High costs, unreliable vendors, lengthy installation and transition processes, disruptions to workflow, reduced productivity-it's no wonder that so few practices have adopted full-featured EHRs.
High costs, unreliable vendors, lengthy installation and transition processes, disruptions to workflow, reduced productivity—it’s no wonder that so few practices have adopted full-featured EHRs. Will new federal incentives for adoption combine with legitimately useful products to provide a much needed transfusion of interest in the EHR market? Or will rates of use continue to pale in comparison to the possibilities of this technology?
Challenging the notion that physician practices have been slow to adopt EHRs is quite difficult. According to survey results published in July 2008, only 4% of medical practices had implemented a full-featured EHR product, whereas another 13% of practices had implemented a basic system. A closer look at the practice-level use of EHRs provides sobering evidence of the difficulty of implementing and benefiting from a full-featured EHR. From increased costs to decreased productivity and, in too many cases, continuing use of paper records while paying for an EHR, many practices have failed to capitalize on the promises of EHR technology.
In reality, many practices that have EHRs actually are computer-assisted paper operations. One often encounters practices that record everything on a piece of paper and then scan the paper into the EHR. Other practices will print relevant pages from the EHR upon patient arrival. The paper follows the patient around the office to support the visit and patient care. Other practices record information in the EHR but print the report, which is placed in the paper record. Are these the type of practice models that would compel you to go to the trouble and expense of using an EHR?
EHR adoption has been inhibited by a number of issues, with many practices refusing to use the technology. From the cost of implementation to the questionable benefits of these tools, there is a wide range of reasons for physician EHR trepidation.
Many practices are not confident in the longevity of EHR vendors and are confused by the conflicting messages from the industry and their care partners. For example, a number of practices have been pressured to purchase an EHR supported by their hospital, physician hospital organization (PHO), or other healthcare provider group. More challenging is when one group wants a practice to use a particular product while another related group is pushing use of a different product. Indeed, some practices have been told to use a different EHR for each office, based on the preferences of the local hospital. In other cases, practices are being compelled by their more powerful hospital and PHO partners to use an EHR that is not appropriate for the practice size and/or the area of medicine. It is difficult to discern which of the 400 active EHR vendors will be able to survive and meet a practice’s long-term needs.
Costs and benefits
The cost issue is complicated by a number of factors. In general, EHR acquisition will cost a practice more than it has spent on almost anything else. Additional barriers to adoption are the spotty return on investment and war stories about lost productivity and revenues. Why should a physician invest a substantial amount of money for a questionable future return? Physicians can expect to spend $1,000 to $2,000 or more per month for an EHR system. If there are few savings or revenue opportunities enabled by the EHR, what would compel the physician to invest such sums when there are competing investments in new equipment, staff, and locations?
Indeed, the benefits of EHR investments are typically harvested by healthcare organizations that did not contribute to the investment. For example, electronic prescriptions certainly decrease errors in the pharmacy and save the pharmacy staff time that would be spent entering data. Similarly, electronic lab orders, surgery information, and patient demographic information are maintained and captured by a physician practice before transmission to other providers. In fact, the AMA estimates that physician practices that pay for EHR systems only see $0.11 of each $1.00 saved. The other $0.89 accrues to the benefit of insurance companies, hospitals, pharmacies, and other healthcare organizations.
The EHR timeline is challenging. Even after spending the six months it frequently takes for a focused selection and decision process, the practice is faced with an EHR implementation process that can take another six months or more. Larger practices could be facing a rollout period across offices and areas of medicine that could take longer than a year. An additional 4-6 months may be needed to implement a practice management system that can support the EHR. Even after all of this effort and expense, the typical practice still faces the time needed to fully transition patients to the EHR. From potentially scanning some or all of a patient chart to backloading important patient information such as immunizations, prescriptions, or previous procedures, physician practices could be working on patient chart transition for 6-12 months after initial use of the EHR.
Unfortunately, achieving success is a long and challenging process. First, a practice must have the governance and management capabilities to support and empower the project. In many cases, EHR projects lack the total, staff-wide commitment that is essential for a successful implementation. Practices may allow staff and doctors to opt out of using the EHR or use it in ways that undermine efficiency and effectiveness. Then, the practice must choose an appropriate product that can manage documents, service patients, facilitate workflow, and provide appropriate structures for the relevant areas of medicine. Not all products provide adequate tools to meet the needs of every practice. Next, the practice must redesign every process and activity in order to integrate the EHR into the workflow. Redesign of the practice and implementation of the EHR product occurs at the same time that the practice continues to serve patients; medical practices cannot shut down for redesign. Finally, the practice must support the ongoing use of the EHR as the practice evolves and as the EHR changes. These keys to success are daunting for many practices that seriously examine using an EHR.
A significant barrier to EHR adoption is the existing information in a patient’s paper chart. Practices may have charts with 10, 20, or more years of information in the mass of paper that represents the patient’s paper record. Some patient charts may have 100 pages or more of a variety of forms from a number of sources. How do you get that information into the EHR? How does the practice deal with the legal requirement to maintain the patient’s chart as the practice moves to an EHR?
Newly practicing doctors today cannot remember a time when they were not using computers to work on school assignments or play games. These new doctors are often confounded by the paper-based systems used in most practices, while they are more than comfortable with computerized clinical tools found in many teaching hospitals and larger organizations. However, many doctors that have been working with paper charts for 10 years or more may lack the computer skills to effectively use an EHR to work with patients. In many practices, key physicians just don’t want to transition to EHRs after years of practicing medicine.
The American Recovery and Reinvestment Act (ARRA) has offset some of these factors and put EHRs on the agenda for many practices. The key issue facing practices is that ARRA will essentially force them to implement an EHR system. Practices that do not could be at a disadvantage and be forced to give up the incentives offered under ARRA.
Physician practices may have no choice but to use tools that are necessary to be an active player in the healthcare industry and, more importantly, to effectively serve patients. Patients are interested in interacting with their doctors over the Internet. Indeed, the ARRA-inspired “meaningful use” standards include availing patients of information over the Internet as well as the percentage of your patients that take advantage of that option. If other practices and healthcare organizations are serving patients through Internet connections, how will practices that keep patients waiting on hold, or leave cryptic HIPAA-compliant phone messages, be perceived?
For example, Doctor A has an EHR and produces a note that includes complete information about the patient service and exam. Doctor B does not have an EHR and receives a paper copy of the complete report that many doctors consider excessive. The length of the paper report is daunting, and the important information is difficult to identify. Doctor A also transmits an electronic version of the report to Doctor C, who uses an EHR. Doctor C can view the report and transfer the prescriptions, conditions, and selected information into her practice’s EHR. Doctors A and C will be able to immediately access their patient information and share it with others. Doctor B will continue thrashing through pages of patient charts to find pertinent information. Why should a patient wait for an hour in an emergency room bed for Doctor B’s staff to accumulate the list of drugs and fax them to the hospital when Doctor A and C can send over the patient’s prescriptions through their EHR on demand at any time? The same lack of EHR support for patients could inhibit a practice’s ability to receive referrals, manage patient treatment orders, and even communicate with other providers in the local referral network.
A number of legitimate issues and challenges have stalled the adoption of EHR tools in physician practices. However, the combination of legitimate EHR products that address real physician needs and the ARRA incentives for EHR adoption should prompt your practice to take a second look at EHRs.
Ron Sterling, President of Sterling Solutions, is an independent EHR consultant and the author of the HIMSS Book of the Year Award-winning Keys to EHR Success.