T en years ago, the healthcare industry prognosticators projected that electronic medical records (EMRs) would be widespread by now and that the cumbersome, bulky and inefficient paper chart would have gone the way of the dinosaurs as dermatologists, and physicians generally, discovered the myriad benefits of going paperless. That hasn’t happened, in part because of the damage done by the eHealth hype of the late 1990s. That era spawned dozens of EMR vendors who promised the moon and then promptly went belly up, not long after the ink on their business plans dried, leaving medical practices in the lurch, investors in the hole — and physicians understandably wary. To boot, while some practices that did take the plunge have witnessed multiple benefits, from increased staff productivity to better financials to far fewer rejected claims, others had less positive experiences. Some found the products clunky or poor performing, or experienced substantial difficulty integrating EMRs into their physicians’ work flow and practice operations. How Many Practices Use Them? Today, despite the shakeout in the EMR market and significant improvements in the EMR, or electronic health record (EHR) products on the market, and competitive pressures that have forced prices down, adoption remains slow: Only an estimated 10% to 30% (depending on which survey one uses) of medical practices have implemented EMR systems. Industry observers suggest that EMR adoption has been higher in certain procedure-intensive specialties, such as dermatology, gastroenterology and orthopedics, compared with primary care specialties. (The American Academy of Dermatology doesn’t gather statistics on EMR use.) Why the Reluctance? Why the lag? For one, many practices are either reluctant or unable to capitalize the expense, which can run into the six figures for a mid-sized practice. But the other reason is practical, suggests Joseph Eastern, M.D., Clinical Assistant Professor of Dermatology at the University of Medicine and Dentistry of New Jersey in Newark. “One of the biggest problems we have is that the EMR data entry is still mostly by keyboard, and that’s slowing things down considerably,” says Dr. Eastern, who frequently makes presentations on dermatologists’ use of office technologies. “If we could get our hands on anything that didn’t involve a keyboard, that would speed up adoption.” That’s not to suggest that Dr. Eastern isn’t a proponent of information technology (IT) in practice operations — he decries the fact that most practices are “still processing clinical data with horse-and-buggy technology.” Rather, it’s that he has received an earful over the years from colleagues who have had less than stellar experiences with EMR systems. Based on his experience talking to dermatologists about EMR use, Dr. Eastern points to what he describes as three distinct camps. On one end of the spectrum are those who have embraced it even though implementation has proved difficult, for the paper-reduction benefits the EMR affords. He points to studies that have found an 85% reduction in chart pulls at 12 months after EMR implementation, a 15% reduction in staffing, and a 20% physician productivity gain. Southern Illinois Dermatology Associates in Herrin, for example, has been able to add five providers and a couple of satellite locations without increasing support staff, since implementing a NextGen EMR system in 2000, notes the practice’s administrator Tracy Wyatt. “If we had still been in the paper-based mode, we wouldn’t have been able to do that,” she says. In the middle camp is “the group that’s keeping their eye on things but are not ready to actually spend any money,” Dr. Eastern says. At the other end are the Luddites, those who actively and vocally resist EMRs. “Those are the dermatologists who say, ‘if I have to switch to an EMR, I’m retiring,’” Dr. Eastern quips. Rhett Drugge, M.D., a Stamford, CT, dermatologist who is Chief Editor of the Electronic Textbook of Dermatology and founded the Internet Dermatology Society, is an outspoken proponent of IT in dermatology practice. He developed his own EMR system 13 years ago, and has a full-time computer programmer in his office who helps him continually tweak his EMR. He agrees with Dr. Eastern that EMR products have some distance to go before they’re as useful, user-friendly or seamlessly “integrateable” as their vendors sometimes promise. Despite those realities, Dr. Drugge thinks that most EMR systems are an improvement over the status quo. “EMRs can be a way to unburden the doctor from unnecessary paperwork. The technology may not have fully arrived, but I would say that the light is dawning,” Dr. Drugge says, adding that the documentation capabilities in EMRs can be a powerful tool for tracking patients and providing supporting data on care delivered. “The EMR will become a care improvement tool in itself, and its use will increase soon, as doctors recognize that.” In fact, a study published in the Journal of the American Medical Association in February found just that: Physicians who used EMRs/EHRs were 60% more likely to have complete patient information at their fingertips in the exam room than those who used paper charts. Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL, which counsels physician practices on EMR system selection, thinks that adoption will continue to increase as quality improvement benefits are supported by scientific data and as prices level off. But sticker shock — and fears of major disruption to the practice — are slowing adoption pace. “The difficulty lies to a large extent with the fact that the people who gain the benefit — Medicare and other payers — are not the ones who have to spend the money to buy EMRs,” he says. “Physicians have to spend the money and expend the effort to accomplish the task — a disequilibrium that I think is hampering the adoption of EMR.” Dr. Fishman, who has counseled more than 1,000 physicians and medical groups since he launched the company, puts that cost at roughly $10,000 to $25,000 per physician for a “mid-level” system license, and up to $50,000 for “Rolls Royce” type systems. It is a big-ticket purchase, Dr. Fishman admits. However, he contends that most practices that make well-informed choices see a payback within 18 months and continuing return on investment in reduced overhead costs. Pressure to go Paperless Dermatologists who have resisted implementing EMR systems may soon experience some “pressure points” to abandon their paper-based systems. For one, the Bush Administration is pushing for EMR implementation, and in his recent State of the Union address, the President reiterated his goal of ensuring that every American patient is attended by an electronic record within 10 years — and one that can be accessed by any entity engaged in caring for that patient. He cited government studies that suggest as much as 20% of the $1.7 trillion healthcare budget could be saved through widespread use of EMRs, and he pledged $50 million in support of health care IT in the 2005 fiscal year. What may be more compelling than the President’s push is the recent decision by the Centers for Medicare and Medicaid Services to pay physicians bonuses for delivering higher-quality care and reducing costs of care for patients with chronic illness. The demonstration project, which involves 10 physician organizations, spurs EMR use, observers say, because the supporting data CMS will require cannot be readily gathered, or substantively provided, without an electronic record. Another government-sponsored initiative, Doctors’ Office Quality Information Technology (DOQ-IT) (go to www.doqit.org for details), is promoting adoption of EMR/EHR systems and increased IT use in small to medium-sized physician offices — with the intent of improving care for Medicare beneficiaries with certain