Challenges in EMR Adoption by Doctors Offices

Adoption of Electronic Medical Records (EMRs) by physicians – particularly by primary care physicians – has been a challenge, for a number of reasons. The Office of the National Coordinator for Health IT (ONC) has been charged with encouraging physicians to adopt Electronic Health Record (EHR) technology, as envisioned in the American Reinvestment and Recovery Act of 2009 (ARRA).

The ONC vision is that a transformed healthcare delivery system which is able to reduce medical errors, implement best-practices standards as they emerge, reduce disparities in care delivery, involve patients in their care, and encourage the coordinated delivery of health care – all of this needs, as a base, the widespread adoption of EHR technology by physicians in all settings of care, across the country. Getting there is the challenge before us all.

EHR adoption has been seen mainly in hospitals, clinics and other large institutions – the costs of traditional EHR systems (both the direct costs, and the indirect costs of needing to build and maintain a local network system in order to make it work) have been prohibitive to smaller practice settings. However, it is precisely those smaller practice setting where the majority of healthcare is delivered in this country.

Fortunately, newer technologies – like secure web hosting, which removes the need to install anything locally – and new business models – like having alternative revenue sources subsidize the web-based EMR so that the system can be offered for free to physician end-users (e.g. Practice Fusion’s free EMR) – have overcome many of the barriers to adoption that have prevented smaller practices from adopting EHR technology.

In light of the recent Health 2.0 in the Doctor’s Office conference, with its focus on newer technologies, we wanted to review some EMR adoption strategies that might help clinicians move from paper-based offices to electronic ones. As a practicing family physician, and relatively early adopter of EMR technology – we have not had paper charts in our practice since 2004.

Hardware recommendations

Regardless of the cost of the EMR system in the first place, a certain investment in hardware will need to be made. With a web-based EMR, this can be pretty minimal. I would discourage the use of fixed, in-exam-room computer equipment (risk of damage when unsupervised, need to close and then log back in when you leave the room in order to keep HIPAA privacy). Instead, I would recommend a wireless laptop or notebook (costs of these are now in the $400-$800 range) – one per clinician – which can be used to carry around the office. Nurses might want to have a fixed desktop computer at their nursing station (these are about $100-$200 less than a notebook these days). Front desk personnel should have a fixed desktop computer – this has been the tradition for some time.

If a locally-installed EMR system is chosen, then there is the whole burden of housing a server, with hardware redundancy to guard against failure, and software costs for that server – operating system, anti-virus, firewall, possibly license fees for the database system used. In addition, there will be the need to do data backup. Such local systems have a vulnerability of theft of Protected Health Information (PHI), which can expose the clinician to a HIPAA breach. Web-hosted EMRs avoid this whole back-end burden.

With a web-based system, internet connectivity is critical. I would recommend a good broadband connection (T1 lines run about $400/month, though DSL services for about half that may be sufficient as well). For safety, a 3G cell phone fail-over backup is also advisable, in the event of breakdown of the internet connection (a rare event these days).

Workflow redesign

Apart from cost, workflow disruption is another barrier to adoption. This is especially true in primary care practices, which function very close to the margin in the first place – any dip in productivity can cause the practice to dip below profitability for a while. Therefore, an intuitive, easy-to-use and flexible EMR design is critical. All the workflows encountered by physicians in an ordinary day need to be facilitated, not disrupted, by the EMR.

There are 7 workflows in an ambulatory practice, which need to be addressed in order to fully abandon paper charts: (1) billing and accounts receivable; (2) scheduling; (3) in-house messaging; (4) documentation of patient interactions; (5) processing refill requests; (6) reviewing and acting on lab results; and (7) managing external correspondence about patients. A way of dealing with each of these items needs to be addressed in order to successfully embrace EHR technology and abandon paper.

Small medical practices have faced challenges in their path toward adopting EHR technology – cost and workflow disruption are the main ones. Newer technologies and business models have overcome many of those barriers. Achieving the “meaningful use of certified EHR technology,” which qualifies a clinician to access ARRA/HITECH incentive payments beginning in 2011, can be achieved through these newer technologies. The old paradigm of massive, burdensome, and stand-alone systems is giving way to novel approaches which can result in widespread EHR adoption, as we have seen from our experience to date.

ROBERT ROWLEY, MD, is the chief medical officer at Practice Fusion, a San Francisco based company.

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Lorraine McGuireSomy Resorts Goa Calangute Beach ExpertComputer ScientistJames M. Maisel, MDdan allen Recent comment authors
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Somy Resorts Goa Calangute Beach Expert

I like this blog so much, saved to favorites. “American soldiers must be turned into lambs and eating them is tolerated.” by Muammar Qaddafi.

Computer Scientist

The attempt to reliably automate (clinical note making) that which can not be reliably duplicated (patient exams and interaction), is inane. Free of government involvement, traditional EMR did not reach adoption for good reasons. The problems in ambulatory care are business related (shrinking reimbursement, increasing costs) not clinically related (an MD now knowing how to treat patients or make notes). The right solution will deliver information TO the physician not require information OF the physician and it absolutley can NOT disrupt the doctor at the point of care. Who wants a physician (heaven forbid a surgeon) who looks lost?

James M. Maisel, MD

While there are many barriers to physician EMR adoption, the biggest hurdle to date has been the inefficiency of the data capture necessitated by the doctor at the point of care. The annual TEPR challenge clearly demonstrates that the most experienced physicians using systems they worked with for years cannot enter an encounter in under 10 minutes. ZyDoc has been working on the problem of efficient data capture and we are very close to releasing a solution that allows physicians to dictate and have the text automatically data mined and moved into the EMR as SNOMED codes. We anticipate rapid… Read more »

dan allen

If anyone would like to learn more about our new possibly FREE emr systm or set up a risk free no obligation demonstration please contact me via email or via phone 954-568-7919 thanks and good luck

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The ONC vision is that a transformed healthcare delivery system which is able to reduce medical errors, implement best-practices standards as they emerge, reduce disparities in care delivery, involve patients in their care, and encourage the coordinated delivery of health care – all of this needs, as a base, the widespread adoption of EHR technology by physicians in all settings of care, across the country.”
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can just anyone write an article here, or do you have to have a company/product to promote?

Lorraine McGuire

Yes, InScribe LLC, can provide a doctor with a remote Scribe, that will make sure they are in compliance, to qualify for incentives offered by the gov’t. You can dictate the way you use to and they will take care of the rest. We can interface with any system, 24/7 support (free). Please call – Lorraine McGuire/Sales/InScribe LLC – 866-496-0062 x 107 for more information and start your worry free service with us!!!