My EMR Reality

My EMR Reality


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"

Jul 14, 2010

You will see you patients and computer screen better if you took off your hat. Everyone should buy the EMR in your office, you are such a doc!

Jul 14, 2010

Yes, I agree it can be done, and efficiency improves. I think the bigger issue is governmental intervention and control . Richard Reece of Medinnovation blog,
• As a profession, we wonder if a universal system of obligatory, government-imposed, interoperable electronic records is worth the estimated price of $27 billion over the ten years. The government has just announced its conditions of “meaningful use” of EHRs, which will require doctors meeting 25 and hospitals 23 conditions for “meaningful use” by 2015, or else, or else being excluded or penalized if EHRs are not adopted and made operable by said date. Given that only 20% of doctors now have even primitive EHRs and hospitals less than 10%, we wonder if this target date is realistic or simply another example of government arrogant overreach. We also worry about privacy and security issues and whether EHRs will become an instrument for electronic police action and federal compliance to the wishes of a ruling elite.
Have you read the ‘simplified meaningful use criteria’.

Lee Barbieri
Jul 14, 2010

Short, sound, logical and right. Your blog should be delivered to every physician in the country. I worked for a large network that used the patients/day ROI for other investments. It makes sense and is easy to grasp. I wonder why the EMR vendors don’t use it?

Jul 15, 2010

This falls in the realm of anecdote. After all these years, why are there no peer-reviewed studies that support the claims that Dr. Lamberts makes? There are some pretty good ones that contradict them.

Jul 15, 2010

pcp, it all depends on the doctor and his/her expectations. Obviously Rob was willing to tinker with templates and other tweaks a fair amount of time. Most physicians expect the “thing” to work for them right out of the box. It doesn’t. Not only that every practice has its idiosyncrasies, every doctor within the practice does too, and almost none of them have the patience, time or inclination to make a huge time investment to mold the EHR to their needs. Arguably, they shouldn’t have to.
So the success stories are techie docs like Dr. L, or large practices with a very strong office manager and/or physician owner and/or a newly created “EHR manager” position.
Everybody else just hobbles through the day without getting much benefit, if they’re lucky.

Bill Jones, MD
Jul 15, 2010

You sound like Blumenthal in the NEJM. Just because Rob says it does not mean it is anything but kool aid. Where are the studies showing benefit? There are two that show no benefit and no cost reduction, and plenty of studies and reports of patient injuring adversity from these EMRs.
The only ROI I see is that I make a ton of money printing records with a clerk’s click providing them to those who demand 5 years of records.
The EMR enables profitable record printing…reams of paper that obfuscate.

Jul 15, 2010

Nice post. I am going to circulate it among my REC team, particularly the Adoption Support subteam I lead.
Will you be going for the Meaningful Use incentive money? 5 docs? That’s $90k on the Stage 1 table (assuming your all EPs under the Medicare piece), available to you as early as next May (assuming Attestation April 1, 2011). Given the significant relaxation of the compliance criteria, I would think this would be relatively easy for your practice.

Jul 15, 2010

Is EMR really expensive for the EMR small practice physician??

Evan Earl Dussia, II, MD
Jul 15, 2010

It sure is great to see a success story about EMRs and it is clear that Dr. Lambert is a fan of his EMR.
It seems to me however that $80,000 for a document management problem in 1996 is excessive at best. I wonder if the good doctor got any of the benefits promised by the EMR vendors—fewer employees and increased cash flow.
In my opinion, based on this case presentation, it would take a long time for Dr. Lambert’s ROI to become positive.

Jul 15, 2010

Our experience is almost identical to Dr L. We started looking in about 1999- started wit ha document scanning program- finally went to a full EMR in about 2003-
No one would go back- following up on x-rayreports, lab results- it akll flows so well in an EMR. if the proper study is done it would show the benefits.
We spent $150k in 2003 for 2 MD’s and 2 NP’s. But we have easily recouped that investment. I truly believe oour quality of care is better -and exceeds 90% of PCP practices in the area. I have great data- unfortunately the paper chart clinics haave no data- so we can’t compare.