diseases. DOQ-IT also offers online resources to help in choosing IT products. Last summer, 14 medical organizations created the Physicians Electronic Health Record Coalition (PEHRC) to provide product-selection assistance and to push for financial support of or incentives for physician deployment of EMRs. Not surprisingly, purchasers are also getting in on the act. The national employer coalition Bridges to Excellence, which represents several of the country’s largest employers, recently announced the first awards generated through its pay-for-performance program to physician practices that have leveraged IT to improve patient care, and tracking and education of patients with chronic illnesses. Finally, even physician groups are leading the charge. One New York IPA, and a second in Massachusetts, have begun awarding grants to member practices that agree to implement EMRs. Beginning of a New Wave? It’s the beginning of what may emerge as a major wave, predicts Dr. Fishman. “The number of third-party entities that are either rewarding doctors for EMR use or are subsidizing EMR is increasing — and that’s going to push adoption,” he says. ‘Must-Haves’ for a Dermatology Practice EMR Any EMR product you’re considering should meet at least bare-minimum criteria, cautions Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL. He urges dermatologists to ask EMR vendors to address the following basic issues and questions before agreeing to a product demonstration or proceeding with pricing discussions: 1. Describe how your EMR system enables documentation of cosmetic procedures. 2. Does the EMR assist with ICD and CPT coding, including E&M coding? 3. Does this feature include software that warns physicians when coding or documentation is inadequate to support reimbursement? 4. Does the system assist with tracking laboratory tests and pathology specimens that have been sent for analysis? 5. Does the system assist with clinical documentation (e.g., consultative reports), alleviating the need for dictation? 6. Does the system automatically generate correspondence notes (e.g., a letter to a referring physician) from information that has previously been entered? 7. Does the system include drawings of skin lesions in the record? 8. Does the system store digital photographs of lesions in the record? 9. Does the system remind physicians and/or practice staff when certain patients are due for additional studies or follow-up exams (such as recheck of a skin lesion)? 10. Does the system allow patients to log on from home and enter basic information or review their own medical records? 11. Does the system easily interface with a practice management software application currently being used? 12. Does the system have pre-built clinical content for dermatology, including materials that have been developed and used by other dermatologists? If so, please describe that content and provide examples. Trying to Choose an EMR? Here’s Help With the number of electronic medical/health record (EMR) systems on the market now topping 250, choosing a product that’s both suitable and affordable — and whose manufacturer will be around 5 years from now — is no small feat. Yet as the government and the health care industry moves toward rewarding physicians for implementing technology that improves and streamlines the provision of care, dermatologists who’ve been on the fence about implementing an EMR system likely will embrace the adoption curve in greater numbers. For those considering taking the plunge, following are resources that may prove useful: Healthcare Information and Management Systems Society (HIMSS), a trade organization for healthcare information technology professionals, has developed an interactive tool intended to help physician practices tailor their EMR search. Called the Ambulatory EHR Selector, the tool provides details on 30 vendors’ products and enables users to conduct searches on more than 350 distinct functions. Searches can also be conducted by practice characteristics or financial criteria: such as medical specialty, practice size, and contract structure and pricing. The tool can be purchased on an annual basis for $149, at a dedicated HIMSS’ Web site, https://www.ehrselector.com/emrtoolkit/ASP/Default.asp. eHealth Initiative (eHI), a Washington, D.C., organization, recently created the Working Group for Health Information Technology in Small Practices, whose aim is to provide physicians working in solo or small-group practices with practical resources on EHRs/EMRs and other technology-based products and services. For details, go to www.ehealthinitiative.org/initiatives/ programs/WorkingGroup.mspx. EMRConsultant.com. This Florida-based consulting service, operated by orthopedic surgeon Eric Fishman, M.D., counsels physicians and practice administrators on EMR cost issues and product selection. He has provided recommendations on approximately 100 of the EMR products on the market, and performs a financial-soundness analysis on any vendor that makes the “short list.” The company’s Web site, https://www.emrconsultant.com, also provides a listing of products suited to particular specialties, including dermatology. American Academy of Family Physicians Center for Health IT, although geared toward the needs of family physicians, offers product ratings as well as useful tips for all types of practices on such issues as choosing an appropriate product and preparing the office for EMR implementation. The URL is www.centerforhit.org. AC Group, a Montgomery, Texas, consulting firm, offers product-function rankings on 50 EMR systems in its recently published 2004 Report on EHRs. It’s available at www.acgroup.org. (For a somewhat dated but nonetheless helpful overview of EMR products, check the California HealthCare Foundation’s October 2003 report, “Electronic Medical Records: A Buyer’s Guide for Small Physician Practices,” available in PDF format at www.chcf.org, in the iHealth & Technology section.) Becoming a Paperless Office: Anything but Pain-Free By Michael H. Gold, M.D. B ecoming a Paperless OfficOur office is in the process of going to a paperless system, and the process has been one of the most frustrating practice events I have ever undertaken or been associated with in my 15-year dermatologic practice. Maybe, just maybe, when everything with our paperless system is actually working the way I have been told it will work, I will recommend paperless systems to my colleagues. For now, I am still evaluating the benefits to be achieved. Paperless charting and automated billing, more officially known as EMR, have been described as a Holy Grail of sorts. Several years ago, my very well-versed and respected IT team and accounting staff informed me that by switching to an EMR system, my office would become more efficient and more cost-effective. I do believe that dermatologists should consider their practices as true businesses and make decisions using sound business principles. So, we purchased an EMR software system and all of the needed hardware components. This move was a far cry from the first few days beginning in practice when we were without computers. We would all sit on the floor and sort our hand-prepared insurance forms. What a jump it was to purchase that first computer! More and more software options and expanded programming evolved in the medical community, computer speed and efficiency increased; and with the advent of the Internet came such improvements as electronic insurance billing, which promised to make us all more efficient. The Collision of Promise and Reality Then along came EMR. We researched many companies and chose one that promised its product would be compatible with our well-tuned medical management software program. Demographic and insurance data are still captured at the front desk. Now our nurses chart all of the pertinent medical information