Your questions and concerns addressed: Is it time for electronic medical records in your practice?
A wind of change is blowing through health care as paper systems are being converted to digital records
IN THIS ARTICLE
CASE A medical practice in disarray
An ObGyn reported the following signs of a problem to a colleague: “Our practice was literally drowning in paperwork. An exam room was recently converted to hold more charts, and 2 warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to the ongoing costs and storage problems.”
What are the treatment options?
Electronic medical records (EMR) have progressed from arcane, slow, cumbersome documentation systems to sophisticated, complex, comprehensive ones. These modern systems hold the potential to reduce administrative and management costs by 30% or more, improve clinical workflow, reduce medical errors, facilitate communication between patient and physician, and enable analysis of data for best practice methods, best outcomes and identifying risks and complications.
For practices like the one described in the preceding paragraph—not a fictional account but actual testimony provided by an ObGyn—EMR offer a powerful potential solution to the problems that result from an overwhelming amount of paper documentation, correspondence, charting, claims, and financial transactions. In this article, I offer a general introduction to EMR; in the next (August) issue of OBG Management, I’ll speak with a group of ObGyns and medical practice managers about their experiences—and inexperience—with EMR.
Progress and paradox
Physicians and scientists have made substantial progress over the past 25 years in pharmacotherapeutics, diagnostic technology, procedures, and treatment protocols. In obstetrics and gynecology alone, consider the array of technologies—3-dimensional ultrasonography, minimally invasive surgery, receptor-specific drugs, in vitro fertilization, long-acting reversible contraceptives—that have advanced the quality and effectiveness of care. Yet little progress has been made in the process of caring for patients.
The fact is that physicians, and other health-care providers, are rooted in paper-based processes that sustain inefficiencies, increase costs, and defy the gains that other industries have made by adopting electronic technologies for handling information. Why are we so stuck?
The state of EMR
EMR—of varying functionality—have been available for longer than 20 years. Early models were developed by physicians who had an interest in software coding and design, and were of limited functionality, arcane, and difficult to use in a clinical setting. Some of those early models, and even a few commercial systems in use today, rely on scanning paper documents into computer files. Such systems may eliminate some paper and facilitate document retrieval, but they do nothing to ease management of the complex transactions of health care, and they do not address handwriting illegibility.
Development of complex EMR systems was limited by primitive technology, inadequate distribution channels, and programming that was cumbersome and expensive to maintain. But these barriers have been overcome with fast processors, inexpensive and abundant memory, broadband Internet connectivity, and programming languages that facilitate automated software development.
Modern EMR systems are not simply data repositories: They also support workflow from the beginning to the end of a patient’s consultation with a health-care provider—an event that generates multiple transactions with multiple recipients. A single consultation may, for example, generate orders for lab tests, imaging studies, a surgical procedure, consultation with other physicians, prescriptions, and counseling, and record the subsequent financial transaction. EMR systems by necessity interact with multiple organizations, institutions, instruments, and other software systems. To software developers, and to the clinicians who use their systems, the challenge is to deftly navigate the complexities of health care.
Forces accelerating adoption
Momentum from the Executive Office. In 2004, President George W. Bush set a goal: nationwide adoption of EMR—to include all medical practices—within a decade. In a speech that year at Vanderbilt University Medical Center, the President said: “One of the amazing discrepancies in American society today is we’re literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper.”1
Certifying body arises from the private sector. Subsequently, the US Department of Health and Human Services (HHS) established the Office of the National Coordinator for Health Information Technology and the American Health Information Community. The sweeping goal of these bodies? Better health care by application of information technology and creation of standards for certifying EMR systems that provide core functionality.
In response, 3 private sector health information management groups jointly formed the Certification Commission for Healthcare Information Technology (CCHIT; www.cchit.org). In 2005, this private-sector entity entered into a contract with HHS, to, in the commission’s words, “develop and evaluate certification criteria and create an inspection process for healthcare information technology” in 3 areas:
- Ambulatory EMR for offices
- Inpatient EMR for hospitals and health systems
- The network components through which EMR share information.
The work of this body is ongoing.
Pay-for-performance pushes the issue. Today, insurers—federal and private— are mandating adherence to standards of care for maximal reimbursement of services. These reimbursement schemes, called pay-for-performance, or P4P, are based on providers delivering documentation that specific protocols are followed and outcomes are monitored. The point is that it will be nearly impossible for physicians to comply with insurers’ P4P requirements unless that documentation is in an electronic format.
The market speaks—loudly. Other forces are bringing clinicians to a reckoning with EMR:
- Some malpractice carriers offer a discount on premiums to physicians who document work using EMR
- Patients are asking for electronic access to their providers by way of Web sites and e-mail
- More and more requests for documentation from multiple interested parties to a patient’s care increase overhead costs and place greater demands on paper-based systems.
