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 replies »

  1. The introduction and spprout for EMRs is based upon a RAND report, funded by the manufacturers of the EMR programs, which highlight transparency and cost savings. The studies have been shown to be flawed, with underlying cherry picking of positive reviews to please the study funders. Reviews coming out now show that the programs do not save money but in fact cost more in dollars and physician time. The programs are inflexible, require every box to be checked prior to moving on, are difficult to navigate and in fact are the very model of user unfriendly .There are at least 17 companies that lead in this industry. All have proprietary programs which absolutely do not speak to each other. So data from one hospital cannot be transmitted to another (a highly touted reason for these systems) as the companies are jealous and protective of their own software in the hopes that theirs alone may be adopted as the national standard. The whole system is a boondoggle and should at least be seriously evaluated by an independent and not monetarily involved body or perhaps it should all be scrapped.

  2. I recently made the switch from paper to electronic and I have not noticed any negative changes in productivity. In fact, my work day seems to run more smoothly. I have learned that it is important to find a company that will guide both you and your staff members through the change. I chose a small company called TNEHR and I would recommend them to any doctor who wants to make the switch.

  3. Hi Rob L,

    I’m curious to see what you think about the the EHR company Nortec EHR. This Company is of course CCHIT and ONC Certifed but also has a Five Star Usability Rating. Any thoughts on this company http://www.Nortecehr.com.

  4. You mention that
    “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.”
    That’s great for you. However, your sample size (n=1) is not a representative sampling of physicians. This is not science. This is not how medicine works.
    Others have had a different experience.
    Example: http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html
    Only looking at the positive side of a domain while ignoring other sides is not science. It is quackery.

  5. I think you made good points about adapting to EMR usage, and i think the choice of EMR is determined on various factors that differs from a speciality or provider or even from a doctor to another.

  6. I serve as a consultant for a medical records company that provides both paper templates and has now released an electronic version of the system, AvivaEMR, for those who prefer an EMR, or, more likely, who feel compelled to switch while the switchin’s good (i.e., supported by federal incentives). I too have heard most if not all of the arguments on both sides of this fence, and the answer, in my opinion, is that it depends on your practice and on the doctor’s own workflow and “style”.
    For some, implementing an EMR is not that big a deal as they are comfortable with getting pretty involved, and actually does result in a more efficient workflow, driving a positive ROI. For others, the learning curve is like passing a kidney stone and overall methodology never feels like a good fit, costing them money every day.
    Arguing that one way or the other is good for EVERYONE ignores the fact that there are positives on both sides and negatives as well, no matter which side of the debate you decide to take. The key factor is fit – does the method fit, or can I make it fit without an unacceptible level of customization or time spent on my own part? After all, at $50 per 15 minute visit (the estimate given above), a doctor’s time spent seeing patients is worth $200 an hour. At that rate you can (and probably should) have a truly qualified software architect write an EMR for you. (I work for one of those too).
    Yet, for many of the doctors we contact, the deciding factors include whether or not they’re going to stay in practice long enough for the government mandated changes to have a significant effect on their practice and whether or not Medicare/Medicaid patients constitute enough of their patient base to worry about the government carrots and sticks. If not, it might not be economically worth making any changes at all, despite how much the government, insurers and pharmaceuticals might benefit from a national digital database.

  7. Great insight and easy to understand. I love your thoughts on this! I am currently Managing Partner for SSi-SEARCH, retained search for health IT leadership. Prior to this I spent 17 years in sales and consulting for EMR / EHRs to hospitals and physicians. Objections? I have heard them all. This background was great training for finding health IT leaders today, CIOs and CMIOs. We are launching a new blog called hospitalcio.org and the focus is on the impact of EHR timelines and the role of the CIO. I’d love to share your perspectives!