on the computer. We started with a template form, which I had to develop specifically for my practice. Now all of my nurses are pretty well-versed in entering the needed data in their own handheld computers. And all caregivers in our office, 18 in total, have personal tablet computers to enter their data. Plus, we added several new terminals at various places in the office, as well as printers and scanners. Each dermatologic disease and each procedure we perform in our office requires me — thankfully, my nurse practitioners provide able assistance — to review the templates in the EMR system and make them user-friendly while ensuring they conform to the original software programs. This process has been a struggle, and a drain on me and my entire office. We sometimes spend as much time on the computer as we do seeing our patients. We expect this entire process to run seamlessly, but it hasn’t yet. You might be thinking that we picked the wrong computer software program. In fact, we know of some doctors who are very happy with this particular EMR system. Based on the information we enter, the system’s billing module creates a super bill. The computer program automatically determines which level of service was provided and which diagnoses codes should be used. Then, supposedly, prescriptions will be e-mailed to the pharmacy of choice, and referral letters, if needed, will be generated and either e-mailed or printed for delivery. Patients will get individualized instruction sheets that explain their disease or their treatment. Finally, proper claims will be created and electronically transmitted to the appropriate insurance company. Still Waiting and Wondering It is a great concept, but we are not there almost 10 months later and after a huge financial investment. My biggest fear still is uncertainty: What happens if the EMR system goes down? Will we revert back to paper and try to catch up at some point in the future? How many back-up systems are necessary to avoid system failures? These issues worry me tremendously. I consider myself fairly astute in business, but this move I still question. We will pursue the project to its completion simply because I do not want to quit now. I sure hope it is worth it. Dr. Gold practices at the Gold Skin Care Center, Tennessee Clinical Research Center, in Nashville, Tenn. Pay-off Continues Years After Implementing an EMR System By Lawrence L. Anderson, M.D., F.A.C.P. D uring my time in the Army, I saw firsthand everything that is wrong with manually maintaining medical records. Not only were soldiers responsible for carrying their own paper charts, but those charts didn’t contain a complete picture of a patient’s health and often lacked vital information about medical history, allergies, recent diagnoses, and test results. Consequently, physicians often ordered duplicate labs or tests and made care decisions without pertinent information. Incorporating Technology From the Start When I left the Army and decided to start my own dermatology practice, I wanted to overcome these challenges, and I knew that technology would play an important role in making that happen. Now, 9 years after my practice implemented an EMR system, I am still a believer. My practice continues to realize many financial and operational benefits of this investment, from both a clinical and administrative point of view. Knowing that it would be easier to use an EMR from the beginning rather than converting data down the road, I searched for a solution that would meet the practice’s unique workflow and business objectives. We eventually chose NextGen Healthcare Information Systems (Clinitec at the time). Since then, we have realized many financial and operational benefits. Incorporating all of our practice processes into the system has enabled us to grow to eight physicians and five mid-level providers at two full-time locations and four 1-day a week satellite offices. Having charts available at the satellite offices has been a huge asset, helping to facilitate our growth. Reaping the Many Rewards Some of the many specific benefits we’ve realized with EMRs include the following: We can create customized templates, which we use to quickly enter information into a patient’s chart. For example, we created templates for Mohs surgery that incorporate post-op notes and follow-up. Having this information in one place also helps us meet state guidelines for an ambulatory surgery center. Reporting capabilities within the EMR have also allowed us to improve patient safety. When warnings were issued about Accutane, for instance, the EMR’s prescription module enabled us to run a report to identify all patients who were taking the drug. We then used the system to generate letters to those patients. These reporting capabilities are also an asset for clinical trials. We use the system to run a report that identifies potential trial participants, allowing practice staff to quickly and efficiently contact prospective study participants. Peer review is also much easier with the EMR. To evaluate recent treatments for psoriasis patients, we can type the corresponding code into the system and generate a printout of all patients with that diagnosis. We also often use the system’s analysis capabilities to assist us with outcomes measurement. By far, one of the biggest benefits of using an EMR is that when I see a patient, I don’t worry about anything except that interaction. I’m not flipping through a paper chart or thinking about coding or dictation. I can focus on the patient’s problems, make the diagnosis, and move on to the next patient. Ultimately, we see more patients in the same amount of time. Dr. Anderson is with Dermatology Associates of Tyler in Tyler, TX.
EMRs: Are We There Yet?
T en years ago, the healthcare industry prognosticators projected that electronic medical records (EMRs) would be widespread by now and that the cumbersome, bulky and inefficient paper chart would have gone the way of the dinosaurs as dermatologists, and physicians generally, discovered the myriad benefits of going paperless. That hasn’t happened, in part because of the damage done by the eHealth hype of the late 1990s. That era spawned dozens of EMR vendors who promised the moon and then promptly went belly up, not long after the ink on their business plans dried, leaving medical practices in the lurch, investors in the hole — and physicians understandably wary. To boot, while some practices that did take the plunge have witnessed multiple benefits, from increased staff productivity to better financials to far fewer rejected claims, others had less positive experiences. Some found the products clunky or poor performing, or experienced substantial difficulty integrating EMRs into their physicians’ work flow and practice operations. How Many Practices Use Them? Today, despite the shakeout in the EMR market and significant improvements in the EMR, or electronic health record (EHR) products on the market, and competitive pressures that have forced prices down, adoption remains slow: Only an estimated 10% to 30% (depending on which survey one uses) of medical practices have implemented EMR systems. Industry observers suggest that EMR adoption has been higher in certain procedure-intensive specialties, such as dermatology, gastroenterology and orthopedics, compared with primary care specialties. (The American Academy of Dermatology doesn’t gather statistics on EMR use.) Why the Reluctance? Why the lag? For one, many practices are either reluctant or unable to capitalize the expense, which can run into the six figures for a mid-sized practice. But the other reason is practical, suggests Joseph Eastern, M.D., Clinical Assistant Professor of Dermatology at the University of Medicine and Dentistry of New Jersey in Newark. “One of the biggest problems we have is that the EMR data entry