By ROBERT ROWLEY, MD
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.
I am writing this as a representative of the examination room – one who sits facing patients, dealing with our healthcare delivery “system” on a daily basis. I am writing this as one who will bear the brunt of what you accomplish or fail to accomplish in your attempts to reform our “system.” I write this as a primary care doctor who makes a living (or not) by what I earn from that “system.” I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”
