Why the return on investment in an EHR is poor

I had a déjà vu experience recently when I visited a medical practice that was like so many others I’ve been to before.

This practice just wasn’t getting their investment back from their EHR.

The practice had been live on the EHR for about five months and was functioning effectively without pulling charts for patient visits. The clinical staff was comfortable with the system and seeing a full complement of patients.

The transition to the EHR had been accomplished by scanning the physician’s preferred information (last two visit notes, ultrasound, etc.) from the paper chart in advance of the patient’s first appointment post-changeover. The group established specific folders for the different scanned documents based on the physician’s preference for easy access.

The physicians and nurses each have a netbook device connected wirelessly.

The physicians bring the netbook into the exam room for reference but do not document in the room.

The nurses also bring the netbook into the exam room for documenting vitals but they use a desktop PC at the nurses’ workstation to enter data such as injections because it’s easier to read data on the larger desktop monitor than on the small netbook screen.

The practice currently has no lab interface so all lab results are scanned into the system.

And all orders are still paper requisitions even though the practice could create the order electronically and print it to accompany the specimen, which would establish a tracking for outstanding results.

Instead, the group continues to maintain a paper tickler file with duplicate requisition copies for tracking outstanding results.

But in a truly successful EHR implementation, the practice would be reducing the redundancy in an office by changing processes. Even before a full lab interface is developed, there are process improvement opportunities like the one presented with the lab requisition forms.

Only when such processes are changed do you gain the real operational efficiency that drives the return on the investment in an EHR.

Not all the practice’s staff members are completely comfortable with technology, either. So they fall back on comfortable ways of doing things as a backstop. For example, the front desk check-in person prints the day’s schedule and checks off patients as they arrive, even though she is also using the check-in function on the electronic schedule.

Although there’s no huge harm in doing this, it still presents a challenge to the work flow. Because the information must be captured electronically, the job is being done twice. To make sure you maximize staff productivity, you might just need to take away print privileges!

In this practice, as in many others, medical device output continues to be a challenge to integrate. For example, the EKG output strip is a long scroll of paper and the office maintains a paper chart file for those documents, although they do enter the interpretation into the EHR.

To fully realize the benefits of the EHR, it may be necessary to invest in new medical equipment, such as a PC-based EKG.

The office manager — who’s driven the entire implementation and has an excellent relationship with the physician-owners of the practice — has been able to move even the most technically-challenged physician onto the system. That being said, the technophobe is a reluctant user, only occasionally e-prescribing and continuing to dictate all patient visit notes.

Bottom line: The implementation “works” but the office has not adopted much of the functionality that would deliver increased operational efficiency.

Unfortunately this is fairly typical. To find out if it’s the case in your practice, walk around the office wearing your consultant hat.

It’s likely that you’ll find plenty of opportunity to increase utilization and earn a real return on your investment.

Rosemarie Nelson is a principal with the MGMA Health Care Consulting Group.

Originally published in MedPage Today. Visit MedPageToday.com for more practice management news.

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  • http://fertilityfile.com IVF-MD

    There are well-established fully functional EHR systems out there that are free and are web-based, thereby requiring no additional hardware other than internet access. In fact, that’s what we’re testing out right now for our office.

    But I agree with you that the ROI can still be poor if you take into account all the time that we have to invest.

  • Vox Rusticus

    Except for someone pulling charts, whose time can now be spent scanning in the documents the practice needs to be electronified, exactly how will this supposed model practice reap any savings, between software and hardware updates? Will they be able to need fewer employees to run their practice? Will the doctors be able to see more patients in a day? Where is the benefit to the practice in cost savings? How does that apply to a one-office small practice that doesn’t need to share a chart among departments or between separate facilities the way a large clinic or hospital system might?

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      There are no savings to reap for a small practice.
      You will not need fewer employees.
      You will most definitely not be able to see more patients in a day.
      If there were obvious financial benefits, the government wouldn’t be paying you to buy one.

      However, I am certain that if you have been in practice for many years, you are aware that health care delivery is about to undergo dramatic changes. The sheer existence of small practices is being questioned and seriously threatened, and one of the reasons for this threat is that small practices supposedly are unable to “advance with the times” and move to electronic communications, computerized medicine, grand research, population management and “innovative” solutions, whatever that means.

      If this makes you angry, and ready to throw in the towel and retire, or at least close your practice and do something else, please don’t. This is not a good time to call it quits.

      Yes, EMRs.are not perfect (not even close), but they represent the cost of doing business in this day and age. There are affordable choices (nothing is truly “free”), and there are ways to cope (yes, cope) with this intrusion. I have seen many solo practices that are doing so successfully.
      If you believe that independent practices should continue to exist and if you want to maintain some semblance of control on how you practice medicine, you should at least try (very, very carefully) to find an EMR you can live with. Maybe start with a little window shopping, and take one small step at a time.

  • pcp

    In a well run office, there are no operational savings to be had with EMRs: the best one can hope for is that, eventually, revenue will return to pre-EMR levels. One still has to store old paper charts, so you’re left with wondering if you’ll be spending $50,000 less per doc on paper to balnce the cost of the EMR. I think the answer’s pretty obvious.

  • P Delaney

    we’ve used EHR for 7 years, and most of my colleagues wish we were still on paper. Generally my older peers, the younger ones wouldn’t think of paper charts at all. EHRs are great and organizing and presenting data. The biggest problem is still getting the information in there. Most of us spend 1-2 hours at home typing our notes. The MDs in our community who love EHR most actually use it the least, having their nurses or “scribes” do the typing/dictating for them. PCPs can’t afford personal assistants.