is still mostly by keyboard, and that’s slowing things down considerably,” says Dr. Eastern, who frequently makes presentations on dermatologists’ use of office technologies. “If we could get our hands on anything that didn’t involve a keyboard, that would speed up adoption.” That’s not to suggest that Dr. Eastern isn’t a proponent of information technology (IT) in practice operations — he decries the fact that most practices are “still processing clinical data with horse-and-buggy technology.” Rather, it’s that he has received an earful over the years from colleagues who have had less than stellar experiences with EMR systems. Based on his experience talking to dermatologists about EMR use, Dr. Eastern points to what he describes as three distinct camps. On one end of the spectrum are those who have embraced it even though implementation has proved difficult, for the paper-reduction benefits the EMR affords. He points to studies that have found an 85% reduction in chart pulls at 12 months after EMR implementation, a 15% reduction in staffing, and a 20% physician productivity gain. Southern Illinois Dermatology Associates in Herrin, for example, has been able to add five providers and a couple of satellite locations without increasing support staff, since implementing a NextGen EMR system in 2000, notes the practice’s administrator Tracy Wyatt. “If we had still been in the paper-based mode, we wouldn’t have been able to do that,” she says. In the middle camp is “the group that’s keeping their eye on things but are not ready to actually spend any money,” Dr. Eastern says. At the other end are the Luddites, those who actively and vocally resist EMRs. “Those are the dermatologists who say, ‘if I have to switch to an EMR, I’m retiring,’” Dr. Eastern quips. Rhett Drugge, M.D., a Stamford, CT, dermatologist who is Chief Editor of the Electronic Textbook of Dermatology and founded the Internet Dermatology Society, is an outspoken proponent of IT in dermatology practice. He developed his own EMR system 13 years ago, and has a full-time computer programmer in his office who helps him continually tweak his EMR. He agrees with Dr. Eastern that EMR products have some distance to go before they’re as useful, user-friendly or seamlessly “integrateable” as their vendors sometimes promise. Despite those realities, Dr. Drugge thinks that most EMR systems are an improvement over the status quo. “EMRs can be a way to unburden the doctor from unnecessary paperwork. The technology may not have fully arrived, but I would say that the light is dawning,” Dr. Drugge says, adding that the documentation capabilities in EMRs can be a powerful tool for tracking patients and providing supporting data on care delivered. “The EMR will become a care improvement tool in itself, and its use will increase soon, as doctors recognize that.” In fact, a study published in the Journal of the American Medical Association in February found just that: Physicians who used EMRs/EHRs were 60% more likely to have complete patient information at their fingertips in the exam room than those who used paper charts. Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL, which counsels physician practices on EMR system selection, thinks that adoption will continue to increase as quality improvement benefits are supported by scientific data and as prices level off. But sticker shock — and fears of major disruption to the practice — are slowing adoption pace. “The difficulty lies to a large extent with the fact that the people who gain the benefit — Medicare and other payers — are not the ones who have to spend the money to buy EMRs,” he says. “Physicians have to spend the money and expend the effort to accomplish the task — a disequilibrium that I think is hampering the adoption of EMR.” Dr. Fishman, who has counseled more than 1,000 physicians and medical groups since he launched the company, puts that cost at roughly $10,000 to $25,000 per physician for a “mid-level” system license, and up to $50,000 for “Rolls Royce” type systems. It is a big-ticket purchase, Dr. Fishman admits. However, he contends that most practices that make well-informed choices see a payback within 18 months and continuing return on investment in reduced overhead costs. Pressure to go Paperless Dermatologists who have resisted implementing EMR systems may soon experience some “pressure points” to abandon their paper-based systems. For one, the Bush Administration is pushing for EMR implementation, and in his recent State of the Union address, the President reiterated his goal of ensuring that every American patient is attended by an electronic record within 10 years — and one that can be accessed by any entity engaged in caring for that patient. He cited government studies that suggest as much as 20% of the $1.7 trillion healthcare budget could be saved through widespread use of EMRs, and he pledged $50 million in support of health care IT in the 2005 fiscal year. What may be more compelling than the President’s push is the recent decision by the Centers for Medicare and Medicaid Services to pay physicians bonuses for delivering higher-quality care and reducing costs of care for patients with chronic illness. The demonstration project, which involves 10 physician organizations, spurs EMR use, observers say, because the supporting data CMS will require cannot be readily gathered, or substantively provided, without an electronic record. Another government-sponsored initiative, Doctors’ Office Quality Information Technology (DOQ-IT) (go to www.doqit.org for details), is promoting adoption of EMR/EHR systems and increased IT use in small to medium-sized physician offices — with the intent of improving care for Medicare beneficiaries with certain diseases. DOQ-IT also offers online resources to help in choosing IT products. Last summer, 14 medical organizations created the Physicians Electronic Health Record Coalition (PEHRC) to provide product-selection assistance and to push for financial support of or incentives for physician deployment of EMRs. Not surprisingly, purchasers are also getting in on the act. The national employer coalition Bridges to Excellence, which represents several of the country’s largest employers, recently announced the first awards generated through its pay-for-performance program to physician practices that have leveraged IT to improve patient care, and tracking and education of patients with chronic illnesses. Finally, even physician groups are leading the charge. One New York IPA, and a second in Massachusetts, have begun awarding grants to member practices that agree to implement EMRs. Beginning of a New Wave? It’s the beginning of what may emerge as a major wave, predicts Dr. Fishman. “The number of third-party entities that are either rewarding doctors for EMR use or are subsidizing EMR is increasing — and that’s going to push adoption,” he says. ‘Must-Haves’ for a Dermatology Practice EMR Any EMR product you’re considering should meet at least bare-minimum criteria, cautions Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL. He urges dermatologists to ask EMR vendors to address the following basic issues and questions before agreeing to a product demonstration or proceeding with pricing discussions: 1. Describe how your EMR system enables documentation of cosmetic procedures. 2. Does the EMR assist with ICD and CPT coding, including E&M coding? 3. Does this feature include software that warns physicians when coding or documentation is inadequate to support reimbursement? 4. Does the system assist with tracking laboratory tests and pathology specimens that have been sent for analysis? 5. Does the system assist with clinical documentation (e.g., consultative reports), alleviating the need for dictation? 6. Does the system automatically generate correspondence notes (e.g., a letter to a referring physician) from information that has previously been entered? 