by Jonathan Nelson

 A panacea to some, 
a sign of the apocalypse to others, 
welcome to the age of the electronic medical record.
 

Remember when mail was just mail? When there was no e-mail and nothing was referred to as snail mail? Remember when there were no cell phones or pagers and when you weren’t available, no one could reach you? Remember when a medical record was a note you scribbled so that you’d remember what you and your patient had discussed in her last visit? Remember when kids learned to tell time on clocks that had hands?

Ah, the halcyon days of yore.

Well, those days are gone, and now you probably have stacks and stacks of folders full of notes filling shelves and occupying many cubic feet of space somewhere in your office. A lot is riding on those records, on how well you keep them and how available they are when needed, on how well they can be interpreted by others and how secure they are for the protection of patient health information.

The inefficiencies of paper health records are obvious and if it were possible to flip a switch and seamlessly convert a busy medical practice to an electronic system that operated at least as well as the paper system being replaced, who wouldn’t do it? Would that it were so simple, or even so cheap.

EMRs are supposed to help you reduce medical errors, increase office efficiency, reduce the need for support staff, improve coding and billing, provide a higher level of security for your records, make your life easier and allow you to focus on patient care. Ten years ago, many experts predicted that a majority of doctors would be operating paperless clinics by now. Yet a recent Harris Interactive study shows that only 17 percent of U.S. primary care physicians use EMRs. Another study reports that while practices with between one and five physicians make up almost half of the potential EMR market, only 5.2 percent actually use one.

So, what gives?

Industry analyst Vinson Hudson says two concerns discourage physicians from implementing EMRs, and the first is the big one: cost. Researchers of a recent study published in Health Affairs found that the upfront cost of EMR implementation at most practices they examined was between $16,000 and $36,000 per physician.

Hudson says the other concern is that physicians don’t believe that the current crop of EMRs address what they do at the physician-patient encounter. As president of Jewson Enterprises, a market research and analysis firm for the health care IT sector, Hudson publishes the “Physician’s Office Management and Medical Information Systems” report and he maintains a database of about 160 EMR systems that he thinks are “somewhat viable.”

Within that database, Hudson says there is a wide spectrum of quality. “Most of them are just sophisticated word processors or ways of getting patient information into a database and having somebody assess this information through some type of report generation. That’s not what has to be done.” Aiding and streamlining the physician’s workflow is the brass ring for EMRs and Hudson says there are some systems out there that do just that.

“Right now, we are at the beginning of growth,” Hudson says, adding that the EMR market totals almost $1 billion in annual sales. By 2004, he predicts sales could increase to $4 billion. “Growth is going to come whether physicians want it or not.”

Forces from many directions are pushing physicians to adopt EMR technology. Business groups, health plans, physician associations and even President Bush are touting the virtues of bringing doctors’ offices into the digital age, but few are willing to help defray the cost. “Right now, the biggest benefit for electronic medical records, believe it or not, is to insurers, health plans and the government,” Hudson says. Incentives are in the works, but he fears that penalties may also be in store for those who choose to stick with paper.

Roland Goertz, M.D., would agree. He is the president of McLennan County Medical Education and Research Foundation, which operates the McLennan County Family Practice Residency Program. He says there are two major drivers in the push to adopt EMRs: concern over patient safety and cost savings for payers. The cost for the Centers for Medicare and Medicaid Services to process a paper transaction is over $2 while the average cost for a bank to handle an ATM transaction is less than 30 cents. The government sees EMR implementation as a huge cost savings.

Goertz is a true believer in EMR technology. In 1997 and ’98, he oversaw the transition from paper to electronic records at Waco Family Practice Center, which houses the residency program. Physicians at the center’s four sites handle about 100,000 patient visits a year — about 400 patients each day. There are 36 residents, 11 family physicians, three obstetrician/gynecologists, one pediatrician, six mid-level providers and a nurse midwife on staff, and all can access the EMR using a wireless connection from any of the sites and from the community hospital. Large radio antennas atop one of the buildings at the clinic are used to link the sites.

From his desk, Goertz can see a list of all patients scheduled for the day; who has arrived, which exam rooms they are in and which physicians are treating them. If one area of the clinic is backing up, administrators can easily redistribute walk-in patients to optimize efficiency.