  8. Electronic medical records, abbreviated as EMR, can be defined as a electronic store of medical records of patient, such as their past medical history, substances or drugs they are allergic to, the treatments or medical procedures they underwent in the past, history of family hereditary details, previous drug prescriptions, all the previous charges and all relevant information that a provider may need at any point of time to ensure proper diagnosis of the ailment.

  9. I thought it was great that I found a doctor who used EMR technology until I asked for a copy of my records. I am being told that they use a Medical Records Release Service which comes to the doctor’s office to retrieve the records for them and the cost to me will be $1.00 per page. I have asked for the records to be copied for me via CD/DVD, memory card, flash drive, etc. which I am willing to supply. I can not afford $1.00 per page for many years of records. Any suggestions would be much appreciated!

  10. Lost in all of your talk of profits and streamlining is whether you patients want their information digitized and accessible to ANTONE with a remote interest. No one bothers to ask. They simply DEMAND compliance.
    It is intrusive and invasive.
    And yes because it is now MANDATED, it doubly unacceptable because that patient information, MY information, not yours, is now subject to viewing by the entire country. Oh yes it will be too.Because it can be.
    So have fun with your new toys and enjoy the nuts and bolts of playing with your shiny new systems.
    But as a patient, I resent the intrusion. And I will NOT play along.

  11. Nice blog. I really like the way you have covered some of the striking and critical issues in having a successful EHR implementation.
    I would just like to add that th use of the right tools & Services through use of specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
    Looking at the profitability of the EHR investment, I think ROI is very important factor that should be duly considered when look achieve ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment.
    Also having the right ( in terms of appropriate knowledge and experience) support function i.ey the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.
    Creating the right infrastructure for implementation by looking at the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the
    ’safe vendor challenge’ as discussed by many critics.
    Do you all agree with me?

  12. Rob:
    Great information. Really well written blog that was educational as well as stimulating. I am researching EMR solutions for a client (a medical practice) and they are looking for a product recommendation, or at least direction. What EMR solution did you select? What are your personal pros and cons about the product/service? Was it easy to install, implement and maintain (from a technology standpoint)?

  13. There are solutions for the solo and group practices that will not break the bank. I2Qmed has made implementing a patient portal and PHR a little easier with their I2QmedEP product which is fully managed and free of charge. For more info visit http://www.i2qmed.com

  14. pcp said:
    “So docs should spend their time, effort, and money using lousy products in the hope that the for-profit EMRS manufacturers will listen to their complaints and eventually come up with something better?”
    Like it or not, docs need to take ownership of the EHR/EMR issue and force vendors to fix their “lousy products”. If they do not, then the vendors are free to continue forcing inadequate and poorly designed (from a treatment and care perspective) “products”. I still see way too much apparent apathy from physicians concerning this whole EHR/EMR issue, which concerns me greatly.
    In the end it is your practice, license, reputation, and patients health that is at stake. If this is not worth some real time and attention, then you have greater issues to think about than if to implement and EMR/EHR or not.

  15. If EMRs had redeeming value for improving medical care, the doctors would embrace them. They would clamor to purchase.
    Right now, it is better to not buy and take the penalty, or delist from Medicare.
    Pcp should report the level 5 requirement to Senator Grassley at whistleblower@finance-rep.senate.gov

  16. I had an interesting/appalling conversation with a resident last night who is finishing up at a major university medical center. The EMR in the ER is configured so that the physician cannot sign the note until enough bullets have been entered to code for a level 5 visit. Regardless of diagnosis (viral URI) or what was done, every visit is a level 5. It is literally impossible to code a level 4 or lower visit. Now that’s what I call progress!

