Fewer primary care physicians using electronic patient data than previously indicated

Jan 21, 2005 By: Ken Terry Medical Economics

Different specialties use different EHRs . . .

Not surprisingly, a higher percentage of young doctors are EHR users. Some, like solo FP Harald Lausen of Springfield, IL, began using a computerized record on their very first day in practice. Says Lausen, "Since I was going to start a new practice, I thought, 'Why wait to convert later? I'd rather start it up the way I think it ought to be done.' "

It's also predictable that more doctors in medium-sized and large groups would have EHRs. The systems can be very expensive, and larger practices have deeper pockets and are more likely to have IT people and administrators who can help the practice implement the system.

Yet, despite the "digital divide" between large and small groups, there are signs that small practices are trying to catch up: 60 percent of soloists with EHRs have bought them within the past two years, and 20 percent of doctors in solo or two-physician practices plan to buy EHRs within the next 12 months.

Different EHRs for different folks One thing is clear: the EHR market is hardly dominated by only a few players. We asked respondents to name the system they own, and we got scores of product names. That's not surprising, says Mark R. Anderson, president of the AC Group, a consulting firm in Montgomery, TX. He notes that there are about 270 EHR vendors, and "their salespeople are very good at confusing people. Doctors don't have enough information to know which EHRs are good and will meet their future needs."

But practice size is a more critical factor

According to our data, SOAPware is the most popular EHR brand among FPs and internists, while the more elaborate IDX and Allscripts EHRs rank highest among pediatricians and ob/gyns. But, overall, the choice of an EHR isn't closely correlated with specialty, and only 32 percent of respondents say their EHR was designed for their specialty. In interviews, physicians who have better-known EHRs said the systems came with templates for their specialties, but that they'd had to customize them quite a bit.

The type of EHR a doctor has depends most on his practice setting. The top brand, Epic, is used mainly by physicians in very large groups or those who work for hospitals or other institutions. In contrast, SOAPware and e-MDs appeal mostly to doctors in practices of 10 or fewer physicians; Med-Informatix, NextGen, PMSI, and A⁴ have a decent penetration in practices of those size, too, but are also popular in groups as large as 20 doctors.

Some of this is related to price, of course: SOAPware and MedInformatix are among the less expensive systems, while Epic is one of the costliest. But most doctors consider many factors before they buy an EHR; and although cost is one of them, it's usually weighed against what the practice needs.

Internist Jeffrey K. Hertzberg, a Minneapolis-based consultant and expert on medical informatics, notes that the pricier EHRs tend to offer many extra features that small practices might be willing to forgo, such as functions related to data structuring, error checking, and disease management.

Do EHRs make you more productive

The features doctors want most Based on our survey and interviews with respondents, physicians who use EHRs tend to be more concerned about workflow features, cost, and return on investment than about functions related to managing patient care.

The only function that nearly all respondents say their EHR can perform is electronic charting. Beyond that, the most common features are a practice management system interface, electronic charge capture, electronic prescribing, and the ability to incorporate scans of paper documents. Only 60 percent of respondents say their EHRs have messaging systems that allow physicians to exchange patient-related information with their staffs.

Even less common are the availability of drug reference and formulary data and the ability to call up lists of patients with specific diagnoses. More widespread than those functions are clinical alerts regarding allergies, drug interactions, and care reminders.

Specialty is a factor in satisfaction with EHRs . .

Only half of the EHRs in use can exchange data with labs and hospitals, but that's mainly because interfaces are expensive. Physicians are eager to use free interfaces provided by some reference labs, but don't want to pay thousands of dollars for them. Hospitals are even less likely than labs to offer connectivity to specific EHRs, but they will do it for a large group or one they're affiliated with. That explains why it's mainly big groups that are online with hospitals.

Different doctors, different approaches The biggest challenge for most doctors in implementing an EHR is adapting its charting system to their practice style. Some physicians dodge the problem by dictating some portions of the record. This approach may speed up documentation but also entails transcription costs that EHRs are supposed to eliminate. Ob/gyn Charles D. Thompson of Abilene, TX, has overcome that obstacle by using a voice recognition program with his MediTalk EHR. He has his staff enter vital signs, then dictates the note using a program that he says is 98 percent accurate. His e-prescribing module generates med lists, and he has all incoming paper reports scanned in. He retrieves data mostly by searching his text for key words.

Internist Robert D. McCartney of Denver, who uses an EHR made by Physician Micro Systems, combines voice recognition with typing. He says he can't use the drop-down-box charting method that's characteristic of most EHRs, because he works exclusively in nursing homes. Most frail elderly patients have numerous problems, he notes, and it would take too long to navigate the structured templates for documentation. So he has his nurse enter vital signs and labs, and he uses the automatic features of the EHR to generate med and problem lists, while using macros to pull past histories into his notes.

