMRs to the health and health care of all Texans demands a comprehensive state strategy to accelerate the adoption of these complex and costly systems."

TMA's Electronic Medical Record System Implementation Survey found that:

  • Only 27 percent of physicians are currently using an EMR system.
  • Almost half of all physicians (46 percent) are planning to implement an EMR system.
  • Physicians who do not plan to implement an EMR system report that the cost is prohibitive and that they would need extensive financial assistance to reconsider that decision.

President George W. Bush has called for significant investment in new health care information technology (HIT). The president and national and state experts agree that EMRs improve the quality of care, enhance patient safety, streamline physician office operations, and reduce redundant services. In its recently released Healthy Vision 2010 document, TMA concluded: "We must move Texas physicians' offices from the days of standalone, paper-based medical records and transactions into an era of shared HIT in which physicians can easily access their practices' clinical information, find the treatment protocols that help them make evidence-based decisions on patient care, and participate in data-based quality improvement activities in their own practices."

In November 2005, TMA received a $1 million grant to improve patient safety by increasing Texas physicians' understanding, adoption, and appropriate utilization of vital health information technologies.

"TMA's new HIT program will provide Texas physicians with tools, resources, education, and consulting services that will demystify the technology," Dr. Gunby said. "We want to help Texas doctors buy the right EMR system for their practice, put it in place efficiently, and learn how to operate it effectively."

The physicians surveyed who already had implemented an EMR system overwhelmingly reported that the most important feature of their system is better medical records access (79 percent), followed by improved work flow (59 percent) and reduced medication errors (56 percent). Physicians also value several features that could improve the financial performance of the practice, including improvements in charge capture (50 percent), visit coding (49 percent), claim submission (48 percent), and reduced medical records storage and transportation cost (48 percent).

The median reported implementation cost per physician was $20,000, but the survey found substantial variation: 17 percent of respondents reported costs less than $2,001 per physician, and 25 percent reported spending more than $30,000.

Those high prices for hardware and software were a significant concern of those physicians who said they plan to purchase an EMR system and an even greater barrier for those who said they have no plans to put an EMR system in their office. The physicians surveyed, however, listed many other barriers, including:

  • The cost of evaluating their practice operations and workflow in preparation for selecting an EMR product.
  • The expected short-term decline in productivity once the new system is in place.
  • Uncertainty surrounding standards for exchanging health care data among physicians, hospitals, laboratories, health plans, and others involved in patient care.
  • Uncertainty over the qualifications and financial stability of the many EMR vendors in the market.
  • The time and money needed to train themselves and their staff.

The survey findings will guide TMA's development of its new services. Of the physicians with EMR systems already in place, a majority (51 percent) reported that they would have benefited from suggestions about appropriate and effective products, and 36 percent would have liked some financial assistance. Significantly, 55 percent said they could have used help to optimize the system for their practice, and 44 percent could have used help with training.

Physicians who do not plan to implement an EMR system reported that the cost is prohibitive (73 percent), that the potential benefits do not justify the cost (62 percent), and that they have concerns about electronic system reliability (50 percent). Approximately half of physicians who have no plans to implement said they might be convinced to adopt an EMR system if they received a grant (56 percent) or if they saw evidence that the system would improve practice operations (52 percent) or improve the quality of patient care (49 percent).

"I am concerned, but not surprised, by those survey findings," Dr. Gunby said. "We must encourage public/private sector collaboration on a plan that will make developing and using HIT affordable for physicians, hospitals, and providers."

A recent Rand Corporation study found that health insurance companies and patients reap most of the financial rewards of broad implementation of HIT, while physicians, hospitals, and providers bear most of the cost. The Rand study also listed high costs, uncertain financial payoffs, and the disruptions that accompany any new technology as barriers to HIT adoption.

TMA's Healthy Vision 2010 recommends developing government grant and loan programs for physicians to purchase and install EMR systems, investing taxpayer money in creating regional health information organizations, urging the federal government to continue to develop uniform standards for electronic health care data collection and sharing, and encouraging health plans, Medicare, Medicaid, and other health care purchasers to include in their reimbursement systems provisions that reflect physicians' HIT-related costs.

"We have good reason to share those costs across the entire system," Healthy Vision 2010 concludes. "A January 2005 study found that a well-designed system linking patient records among physicians, hospitals, health plans, and others 'could yield $77.8 billion annually, or approximately 5 percent of the projected $1.661 trillion spent on U.S. health care in 2003.'"

TMA conducted the Electronic Medical Record System Implementation Survey during the fall of 2005 as a Web survey with a supplemental mail sample. Invitations to participate in the Web survey were e-mailed to members of TMA and the Texas Medical Group Management Association. An additional 2,000 physicians were mailed written surveys. A total of 1,772 responses were received, of which 154 were from the mail sample group.

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