Dr. Maxwell: EMRs today should include speech recognition, e-prescribing, integrated practice management (PM) billing software, fully functional word processing with spell check, an integrated picture archiving and communication system (PACS), and optical mark recognition for outside practice reports.

AAOS Now

Published 9/1/2009

What’s your perspective on EMRs?

A roundtable discussion on electronic medical record systems

Medical practices have gradually begun adopting electronic medical record (EMR) systems, and recent funding opportunities under the American Reinvestment and Recovery Act may facilitate that shift. But is it an advisable strategy for all practices?

AAOS Now explored the issue with five physicians: Jon M. Maxwell, MD, a solo practitioner in Adrian, Mich.; Robert Blotter, MD, a general orthopaedist in a small group practice in Marquette, Mich.; Charles E. Rhoades, MD, a member of a 14-surgeon practice in Mission Hills, Kans.; Michele M. Zembo, MD, MBA, professor of orthopaedics at Tulane Medical Center in New Orleans; and Robert Lynch, MD, the former national chair of the Veterans Administration EMR committee and current CEO of Tulane University, New Orleans.

AAOS Now: What is the state of the art of EMRs today?

Dr. Blotter: Effective EMR systems must provide security and interoperability, particularly as more providers adopt them. A system will be inadequate if it is unable to communicate with other systems. Many EMRs are still cumbersome and difficult for the “computer-challenged.”

Systems must meet the Certification Commission for Healthcare Information Technology (CCHIT) criteria, although in July, the Department of Health and Human Services (HHS) Health Information Technology (HIT) Policy Committee expressed the possibility of developing a separate set of standards.

Dr. Zembo: I am not sure there is a “state of the art” but an evolution. EMRs are following a typical pattern for new and evolving technology. Initially, small companies developed systems targeting specialty areas, and large medical centers may develop homegrown systems. As things proceed, larger, more established companies move into the market and consolidate the industry, looking to integrate EMRs with other systems such as PM software, PACS, physician order entry, and pharmacy management.

Dr. Lynch: “State of the art” implies provider order entry, clinical decision support, provider documentation tools, integrated imaging, data warehousing, and integration of clinical, billing, and business analytic capabilities. Unfortunately, this total package is rarely achieved due to cost, complexity, business process reengineering, and systems integration issues.

AAOS Now: How far do today’s EMRs go toward improving the quality of care patients receive, and how is that improvement quantified?

Dr. Maxwell: Use of EMRs allows for standardization of care and development of care protocols. Precise and timely documentation of care, especially patient messages and prescription refills, can be done effectively while reducing time burdens for the physicians and their staff.

Quantifying these improvements, though, is difficult. Currently, we have no mechanism within our practice that would really help us quantify how and if our perceptions of quality improvement for our patients are actually taking place.

Dr. Rhoades: Today’s EMRs anecdotally provide huge advances in patient care—better communication, fewer omissions, electronic reminders of accepted care plans, real-time alerts for allergies, and other built-in electronic safeguards. Evidence-based data are lacking at this time, but practices with fully functioning EMR systems almost universally feel they have improved the care. The primary caregivers (nurses, office staff, phone/receptionist staff) strongly support the EMR system after it has been installed and they have learned to use it.

AAOS Now: How far do today’s EMRs go toward reducing costs?

Dr. Maxwell: Time and cost savings are available, reducing paper usage and the need for support staff. Transcription costs can be entirely eliminated.

Dr. Blotter: Most EMR vendors promise efficiencies in documenting visits, increasing physician appointments per day, and decreasing personnel. This has not been our experience. We did decrease one full-time employee when we began using EMRs, but this was soon offset by the need for a full-time employee who does nothing but scan and enter outside documents to our system.

We have seen no difference in transcription costs for our practice. I am often puzzled to see what I perceive as work transfer with many EMR systems that transfer the work from one of the least expensive employees—transcriptionists—to the most expensive employees—physicians. When we looked at the time savings per physician, dictation was more cost-effective and time-savings than the multiple clicks, pastes, and typing required to provide a relevant clinical note.