What does your EHR let you do?

Because family practice covers such a wide territory, FPs and GPs have to customize EHR templates more than pediatricians and ob/gyns do. While only 37 percent of FPs/GPs say they found that to be a lot of work, some physicians told us they encountered severe problems in this area.

For instance, FP Allen H. Butler of Huntsville, AL, says his Dr. Notes EHR came with internal medicine templates but nothing applicable to pediatrics. "It was really troublesome, because there was no place for vaccinations, for example. The EHR was extremely cumbersome to use, and I couldn't get over the initial amount of time needed to make it efficient." While he hasn't given up, he's discouraged.

Other physicians have become quite efficient in using their EHRs, although most say it took them at least six months to get fully up to speed. The ones who have mastered documentation often chart by exception—that is, they record only abnormal findings. But just 60 percent of respondents say that their EHRs permit them to do that.

Are EHR templates close to doctors' practice styles?

The other barrier to EHR implementation is workflow. "We had to change the office flow so it was centered around the electronic record," recalls FP Jeffrey A. Hopland of Elizabethtown, TN. "We don't have to follow the paper chart around, so we move people in a completely different way now." While that, combined with learning to use the EHR, slowed the office down at first, he's now charting as fast as he did on paper. "And office efficiency has gone through the roof," he says.

But Hopland's experience isn't universal. Although 46 percent of respondents say their EHRs have speeded up their work, 34 percent say it slowed them down. The rest say there has been no change.

Satisfaction:correlated with ROI The most satisfied doctors are those who say their system has paid for itself or soon will. FPs, younger doctors, and doctors in smaller practices are more likely to say they've gotten or expect a return on their investment.

Doctors had difficulty customizing templates

EHRs can pay for themselves by eliminating transcription or lowering labor costs for tasks such as chart handling. By increasing office efficiency, some groups find they can expand without adding staff. That was the case with a 20-doctor primary care practice in Elizabethtown, TN, which has about half the number of FTE staffers per physician than the average primary care group does.

Some EHRs help doctors boost their reimbursement by suggesting E&M codes based on what they've recorded in the note. FP Kurt Wilhelm of Boscobel, WI, says his WebMD EHR can do this (only about 30 percent of EHRs can, says Anderson), but that it sometimes suggests the wrong codes. "The good news is that we've been getting better at billing, because we're documenting better what we're doing."

Still, it would be wrong to assume that EHRs please physicians only if the systems make money. Even some physicians who are barely breaking even on their EHRs are impressed by how they improve the practice of medicine. Pediatrician Jonathan A. Cheek of Canton, GA, says his MedInformatix EHR has eliminated misfiled charts, cut potential prescribing errors, improved documentation, and made it easier to read his partners' notes when he's on call. But because of the time it takes to enter information, he's seeing fewer patients than before, and he hasn't had a return on his investment yet.

Internist Revel D. Porter of Jonesboro, AR, says he was seeing as many patients as ever within three weeks of switching to a GE system. By the six-month mark, he was no longer staying late to finish his documentation, and he now finishes all of his paperwork by the end of the day.

After seven years on the EHR, Porter's 18-doctor multispecialty group has just about broken even on its investment, he says. "Our costs for transcription and medical records personnel are way down, and our ability to code more accurately has brought in more revenue. By automating our documentation, we're also less likely to lose charges." But because of the high costs of the hardware, software and maintenance, he adds, "it's a wash financially."

Nevertheless, Porter says his EHR "is a tremendous convenience. When Vioxx was withdrawn from the market, it took five minutes to have a list of every patient on the medication, and another five minutes to print out a form letter to send them." He also observes that the ability to access his charts from home has increased his productivity substantially.

Overall, says Porter, having everything organized, accessible, and up to date "increases your efficiency. All those things are well worth it, even if it doesn't bring in added revenue. It makes life much nicer and more secure."

Resources to help you compare EHRs The first stop for any physician interested in buying an EHR should be the Web site of the American Academy of Family Physicians. The healthcare IT section of this site (www.centerforhit.org) offers a wealth of information, including how to prepare your practice for an EHR, what kind of EHR your practice needs, and how to implement an information system. There are also product reviews (available to AAFP members only) that include structured ratings on quality, price, ease of use, support, and productivity.

The Healthcare Information Manage-ment and Systems Society (HIMSS), which is the leading organization of healthcare IT professionals, offers a resource called the Ambulatory EHR Selector (www.solutions-toolkit.org/EMRtoolkit/ASP/default.asp). This interactive tool, which costs $149 a year, includes comparative information on products from 30 vendors. You can use the Selector to do searches on up to 375 functions, plus characteristics such as practice size, specialty, pricing, and contract details.