Their EMR is completely integrated, so scheduling, the delivery of care and billing are all contained within the system, and multiple users can access the same record at the same time. When lab work is ordered at the point of care, it is instantly coded, linked to the correct diagnosis and billed. About 90 percent of the lab work ordered is performed in the clinic and all of those results flow directly into the patients’ charts and into the electronic “in-baskets” of the ordering physicians for review. The clinic’s primary reference lab also interfaces with the system, so those lab results come in the same way.

“Unless an [EMR] changes your workflow and your daily habits, it is not working,” Goertz says. “It is not just something you plug in to mimic what you are currently doing.”

An example of this change is evident in the daily routine of the residents and faculty at the program. Their first task each day is to logon to the system and check their in-baskets for lab results, patient messages, telephone calls and prescription refill requests. “It takes them less than 30 minutes to do all of that,” Goertz says. “It used to take two or three times that, strung out through the day.” And, he adds, now no lab results are lost. Many of the physicians check their in-baskets again before lunch and they are all asked to check a final time at the end of the day.

Like many EMRs, theirs is a template-based system, so most of the information gathered at the point of care is entered by making selections from drop down lists, by checking boxes and by selecting commonly used text from choices suggested by the system. There is surprisingly little data that has to be typed into the record. Protocols in the record alert the physician to tests or immunizations that are due and prescriptions can be created with a couple of mouse clicks, “and they’re all legible,” Goertz says. “You don’t get any pharmacy calls saying ‘What the heck does that script say?’” Considering their rate of 9,000 prescriptions per month, he estimates that they saved $60,000 in the first year alone once they stopped handwriting scripts. “Every one of those calls takes a certain amount of time, generally three to five minutes. Because what does the call stimulate if you don’t have an electronic medical record? I have to go pull the chart. So, where’s the chart? It may even generate two calls, because we may have to call back once we’ve found the chart.”

If timesavings and a secure, efficient method of keeping medical records were all EMRs had to offer, Goertz says it would be enough, but there’s much more. The ultimate task for an EMR is decision support — helping you give better care to your patients, and the ability to query your entire patient population through a relational database is the key to this level of care.

For instance, the physicians at the clinic wanted to increase their standard of care for their diabetic population, so they built a protocol into the EMR that would check how much time had lapsed since a diabetic patient had last had a lipid screen and a hemoglobin A1c test. The system would alert the physician during the patient encounter if the patient history did not meet the standard and a message would appear asking the physician if he or she would like to order the tests. With one click, the labs could be ordered, coded and billed.

Tim Barker, M.D., director of the residency program, says the protocol worked. “Within a year of doing that, our average [HbA1c] fell from above 9 to 8 [percent], and that’s a significant difference.” A prominent diabetes study shows that reducing the HbA1c by 1 percent correlates to a 35 percent reduction in microvascular complications and a 7 percent reduction in all-cause mortality. “We did that for 2,500 patients,” Barker says.

“That’s real lives saved,” Goertz says.

“EHR is a wonderful tool,” Barker says. “It’s like a stethoscope of the future. It allows you to hear things you never heard before and see things you never saw before.”

The application of powerful medical record software to an entire population of patients is a higher order of operation than the definition of an electronic medical record would seem to allow. That may be why many in the industry including Goertz, Barker and the AAFP often use the term electronic health record. Whether you call it an EMR or an EHR, those who are using systems for these purposes are excited about them.

“There is no question this system allows us to provide better care for the patient — infinitely better care,” says Allen Patterson, chief financial officer and chief operating officer of the Waco Family Practice Clinic. He says the system is often the “critical ingredient” for recruitment of top quality physicians and residents to the program.

Implementing the EMR was no easy task. It was a monumental organizational change. “Everything you do is different,” Barker says. “When we first went live, it was like everybody’s first day on the job.” Goertz advises physicians to cut back on their business for three to six months when implementing an EMR to accommodate the steep learning curve. But once you have experts on staff who have been using the system for a while, bringing on new nurses and physicians is not so hard. Twelve hours of education is the current standard for new employees at the clinic.

Instead of transferring all of the data from their paper records into the EMR during the initial implementation, Goertz and his team decided to simply pick a day when they would no longer make entries into the paper charts and begin from there. As they needed, they pulled paper charts for reference and when they found critical entries, they would note them in the electronic record. Now, Barker says he has to pull a chart once out of every 20 encounters, and each day the chances of having to do that are less. 

