Electronic Health Records

Health policy analysts predict efficiency and patient safety savings of hundreds of billions of dollars — up to $371 billion in one study1. That’s an attractive prospect. So why do so many physicians still use the records their great-grandfathers designed?

Fewer than 15 percent of physicians in the United States use fully functional electronic medical records in their practices. That’s after more than 30 years of study and experimentation. There has been progress with computers, of course:

• Practically all physicians use a computer to record and bill all of their patient transactions, and have done so for decades.
• The majority of insurance claims are now submitted electronically, and many payments are available as electronic remittances banked directly into the practice checking account and explanation of benefits information downloaded right into the practice computer.
• Nearly all practices schedule all patient appointments on the practice management system, allowing many hands to write in a single “book” at the same time and print a customized encounter form for every patient on the schedule.
• We’ve learned to use the Internet to check patient insurance eligibility and email to request referrals and pre-authorizations.
• Email technology is increasingly handy for refilling prescriptions.

Scanned paper document management is being adopted as a task-specific adjunct to traditional paper medical records for fast and easy file access to remittance advices and workers’ compensation work status reports.

Storage of transcribed dictation as an appendix to the practice management or document image management system is another supplement to the paper chart system that has been useful for twenty years at a reasonable cost.

These advances have easily paid for themselves in labor savings and error prevention. So it would seem that applying this technology to compiling and storing “the rest” of the clinical record in some sort of relational database system would be an obvious winner.

The first electronic medical record system we ever saw outside of an academic setting came on dozens of 5.25” mini-floppy disks (160kb each!) with a handsomely printed manual in an elegant slip-case boxed set. The year was 1982, and the system, state-of-the art at the time, was the product of a pioneering internist in Texas with a mission to make every part of every patient encounter seamlessly digital. Nobody could afford it then. Oddly, few say they can afford it now, even with computers geometrically more powerful and with terabytes of storage for mere hundreds of dollars. Here are some of the obvious costs that are so hard to overcome:

• These systems are complex and sophisticated and, because of the limited market size, software licenses are priced high.
• The equipment needed means a significant upgrade, if not an outright replacement, of existing IT systems. More data entry and lookup terminals are required, often more than doubling those needed for the practice management applications.
• System training means taking workers, including physicians and mid-level providers, out of their normal tasks for classroom and onsite training for days at a time. Productivity is lost, some of it billable. Only larger groups can organize to operate without these workers while training is done.
• Conversion of paper records into the electronic system is slow and tedious knowledge-work involving reading the chart, extracting identifiable data elements, and populating fields in the new system, then scanning in the rest of the record. As a practical matter, most groups can only convert the charts of returning and new patients, leaving the inactive records in the “archives” (storage shed) until they can be safely shredded.
• New features you will want in your system will be offered each year. Expect to pay for them. Enhancements to most software are included in the maintenance/support fees you pay, but not for EHR systems. As they say in retailing, “After the razor, comes the blades.” Expect to be asked to license each new feature as an “add-on module.”

In our consulting work, we’ve observed additional, unanticipated costs as well. Practices are not always candidly prepared by vendor sales staffs for the complexity of the new IT network and the need for expert local support. This kind of work comes at an annual salary level in the high five figures, which, when purchased part-time or by the hour, can annualize even higher. Odds are, if anyone working in the practice has tech skills above the hobbyist level, it’s a physician, whose time can’t be used this way in the business.

Another hidden cost: the “refresher” required for the equipment. That’s IT code for replacing the expensive parts of the network about every three years. Your keyboard and mouse will last just fine, but those server “blades” are just too important to risk getting old. A crash, even when backup is almost continuous, brings everything to a standstill. Losing a chart is one thing — we’ve learned how to vamp without it. Losing them all, even for a day, will ruin your month.

As if those were not enough, you’ll have to factor in the cost of lost physician production. The academics who write the cost/benefit studies of EHR usually estimate this at a 15 percent reduction in productivity for three months. That’s optimistic in our anecdotal experience. It’s this item that causes so much resistance from some physicians in groups trying to adopt EHRs. When a partner can’t make the system work perfectly in a half-day of trying, expect to continue providing him paper charts.

Then there’s the cost associated with the conversion of your practice management — billing and scheduling — system to one that will be integrated with the new EHR to get full functionality. If you have ever converted from one billing system to another, you know it never goes smoothly, and cash flow can slow — or stop — while you iron out the kinks.

Are There Any Success Stories?

So, is a modern EHR system a rule-out? By no means. I wouldn’t want to try to practice primary care without a robust EHR to remind me of suspect adverse reactions, allergies, and the myriad other complexities of patient management.

Here’s what the success stories we’ve seen are like. Most of them are solos or very small groups where there is a uniform commitment to make the technology work on the part of the owners. Three partners can agree and support each other, in a way six often cannot. Larger groups breed non-conformity in group members where their antisocial behaviors are diluted by numbers. We see it all the time. That stops, too, when groups get so big the physicians start feeling like employees and are more likely to follow administrative and medical director leadership.

Big groups sometimes have access to financing that smaller, more traditional practices don’t. Earnings from an endowment or grants are more available to giant, multi-specialty groups, but that’s about to change. The people who should be sponsoring EHRs, even underwriting them, are hospitals, IPAs, and state governments. There were Stark anti-kickback law and Treasury Department private inurnment prohibitions on hospitals doing nice things for their medical staffs. That just changed this past summer. The IRS and CMS have both lifted the ban on hospitals helping physicians to put EHRs in place. We think 2008 and 2009 will be good years to take another look at this tempting, if daunting, technology.

Sources:

1) Hillestad, Richard et al., “Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs.” Health Affairs 24, no. 5 (2005): 1103-1117.