Every day more and more physicians' practices, hospitals and other healthcare organizations are adopting an electronic medical record (EMR). Our national government has given its opinions on the benefits. The non-medical press is covering the transformation on a fairly regular basis. Every major specialty, in their national meetings, seems to be offering information to its members on the transformation to computerized patient information management. It comes up in doctors' lounges.
However, in none of these settings are actual EMR purchase and implementation decisions made. These decisions are commonly made in discussions and meetings among the financial and medical leaders in a medical practice. Often, in these settings, there are physician partners who are reluctant to make the transition from the traditional written and dictated medical record to the electronic.
It is vital in the very earliest stages of discussion to understand and openly face the concerns and objections. Failure to successfully keep this discussion pleasantly moving forward will likely doom the move to an EMR to an early dismissal or to a protracted and unpleasant implementation with many lingering hard feelings. It is even possible that it could lead to the complete failure, for either financial or personal reasons, of a partnership or group practice.
I started my odyssey toward an EMR in October of 2002. I had been a partner in a multi-specialty group and was leaving it to start, with my office partner of ten years, a small family practice office. I went to a national office management conference in Florida, where one of the lectures really piqued my interest in EMRs. Upon coming home to Colorado Springs, I researched and convinced my partner and our office manager to change our ways away from paper and we went live with Allscripts HealthMatics EHR in June 2003. Paying attention to open discussion of all of our concerns, we had a rather rapid and a very smooth decision making and implementation process.
Over the years since our installation, since I have become somewhat of an EMR evangelist, I have talked with many physicians and managers. In fact, my wife is an obstetrician-gynecologist who is in a five-physician practice. She was previously not at all oriented toward computerization, but has come to see the benefits and is now looking forward to using digital media in her patient care. Unfortunately, two of her partners are completely opposed to the whole idea. There are, in general, three major areas of resistance.
The initial objection for many is just "the thought" of having to use a computer. Sometimes, this is not even completely recognized and just expresses itself as other concerns are continually raised. It is difficult to convince the inexperienced computer user that things can actually be easier than the old familiar pen, paper and tape recorder. Two things may help decrease computer anxiety.
First, try to help others realize the benefits that they already unknowingly receive from computerization. Many people, who otherwise would not touch a keyboard, will correspond and exchange digital photos with e-mail. Explain that ATMs are just computers that track money and give it out 24 hours per day. Online news, weather, travel, sports and medical information are often utilized by the computer un-savvy, yet they do not think of these as "computer work." Good EMRs can be as intuitive and smooth as good Web sites. Second, try to help them understand that they will not have to go through it alone or figure it out themselves. Again, good EMRs come with lots of training and adapt their instruction to all levels of students — from hand-holding and baby steps to higher levels of customization.
The second objection, and often the first one actually verbalized, is the cost. There are some very inexpensive options out there. A search through physician management journals will offer suggestions. Typically, though, most practices will be looking for full-featured solutions with unified or linked practice management systems, training, support and coordinated product development and evolution. Though there is considerable variation, these options tend to be more expensive.
In trying to get past this objection, it is important to review the current costs of generating, using and storing paper charts and dictation. Direct and obvious expenses include the actual costs of the folders and paper, tape recorders or phones to get to the transcriptionists, transcription fees, costs of copying and sending records and records clerks. Transcription is expensive. For the EMR, such costs include the EMR software itself, training, hardware, yearly license, support fees, and local hardware maintenance and repair. Most of these numbers should be readily available and may well, if compared over a three- or five-year period, be enough to convince the skeptic of the financial benefits of an EMR.
There are other costs that are more difficult to directly measure. For example, in our office with two full-time physicians and a 3/4-time nurse practitioner, we have no "coder" and one to two fewer receptionists or medical assistants than we would have under a paper-based record system. The EMR accurately tracks the number of "data items" in history taking, review of systems, review of history and physical examination, thus assisting with accurate coding and proper reimbursement.
We will soon be moving to a new office and will require less office space specifically because we have no charts to store. EMRs lend themselves nicely to proper documentation in the recent trend toward "pay for performance." Our malpractice insurer specifically encourages use of an EMR and notes that, through more complete documentation and other medical care improvements, malpractice rates will be lower.
One change in the area of cost is the recent relaxation of the Stark regulations. Now, outside healthcare systems (mostly hospitals) are allowed to purchase EMR solutions for physicians' offices. Obviously, there are significant considerations in entering into such a relationship. From a purely financial point of view, it is always nice to have someone else foot the bill. Pay attention to the attendant obligations and make sure that the software (often selected by the hospital) is one which will be the best for the physicians and staff of the private office.
The third and final, major area of objection to an EMR is that it will get in the way of good care of the patients. This is the easiest to refute, both in the area of general patient satisfaction and in the area of practicing state-of-the art medicine. Since implementation of our EMR, patient satisfaction has been tremendous in our office. Our patients get to securely review or request medications, request appointments, update or verify their contact or insurance information, or send messages to our physicians or staff 24-hours per day. They get up-to-date medication, diagnosis and preventive care information handouts at their visits.
Compared to a paper chart system, their personal information is more secure and is stored in daily back-up files. Work notes, school notes and referral letters can be produced with a few keystrokes and a click. Prescriptions are never illegibly scribbled on a pad. Most commonly, they are sent electronically to the pharmacy directly, before the patient even leaves the office. We have every patient's chart at all times, so, for example, when a mother is in for a visit, she can ask when her child's next shots are due.
Even more importantly, we can take better care of them. Health maintenance reminders can be automated. Communication in the office goes directly between the individuals involved, without others relaying messages or pulling charts. Every conversation and note with patients is documented so things are not forgotten. The EMR automatically screens for medication allergies and interactions. Personalized question sets and exam outlines serve as reminders to be thorough during appointments. Follow-up reminders can be set at the time of an office visit. Patient records are securely available from outside the office when patients need care on call or information is needed at the hospital. With the computer, the vast array or medical information on the internet is available at all times.
Physicians and medical management professionals are, for the most part, reasonable people. They typically will not be coerced or tricked into making a major decision. Their concerns and initial objections are valid and important. In fact, were they not raised, it would be due to a lack of due diligence.
Proper financial investigation is paramount. Verification of the availability of proper training will help relieve the anxiety of the computer-phobic. With these two issues resolved, it should be possible to stress the increased patient satisfaction and, most importantly, the increased level of medical safety and medical care. Satisfaction, safety and care are universal goals to which all physicians should strive.
Steve Ryan, M.D., is a physician with Carefree Family Medicine, a two-physician, one-nurse practice in Colorado Springs, Colo.