Probably the biggest cost savings that we have seen is the integration of the EMR and PM systems, which has allowed us to improve coding accuracy.

Dr. Lynch: Initial adoption generally does not reduce cost. A fully paperless system would obviate the overhead of traditional record keeping, improve billing and accounts receivable, and avoid overutilization and costly errors. It can also improve patient throughput in most cases.

AAOS Now: Do EMRs actually provide a benefit or time savings to the physician (not just practice staff)?

Dr. Maxwell: A qualified, absolute yes. The software must be flexible enough to allow any doctor’s paradigm of practice documentation to be taken directly to the electronic screen. That is, the only difference in the documentation processes should be that it is done electronically and not on paper charts. The processes for documentation can then stay the same, but the time required to do so is greatly reduced and the detail of information is easily expanded.

Dr. Blotter: We have not experienced time savings for the physician. Some of the problem was our inability to fully adapt to the template system. We initially had a lot of training on the templates, but the number of template designs needed for the many different patients our practice sees was overwhelming. A similar practice hired an IT specialist who works full-time on developing various templates and macros for the physicians. But I see this as a transfer of a job to a more expensive employee.

Dr. Rhoades: Initially, using an EMR system will slow a physician down in his or her daily routine of seeing patients. Over the course of time, though, most physicians can become just as efficient as they were prior to the implementation of the system. If the physician is willing to consider his or her time as a part of a complex process and not simply a stand-alone event, the EMR efficiency is unquestionably positive. Too often, physicians lose the commitment to using the technology early in the implementation phase as a result of seeing fewer patients.

Dr. Maxwell: EMRs today should include speech recognition, e-prescribing, integrated practice management (PM) billing software, fully functional word processing with spell check, an integrated picture archiving and communication system (PACS), and optical mark recognition for outside practice reports.
Dr. Blotter: Our adoption of EMR has helped in locating a patient’s information more readily and allowed us to decrease the time spent dealing with telephone inquiries, prescriptions, and the like. The data retrieval capabilities of some EMR systems, if properly used, also can help identify subsets of patients when necessary.
Dr. Zembo: The potential for improving the quality of care is real. According to a 2005 Rand study, 90 percent adoption of EMRs could prevent 2.2 million adverse drug events with a cost savings of $4 billion a year. Health benefits from prevention and management of disease alone could help avoid 400,000 deaths and add 40 million workdays, with potential cost savings of $81 billion a year.
Dr. Rhoades: The current EMR systems probably do not create a significant drop in cost initially. They do, however, enable organizations to absorb new requirements for information, documentation, and monitored processes without additional costs.
Dr. Lynch: Time savings depend on the specific practice and specialty. A specialty such as rheumatology can assess complex clinical data more efficiently with an EMR than with paper records. Physician documentation can be a major sticking point, particularly for those who are not comfortable with the technology.

Dr. Zembo: Improved documentation can lead to improved coding and billing, and better support in malpractice cases. A truly integrated system—used by hospitals and an entire practice group—will give a more complete picture of the patient’s health status, leading to better treatment decisions. EMRs also can facilitate clinical research and patient recruitment, and provide easier access to patient education material.

A 2005 study of 14 solo or small group practices of primary physicians found that switching to an EMR initially cost $44,000 per full-time provider (FTP), with ongoing costs of $8,500 per FTP. The average practice paid for the cost of implementing an EMR system in 2.5 years and averaged financial benefits of $33,000 per FTP per year, primarily from improved coding and increased efficiency-related savings. Practices that anticipate applying for financial support under the Health Information Technology Act will need to meet meaningful use definitions and measurements as prescribed by the HHS HIT Policy Committee.

AAOS Now: What downsides, if any, are associated with EMRs?

Dr. Maxwell: Software, hardware support, and maintenance can be unrecognized costs. Electrical blackouts and brownouts can shut down a practice. Any EMR system requires a 99.99 percent ‘uptime’ rate. Practices need a redundant backup system in case of complete hardware failures. No EMR system is worth its price unless documentation takes no longer than the current paper chart system, and taking less time is even better. So be careful what you buy.