  • soloFP

    Outpatient EHR means that the docs end up typing the notes instead of dictating. Much of the visit is spent typing and editing templates.

    Both of my local hospitals are implementing a multi stage system, with currently vitals and labs moved from the chart into the EHR. I now have to print my vitals and labs to reference when talking to patients, entering them into the SOAP note that is still handwritten, and add to the office charts. When I have a transfer from the ICU to the regular floor, a discharge home, or an ER admission, I end up filling out 4-6 pages of med sheets that are printed first and then must be signed by hand. The amount of paper has not decreased with EHR and time saving is minimal to none.

  • http://doctorstevenpark.com Steven Park, MD

    I’m VERY tech savvy and made a successful switch to an online EMR about 6 months ago. However, after the adjustment period, I found that the EMR was actually slowing me down. I’m a specialist and don’t have any complex charting needs.

    I refuse to chart during a patient encounter—you need to make constant eye contact and interact with your patient, and not just listen to what they’re saying. I’m very good at documenting afterwards, but even a streamlined EMR charting system was about 2-3 times slower, no matter how many templates or keyboard shortcuts I use (TypeIt4Me is great). I ended up charting on paper again, and have my staff scan it in. I’m much happier now.

    The other really annoying thing about EMRs is that when you look through a past patient’s chart, having to individually preview or click on every test or document is not satisfying. I’m only able to absorb 50% of what I used to do with paper charts, and it takes twice as long.

    Unfortunately, we’re stuck with EMRs in the long run. Eventually, something has to give: spend less time with patients, document less, hire a full time scribe, or go into a different field.

  • ErnieG

    Steven Park’s experience is what most people who have not dealt with EMRs fail to grasp- no matter how tech savvy or willing you are to go into EMR, the physician’s interaction with the EMR to document patient visits is very slow, inefficient, and unsatisfying. A well prepared tabbed paper chart is like having multiple windows at the bottom of the computer screen all on the same patient. The ability to visually scan and absorb multiple reports is much greater with paper. I am a young physician who feels very comfortable with computers, and I made the plunge 2-3yrs ago. These are not growing pains.

    • http://doctorstevenpark.com Steven Park. MD

      I think there is a way to completely re-engineer the EMR interface, using current web-based technologies. It’ll take creative minds to think completely outside the box, working closely with doctors that are in the trenches. Maybe apple should get into the EMR business, and do the same thing for health care that it did with music. Now with iPads beginning to infiltrate the medical fields, it’s not too far fetched.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Marie, good to see you have such a stimulating article. I agree with most of the replies: there is still a lot to evolve and learn about making EHR use effective at PCP offices.

    I find it interesting that no one has brought up the fact that you do get some benefits like the 2% bonus for e-prescribing. Besides, e-prescribing definitely improves safety for patients.

    What are some of the other benefits that docs and staff see in the use of an EHR?

    • pcp

      “Most of us spend 1-2 hours at home typing our notes”
      “2% bonus for e-prescribing” (that is, 2% of Medicare, or next to nothing).

      Get real.

  • http://doctorstevenpark.com Steven Park. MD

    I have to admit that e-prescribing is easier, something I can do online from anywhere. Documenting patient calls and having test results available instantly is also a plus. But none of this makes up for the inefficiencies of the patient encounter, which I described previously. So far, I’ve yet to meet any doctor that’s happy using EMRs.


  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    e-Prescribing (when done well) is more efficient, and so is receiving lab results electronically, which really is indicative of what EMRs are good for – replacing paper communications and making the chart mobile, so you can access it outside the office. The other efficiencies are mainly accruing to office staff, not physicians.
    If you look at computerization of other industries, most of the time the goal was to minimize or outright eliminate human interactions which in supply chain and manufacturing, for example, is 100% wasted time and money.
    The patient encounter piece of medicine, which arguably provides the highest value to the customer, is not something that benefits from automation, at least not until the doctor is in large part replaced by a computer. Since this is not very likely to occur any time soon, we either computerize ancillary functions around the edges of the encounter, or forcefully try to automate the encounter in order to benefit the secondary processes.
    The latter is what most (not all) certified EMRs are attempting to do, and as P Delaney commented above, happy physician users are usually those who managed to delegate most of the EMR work to staff.

    • pcp

      I wonder how many IT company CEOs type up lengthy documentation of every 15 minute unit of work they do?

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        That’s exactly the problem in a nutshell – none do, of course.
        Until the powers-to-be acknowledge this error in strategic thinking, there is very little all of us can do.

        • pcp

          It’s really tough to figure out who are the “powers that be” who would be motivated to change things, isn’t it?

          Health IT seems to have morphed into a juggernaut rolling along under the force of inertia, having completely shed any interest in usability, customer satisfaction, etc.

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            It’s the money… Those billions of dollars in HITECH funds that are effectively orchestrating events right now. Money is very powerful :-)

    • JustADoc

      I find that it takes me much longer to do labs on-line. Yes they are right there. That’s nice. They aren’t lost. ANd it saves my staff time. That’s nice. But it takes me longer. As now when I want to tell my nurse to do something with the lab I have to type it in and then forward it to here. As opposed to flipping thru a stack of 20 labs in 5 minutes, it now takes, on average, 45 seconds a lab. Why is all the efficiences accruing to the lowest paid people and being absorbed by the highest paid. Isn’t that the exact opposite of sensical?

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