My EMR Reality

My EMR Reality

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OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

I was practicing with another PCP at that time.  We were employed by a hospital, but were growing increasingly frustrated with their lack of interest in running our practice efficiently.  So we left them in 1996, bucking the trend at that time of hospital ownership of practices for the sake of personal control.  It put us under far more financial pressure, but the control made it worthwhile for both of us.

Feeling the sting of the missed test result, and feeling the empowerment that self-employment brought, my partner and I set about to look at EMR products.  My brother-in-law worked in a nearby practice that had already been on EMR for a few years and was functioning far more efficiently than we could ever hope with our paper record.  We both visited his practice and saw just how much we could gain from a computerized record.  Once we saw this, the question was not whether we were going up on an EMR, it was which EMR product we’d choose.

We narrowed our choice down to two products: one that was well-known and well respected, but more expensive; and one that was cheap, slick, but had a very small user-base.  We were sorely tempted by the slick sales presentation, but listened to our better judgement and went with the more established product.  After buying the product, the cost would end up being $1000 extra per month per physician (given the terms of the loan we could secure for an $80,000 installation).  We both winced at this, given our short time of independence, but then my partner boiled it down very simply:

  • How much do we earn on average per patient visit? We shot low, and said $50 per visit.
  • How many days do we work each month? Both of us worked 20 days per month at that time.
  • How many extra patients would we each have to see to pay the $1000 monthly loan payment? One extra patient per day would easily cover our expense.

One patient per day?  That’s all??  It made the decision quite easy, and it made the ROI quite easy to grasp.  Our goal was to use the EMR in such a way that it would improve efficiency (something we had seen in my brother-in-law’s practice) and focus on other benefits of EMR once we had it paying for itself.  We reached that goal easily within the first 6 months of using our EMR, and exceeded it soon thereafter. Neither of us saw ourselves as slaves to the EMR, we saw the EMR as a tool.  Consequently, we found our own means of accomplishing our goals, using the EMR in ways that other users hadn’t considered.

  • We didn’t care about being paperless, the goal was efficiency and quality of care, not saving trees.
  • We didn’t like the standard templates supplied by the EMR vendor, so we made our own.
  • Whenever I became frustrated with a process, I talked to my partner and then changed the template to fix the process.  I soon became an expert at template development, gaining prominence among users of our product.
  • When the process inefficiency was not template-driven, such as the use of nurses, the process of answering phone calls, or other common situations encountered in our office, we talked with our office manager and staff and came up with a solution.  Our EMR gave us a bunch of options for solutions we would have not had without computers.
  • We quickly realized that fixing too many things at once created trouble.  I adopted the philosophy: “a good idea at the wrong time is a bad idea.”  So we worked to prioritize problems in terms of their seriousness and how easy the solution was.
  • Once we had an efficient workflow, we realized there were incredible gains to be had from a care-quality standpoint.  We were not paid more for good quality, but our efficient workflow afforded us the opportunity to focus on it nonetheless.  That may seem backwards for non-clinicians, but it is the reality of private practice.  In truth, our quality had already gotten significantly better simply from the improved organization of our records and instant accessibility anywhere, any time.

Forward to 2010, and here is where we stand:

  • I see on average 25 patients per day, working 4 days per week.
  • We have 5 Physicians and 2 PA’s.  The efficiency of our office has increased with each additional provider, as we haven’t had to increase overhead much at all with each addition.
  • We no longer see patients in the hospital (except pediatrics, which is a small number), and we don’t do many in-office labs or other procedures.
  • Despite this, our income has been very good – well above the national average for PCP’s.
  • On quality measures, our practice has excelled every time we’ve been measured.  We easily qualified for NCQA diabetes certification, and our measures for prevention are impressive – with colon cancer screening, childhood immunizations, adult immunizations, and cholesterol screening far above national averages.
  • Most importantly, I give my patients the time they need.  I make a point to not rush my visits.  Each visit is given 15 minutes, no matter of the type, but visits that require 30 minutes are given that time (which is usually offset by the 5 minute sinus or ear infection visit).

That is why the arguments against EMR ring hollow to me.  I see it like the arguments people give against exercise:

“I don’t have enough time to devote to exercise.”

“I hurt after I exercise, and basically feel lousy.  I can’t afford to feel that bad.”

“I need my sleep in the mornings and am too tired at night to exercise.  I’m doing OK without it for now.”

Yes, I sympathize with these arguments.  I have made them all myself, and still struggle to exercise regularly.  But anyone who says people are better off not exercising are just plain wrong.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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48 Comments on "My EMR Reality"


Guest

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Guest
EHRDoc
Aug 2, 2011

I recently made the switch from paper to electronic and I have not noticed any negative changes in productivity. In fact, my work day seems to run more smoothly. I have learned that it is important to find a company that will guide both you and your staff members through the change. I chose a small company called TNEHR and I would recommend them to any doctor who wants to make the switch.
http://www.tnehr.com

Guest
c'est moi
Sep 12, 2012

How much do you sales guys get paid?

Guest
Apr 5, 2011

Hi Rob L,

I’m curious to see what you think about the the EHR company Nortec EHR. This Company is of course CCHIT and ONC Certifed but also has a Five Star Usability Rating. Any thoughts on this company http://www.Nortecehr.com.

Guest
Information scientist
Dec 4, 2010

You mention that
“True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away. True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.”
That’s great for you. However, your sample size (n=1) is not a representative sampling of physicians. This is not science. This is not how medicine works.
Others have had a different experience.
Example: http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html
Only looking at the positive side of a domain while ignoring other sides is not science. It is quackery.