The physicians at Family Medical Specialists of Texas in Plano are pretty excited about their EMR. Christopher Crow, M.D., and Sander Gothard, M.D., have been in business together for three years. They installed their EMR, one year ago, and Crow says he could talk about it all day.

They practice in an affluent, suburban, technology corridor where patients appreciate tech savvy. Patients have plenty of choices in the area. In fact, theirs isn’t the only family practice clinic in their office building. “This is about customer service,” Crow says. “That’s what it boils down to.”

With electronic prescribing and one-click script faxing capabilities plus lab interfaces so that most results flow directly into the system, Crow and Gothard can wow patients with quick turnarounds. They promise lab results within 24 hours and patients can call a secure voice mail system and hear the results from a recording left for them by their doctor.

“Patients are ecstatic,” Crow says. “Patients perceive that since we are on the top of the curve with electronic medical records, that we are on top of the curve with providing quality health care, and I think there is truth to that.”

They believe their EMR helps them practice better and more consistent medicine. Gothard says that even if he’s having a bad day or is a little off his game, he’s not going to forget disease management standards and he’s going to be alerted if he prescribes a medication at the wrong dosage or one that interacts adversely with another medication the patient is taking.

“We all know what to do,” Crow says, “but the stats show we don’t do it. Why are only half of the people with coronary artery syndrome coming out with a beta-blocker when we all know you need one? … Because we’re human? That’s the only thing I can come up with, so that’s why you automate … It’s definitely helped us practice better quality medicine.”

Gothard agrees, remembering how comparatively disorganized the practice was before implementing the system, when charts would disappear at inopportune moments. “It was very poor care when I had to go from memory on a 60-year-old diabetic with heart disease. I’d get really upset with my staff and three people would be looking for the chart.”

That brings up another point: there is less stress at the office and the staff enjoys their work more. And why not? The desktops and countertops all around the office are clean and neat, free of stacks of paper records. They’re fielding fewer calls, they’re not hunting charts and the information they need to do their work is at their fingertips.

Gothard and Crow say their quality of life is much better, too. They leave the office on time everyday without any charts to take home, but when they see the other family physician in the building come and go, he usually has an armload of charts. Gothard and Crow can access their system from any computer, so they can check lab results and messages, make calls, and handle referrals and refills from home. These days, Crow does most of that while he feeds his infant son breakfast.

Gothard says he took a day off recently to attend his 3-year-old’s end-of-year school party. He logged on to his computer for about 30 minutes while his daughter was getting ready and he completed a pre-operative clearance for one patient and refused clearance for another. Without the EMR, he says he would have had to find time to drop by the office on his day off.

Their EMR is template-based, like the one in Waco, and uses many of the same tools to allow physicians to quickly enter detailed information during the patient encounter. Gothard and Crow can build new protocols to suit their needs. They can flip through a complex patient chart, seeing past visits at once or viewing with a prescription priority, or by a record of lab results — all with a few clicks. At the end, the physician has a detailed, prose progress note.

One of the last screens asks about the level of the visit and how it should be coded. If the note doesn’t support the selected code, the system will explain why. Often the reason is that the physician forgot to record something he or she had asked the patient, so the physician makes the adjustments and bills for the more advanced visit. The progress note is complete and the visit is coded and billed before the doctor leaves the exam room. Crow says the coding advice helps to ensure that he’s billing at the proper levels so his average reimbursement rate is higher, plus he receives fewer rejections from health plans.

Sander Gothard, M.D. and Christopher Crow, M.D., have a desktop computer in each exam room. They like to turn the screen so patients can see their own record.

Gothard and Crow admit that the transition wasn’t easy. “You’re not happy on day one,” Gothard says. “It took me one month to see the same amount of patients electronically that I did with paper charts. It took me two months to see more.”

Crow says that in three or four months, the office was cruising. Their transition was somewhat eased by the fact that both Crow and the head nurse at the clinic had used this particular system before.

Both he and Gothard firmly believe they are getting a great return on their investment. “After a year, you’re going to save money and after two years, you’re going to start increasing profit,” Crow says. They say the system is saving them two full-time employees and they plan to add a third physician this summer but they don’t plan to hire any additional support staff. That means their practice will consist of three doctors operating with three front-office employees, three nurses and one person handling insurance and billing.

Fewer employees, no transcription costs, better reimbursement rates — it all adds up to a good deal for these doctors. Crow’s advice: “Invest in yourself. You know what you need.”

