..as published in Skin & Aging
EMRS: Are We There Yet?
– By Bonnie Darves, Contributing Editor
Technology improvements and major national initiatives are ushering in a new era for the EMR.
Ten years ago, the healthcare industry prognosticators projected that electronic medical records (EMRs) would be widespread by now and that the cumbersome, bulky and inefficient paper chart would have gone the way of the dinosaurs as dermatologists, and physicians generally, discovered the myriad benefits of going paperless.
That hasn’t happened, in part because of the damage done by the eHealth hype of the late 1990s. That era spawned dozens of EMR vendors who promised the moon and then promptly went belly up, not long after the ink on their business plans dried, leaving medical practices in the lurch, investors in the hole — and physicians understandably wary.
To boot, while some practices that did take the plunge have witnessed multiple benefits, from increased staff productivity to better financials to far fewer rejected claims, others had less positive experiences. Some found the products clunky or poor performing, or experienced substantial difficulty integrating EMRs into their physicians’ work flow and practice operations.
How Many Practices Use Them?
Today, despite the shakeout in the EMR market and significant improvements in the EMR, or electronic health record (EHR) products on the market, and competitive pressures that have forced prices down, adoption remains slow: Only an estimated 10% to 30% (depending on which survey one uses) of medical practices have implemented EMR systems.
Industry observers suggest that EMR adoption has been higher in certain procedure-intensive specialties, such as dermatology, gastroenterology and orthopedics, compared with primary care
specialties. (The American Academy of Dermatology doesn’t gather statistics on EMR use.)
Why the Reluctance?
Why the lag? For one, many practices are either reluctant or unable to capitalize the expense, which can run into the six figures for a mid-sized practice. But the other reason is practical, suggests Joseph Eastern, M.D., Clinical Assistant Professor of Dermatology at the University of Medicine and Dentistry of New Jersey in Newark. “One of the biggest problems we have is that the EMR data entry is still mostly by keyboard, and that’s slowing things down considerably,” says Dr. Eastern, who frequently makes presentations on dermatologists’ use of office technologies. “If we could get our hands on anything that didn’t involve a keyboard, that would speed up adoption.”
That’s not to suggest that Dr. Eastern isn’t a proponent of information technology (IT) in practice operations — he decries the fact that most practices are “still processing clinical data with horse-and-buggy technology.” Rather, it’s that he has received an earful over the years from colleagues who have had less than stellar experiences with EMR systems.
Based on his experience talking to dermatologists about EMR use, Dr. Eastern points to what he describes as three distinct camps. On one end of the spectrum are those who have embraced it even though implementation has proved difficult, for the paper-reduction benefits the EMR affords.
He points to studies that have found an 85% reduction in chart pulls at 12 months after EMR implementation, a 15% reduction in staffing, and a 20% physician productivity gain. Southern Illinois Dermatology Associates in Herrin, for example, has been able to add five providers and a couple of satellite locations without increasing support staff, since implementing a NextGen EMR system in 2000, notes the practice’s administrator Tracy Wyatt. “If we had still been in the paper-based mode, we wouldn’t have been able to do that,” she says.
In the middle camp is “the group that’s keeping their eye on things but are not ready to actually spend any money,” Dr. Eastern says. At the other end are the Luddites, those who actively and vocally resist EMRs. “Those are the dermatologists who say, ‘if I have to switch to an EMR, I’m retiring,'” Dr. Eastern quips.
Rhett Drugge, M.D., a Stamford, CT, dermatologist who is Chief Editor of the Electronic Textbook of Dermatology and founded the Internet Dermatology Society, is an outspoken proponent of IT in dermatology practice. He developed his own EMR system 13 years ago, and has a full-time computer programmer in his office who helps him continually tweak his EMR. He agrees with Dr. Eastern that EMR products have some distance to go before they’re as useful, user-friendly or seamlessly “integrateable” as their vendors sometimes promise. Despite those realities, Dr. Drugge thinks that most EMR systems are an improvement over the status quo.
“EMRs can be a way to unburden the doctor from unnecessary paperwork. The technology may not have fully arrived, but I would say that the light is dawning,” Dr. Drugge says, adding that the documentation capabilities in EMRs can be a powerful tool for tracking patients and providing supporting data on care delivered. “The EMR will become a care improvement tool in itself, and its use will increase soon, as doctors recognize that.”
In fact, a study published in the Journal of the American Medical Association in February found just that: Physicians who used EMRs/EHRs were 60% more likely to have complete patient information at their fingertips in the exam room than those who used paper charts.
Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL, which counsels physician practices on EMR system selection, thinks that adoption will continue to increase as quality improvement benefits are supported by scientific data and as prices level off. But sticker shock — and fears of major disruption to the practice — are slowing adoption pace.
“The difficulty lies to a large extent with the fact that the people who gain the benefit — Medicare and other payers — are not the ones who have to spend the money to buy EMRs,” he says. “Physicians have to spend the money and expend the effort to accomplish the task — a disequilibrium that I think is hampering the adoption of EMR.”
Dr. Fishman, who has counseled more than 1,000 physicians and medical groups since he launched the company, puts that cost at roughly $10,000 to $25,000 per physician for a “mid-level” system license, and up to $50,000 for “Rolls Royce” type systems. It is a big-ticket purchase, Dr. Fishman admits. However, he contends that most practices that make well-informed choices see a payback within 18 months and continuing return on investment in reduced overhead costs.