Jul 15, 2010

@Shawne –
No. Look at the inexpensive pricing alternatives provided by, say, eClinicalWorks. You can do a client-server install, of web-based subscription model. It’s not expensive at all, adroitly shopped.
Moreover, you have to keep in mind the “net marginal differential.” e.g., assume you see 5,000 pts/year (e.g., 25 pts/day, 4 days/wk, 50 wks/yr)and spend on AVERAGE only 5 minutes chasing each chart (pulling, handling/transporting, updating, photocopying, refiling, etc). Now, plausibly assume a fully-costed (“G&A multiplied”) blended labor cost of $40/hr for everyone who had to touch the record. Right there you’re spending almost $17k/yr FTE, exclusive of the other costs associated with the paper (supplies, storage sq-ft space, offsite paper backup, etc).
Probably 85-90% of that overhead goes away with an EHR. Long-term — even near-term — the EHR is cheaper. You’re already paying for it.
It all comes down to dollars per record per year, no matter what your method. If you spend $20k/yr for HIT and you see 5,000 pts, that’s $4/pt “chart”/yr for the data that comprise the CORE of your business. Expressed as a % of your gross, it’s minimal, particularly when you consider the numerous upsides.
I had an idea recently: What if a practice asked of its patients a $5/yr cash “technology fee”? Of course, you’d have to make the case to your pts that this was necessary and to their benefit (and there would be some grumbling, no doubt; we’re all sick of being hit with “fees” for everything). Such would likely cover your EHR expenditure.

Jul 15, 2010

I have one nurse and one receptionist/medical record/insurance clerk, with income in the top 20% of family docs. Which one do I fire when I buy my EMR?

Jul 15, 2010

@pcp –

Oct 31, 2013

niether it says

Wyatt Hendricks
Jul 15, 2010

Dr. Jonas Simpson, Sundial Medical Specialty Clinic, Tempe AZ
I decided to become a doctor for two simple reasons, I wanted to help people and I have an entrepreneurial bent. By opening my own practice with some of my colleagues, I was able to diagnose and treat patients in a setting I created, and I was quite successful in doing so…or so I thought.
Then our Extormity sales consultant convinced my partners and me that our workflow wasn’t really working for us. She showed us, over the course of several dinners, that we were doing things simply because it was the way we had always done them, and because they fit our individual preferences and approaches to practicing medicine.
When she pointed out that other successful practices were spending small fortunes on IT infrastructure and personnel and following rigid practice guidelines mandated by a proprietary software platform, we began to feel inadequate and grew concerned that we were not investing enough in consultants, hardware, software and expensive integration packages.
Thanks to Extormity, we have now spent a significant sum on a healthcare IT system that forced us to unlearn our preferences in favor of an approach that makes us treat each patient the same way, regardless of our medical training and instincts. We have also learned new skills, and some of us have become as adept at data entry as we have at diagnosis and treatment.
Sure, there were less expensive and more flexible approaches to adopting an electronic health record, but none of those would have created the extreme upheaval necessary to force us out of our comfort zones.
Customer testimonial scraped from

Jul 15, 2010

BobbyG, listened to tons of vendor pitches lately… :-)
The most important metric is not dollars per record per year. It is how many patients can the doctor see per year. Everything else in a practice is cost.
If the EHR adds 1 minute of doctor time per visit, just 1 minute, it translates into one patient less per day, which is a six figure dollar amount loss per year.
All the paper, cartridges and storage space pale by comparison, and as pcp said, you can’t really fire anybody because the EHR and the new regulatory tasks will be adding enough time to staff duties to offset any efficiency gains.
The only place where EHR can add to a practice bottom line is when it maximizes billing and collections.