Triumphing Over EMR Angst

Detroit pediatrician Alexander Seguro* is shopping for an EMR with the kind of mixed feelings found in a divorcee who’s eyeing a second marriage.

Seguro, after all, has been around the block. He used an EMR in Texas before he moved to Michigan, where he practices with another pediatrician. So he knows the technology’s upside and downside. He has a better idea of what he wants, and doesn’t want. In short, he’s simultaneously gung-ho and gun-shy.

We’ve turned to two healthcare IT consultants for some pre-EMR counseling to help Seguro over his qualms. Their advice will benefit other EMR shoppers, who, like Seguro, hope to qualify for incentive money in the federal economic stimulus package, but wonder what they’re getting themselves into.

Phase in complex programs

Seguro would prefer an EMR that’s less expensive and less complicated than the one from his Texas days. “A lot of programs seem over-engineered for a small practice and consequently cost an exorbitant amount,” he says. “For example, my old program let you mark the location of a rash or lesion on a diagram of a body. That’s great for a dermatologist, but not so important for a pediatrician. I’d just as soon write a description.”

Seguro’s modest preferences, though, run up against the stimulus legislation that rewards doctors who implement an EMR. He qualifies for up to $65,000 over six years under Medicaid because that program accounts for least 30 percent of his patients (the maximum under Medicare is $44,000). And he’d like to collect that money. But there’s another prerequisite - the software must be certified. The legislation doesn’t say certified by whom, but the likely answer is the Certification Commission on Healthcare Information Technology, says Seattle healthcare IT consultant Bruce Kleaveland.

The trouble is, CCHIT-certified programs are way pricier than most, and Kleaveland concedes that they pack more features than a doctor might use. However, nobody needs to swallow the elephant whole.

“You don’t have to implement every feature at once,” says Kleaveland. “Start with the basics like progress notes and e-prescribing. Save other features such as health-maintenance alerts and order entry for labs and physical therapy for later.”

How to avoid that “locked in” feeling

Seguro wants a long marriage to his next EMR, but he also frets about his ability to bail out. “What if the company goes bankrupt, or raises its prices, and I need to transfer my records to another program?” he asks.

This situation isn’t as scary when you buy a system installed on a client-server network in your office, says Rosemarie Nelson, a healthcare IT consultant in Jamesville, N.Y. “You control the data that way.” But Seguro favors a Web-based program from an application service provider that’s usually less expensive and easier to maintain than a client-server version. There’s no server to buy, no data to back up. Seguro, however, has heard stories of ASPs who claim to own the data and may only give the doctor printouts of patient charts when there’s a breakup.

Horror stories and urban myths no doubt abound. The physician’s job here is just to make sure his data is safe. Physicians can contractually require an ASP to guarantee access to their data if they want out. “Have the vendor agree to put the patient data and a copy of their application software on a single computer in the office for a single user,” Kleaveland advises.

Buying a CCHIT-certified program will increasingly simplify the job of funneling patient data into a new system regardless of who’s hosting your program, he adds. Last year, CCHIT enacted standards for interoperability -the ability to exchange data - that call for programs to generate portions of an exportable record summary called the continuity of care document, or CCD. Those subsets now consist of patient demographics, medications, and allergies, with standards for more subsets on the way, says CCHIT spokesman John Morrissey. As of press time, 21 vendors have programs meeting the 2008 CCHIT standards. If you have one of these programs and decide to switch to another vendor in this group, you can export CCDs as “XML” files, according to Kleaveland. As CCHIT standards for interoperability evolve, pulling off such data transfers will become easier, he says.

Help for the older gent

In his Texas practice, Seguro fully adopted the EMR while his four partners didn’t. “Two were older gents who couldn’t get the hang of it,” says Seguro.

Seguro needs to remember the past to avoid repeating it. After all, his current partner, Richard Penrod*, is an older doctor who probably will retire in three years. Penrod isn’t computer illiterate. He uses electronic prescribing software, just as Seguro does. And he’s willing to give an EMR his best shot. But Penrod’s not the geek that Seguro is. So Seguro needs to factor this in lest Penrod becomes frustrated with the EMR and reverts to paper, wrecking the implementation.

Kleaveland recommends that Seguro cut his partner some slack on the often troublesome issue of data entry. “If there’s a choice of method, let Penrod choose what’s easiest for him,” he says. “If he’s used to dictating, let him dictate, and have a clerk copy the transcription into the EMR.”

Rosemarie Nelson suggests that Seguro accommodate Penrod financially as well. “An EMR investment is often calculated over five years,” says Nelson. “If the partner is going to be around for only three more years, maybe he should pay only three-fifths of his normal share of the cost. That will make the partner feel better about the EMR.”

Don’t underestimate the ROI

Seguro wants an EMR that can pay for itself, but he’s not sure he can find one like that. “I’m not convinced that an EMR makes economic sense for a practice like mine.”

Kleaveland thinks Seguro’s expectations are unrealistically low, based on a study published four years ago in the journal Health Affairs of 14 primary-care practices that implemented an EMR. The average practice recovered its costs in 30 months. One reason why was higher coding for 15 percent of office visits, since improved documentation made play-it-safe undercoders more comfortable choosing, say, a 99214 instead of a 99213.

“Assume that a pediatrician sees 6,000 patients a year, and codes 15 percent, or 900, of those higher than he normally would,” says Kleaveland. “If higher codes for those 900 visits boost payment on average by $25, revenue goes up $22,500, or $112,500 over five years.”

That same study states that EMR users should be able to increase their patient visits by 1 percent, or 60 visits. Seguro says he didn’t experience such a productivity gain with his old EMR. However, the Health Affairs study also claims that digital doctors can expect to trim their medical records staff by 0.25 full-time-equivalent employee per doctor. Sounds feasible to Seguro - he witnessed a similar labor reduction at the Texas practice. Accordingly, Seguro and his partner could at least dispense with a part-time records clerk and $10,000 in annual compensation, or $50,000 over five years.

This right-sizing brings potential EMR gains over five years to $162,500 ($50,000 plus $112,500). Even if Seguro bought a high-end CCHIT-certified system - hardware, implementation, training, and support included - that cost $50,000 the first year and $20,000 a year for the next four, for a total outlay of $130,000, he’d still come out ahead, says Kleaveland. The federal incentives would just be gravy.

“The numbers are pretty interesting,” says Kleaveland. And maybe just interesting enough to motivate the tentative Seguro to propose to an EMR vendor.

* The names of the physicians have been changed.

Robert Lowes is an award-winning journalist based in St. Louis who has covered the healthcare industry for 20 years. He can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the June 2009 issue of Physicians Practice.