Dr. Blotter: I think the biggest downside is the lost productivity when adopting an EMR system. The cost of user licenses plus hardware can be quite high, especially if the system charges by the number of users. With more clinic rooms than user licenses, we must take our laptops from room to room.

Dr. Rhoades: The initial cost and the pain of implementation are the greatest downfalls of the EMR concept. Physicians must be willing to embrace the technology, to change their work processes, and to accept different ways of accomplishing the same tasks they have performed in the paper world.

Dr. Zembo: Longer charting times can be an issue. Documentation times could be dependent on the availability of options: dictation, physician entry, or voice recognition. Also, additional policies and procedures will need to be developed for EMR systems.

Dr. Lynch: Cost always must be considered. The failure of all physicians in an organization to fully adopt a system can blunt the positive effects while exacerbating costs. The lack of a dominant vendor or universal interoperability leads to difficulty in integration and the risk of technical obsolescence.

AAOS Now: What has been your personal experience with EMRs?

Dr. Maxwell: I tried four systems before I found the right software. Once I did, I was able to reduce overhead and offset the cost of acquisition and implementation in just 6 months!

Dr. Blotter: We studied EMRs for about 18 months before we decided to adopt the technology. We implemented the system two physicians at a time, choosing our most computer-literate physicians first, which helped ease it in to our practice and helped manage the time-off for training by our employees and physicians. Our selection of an EMR system had a lot to do with our PM system, which was from the same vendor and integrated well. We have seen improvement in terms of the capture of coding, but little or no improvement to our efficiency on the clinical side.

We have been able to save space by eliminating a vast quantity of physical charts. We hope to work out the bugs in terms of efficiency on the clinical side.

Dr. Rhoades: Our practice implemented a fully functional EMR system in October 2004—in a single day. Paper backup was phased out as physicians and staff became comfortable with the EMR infrastructure. We have implemented electronic prescriptions, electronic fact server, some specialty-specific forms and protocols, and offsite access to physicians for the records. The transition has been successful. Neither physicians nor patients would return to the paper world electively.

Dr. Zembo: The whole process takes a lot longer than you plan. Be prepared for frustration. Physicians definitely like the improved reimbursements that have been realized, particularly in early phases when documentation for each patient visit is taking longer. It is important to test the EMR system’s coding and documentation to ensure accuracy for evaluation and management codes.

Dr. Lynch: I experienced the evolution of the VA’s current system, which has received justifiably high marks. It improved efficiencies, safety, and outcomes. I was also involved in the evacuation of the New Orleans VA Medical Center after Katrina. These patients’ records were available to clinicians at every VA medical center in the country—a powerful testament to the flexibility of an integrated EMR system.

AAOS Now: What single piece of advice would you offer a physician whose practice has not yet implemented an EMR system?

Dr. Maxwell: Do it! But make sure that the software will really fit your (and your partners’) style of practice!

Dr. Blotter: Listen carefully to the vendor’s sales pitch. Count on obstacles and hurdles in your adaptation of a system. Allow enough time for training and implementation.

Dr. Rhoades: Accept the fact that you will need an EMR system in the very near future, shop the available national vendors, and pick a system that fits your budget and user preferences. Anticipate a short period of difficulty followed by a prolonged period of benefit.

Dr. Zembo: Do your homework first and be prepared for change: Get buy-in from the people involved, from physicians and office staff; honestly evaluate how the practice runs and be willing to make changes when needed.

Dr. Lynch: Be sure of what you are trying to accomplish with an EMR system. It is ultimately just a tool with specific benefits. Do your homework as thoroughly as you would for any other major investment decision. Get feedback from someone who uses the products you are considering. Lastly, make sure everyone is committed to the implementation.

Download a free EMR primer

View the HIT Policy Committee Matrix on Meaningful Use and Measurements (p. 35)