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.