Reader mail: EMR advice from an IT insider

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.

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6 replies »

  1. It seems like so many people forget some of the no brainer benefits of EMR. Possibly because they are so apparent, but they can’t be understated. Things like legibility of records and availability of charts. The problem is that those things are very valuable, but can’t be given a nice ROI number.
    I agree that I haven’t seen many (if any) EMR that have done a good job of being physician focused. However, considering the crazy insurance billing demands, it’s no wonder that it’s taken over the EMR development process.

  2. I agree with most of what the writers above have said.
    However they have left out one critical component…regarding ethnology, or the structure of the human-machine interface. Can the physician use it comfortably at the physician-patient interface…..
    Also neither of the comments address the functionality that a physician needs, ie, the ability to enter a complete, and cogent history and physical without diversions regarding administrative details.
    Is the basic financial system integrated, and reliable to get a report at the end of the day about encounters, billings, payments, and/or a day sheet for reconciliation with deposits, refunds, etc.
    I cannot imagine anyone buying or implementing an EMR without being certain you could collect the billings which will help pay for the system with reduced efficiency….for at least six months to one year….

  3. By the way, now that Matt (or whomever) has been so kind as to put my comment on the front page, I should stress that I am not employed by the Primary Care Information Project nor do I speak on its behalf. I have had the good fortune to work with them as one of their many partners in expanding EMR use in New York City.

  4. You are right that I am not an MD. I have spoken with several about their experiences with EMRs, and of course I read complaints all the time on this blog and elsewhere.
    I do not claim that EMRs save physician time, and in the beginning they clearly slow things down. A well-designed EMR that has had the office workflow intelligently re-shaped around it should result in a roughly equal number of visits per day. It will speed up some things and slow down others from your point of view. But from the point of view of the system as a whole it allows for massively better speed, efficiency and quality control. I don’t think you want to debate that, but are focused instead on the self-interest of the individual physician. That’s fine, we all tend to look out for ourselves.
    Almost no major IT transition in the workplace is welcomed by those who have their work routine transformed by it. And yet, those of us working in larger institutions inside and outside of healthcare have gone along with these transitions, because the resources of the institution made it possible and the power of the institution made it mandatory. The same point you made about EMRs could be made about word processing: formerly those in middle and upper management were able to dictate to secretaries rather than fiddle with the formatting and editing controls of Microsoft Office. We’re all typists now!
    Does that make offices less efficient due to the use of workstation PCs? Should we go back? Rhetorical questions, but I think you need to put your comment that an EMR is not “an effective use of my time” in context. The medical system should not be designed to maximize your billable revenue. If having you take an extra couple minutes to get some things done right at the front end saves many minutes or hours or even days on the back end (and might also save a life!) then it is an efficient use of time–full stop.
    Here is another case where the institutional vs. private practice distinction is so important. In a small private practice, the boss is the physician or physicians. Bosses tend to organize things to make them more convenient for themselves, naturally. What that means is that there is another powerful barrier to the introduction of an EMR even if it will (within the next few years if not today) improve the efficiency and quality of care delivery overall, so long as it threatens to make the physician’s job more engaged with minutiae.
    Of course, if you can find a way to do some of those tedious things with an office assistant or nurse just as effectively as with yourself, then that’s great. Anything that can be done just as well when a less skilled and highly paid assistant does it should be done by that assistant. Have you looked at other practices and hospitals to see if there are divisions of labor you could adopt?
    Final thought: The killer apps of EMRs are not so much the in-office reminders and coding functions, but the care integration functions and data sharing functions that combine with data mining tools to make care more efficient and effective. A stand-alone EMR is sort of like a standalone PC without access to email or the internet…not useless, but far less useful than we have come to expect.

  5. I suspect who ever wrote this was NOT a physician. I have worked with two EMRs in the last 4 years. The hosptial that implemented the first EMR has saved money on the backs of the physician–we now do order entry, so the hospital could get rid of all the ward clerks! Doing order entry adds between 10-20 minutes to each admission, as I search for appropriate “prn” reasons, lab panels and answer dietary questions, “can the patient use the phone to call the kitchen?”. This is not effective use of my time. I think the resistence to EMRs by physicians is not because we are techno idiots-it is that we recognize yet another drain on our time and money, taking us away from patient care. (Oh, yeah the patients!) My face behind a computer does not count as “face time” with a patient.
    There is not yet an appropriate user friendly EMR out that saves PHYSICIAN time and money. We just aren’t there yet, and saddling small primary care offices with the bill for an EMR is another smack in the face. It’s no wonder that just 3% of of todays residents want to go into general internal medicine…