  17. Margalit is correct about EMRs being billing tools that are useful in the business realm of an office or hospital and are successfully used for practice management. EMRs are not clinical tools designed to communicate clinical information between clinicians—see bev md posted above.
    Here in Florida we have a very sophisticated hospital system that has 4 EMR systems deployed—2 for PCP groups and 2 for hospitals—that cannot even acknowledge each others existence.
    If doctors are basing their EMR decision on the market rate loan promised by ARRA and the 1-3% increased payment promised by Medicare, then more power to them.
    EMRs have been around for more than 15 years as Dr. L has testified. It didn’t take busy clinicians 15 years or “studies” to determine the utility of a cell phone to improve patient care.
    Patient No Pain, I think we are all patients or guardians of patients on this discussion.
    Clinical people are focused on clinical activities. We are looking for clinical tools to enhance our patient-to-clinician experience—not wasting our time diverting our attention away from the patient we are attending because we have to deal with some electronic device.
    I believe that the continued movement toward clinical communication systems will result in better medical care. After all, medicine is a face-to-face, one on one activity whether we use paper or electronic means for documentation.

  18. pcp,I don’t think one excludes the other. I do think we need research and studies on how to best use technology in health care, and most important some sort of FDA oversight regarding safety. But we also need to reach a critical mass of users in order to realize the real benefits of interoperability. I don’t think there will be many benefits accruing to anybody from disconnected systems and I don’t think we can have connected systems until enough docs have the necessary software. We just need to start somewhere and Dr. L is showing us that it need not be a painful start.
    I will write more on this, I think…..

  19. Margalit:
    I always enjoy your posts, but I think you struck out here!
    “I don’t recall cost effectiveness studies for e-mail, cell phones and computers in general.”
    But cost effectiveness is still a major selling point for the vendors, and was the major reason the administration got behind the push for EMRs. So isn’t it reasonable to ask to see data that supports these claims? I don’t remember anyone claiming that cell phones would save the country billions of dollars.
    “We need better EMRs, but for that too, we need more users on the system.”
    So docs should spend their time, effort, and money using lousy products in the hope that the for-profit EMRS manufacturers will listen to their complaints and eventually come up with something better?
    “Does anybody think that medicine will be practiced on paper ad infinitum?”
    No, I don’t think anyone thinks that. But before we jump into this, can’t we identify exactly what we want EMRs to do? Can’t we identify exactly to whom the benefits will accrue (i.e., insurance companies and government agencies, primarily) and have them pick up the tab? Can’t we come up with products that are usable and safe?
    Thanks for your posts.

  20. No, no exercise is necessary. Let’s just keep buying big macs on credit and leave the walking for saturday mornings (on the treadmill, of course).

  21. What seems to be missing here (except perhaps in Bev MD’s post) is the patient POV. As a patient, I tell reluctant physicians this: you are a service provider to me. I demand of my PCP that I am able to communicate online, make appointments that way, pay bills that way, etc. I also demand MY healthcare record electronically when *I* want it.
    I demand those things of all my other services providers. Why wouldn’t I expect it of you?
    Unrelated to EMR, I also demand more accountability than is provided through the local medical society.
    The times? They’re a changing.

  22. There indeed are many problems with EMR and there indeed are no studies showing cost effectiveness. I don’t recall cost effectiveness studies for e-mail, cell phones and computers in general. Maybe there were.
    We do need studies, but for that we need more implementations. We need better EMRs, but for that too, we need more users on the system.
    One thing we need right away is FDA oversight.
    All that said, I have one question: Does anybody think that medicine will be practiced on paper ad infinitum?

  23. Bev:
    In regard to your seemingly hysterical statement: “The hospitalist was ocmpletely flying blind except for – me; and I only knew some parts of her history. This is unacceptable in a 1st world country. Why are we putting up with it?”
    Many a family doc, hospitalist, and intensivist have flown blind too when the EMRs went down for hours. Many have ordered tests because they could not find them on the EMR (too many silos), and many have ordered tests because it is quicker than scrolling to find the old ones.
    It works both ways, and pcp is right, where is the proof that outcomes are better, that care is safer, and care is more cost effective, after spending $ billions on meaningfully unusable HIT equipment that increases malpractice and malpractice insurance costs.

