ACP: My EHR report card

ACP: My EHR report cardA guest column by the American College of Physicians, exclusive to KevinMD.com.

Even though September is “back to school month” and students won’t get their report cards for a while, I have a report card to share with you now. In September 2006, my practice went “live” with an EHR, so I thought that the sixth anniversary of this event would be a good time for an assessment. For this report card, the grading is based on my expectations when I made the decision to purchase an EHR. I will not identify my EHR because these comments are applicable to most of them and reflect the state of the technology more than the features or shortcomings of a specific product.

For those of you who want vendor-specific evaluations, AmericanEHR Partners, which the American College of Physicians (ACP) co-founded, provides user-submitted ratings and reviews for most of the widely used EHRs.

Time. My day is about half an hour longer than it was pre-EHR, because entering data from visits still takes more time than when I dictated my notes. However, I save many hours per week when retrieving data. No more waiting for charts to be pulled or searching through piles of paper to find a lab report that’s not in the chart. “Time” doesn’t refer to just my time; my staff spends less time on many tasks as well. While the EHR hasn’t gotten me home earlier, it has made my office and me more productive, so I would grade this promise “Meets Expectations.”

Practice finances. Some vendors claim that the EHR makes it possible to see more patients in the same amount of time. Perhaps, but not in my office. Nevertheless, there are areas in which the EHR helps practice finances. Our staff is more efficient, so we’re able to get our work done with fewer people. Our claims are cleaner, but at the cost of the doctor becoming the coder, since without an ICD-9 diagnosis you cannot order tests or close a note. We qualify for incentive payments from various private insurance and Medicare programs because of our EHR use. Even when weighed against the cost of purchasing and maintaining the hardware and software, EHR adoption has improved my practice’s financial health significantly, so I would give this one a grade of “Above Expectations.”

Quality of care. Compared to paper records, EHRs make it easier to track things and measure how well I manage chronic diseases such as diabetes and hypertension. However, the EHR doesn’t do this out of the box. The user has to set it up to do so, which can be time consuming, and creating reports can take a while if the database is large. One area where I saw immediate benefits is the on-call care that I give to my partners’ patients, most of whom I don’t know. Being able to see a patient’s medications, allergies, testing, and progress notes helps me to provide better care then I did with much more limited information pre-EHR.

My greatest disappointment is in the area of decision support. Some products feature context-sensitive evidence-based guidelines and pop-up reminders, but require too many clicks or generate too many irrelevant alerts. On the other hand, having a computer with internet access in the room facilitates the use of resources such as ACP’s PIER to fill the gap. I would grade this category “Below Expectations.”

Information exchange. While the EHR lets me share information with other members of my practice, it’s a different story with physicians and other providers outside my group. We have electronic interfaces with a major lab and limited data exchange with the largest hospital system in town, but for the rest it’s still fax and paper mail. The EHR streamlines sending and receiving faxes, but received faxes are stored in our patients’ records as images, not as data that can be integrated into the record and used for quality measurement and reporting. Meaningful Use requirements and the development of regional health information exchanges will help to get us to the level of interoperability that we will need to get the most out of our EHRs, but we have a way to go. Even with the use of national standards, we haven’t achieved “plug and play.” This area gets a grade of “Below Expectations.”

Reliability and safety. Critics often raise concerns about system reliability and errors. In six years of use, I can recall fewer than ten instances where the system went “down,” and most lasted no more than several minutes. EHRs prevent some types of errors but can introduce others; one has to remain vigilant, but the magnitude of this problem is not great. Let’s not forget that the paper era was not error proof either. I would give this a grade of “Meets Expectations.”

I don’t think that this report card is one that you’d put on your refrigerator door, but it isn’t cause for expulsion (or even repeating a year) either. While there’s work to be done to enhance the user experience and provide true interoperability, I am convinced that EHR use has improved how I take care of my patients and that will only get better.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • rswmd

    Sorry, but doesn’t add up.

    You claim that your days are 30 minutes longer, you don’t see more patients, but somehow you’re more productive? By any definition of the term, more time to see same number of patients is LESS productive.

    If you add in 30 minutes of doctor time daily (comparable to two more OVs), have you really improved office finances?

    • Yul Ejnes, MD, MACP

      I understand that the statement may not make sense, so I’ll give a longer explanation – while I spend slightly more time documenting, I spend less time looking for things, can spend more time reviewing data and thinking about it, coordinate things better with my staff (which frees me up to do other things during my patient visits other than play clerk), have more efficient options for communicating lab results with patients (both paper and electronic), and have more flexibility in where and when I do my work (my charts are wherever I want them to be). On my non-patient care day (the old “day off” that really isn’t), II spend less time catching up, which frees up time to do some of the patient-related and non-patient-related things that I couldn’t do before.

      My use of the term “productive” refers to accomplishing more per unit of time (even accounting for the longer time spent entering data) and not to generating more charges or seeing more patients (and mine is a fee-for-service practice, in case you were wondering). I realize that some of that “accomplishment” is subjective (as opposed to measuring receipts or RVU’s), but improving job satisfaction has a value of its own.

      Now don’t get me wrong – I want to spend less time documenting my visits. I plan to start using voice recognition because what slows me down is my insistence on typing narrative comments for the HPI rather than clicking my way through the note (which generates something that reminds me of a Mad Lib).

      Our office finances improved in several ways (even before HITECH and other incentive programs). Cleaner claims improved our collections. My E/M distribution improved because I felt more confident that the documentation supported a higher level of service in some cases where I would have been unsure and erred on the side of the lower code pre-EHR (note that I don’t use any of the prompts and “aids” that could lead to overdocumentation and overcoding). Within a month of our implementation, we let go a staff member for unrelated reasons but realized that we did not have to replace her because the rest of the staff was working more efficiently with the EHR. At the one-year mark we did an analysis and found that we not only broke even but were ahead by a bit. And then the payer incentives added to that.

      As with all such things, “your mileage may vary,” but that was my experience. I hope this clarifies my statement, though it may generate more questions (that I’ll try to address).

  • David Sack

    I agre with your findings entirely. I did have a perfectly serviceable EHR for the past 10 years, and it is only thanks to the HiTech act and so-called “meaningful use” that we were compelled to install our new one a month ago. I know the pain will end eventually, but right now it’s just like it was 10 years ago: mostly pain and no gain. And for all I know, our practice will be swallowed by a larger entity that imposes its own favorite EHR, or our vendor will be gobbled, or our product become obsolete when truly interfaced applications become available. I can only hope to amortize the start-up cost (labor, not $) over another 10 years.