July 18, 2005

Prescription for EMR Success

Girish Kumar and Seth Eaton, MD

The front lines of health care are small and medium-sized medical practices that deliver 70 percent of America’s health care. Initiatives by Health and Human Services and the proposed bills of Senators Clinton, Frist and others have put the spotlight on technology. Yes, these are positive catalysts for IT adoption. Standards and interoperability will move the process 25 percent faster than would otherwise happen.
However, adoption can move still faster if additional steps are taken to guide our efforts:

1.  Inspire small and medium sized physician groups to adopt an EMR. For parallels, consider the financial services industry and the adoption of credit cards. In health care, government, insurers and providers must work together to devise an equation that benefits all. One possible approach: Medicare fee schedules with EMR discounts.

The challenge in creating a national integrated health information system is that the health care industry historically has been fragmented. Small doctor’s offices, which on average have about 2.5 physicians on staff, will not move as quickly without help compared to large hospitals. But even in the hospital sector, nearly 80 percent are non-profit, single-site facilities. Therefore, only 20 percent of the hospital capacity in the United States is actually in a position to retain earnings that can be reinvested in any form of health care process improvements or technology.

2.  Increase pay-for-performance programs. Following closely on incentives is pay-for-performance. Health plans are already taking tentative steps in this area, but a standardized and broader system for pay-for-performance will be possible though widespread EMR adoption.

3.  Beware of too many standards. Physician practices are the nodes of delivery for the health care infrastructure. As different standards are proposed by public and private interests, consider that interoperability without the nodes is like a highway without cars. Government is forging the vision, and private industry can collaborate to make sure small and medium-sized physician offices make their way onto the highway.

4.  Enable EMR technology to pay for itself. For small practices, technology investments often don’t pay off, which is reflected in low adoption rates. Streamlined workflow, increased doctor efficiency, clinical data collection and decision support are all one side of the coin. The other side: While improving workflow and reducing costs is helpful, a truly valuable EMR addresses coding, reimbursement management and payer interactions to help drive practice profitability. If an EMR system pays for itself with increased collections, the practice will be highly motivated to completely adopt the system.

To see the impact that EMR technology can make on small practices, consider the example of MedPeds, a six-physician pediatrics and adult medicine practice in Laurel, Md. Last year MedPeds made the transition from a practice operating with paper-based charts to one utilizing EMR technology from eClinicalWorks.

Many physicians are reluctant to adopt EMR technology if it does not mirror workflow. An intuitive, easy-to-use system is key to adoption. MedPed’s head nurse had never used a computer prior to implementation. When MedPeds moved to electronic tablet PCs, the nurse considered retiring because the process overwhelmed her. Within two months, however, she became enamored with what she could now do for patients in her job as a triage nurse. She is now an EMR advocate because of how easy her job became, how quickly she was able to pull information from a patient’s electronic record and how easily her messages transferred from her desk to the physician’s desk and back again. A message from a triage nurse now goes to a physician and back an average of one day faster than before the EMR was implemented.

Chart tacks have been eliminated and, as a result, employees no longer search throughout the office for patient information. Instead, all necessary employees enjoy instant access to patient information, which is more accurate, in-depth and available then ever before. Additionally, chart creation time has been reduced to a couple of minutes, while the management of phone calls and messages has greatly improved.

MedPeds found these “soft” benefits invaluable when considering the efficiency increases and flexibility EMRs have given doctors and nurses. For example, physicians on call can view from home complete patient histories, past visits, current medications, allergies, labs and charts. The on-call doctor can then speak to the patient and send one of her partners a message or a phone encounter, right to her inbox, so that when she comes in Monday morning, she can manage her patient. In this way, and many others, an EMR solution helps the practice with continuity of care. Medical reminders and alerts communication, lab tracking and database management are also distinct advantages, as is the ability to run reports to see trends or quickly view previous patient visits.

Today many consumers are clamoring for increased knowledge and empowerment. In this regard, an EMR solution with patient-doctor interaction should be strongly considered. MedPed is implementing a patient portal, an application that will make the patient experience more pleasant and customer-friendly.

The current paradigm is that information is physician- and telephone-centric, whereas the patient portal is patient- and Web-centric with patients controlling their access to key information: prescriptions, referrals, lab results and appointments. The elegance of a patient-centric data flow is that it will save physicians money and enhance patient satisfaction. Information patients want to receive and send is so tightly integrated with the EMR that much staff time will be saved in patient communications, while avoiding the hassle of the customary “telephone tag.”

At MedPeds, the EMR technology has reduced non-physician support staff by 33 percent. The office overhead for the practice has decreased by about 15 percent, overdue accounts have decreased by 50 percent, and income per visit has increased as doctors have documented more detailed progress notes. Patient volume has increased by 10 percent, and new patient volume increased by 50 percent. Return on investment for the EMR is 100 percent in one year.

Meanwhile, patient satisfaction has increased per managed care patient satisfaction surveys and in patient comments in the office. Patients like the ease of access to their records when they call in for advice from the nurse, the ease of communication with the specialist, prescriptions waiting for them at the pharmacy and the ease of obtaining accurate information from the doctor on call.

Providers, payers and the government need to take on responsibility for a much more sophisticated, much more involved shepherding of health care information. Standards and regulation are needed so that the information that they accumulate is acceptable and usable for the public good.

Policy makers and the private sector must work together to turn guiding tenets into practical realities.  
 
Dr. Eaton is with MedPeds, a six-physician adult medicine and pediatrics practice in Maryland.

Mr. Kumar is founder of eClinicalWorks, an electronic medical records and practice management company in Massachusetts