Pressure to go Paperless
Dermatologists who have resisted implementing EMR systems may soon experience some “pressure points” to abandon their paper-based systems. For one, the Bush Administration is pushing for EMR implementation, and in his recent State of the Union address, the President reiterated his goal of ensuring that every American patient is attended by an electronic record within 10 years — and one that can be accessed by any entity engaged in caring for that patient. He cited government studies that suggest as much as 20% of the $1.7 trillion healthcare budget could be saved through widespread use of EMRs, and he pledged $50 million in support of health care IT in the 2005 fiscal year.
What may be more compelling than the President’s push is the recent decision by the Centers for Medicare and Medicaid Services to pay physicians bonuses for delivering higher-quality care and reducing costs of care for patients with chronic illness. The demonstration project, which involves 10 physician organizations, spurs EMR use, observers say, because the supporting data CMS will require cannot be readily gathered, or substantively provided, without an electronic record.
Another government-sponsored initiative, Doctors’ Office Quality Information Technology (DOQ-IT) (go to www.doqit.org for details), is promoting adoption of EMR/EHR systems and increased IT use in small to medium-sized physician offices — with the intent of improving care for Medicare beneficiaries with certain diseases. DOQ-IT also offers online resources to help in choosing IT products.
Last summer, 14 medical organizations created the Physicians Electronic Health Record Coalition (PEHRC) to provide product-selection assistance and to push for financial support of or incentives for physician deployment of EMRs. Not surprisingly, purchasers are also getting in on the act. The national employer coalition Bridges to Excellence, which represents several of the country’s largest employers, recently announced the first awards generated through its pay-for-performance program to physician practices that have leveraged IT to improve patient care, and tracking and education of patients with chronic illnesses. Finally, even physician groups are leading the charge. One New York IPA, and a second in Massachusetts, have begun awarding grants to member practices that agree to implement EMRs.
Beginning of a New Wave?
It’s the beginning of what may emerge as a major wave, predicts Dr. Fishman.
“The number of third-party entities that are either rewarding doctors for EMR use or are subsidizing EMR is increasing — and that’s going to push adoption,” he says.
‘Must-Haves’ for a Dermatology Practice EMR
Any EMR product you’re considering should meet at least bare-minimum criteria, cautions Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL. He urges dermatologists to ask EMR vendors to address the following basic issues and questions before agreeing to a product demonstration or proceeding with pricing discussions:
1. Describe how your EMR system enables documentation of cosmetic
procedures.
2. Does the EMR assist with ICD and CPT coding, including E&M coding?
3. Does this feature include software that warns physicians when coding or
documentation is inadequate to support reimbursement?
4. Does the system assist with tracking laboratory tests and pathology specimens
that have been sent for analysis?
5. Does the system assist with clinical documentation (e.g., consultative reports), alleviating the need for dictation?
6. Does the system automatically generate correspondence notes (e.g., a letter
to a referring physician) from information that has previously been entered?
7. Does the system include drawings of skin lesions in the record?
8. Does the system store digital photographs of lesions in the record?
9. Does the system remind physicians and/or practice staff when certain
patients are due for additional studies or follow-up exams (such as
recheck of a skin lesion)?
10. Does the system allow patients to log on from home and enter basic
information or review their own medical records?
11. Does the system easily interface with a practice management software
application currently being used?
12. Does the system have pre-built clinical content for dermatology, including
materials that have been developed and used by other dermatologists?
If so, please describe that content and provide examples.
Trying to Choose an EMR? Here’s Help
With the number of electronic medical/health record (EMR) systems on the market now topping 250, choosing a product that’s both suitable and affordable — and whose manufacturer will be around 5 years from now — is no small feat. Yet as the government and the health care industry moves toward rewarding physicians for implementing technology that improves and streamlines the provision of care, dermatologists who’ve been on the fence about implementing an EMR system likely will embrace the adoption curve in greater numbers. For those considering taking the plunge, following are resources that may prove useful:
Healthcare Information and Management Systems Society (HIMSS), a trade organization for healthcare information technology professionals, has developed an interactive tool intended to help physician practices tailor their EMR search. Called the Ambulatory EHR Selector, the tool provides details on 30 vendors’ products and enables users to conduct searches on more than 350 distinct functions. Searches can also be conducted by practice characteristics or financial criteria: such as medical specialty, practice size, and contract structure and pricing. The tool can be purchased on an annual basis for $149, at a dedicated HIMSS’ Web site,http://www.ehrselector.com/emrtoolkit/ASP/Default.asp.
eHealth Initiative (eHI), a Washington, D.C., organization, recently created the Working Group for Health Information Technology in Small Practices, whose aim is to provide physicians working in solo or small-group practices with practical resources on EHRs/EMRs and other technology-based products and services. For details, go towww.ehealthinitiative.org/initiatives/programs/WorkingGroup.mspx.
EMRConsultant.com. This Florida-based consulting service, operated by orthopedic surgeon Eric Fishman, M.D., counsels physicians and practice administrators on EMR cost issues and product selection. He has provided recommendations on approximately 100 of the EMR products on the market, and performs a financial-soundness analysis on any vendor that makes the “short list.” The company’s Web site, http://www.emrconsultant.comalso provides a listing of products suited to particular specialties, including dermatology.
American Academy of Family Physicians Center for Health IT, although geared toward the needs of family physicians, offers product ratings as well as useful tips for all types of practices on such issues as choosing an appropriate product and preparing the office for EMR implementation. The URL is www.centerforhit.org.
AC Group, a Montgomery, Texas, consulting firm, offers product-function rankings on 50 EMR systems in its recently published 2004 Report on EHRs. It’s available atwww.acgroup.org.
(For a somewhat dated but nonetheless helpful overview of EMR products, check the California HealthCare Foundation’s October 2003 report, “Electronic Medical Records: A Buyer’s Guide for Small Physician Practices,” available in PDF format atwww.chcf.org, in the iHealth & Technology section.)