7. Does the system include drawings of skin lesions in the record? 8. Does the system store digital photographs of lesions in the record? 9. Does the system remind physicians and/or practice staff when certain patients are due for additional studies or follow-up exams (such as recheck of a skin lesion)? 10. Does the system allow patients to log on from home and enter basic information or review their own medical records? 11. Does the system easily interface with a practice management software application currently being used? 12. Does the system have pre-built clinical content for dermatology, including materials that have been developed and used by other dermatologists? If so, please describe that content and provide examples. Trying to Choose an EMR? Here’s Help With the number of electronic medical/health record (EMR) systems on the market now topping 250, choosing a product that’s both suitable and affordable — and whose manufacturer will be around 5 years from now — is no small feat. Yet as the government and the health care industry moves toward rewarding physicians for implementing technology that improves and streamlines the provision of care, dermatologists who’ve been on the fence about implementing an EMR system likely will embrace the adoption curve in greater numbers. For those considering taking the plunge, following are resources that may prove useful: Healthcare Information and Management Systems Society (HIMSS), a trade organization for healthcare information technology professionals, has developed an interactive tool intended to help physician practices tailor their EMR search. Called the Ambulatory EHR Selector, the tool provides details on 30 vendors’ products and enables users to conduct searches on more than 350 distinct functions. Searches can also be conducted by practice characteristics or financial criteria: such as medical specialty, practice size, and contract structure and pricing. The tool can be purchased on an annual basis for $149, at a dedicated HIMSS’ Web site, https://www.ehrselector.com/emrtoolkit/ASP/Default.asp. eHealth Initiative (eHI), a Washington, D.C., organization, recently created the Working Group for Health Information Technology in Small Practices, whose aim is to provide physicians working in solo or small-group practices with practical resources on EHRs/EMRs and other technology-based products and services. For details, go to www.ehealthinitiative.org/initiatives/ programs/WorkingGroup.mspx. EMRConsultant.com. This Florida-based consulting service, operated by orthopedic surgeon Eric Fishman, M.D., counsels physicians and practice administrators on EMR cost issues and product selection. He has provided recommendations on approximately 100 of the EMR products on the market, and performs a financial-soundness analysis on any vendor that makes the “short list.” The company’s Web site, https://www.emrconsultant.com, also provides a listing of products suited to particular specialties, including dermatology. American Academy of Family Physicians Center for Health IT, although geared toward the needs of family physicians, offers product ratings as well as useful tips for all types of practices on such issues as choosing an appropriate product and preparing the office for EMR implementation. The URL is www.centerforhit.org. AC Group, a Montgomery, Texas, consulting firm, offers product-function rankings on 50 EMR systems in its recently published 2004 Report on EHRs. It’s available at www.acgroup.org. (For a somewhat dated but nonetheless helpful overview of EMR products, check the California HealthCare Foundation’s October 2003 report, “Electronic Medical Records: A Buyer’s Guide for Small Physician Practices,” available in PDF format at www.chcf.org, in the iHealth & Technology section.) Becoming a Paperless Office: Anything but Pain-Free By Michael H. Gold, M.D. B ecoming a Paperless OfficOur office is in the process of going to a paperless system, and the process has been one of the most frustrating practice events I have ever undertaken or been associated with in my 15-year dermatologic practice. Maybe, just maybe, when everything with our paperless system is actually working the way I have been told it will work, I will recommend paperless systems to my colleagues. For now, I am still evaluating the benefits to be achieved. Paperless charting and automated billing, more officially known as EMR, have been described as a Holy Grail of sorts. Several years ago, my very well-versed and respected IT team and accounting staff informed me that by switching to an EMR system, my office would become more efficient and more cost-effective. I do believe that dermatologists should consider their practices as true businesses and make decisions using sound business principles. So, we purchased an EMR software system and all of the needed hardware components. This move was a far cry from the first few days beginning in practice when we were without computers. We would all sit on the floor and sort our hand-prepared insurance forms. What a jump it was to purchase that first computer! More and more software options and expanded programming evolved in the medical community, computer speed and efficiency increased; and with the advent of the Internet came such improvements as electronic insurance billing, which promised to make us all more efficient. The Collision of Promise and Reality Then along came EMR. We researched many companies and chose one that promised its product would be compatible with our well-tuned medical management software program. Demographic and insurance data are still captured at the front desk. Now our nurses chart all of the pertinent medical information on the computer. We started with a template form, which I had to develop specifically for my practice. Now all of my nurses are pretty well-versed in entering the needed data in their own handheld computers. And all caregivers in our office, 18 in total, have personal tablet computers to enter their data. Plus, we added several new terminals at various places in the office, as well as printers and scanners. Each dermatologic disease and each procedure we perform in our office requires me — thankfully, my nurse practitioners provide able assistance — to review the templates in the EMR system and make them user-friendly while ensuring they conform to the original software programs. This process has been a struggle, and a drain on me and my entire office. We sometimes spend as much time on the computer as we do seeing our patients. We expect this entire process to run seamlessly, but it hasn’t yet. You might be thinking that we picked the wrong computer software program. In fact, we know of some doctors who are very happy with this particular EMR system. Based on the information we enter, the system’s billing module creates a super bill. The computer program automatically determines which level of service was provided and which diagnoses codes should be used. Then, supposedly, prescriptions will be e-mailed to the pharmacy of choice, and referral letters, if needed, will be generated and either e-mailed or printed for delivery. Patients will get individualized instruction sheets that explain their disease or their treatment. Finally, proper claims will be created and electronically transmitted to the appropriate insurance company. Still Waiting and Wondering It is a great concept, but we are not there almost 10 months later and after a huge financial investment. My biggest fear still is uncertainty: What happens if the EMR system goes down? Will we revert back to paper and try to catch up at some point in the future? How many back-up systems are necessary to avoid system failures? These issues worry me tremendously. I consider myself fairly astute in business, but this