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Electronic medical records: Ascending the Tower of Babel
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While many orthopedists agree that the implementation of electronic medical records is necessary and acknowledge the potential benefits of this technology, some have raised concerns regarding its universality, cost and ease of use.
“In terms of the decision to use or not to use these systems, I think that it is a question of when and not if,” Randale C. Sechrest, MD, an orthopedic surgeon with more than 20 years of experience with electronic medical records (EMRs) told Orthopedics Today. “I think that everything is moving toward a non-paper based system and everybody is going to have to face this decision.”
Sechrest, who was on a design team to create an EMR and also spent time using and evaluating EMRs in different practices, said that the greatest benefit of EMRs are that they give physicians unparalleled access to data.
“EMRs give you the capabilities of storing a huge amount of data, both textual data as well as, potentially, voice data and for the orthopedist, the most important piece of that is image data,” he said.
Simply conceptualizing EMRs as a method to generate an office note, Sechrest said, misses the bigger picture.
“EMR is designed to give you the benefit of going in and retrieving that information once it is stored,” he said.
Similar to the impact of implementing a PAC (picture archiving and communication) system, using EMRs may help surgeons improve their quality of care.
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Image: Mike Williams Photography |
“Once you see what that does in your workflow, and you understand how that changes your ability to make decisions quickly and more accurately; if you extend that paradigm to all data types, it quickly becomes apparent to most knowledgeable physicians that this can significantly improve their decision making,” Sechrest said.
Others experienced with EMRs highlight a potential increase in practice efficiency.
“The biggest pro of using an EMR is that it can increase the efficiency in your office,” Richard M. Dell, MD, told Orthopedics Today. “But to see this efficiency increase, the EMR must be implemented correctly and the EMR must be used correctly as a tool for better patient care and office efficiency. It takes a focused effort to make that transition from a paper-based world, to a hybrid paper, and then to a fully digital system.
“The effort is worth it,” he added.
Dell, who has more than 16 years of experience with EMRs (see 4 Questions interview), noted that although multiple methods exist for making digital data entry easy – including templates, smart phrases, and optical character and voice recognition software – many physicians fear that the process of transitioning to digital records will be arduous.
Ease of use
Orthopedics Today’s Business of Orthopedics Section Editor Jack M. Bert, MD, is using a scan and paper-based system and is in the process of determining which EMR to use.
“EMRs are going to be necessary in the future. There is no question about that,” Bert told Orthopedics Today. “The problems with them are that they are very cumbersome and time consuming.”
He noted that most EMRs incorporate the use of drop-down boxes which require users to return to the main menu screen after making each selection. Bert estimates that using these EMRs takes about 5 additional minutes per patient. In an effort to improve efficiency, he is looking into records that use optical scanning technology which allows users to record data regarding a patient’s history and physical exam in about 40 seconds.
A tower of Babel?
Charles L. Rosen, MD, a neurosurgeon who chaired an American Medical Association committee on establishing a standard of care for sharing and storing imaging data, cited the lack of a universal interface and the inability to share data across vendors as the main issues surrounding EMRs.
“I am actually very concerned about the future of EMR in that we are going to have a Tower of Babel for some time,” Rosen said. He noted that the market is full of proprietary systems using their own interfaces and mechanisms for storing information.
Recouping costs
Rosen and other specialists have cited the high costs of investing in EMRs as prohibitive.
“In terms of recouping the capital expense, it really does depend upon how greedy the company is that is trying to sell you the equipment,” Bert said. “So many of these are selling the capital equipment very inexpensively, but then demanding that you spend $10,000 to $15,000 per-doctor per-month to maintain administrative costs. I think that is just ludicrous.”
Some surgeons are also wondering who really financially benefits from EMRs.
“A lot of folks have argued that when a practice implements an EMR, it is not the practice necessarily that benefits,” Sechrest said. “The practice takes a huge productivity hit to implement the EMR and a huge cost. Most of the benefits of EMR and digitized records are to the insurance companies, the government and lots of other people.”
Government incentives
With an eye toward the potential advantages of EMRs, the American Recovery and Reinvestment Act of 2009 offers incentive payments beginning in 2011 to physicians who demonstrate “meaningful use” of a certified EMR.
“These payments can total as much as $18,000 in the first year in the case of physicians who adopt in 2011 or 2012, with at least $15,000 for physicians who adopt in 2013 and a slightly lower amount for those who do so in 2014; incentives are gradually reduced and then end in 2016,” the National Coordinator for Health Information Technology for the U.S. Department of Health & Human Services, David Blumenthal, MD, MPP, told Orthopedics Today. “Thus, physicians demonstrating meaningful use starting in 2011 could collect $44,000 over 5 years,” “Waiting until 2013 would result in a maximum bonus of $27,000 over 3 years.
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Experts estimate the cost of purchasing, installing, and implementing an electronic-records system in a medical office at about $40,000.”
The law requires that physicians meet all 25 meaningful use criteria to receive incentive payments. Beginning in 2015, those who fail to meet this use will be penalized.