  24. Bobby and Bev,
    My comments were related strictly to financial benefits. The clinical portion of an EHR, on its own, cannot make a doctor more money. The savings and the expenditures even out if, big if, the implementation was correctly done.
    The benefits, of course are different and go more to continuity of care and just plain availability of information, and those benefits are very important even if you just break even with the EHR.
    If you want to increase your revenue via EHR, pay attention to the attached billing system. That’s where the money is and that’s where the money should be.
    I am all for EHR adoption and while Dr. L’s experience is anecdotal, it proves that EHRs can be satisfactorily implemented and Bobby is 100% correct, there are very good and very affordable choices out there.

  25. ‘It drives me crazy when people say it cannot be done, or that somehow my story is an “anecdote.” ‘
    1. Not saying it can’t be done; just saying that in my situation it isn’t worth doing: no benefit to me or my patients. And that’s a decision based on looking at systems for the past 15 years. And no, I’m not a techno-phobe: I wrote my first computer program in 1967 at age 10.
    2. But, yes, your one report of success does qualify as an anecdote. We’re still waiting for studies that prove EMRs result in better outcomes and/or reduced health care expenditures.
    Thanks for your posts.

  26. I am not a magician. I am not smarter than other docs. I just did what we needed to make EMR work. If any doc wants to see it done successfully (without ANY funding from hospitals, governments, or other benefactors), they have an open invitation to come to my office. The $80K was high, but that included all computers, installation, networks, etc, and we DID have break even within the 1st 6 months.
    It drives me crazy when people say it cannot be done, or that somehow my story is an “anecdote.” Uh, no. It was no coincidence. It was not happenstance. It is not imaginary. I am not in denial, I am a real-life example of the fact that it IS possible. It CAN be done. Folks who say it can’t are the ones in denial. If anything, the systems are better, the computers are faster, and the environment easier for EMR adoption than ever before, certainly FAR better than when I adopted.
    We will go for (and get) the HITECH money, but in truth it will just be extra income. We did not need it and now just see it as a bonus for our foresight. Even without that money, we are still making more money BECAUSE OF our EMR system than most other docs in our specialty. I just got a $5000 P4P bonus check that I could not have earned without my EMR.

  27. “reduce or eliminate non-value-adding process steps, particularly where they impact the physician.”
    Does that include data entry? I’m a whiz typist, but I can still dictate twice as fast.

  28. Margalit;
    I am surprised that your last comment is so negative? What is your point, that the vendors don’t have a good product or that the whole idea of office EMR is bad?
    My own viewpoint as a patient/family member is that medicine has done without adequate medical records for so long we’ve forgotten how critical they really are. When my mom was admitted to the hospital with drug delirium/RO stroke and her PCP was in Hawaii, no one, not even his office, could produce quickly a current medication list, recent imaging tests (resulting in some very expensive ones being repeated in the hospital but hey – more $$ for them, right? Our Medicare taxes paid for it), past medical history, etc. etc. The hospitalist was ocmpletely flying blind except for – me; and I only knew some parts of her history. This is unacceptable in a 1st world country. Why are we putting up with it?

  29. @Margalit –
    I could not agree more with the observation that added physician workflow burden is a net negative from the bottom line perspective. My only point was that the imposing ostensible capital “cost” barrier of EHR adoption is largely chimerical. Records capture and maintenance costs are there, period. Part of effective adoption support is to reduce or eliminate non-value-adding process steps, particularly where they impact the physician.

  30. @Gary,
    Your Richard Reece sounds like one of my teenagers: “Yes, I know what the right thing is to do, and I know it will benefit me, but since someone is forcing me to do it, I don’t wanna.”
    Cripes, how childish.

  31. 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.

  32. 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 extormity.com.

  33. 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?

  34. @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.

  35. 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.

  36. 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.

  37. 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.

  38. 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.

  39. 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.

  40. 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.

  41. 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?

  42. 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’.

  43. 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!