move I still question. We will pursue the project to its completion simply because I do not want to quit now. I sure hope it is worth it. Dr. Gold practices at the Gold Skin Care Center, Tennessee Clinical Research Center, in Nashville, Tenn. Pay-off Continues Years After Implementing an EMR System By Lawrence L. Anderson, M.D., F.A.C.P. D uring my time in the Army, I saw firsthand everything that is wrong with manually maintaining medical records. Not only were soldiers responsible for carrying their own paper charts, but those charts didn’t contain a complete picture of a patient’s health and often lacked vital information about medical history, allergies, recent diagnoses, and test results. Consequently, physicians often ordered duplicate labs or tests and made care decisions without pertinent information. Incorporating Technology From the Start When I left the Army and decided to start my own dermatology practice, I wanted to overcome these challenges, and I knew that technology would play an important role in making that happen. Now, 9 years after my practice implemented an EMR system, I am still a believer. My practice continues to realize many financial and operational benefits of this investment, from both a clinical and administrative point of view. Knowing that it would be easier to use an EMR from the beginning rather than converting data down the road, I searched for a solution that would meet the practice’s unique workflow and business objectives. We eventually chose NextGen Healthcare Information Systems (Clinitec at the time). Since then, we have realized many financial and operational benefits. Incorporating all of our practice processes into the system has enabled us to grow to eight physicians and five mid-level providers at two full-time locations and four 1-day a week satellite offices. Having charts available at the satellite offices has been a huge asset, helping to facilitate our growth. Reaping the Many Rewards Some of the many specific benefits we’ve realized with EMRs include the following: We can create customized templates, which we use to quickly enter information into a patient’s chart. For example, we created templates for Mohs surgery that incorporate post-op notes and follow-up. Having this information in one place also helps us meet state guidelines for an ambulatory surgery center. Reporting capabilities within the EMR have also allowed us to improve patient safety. When warnings were issued about Accutane, for instance, the EMR’s prescription module enabled us to run a report to identify all patients who were taking the drug. We then used the system to generate letters to those patients. These reporting capabilities are also an asset for clinical trials. We use the system to run a report that identifies potential trial participants, allowing practice staff to quickly and efficiently contact prospective study participants. Peer review is also much easier with the EMR. To evaluate recent treatments for psoriasis patients, we can type the corresponding code into the system and generate a printout of all patients with that diagnosis. We also often use the system’s analysis capabilities to assist us with outcomes measurement. By far, one of the biggest benefits of using an EMR is that when I see a patient, I don’t worry about anything except that interaction. I’m not flipping through a paper chart or thinking about coding or dictation. I can focus on the patient’s problems, make the diagnosis, and move on to the next patient. Ultimately, we see more patients in the same amount of time. Dr. Anderson is with Dermatology Associates of Tyler in Tyler, TX.
T en years ago, the healthcare industry prognosticators projected that electronic medical records (EMRs) would be widespread by now and that the cumbersome, bulky and inefficient paper chart would have gone the way of the dinosaurs as dermatologists, and physicians generally, discovered the myriad benefits of going paperless. That hasn’t happened, in part because of the damage done by the eHealth hype of the late 1990s. That era spawned dozens of EMR vendors who promised the moon and then promptly went belly up, not long after the ink on their business plans dried, leaving medical practices in the lurch, investors in the hole — and physicians understandably wary. To boot, while some practices that did take the plunge have witnessed multiple benefits, from increased staff productivity to better financials to far fewer rejected claims, others had less positive experiences. Some found the products clunky or poor performing, or experienced substantial difficulty integrating EMRs into their physicians’ work flow and practice operations. How Many Practices Use Them? Today, despite the shakeout in the EMR market and significant improvements in the EMR, or electronic health record (EHR) products on the market, and competitive pressures that have forced prices down, adoption remains slow: Only an estimated 10% to 30% (depending on which survey one uses) of medical practices have implemented EMR systems. Industry observers suggest that EMR adoption has been higher in certain procedure-intensive specialties, such as dermatology, gastroenterology and orthopedics, compared with primary care specialties. (The American Academy of Dermatology doesn’t gather statistics on EMR use.) Why the Reluctance? Why the lag? For one, many practices are either reluctant or unable to capitalize the expense, which can run into the six figures for a mid-sized practice. But the other reason is practical, suggests Joseph Eastern, M.D., Clinical Assistant Professor of Dermatology at the University of Medicine and Dentistry of New Jersey in Newark. “One of the biggest problems we have is that the EMR data entry is still mostly by keyboard, and that’s slowing things down considerably,” says Dr. Eastern, who frequently makes presentations on dermatologists’ use of office technologies. “If we could get our hands on anything that didn’t involve a keyboard, that would speed up adoption.” That’s not to suggest that Dr. Eastern isn’t a proponent of information technology (IT) in practice operations — he decries the fact that most practices are “still processing clinical data with horse-and-buggy technology.” Rather, it’s that he has received an earful over the years from colleagues who have had less than stellar experiences with EMR systems. Based on his experience talking to dermatologists about EMR use, Dr. Eastern points to what he describes as three distinct camps. On one end of the spectrum are those who have embraced it even though implementation has proved difficult, for the paper-reduction benefits the EMR affords. He points to studies that have found an 85% reduction in chart pulls at 12 months after EMR implementation, a 15% reduction in staffing, and a 20% physician productivity gain. Southern Illinois Dermatology Associates in Herrin, for example, has been able to add five providers and a couple of satellite locations without increasing support staff, since implementing a NextGen EMR system in 2000, notes the practice’s administrator Tracy Wyatt. “If we had still been in the paper-based mode, we wouldn’t have been able to do that,” she says. In the middle camp is “the group that’s keeping their eye on things but are not ready to actually spend any money,” Dr. Eastern says. At the other end are the Luddites, those who actively and vocally resist EMRs. “Those are the dermatologists who say, ‘if I have to switch to an EMR, I’m retiring,’” Dr. Eastern quips. Rhett Drugge, M.D., a Stamford, CT, dermatologist who is Chief Editor of the Electronic Textbook of Dermatology and founded the Internet Dermatology Society, is an outspoken proponent of IT in dermatology practice. He developed his own EMR system 13 years ago, and has a full-time computer programmer in his office who helps him continually tweak his EMR. He agrees with Dr. Eastern that EMR products have some distance to go before they’re as useful, user-friendly or seamlessly “integrateable” as their vendors sometimes promise. Despite those realities, Dr. Drugge thinks that most EMR systems are an improvement over the status quo. “EMRs can be a way to unburden the doctor from unnecessary paperwork. The technology may not have fully arrived, but I would say that the light is dawning,” Dr. Drugge says, adding that the documentation capabilities in EMRs can be a powerful tool for tracking patients and providing supporting data on care delivered. “The EMR will become a care improvement tool in itself, and its use will increase soon, as doctors recognize that.” In fact, a study published in the Journal of the American Medical Association in February found just that: Physicians who used EMRs/EHRs were 60% more likely to have complete patient information at their fingertips in the exam room than those who used paper charts. Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL, which counsels physician practices on EMR system selection, thinks that adoption will continue to increase as quality improvement benefits are supported by scientific data and as prices level off. But sticker shock — and fears of major disruption to the practice — are slowing adoption pace. “The difficulty lies to a large extent with the fact that the people who gain the benefit — Medicare and other payers — are not the ones who have to spend the money to buy EMRs,” he says. “Physicians have to spend the money and expend the effort to accomplish the task — a disequilibrium that I think is hampering the adoption of EMR.” Dr. Fishman, who has counseled more than 1,000 physicians and medical groups since he launched the company, puts that cost at roughly $10,000 to $25,000 per physician for a “mid-level” system license, and up to $50,000 for “Rolls Royce” type systems. It is a big-ticket purchase, Dr. Fishman admits. However, he contends that most practices that make well-informed choices see a payback within 18 months and continuing return on investment in reduced overhead costs. Pressure to go Paperless Dermatologists who have resisted implementing EMR systems may soon experience some “pressure points” to abandon their paper-based systems. For one, the Bush Administration is pushing for EMR implementation, and in his recent State of the Union address, the President reiterated his goal of ensuring that every American patient is attended by an electronic record within 10 years — and one that can be accessed by any entity engaged in caring for that patient. He cited government studies that suggest as much as 20% of the $1.7 trillion healthcare budget could be saved through widespread use of EMRs, and he pledged $50 million in support of health care IT in the 2005 fiscal year. What may be more compelling than the President’s push is the recent decision by the Centers for Medicare and Medicaid Services to pay physicians bonuses for delivering higher-quality care and reducing costs of care for patients with chronic illness. The demonstration project, which involves 10 physician organizations, spurs EMR use, observers say, because the supporting data CMS will require cannot be readily gathered, or substantively provided, without an electronic record. Another government-sponsored initiative, Doctors’ Office Quality Information Technology (DOQ-IT) (go to www.doqit.org for details), is promoting adoption of EMR/EHR systems and increased IT use in small to medium-sized physician offices — with the intent of improving care for Medicare beneficiaries with certain diseases. DOQ-IT also offers online resources to help in choosing IT products. Last summer, 14 medical organizations created the Physicians Electronic Health Record Coalition (PEHRC) to provide product-selection assistance and to push for financial support of or incentives for physician deployment of EMRs. Not surprisingly, purchasers are also getting in on the act. The national employer coalition Bridges to Excellence, which represents several of the country’s largest employers, recently announced the first awards generated through its pay-for-performance program to physician practices that have leveraged IT to improve patient care, and tracking and education of patients with chronic illnesses. Finally, even physician groups are leading the charge. One New York IPA, and a second in Massachusetts, have begun awarding grants to member practices that agree to implement EMRs. Beginning of a New Wave? It’s the beginning of what may emerge as a major wave, predicts Dr. Fishman. “The number of third-party entities that are either rewarding doctors for EMR use or are subsidizing EMR is increasing — and that’s going to push adoption,” he says. ‘Must-Haves’ for a Dermatology Practice EMR Any EMR product you’re considering should meet at least bare-minimum criteria, cautions Eric Fishman, M.D., President of EMRConsultant.com in Palm Beach Gardens, FL. He urges dermatologists to ask EMR vendors to address the following basic issues and questions before agreeing to a product demonstration or proceeding with pricing discussions: 1. Describe how your EMR system enables documentation of cosmetic procedures. 2. Does the EMR assist with ICD and CPT coding, including E&M coding? 3. Does this feature include software that warns physicians when coding or documentation is inadequate to support reimbursement? 4. Does the system assist with tracking laboratory tests and pathology specimens that have been sent for analysis? 5. Does the system assist with clinical documentation (e.g., consultative reports), alleviating the need for dictation? 6. Does the system automatically generate correspondence notes (e.g., a letter to a referring physician) from information that has previously been entered? 7. Does the system include drawings of skin lesions in the record? 8. Does the system store digital photographs of lesions in the record? 9. Does the system remind physicians and/or practice staff when certain patients are due for additional studies or follow-up exams (such as recheck of a skin lesion)? 10. Does the system allow patients to log on from home and enter basic information or review their own medical records? 11. Does the system easily interface with a practice management software application currently being used? 12. Does the system have pre-built clinical content for dermatology, including materials that have been developed and used by other dermatologists? If so, please describe that content and provide examples. Trying to Choose an EMR? Here’s Help With the number of electronic medical/health record (EMR) systems on the market now topping 250, choosing a product that’s both suitable and affordable — and whose manufacturer will be around 5 years from now — is no small feat. Yet as the government and the health care industry moves toward rewarding physicians for implementing technology that improves and streamlines the provision of care, dermatologists who’ve been on the fence about implementing an EMR system likely will embrace the adoption curve in greater numbers. For those considering taking the plunge, following are resources that may prove useful: Healthcare Information and Management Systems Society (HIMSS), a trade organization for healthcare information technology professionals, has developed an interactive tool intended to help physician practices tailor their EMR search. Called the Ambulatory EHR Selector, the tool provides details on 30 vendors’ products and enables users to conduct searches on more than 350 distinct functions. Searches can also be conducted by practice characteristics or financial criteria: such as medical specialty, practice size, and contract structure and pricing. The tool can be purchased on an annual basis for $149, at a dedicated HIMSS’ Web