You might also want to look at the AC Group's 2004 report on EHRs, which ranks nearly 50 products on the basis of what they can do (www.acgroup.org). The AC Group, a consulting firm based in Montgomery, TX, is run by Mark Anderson, a leading healthcare IT expert, and the company's detailed reports have gained a following from their release at the annual Towards an Electronic Patient Record (TEPR) conferences of the Medical Records Institute. The dozen or so EHRs that have earned five-star ratings provide just about every function that a physician could need.

Dr. Lowe's cheap EHR reaps unexpected gains When FP Terry R. Lowe of Hattiesburg, MS, and his four partners decided to buy an EHR in 2001, they chose a product called SOAPware for one reason: It cost only $300 per doctor per year. At first, he and his colleagues planned to continue dictating notes and to use the EHR for other things. But as the doctors became comfortable with electronic charting, they stopped dictating and were able to realize savings on transcription, Lowe recalls.

To scan in outside documents, the practice bought a scanning module from SOAPware, raising their cost a bit. But they skipped the E&M coder and the drug interaction modules, preferring to use Epocrates on their PDAs. They paid for a lab interface, and Lowe himself wrote a simple interface to bring patient demographic data into the EHR from his practice management system. The doctors use a scanning system (not part of SOAPware) to input charge tickets.

Lowe and his partners found it easy to customize the note-taking templates provided by SOAPware. E-prescribing is also simple, he says, but the module is fairly primitive; it doesn't let you put in dosage or frequency or search for other drugs in the same class. Lowe's version of SOAPware has no internal messaging system (a more recent version does), but it works with voice recognition and allows insertion of free text or transcription.

The group is saving $4,000 a month on transcription and has pared its medical records staff. After slowing down for the first six months, says Lowe, "we're able to see more patients and see them more rapidly now." He finds that he can document visits faster than he can dictate. "So that's where the time saving is—you don't have to sit down and dictate that chart later. When you're through, you're through, and you go home."

Dr. Wilhelm tries to think like a computer The biggest problem that FP Kurt Wilhelm of Boscobel, WI, has with his OmniDoc EHR from WebMD is that he can't always think like a computer. When he tries to put in a diagnosis-related phrase that he's used for a long time, the EHR might not find it on any of its pick lists. "Then you reword it, and it's like playing the game of 'read my mind.' That can be frustrating. But with time and experience, we've narrowed it down some."

Wilhelm, his three partners, and their NP started using the EHR a year ago. They all worked together on adapting the templates, which were not especially suited to family practice. A computer-savvy staffer was a big help, but it took six months for Wilhelm to restore his productivity without staying late every night. He still stays late some days, but says a couple of his colleagues finish all their documentation during office hours.

The doctors bought OmniDoc because it interfaced with their Medical Manager practice management system. However, Wilhelm observes, OmniDoc doesn't have clinical alerts, as some comparably priced products do. And while the EHR allowed them to scan in their old charts, there's no obvious way for doctors to call up the scanned documents while they're taking notes in the EHR. The doctors finally figured it out without help from the vendor.

Although the EHR has made the practice more efficient and helped increase billings through better charge capture, Wilhelm doesn't know whether the group will get a return on its $150,000 investment in the system. "This won't allow us to see a greater number of patients," he says. "But it helps us do things more efficiently, with greater clarity of documentation."

Dr. Campion's manual approach to computerization Instead of scanning paper records into their NextGen EHR when they introduced it in August 2003, a nine-doctor primary care group in Newport Beach, CA, decided to input key portions of the charts manually. FP Catherine A. Campion supported this choice, because she wanted the EHR to be "a living thing" when she started using it. But she and some colleagues didn't like the idea of having staffers input past histories, so they began taking stacks of charts home every night. "It took me around 8 months to get the majority of my patients entered, and it was a lot of work," she says. "But now it's rare that a patient isn't in the EHR, and I have everything in the form I want."

Campion "hates templates," especially for taking down the history of present illness. So except for very common complaints, she types most of the subjective, assessment, and plan portions of her notes. She does, however, use templates for physical exams, charting by exception. After four to six weeks on NextGen, she says, she was seeing as many patients as before; but it took much longer to adjust to the new way of working. She wasn't able to complete all her documentation during office hours for a full year.

On the positive side, she says, the EHR has already paid for itself through staff reductions. And the clinical benefits, from allergy and drug interaction alerts to more complete documentation, are impressive. She hasn't become more efficient and isn't seeing more patients, but she believes what she gets out of the EHR is worth what she's putting in.

"It's wonderful to get a phone call from an ER doc and not have to say, 'Mary, can you pull that chart?' You can just open the electronic record, give him the information, make a note quickly as to what's been done, and go back in the exam room."