Physicians cannot meet these demands with paper-based record-keeping.
Reticence has been the watchword
Despite the external and internal forces that are driving adoption, physicians have, as a whole, been reticent to adopt EMR. The nonprofit Healthcare Information and Management Systems Society (HIMSS) reports that 26% of ambulatory practices have adopted EMR, but this penetration is predominantly in multi-specialty clinics and hospital-owned practices.2 Few data exist on the penetration of EMR in single-specialty ObGyn practices; anecdotally, vendors estimate a penetration of 10% to 15%.
Why this slow pace toward something broadly acknowledged as key to the well-being of health care?
It means a change. Adopting EMR represents change; well-designed EMR systems streamline workflow in a practice by automating many functions, eliminating duplications of effort, and shifting roles from moving paper to managing digital information. Fear of change and resistance to change are the most common reasons that single-specialty ObGyn practices have not adopted EMR.
It costs. Expense is often cited as the reason why a practice has not adopted an EMR. True: Upfront hardware costs, software costs (license fees, subscription fees), implementation fees, and training costs add up. But a well-designed EMR system should provide a substantial return on investment (ROI) based on savings and on an increase in revenue.
It may be awkward. Some physicians cannot type well. They do not adopt EMR, therefore, because they fear embarrassment using a computer to enter clinical documentation in the consultation room in front of a patient.
On the plus side
On the other side of the coin, the advantages of EMR to physicians are several:
Documentation. EMR facilitate complete documentation of a patient’s visit, current needs and care plan, and record—thereby reducing the clinician’s liability and the risk of medical error. Functions include order entry, prescribing, accurate coding based on work-effort, tracking of outstanding lab tests, and notification.
No chart pulls. With EMR, patient chart pulls are almost nonexistent. A chart is available anywhere a computer is located, any time it is needed.
Decision-making. Probably most importantly, EMR provide clinical decision support by means of alerts (drug interactions, allergies) and reminders (need for follow-up, test orders).
Portal to the patient. Internet-accessed portals that are part of EMR systems facilitate asynchronous communication with patients. A patient can make an appointment, refill a prescription, and request educational materials through such a Web portal. Once an appointment is scheduled, the patient can enter her medical history so that it is specific to the appointment—a feature that is particularly useful when a woman knows the reason that she is visiting the ObGyn (“I’m pregnant,” “My cycle has changed”).
Such a patient-entered history can populate the EMR and contribute elements for appropriate coding. Furthermore, a Web portal in an EMR system enables the physician to reply to a patient with secure messages 1) about lab results, reminders, and appointments and 2) that deliver educational materials.
Because EMR are still used by only a small minority of practices, those that seek to move away from the paper record are almost always doing so for the first time. Uncertainty about the adoption adds to anxiety. There are, however, simple steps to take to maintain control over the adoption process and methodically manage it to a successful outcome.
Begin with the end in mind. The goal of adoption is not to purchase an EMR system; EMR are only a tool. The goal of the practice should be to transform its existing workflows to make significant improvements over the status quo. Before ever looking at an EMR system, you (and your colleagues, when applicable) must answer several key questions:
- What are we trying to accomplish?
- What is it about the status quo that we want to change?
- How will we measure success a year after completing the transition?
Determine whether you have the resolve to make the transition. As I said, adopting EMR represents change, and the proper motive for adoption is engineered change. Change, however, exposes the human element of transformation. The people who work in the practice are the true determining factor for a successful transforming project, so ask yourself:
- Do you know whether they are ready for change?
- Do they understand change?
- Are they threatened by it?
- Is there broad and vocal leadership backing the impending changes?
- Has the impact of the change been discussed with all people involved so they have a clear understanding of its impact on their personal future?
- And is the practice, as a team, prepared to go through the turmoil of change as a necessary step on a path to transformation?
Assess your sense of urgency—objectively. Because this transition represents a transformation, you’ll have to overcome significant inertia. Without a sense of urgency and aggressive, consistent management of this transition by the leaders of the practice, overcoming human barriers to change will be difficult.
A medical practice that addresses these 3 initial tasks sets itself up for a successful transition from paper to EMR. A good plan—in which goals are well defined and a sense of urgency is consistently communicated and supported by the practice’s leadership—has an excellent chance of resulting in the best possible selection and implementation of an EMR system and accomplishing the goals set for the practice.
In contrast, a transition from paper that begins with such a vague notion as “I guess we need an EMR eventually, so we might as well start now” is much more likely to spark turmoil among staff. The staff then embarks on a selection and implementation process that is heavily influenced by emotion and interpractice politics. They face a diminished opportunity for completing the transition efficiently and successfully.