Ellen B. Griffith, a Centers for Medicare & Medicaid spokesperson, told Orthopedics Today that physicians must use EMR systems that meet certification criteria in order to qualify for the bonus payments.
“These criteria are expected to be released in the near future,” she said. “There are no regulatory requirements that mandate the use of vendor specific EMR systems.”
Carrots and sticks
“If you think about all of the industries in America today, the medical industry is the last one to not go fully digital,” Dell said. “We are the last hold outs. But, at some point, we have to make that transition. We have to come into the 21st Century so to speak. The federal government is now forcing the issue by saying that if you do not do this by 2015, there will be penalties associated with it. That is the stick.”
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Sechrest said that the stimulus will lead to an increased awareness and industry push for EMR use.
“I think it is going to be a marketing aspect because all of these companies are going to use it to make a sales pitch,” he said. “The fact that these government incentives exist creates a huge story for the EMR companies to tell clients: ‘Now is the time to buy these EMRs. You are going to have to have them, and right now you are going to get a tax break if you buy them.’”
What to look for in an EMR
Regardless of the manufacturer, Sechrest said that physicians should look for EMRs that are easy to navigate, have well-designed web tools and allow users to modify templates and customize the workflow.
Bert said that optical scanning technology is crucial to ensuring office efficiency.
“You have to have the necessary requirements to get the outcomes data, and it is critical to have an efficient system,” Bert said. “[Make] sure that you negotiate with your vendors because they are going to try to make sure that you pay on a monthly basis for the rest of your life to recapture their cost of developing the software that they are selling you.”
Sechrest said that the field of EMRs will continue to grow. “I do not think that this is going to go back,” he said. “I think that EMRs are absolutely going to be a necessity. [I] think that we are going to be in an EMR world and orthopedists are going to have to realize that and move into that world.” – by Gina Brockenbrough
Editor’s note
For more in-depth coverage of Richard M. Dell, MD’s experience with the Kaiser Permanent EMR system, read the 4 Questions interview.
- Jack M. Bert, MD, can be reached at 17 W Exchange St., 307 Gallery Medical Building, Saint Paul, MN 55102; 651-223-9204; bertx001@tc.umn.edu.
- David Blumenthal, MD, MPP, and Ellen Griffith, can be reached at Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244; 202-690-6145; e-mail: Ellen.Griffith@cms.hhs.gov.
- Richard M. Dell, MD, can be reached in the Department of Orthopedics, Kaiser Permanente Downey Medical Center, 9353 E. Imperial Highway, Downey, CA 90242; 562-657-4125; e-mail: Richard.M.Dell@kp.org.
- Charles L. Rosen, MD, PhD, can be reached at Mary Babb Randolph Cancer Center One Medical Center Drive, Health Sciences Center, Morgantown, WV 26506; 304-598-6127; e-mail: crosen@hsc.wvu.edu.
- Randale C. Sechrest, MD, can be reached 2300 Regent St., Suite 205, Missoula, Montana 598012; 406-777-3868; e-mail: Randale@sechrest.com.
Should orthopedic surgeons invest in EMRs now? Why or why not?
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The time is now
Yes, because it will be mandatory and will eventually make the practice of orthopedics more efficient. In light of the incredible regulation of medicine (Recoverty Audit Contractor [RAC] program, etc.) the procurement, maintenance and security of medical information is mandatory for the practicing orthopedist. EMR is the only real choice. The key is to focus on tools that maximize that efficiency.
William R. Beach, MD, is an orthopedic surgeon with Tuckahoe Orthopedics, Richmond, Va.
Not at this time
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Despite the government incentives of $44,000-$64,000, there are several reasons doctors are slow to completely incorporate electronic records into their offices. While it is definitely the system of the future and most physicians will acquire it, these are some issues to be resolved:
- The “meaningful use” clause has yet to be defined to qualify for the financial incentives;
- The certifying electronic health record bodies have yet to make clear what it will take to be certified;
- There is a frenzy among the companies to sell their products as they see large numbers of physicians making purchases in the next few years. The pricing still does not reflect real competition that will evolve. [I believe that] prices should come down;
- The interconnectivity among different products is still not good;
- Hospitals have the most to gain [from] having connectivity with their physicians. They will need to subsidize more of these costs;
- The systems have to be more user friendly. For example, I personally would like to dictate into my cell phone with voice recognition, have a web-based system with minimal hardware that I have to purchase, updates to the software in real-time and not have to pay $25,000 at the end of a year, monthly fees based on usage and better interconnectivity with the hospital, laboratory, imaging, referring physicians, etc.;
- Currently, I think that it will take about 10 years to recoup all my capital expenses, if ever;
- EMR does not necessarily improve the quality of care. Many will argue this, but that literature does not exist at this time. To me, it is not a quality issue but a business decision. Our hospital has EMR and we have an electronic business package, but it has not made financial sense for me to purchase the complete system at this time.
Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today.