JD’s comment on a recent post was so excellent it deserved re-running.
Large medical systems generally have implemented EMRs while small, independent practices have not. It’s not a government or socialism thing. That 13% EMR penetration statistic masks a huge disparity between the bulk of physicians in 1-3 person practices and the minority of physicians in large practices (or at hospitals).
The EMR problem reflects on a larger problem of fragmentation in the US medical sector that serves no purpose for the larger public interest. The Mayo clinic manages to offer some of the highest quality care in the US, does cutting edge research, has some of the lowest rates of unnecessary resource utilization, and pays its doctors a salary. Those things are not accidentally connected (well, the cutting edge research part is).
Given the huge lift necessary to move physicians into integrated delivery systems, I’m not holding my breath that it happens soon. There are things that can be done with private practices, but they present challenges of their own.
One relatively unheralded effort I’ve been involved with is New York City’s Primary Care Information Project, which is providing a good, standardized EMR at highly subsidized rates (over 50%). These EMRs are equipped with public health-directed enhancements like connections to disease and immunization registries and reporting of HEDIS-like data. The plan is to link them in a health information exchange and allow for more sophisticated (and easy to administer) pay for performance or value-based payment. The physicians involved are in small private practices and public health clinics.
But it is a huge slog to get these physicians signed up in the small private practices. For some physicians, the comprehensive EMRs are almost free and yet you have to talk to 20 doctors to get a single one to sign up. It’s not just resistance to change. There is also an attitude among some that they’re making enough money as is, and doesn’t need to make any change. There is a resource problem: these offices have just a couple staff people who aren’t very technically proficient.
This is a big problem. Sometimes staff will undermine your effort to get in touch with the physician because they don’t want to be bothered, and also because they suspect (rightly) that their jobs may be in jeopardy. A large practice can reduce administrative FTEs by about 1 per physician. How this translates into a small private practice is a vexed issue. Do you fire one of the three staff people who have been working with you for years and feel like family? Or maybe your staff actually are family members. Sometimes the solution is to turn one staff member into a part time worker, though that can create its own dramas and problems for solo practices. But if you don’t let anyone go or reduce FTEs, you aren’t going to save money on your EMR.
Problems like this obstruct progress in EMR implementation less in a large institutional context where letting people go or retraining is easier, where tech support is a whole department, where people can spend time thinking about the strategic direction the EMRs serve and can engage in a formal RFP process to at least have a better chance of not getting stuck with a loser EMR, and where large capital investments can be more easily managed as part of the corporate planning process.