Austin’s Ajay Gupta, M.D., is more skeptical than Gothard and Crow about going digital, but he’s no Luddite. Since last August, he’s been beta testing an EMR developed by an Austin-based technology firm. The company plans to launch the system in the fourth quarter of this year. “You have to go through all the kinks on a beta test. It was definitely a work in progress,” Gupta says.

At first there were bugs to be reported and worked out by the software developers. Then Gupta found himself advising the developers on how the system could be more convenient from the perspective of a practicing physician. All the while, Gupta, the other three physicians in the parctice and their staff were still operating with paper records. As the process progressed, the other physicians began learning the EMR as well. “Everyone is pretty impressed with the software,” he says.

Sometime this summer they plan to complete the process and stop using paper charts, although Gupta is pretty happy about the way he was practicing medicine before. He believes a physician should choose an EMR that won’t dramatically change the way he or she practices. “They talk about how you can see patients faster,” he says. “I think there’s no doubt that I can write faster than I can type or I can click on a tablet. So I think for most docs, writing is going to always be the fastest way to do anything.” He admits that the documentation might not be as complete, but he insists that a good EMR should not slow a physician down. “I can finish a [paper] chart while I’m in the room … I’m done with your chart as you’re leaving the room. That’s as good as it gets. I wanted something as fast as that.”

Ajay Gupta, M.D., (right) meets with Boris Portman, who is the vice president of engineering for the company developing the 
EMR that Gupta is beta testing.

Unlike the configurations used in both the Waco clinic and the Plano clinic, where there are desktop computers in every exam room, Gupta carries a tablet PC and uses a stylus to input information and flip through the record. This allows him to walk around as though he were carrying a paper chart, and he can use his stylus to write additional notes in designated fields that interpret handwriting.

This system is another template-based EMR, but it is much more graphically oriented than most systems. When examining a hand, the record shows a graphic representation of a hand. There are intricate graphics for most parts and systems of the body and when the user clicks on one, the software opens templates specific to that area. The developers hope that physicians who become accustomed to the system will be able to interpret the visual graphics more quickly than menu- and outline-based templates.

There is something to be said for having complete documentation. Gupta reviews charts for a large medical liability carrier and he’s having a tough time deciphering the handwriting. “I’m pulling my hair out. And the other thing that is screwing these doctors up, too, is they don’t document.”

An example entry he gives is: Physical Exam – normal.

“Okay, what does that mean? Did you look in their eyes? Did you look in their ears?”

Progress notes generated by an EMR should contain the details of the physical examination, so the documentation is complete. “That’s why these malpractice companies will love it,” Gupta says.

Kevin Spencer, M.D., has the optimal situation; he’s opening a brand new clinic in Austin this summer and he’s setting up a wireless EMR system from the beginning. “We all have to keep records. We have to store data, we have to be able to reference the data and we have to be able to utilize the data … There’s no better way to do it than electronic medical records,” Spencer says.

He recently moved back to Texas after completing residency and practicing for seven years in North Carolina, where he was part of a group practice that considered the transition and shopped for EMRs. When he weighed the pros and cons of starting his new practice with an EMR, cost and implementation were the biggest detractors. “Well, being a new practice, I have none of the implementation worries,” he says. “Yes, I’ll have to learn how to use it, the nurse will have to learn … but we’re not in a busy practice initially so we’ll have time to learn how to use it.”

As for cost, Spencer says he got a good deal by choosing to purchase his EMR through AAFP’s Partners for Patients, a program whereby the Academy has entered into strategic alliances with several health care IT companies to offer reduced prices for AAFP members and to work toward some standard “guiding principles” for the industry. To learn more about this AAFP initiative, click on the Center for Health Information Technology link on the AAFP Web site at www.aafp.org, then select the link that reads “Current Projects.”

On day one, Spencer plans to have one nurse and an office manager. He and the nurse will have tablet PCs and the office will be equipped with wireless technology.

He says he understands why physicians in busy practices would find it hard to justify the expense and the trouble of switching to an EMR, but he also sees the other side: the frustration of a patient who has to go in for a repeat echocardiogram because the test results can’t be found, the blood work that must be done again because the labs from last week were lost. He questions how much waste exists because the health care industry doesn’t have efficient systems for transferring data. “Not to say that there won’t be some bugs to work out,” Spencer says, “but the reality is the rest of the world operates this way. Medicine doesn’t.”