Guest
Nov 27, 2010

I think you made good points about adapting to EMR usage, and i think the choice of EMR is determined on various factors that differs from a speciality or provider or even from a doctor to another.

Guest
Nov 22, 2010

I serve as a consultant for a medical records company that provides both paper templates and has now released an electronic version of the system, AvivaEMR, for those who prefer an EMR, or, more likely, who feel compelled to switch while the switchin’s good (i.e., supported by federal incentives). I too have heard most if not all of the arguments on both sides of this fence, and the answer, in my opinion, is that it depends on your practice and on the doctor’s own workflow and “style”.
For some, implementing an EMR is not that big a deal as they are comfortable with getting pretty involved, and actually does result in a more efficient workflow, driving a positive ROI. For others, the learning curve is like passing a kidney stone and overall methodology never feels like a good fit, costing them money every day.
Arguing that one way or the other is good for EVERYONE ignores the fact that there are positives on both sides and negatives as well, no matter which side of the debate you decide to take. The key factor is fit – does the method fit, or can I make it fit without an unacceptible level of customization or time spent on my own part? After all, at $50 per 15 minute visit (the estimate given above), a doctor’s time spent seeing patients is worth $200 an hour. At that rate you can (and probably should) have a truly qualified software architect write an EMR for you. (I work for one of those too).
Yet, for many of the doctors we contact, the deciding factors include whether or not they’re going to stay in practice long enough for the government mandated changes to have a significant effect on their practice and whether or not Medicare/Medicaid patients constitute enough of their patient base to worry about the government carrots and sticks. If not, it might not be economically worth making any changes at all, despite how much the government, insurers and pharmaceuticals might benefit from a national digital database.

Guest
Nov 16, 2010

Great insight and easy to understand. I love your thoughts on this! I am currently Managing Partner for SSi-SEARCH, retained search for health IT leadership. Prior to this I spent 17 years in sales and consulting for EMR / EHRs to hospitals and physicians. Objections? I have heard them all. This background was great training for finding health IT leaders today, CIOs and CMIOs. We are launching a new blog called hospitalcio.org and the focus is on the impact of EHR timelines and the role of the CIO. I’d love to share your perspectives!

Guest
Oct 23, 2010

Electronic medical records, abbreviated as EMR, can be defined as a electronic store of medical records of patient, such as their past medical history, substances or drugs they are allergic to, the treatments or medical procedures they underwent in the past, history of family hereditary details, previous drug prescriptions, all the previous charges and all relevant information that a provider may need at any point of time to ensure proper diagnosis of the ailment.

Guest
Sep 23, 2010

I thought it was great that I found a doctor who used EMR technology until I asked for a copy of my records. I am being told that they use a Medical Records Release Service which comes to the doctor’s office to retrieve the records for them and the cost to me will be $1.00 per page. I have asked for the records to be copied for me via CD/DVD, memory card, flash drive, etc. which I am willing to supply. I can not afford $1.00 per page for many years of records. Any suggestions would be much appreciated!

Guest
adder
Sep 11, 2010

Lost in all of your talk of profits and streamlining is whether you patients want their information digitized and accessible to ANTONE with a remote interest. No one bothers to ask. They simply DEMAND compliance.
It is intrusive and invasive.
And yes because it is now MANDATED, it doubly unacceptable because that patient information, MY information, not yours, is now subject to viewing by the entire country. Oh yes it will be too.Because it can be.
So have fun with your new toys and enjoy the nuts and bolts of playing with your shiny new systems.
But as a patient, I resent the intrusion. And I will NOT play along.

Guest
Vishal
Aug 12, 2010

Nice blog. I really like the way you have covered some of the striking and critical issues in having a successful EHR implementation.
I would just like to add that th use of the right tools & Services through use of specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
Looking at the profitability of the EHR investment, I think ROI is very important factor that should be duly considered when look achieve ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment.
Also having the right ( in terms of appropriate knowledge and experience) support function i.ey the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.
Creating the right infrastructure for implementation by looking at the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the
’safe vendor challenge’ as discussed by many critics.
Do you all agree with me?

Guest
John
Jul 26, 2010

Rob:
Great information. Really well written blog that was educational as well as stimulating. I am researching EMR solutions for a client (a medical practice) and they are looking for a product recommendation, or at least direction. What EMR solution did you select? What are your personal pros and cons about the product/service? Was it easy to install, implement and maintain (from a technology standpoint)?
Thanks,
JSD

Guest
Jul 23, 2010

There are solutions for the solo and group practices that will not break the bank. I2Qmed has made implementing a patient portal and PHR a little easier with their I2QmedEP product which is fully managed and free of charge. For more info visit http://www.i2qmed.com

Guest
Brian
Jul 21, 2010

pcp said:
“So docs should spend their time, effort, and money using lousy products in the hope that the for-profit EMRS manufacturers will listen to their complaints and eventually come up with something better?”
Like it or not, docs need to take ownership of the EHR/EMR issue and force vendors to fix their “lousy products”. If they do not, then the vendors are free to continue forcing inadequate and poorly designed (from a treatment and care perspective) “products”. I still see way too much apparent apathy from physicians concerning this whole EHR/EMR issue, which concerns me greatly.
In the end it is your practice, license, reputation, and patients health that is at stake. If this is not worth some real time and attention, then you have greater issues to think about than if to implement and EMR/EHR or not.

Guest
praetorius
Jul 16, 2010

If EMRs had redeeming value for improving medical care, the doctors would embrace them. They would clamor to purchase.
Right now, it is better to not buy and take the penalty, or delist from Medicare.
Pcp should report the level 5 requirement to Senator Grassley at whistleblower@finance-rep.senate.gov