site, https://www.ehrselector.com/emrtoolkit/ASP/Default.asp. eHealth Initiative (eHI), a Washington, D.C., organization, recently created the Working Group for Health Information Technology in Small Practices, whose aim is to provide physicians working in solo or small-group practices with practical resources on EHRs/EMRs and other technology-based products and services. For details, go to www.ehealthinitiative.org/initiatives/ programs/WorkingGroup.mspx. EMRConsultant.com. This Florida-based consulting service, operated by orthopedic surgeon Eric Fishman, M.D., counsels physicians and practice administrators on EMR cost issues and product selection. He has provided recommendations on approximately 100 of the EMR products on the market, and performs a financial-soundness analysis on any vendor that makes the “short list.” The company’s Web site, https://www.emrconsultant.com, also provides a listing of products suited to particular specialties, including dermatology. American Academy of Family Physicians Center for Health IT, although geared toward the needs of family physicians, offers product ratings as well as useful tips for all types of practices on such issues as choosing an appropriate product and preparing the office for EMR implementation. The URL is www.centerforhit.org. AC Group, a Montgomery, Texas, consulting firm, offers product-function rankings on 50 EMR systems in its recently published 2004 Report on EHRs. It’s available at www.acgroup.org. (For a somewhat dated but nonetheless helpful overview of EMR products, check the California HealthCare Foundation’s October 2003 report, “Electronic Medical Records: A Buyer’s Guide for Small Physician Practices,” available in PDF format at www.chcf.org, in the iHealth & Technology section.) Becoming a Paperless Office: Anything but Pain-Free By Michael H. Gold, M.D. B ecoming a Paperless OfficOur office is in the process of going to a paperless system, and the process has been one of the most frustrating practice events I have ever undertaken or been associated with in my 15-year dermatologic practice. Maybe, just maybe, when everything with our paperless system is actually working the way I have been told it will work, I will recommend paperless systems to my colleagues. For now, I am still evaluating the benefits to be achieved. Paperless charting and automated billing, more officially known as EMR, have been described as a Holy Grail of sorts. Several years ago, my very well-versed and respected IT team and accounting staff informed me that by switching to an EMR system, my office would become more efficient and more cost-effective. I do believe that dermatologists should consider their practices as true businesses and make decisions using sound business principles. So, we purchased an EMR software system and all of the needed hardware components. This move was a far cry from the first few days beginning in practice when we were without computers. We would all sit on the floor and sort our hand-prepared insurance forms. What a jump it was to purchase that first computer! More and more software options and expanded programming evolved in the medical community, computer speed and efficiency increased; and with the advent of the Internet came such improvements as electronic insurance billing, which promised to make us all more efficient. The Collision of Promise and Reality Then along came EMR. We researched many companies and chose one that promised its product would be compatible with our well-tuned medical management software program. Demographic and insurance data are still captured at the front desk. Now our nurses chart all of the pertinent medical information on the computer. We started with a template form, which I had to develop specifically for my practice. Now all of my nurses are pretty well-versed in entering the needed data in their own handheld computers. And all caregivers in our office, 18 in total, have personal tablet computers to enter their data. Plus, we added several new terminals at various places in the office, as well as printers and scanners. Each dermatologic disease and each procedure we perform in our office requires me — thankfully, my nurse practitioners provide able assistance — to review the templates in the EMR system and make them user-friendly while ensuring they conform to the original software programs. This process has been a struggle, and a drain on me and my entire office. We sometimes spend as much time on the computer as we do seeing our patients. We expect this entire process to run seamlessly, but it hasn’t yet. You might be thinking that we picked the wrong computer software program. In fact, we know of some doctors who are very happy with this particular EMR system. Based on the information we enter, the system’s billing module creates a super bill. The computer program automatically determines which level of service was provided and which diagnoses codes should be used. Then, supposedly, prescriptions will be e-mailed to the pharmacy of choice, and referral letters, if needed, will be generated and either e-mailed or printed for delivery. Patients will get individualized instruction sheets that explain their disease or their treatment. Finally, proper claims will be created and electronically transmitted to the appropriate insurance company. Still Waiting and Wondering It is a great concept, but we are not there almost 10 months later and after a huge financial investment. My biggest fear still is uncertainty: What happens if the EMR system goes down? Will we revert back to paper and try to catch up at some point in the future? How many back-up systems are necessary to avoid system failures? These issues worry me tremendously. I consider myself fairly astute in business, but this move I still question. We will pursue the project to its completion simply because I do not want to quit now. I sure hope it is worth it. Dr. Gold practices at the Gold Skin Care Center, Tennessee Clinical Research Center, in Nashville, Tenn. Pay-off Continues Years After Implementing an EMR System By Lawrence L. Anderson, M.D., F.A.C.P. D uring my time in the Army, I saw firsthand everything that is wrong with manually maintaining medical records. Not only were soldiers responsible for carrying their own paper charts, but those charts didn’t contain a complete picture of a patient’s health and often lacked vital information about medical history, allergies, recent diagnoses, and test results. Consequently, physicians often ordered duplicate labs or tests and made care decisions without pertinent information. Incorporating Technology From the Start When I left the Army and decided to start my own dermatology practice, I wanted to overcome these challenges, and I knew that technology would play an important role in making that happen. Now, 9 years after my practice implemented an EMR system, I am still a believer. My practice continues to realize many financial and operational benefits of this investment, from both a clinical and administrative point of view. Knowing that it would be easier to use an EMR from the beginning rather than converting data down the road, I searched for a solution that would meet the practice’s unique workflow and business objectives. We eventually chose NextGen Healthcare Information Systems (Clinitec at the time). Since then, we have realized many financial and operational benefits. Incorporating all of our practice processes into the system has enabled us to grow to eight physicians and five mid-level providers at two full-time locations and four 1-day a week satellite offices. Having charts available at the satellite offices has been a huge asset, helping to facilitate our growth. Reaping the Many Rewards Some of the many specific benefits we’ve realized with EMRs include the following: We can create customized templates, which we use to quickly enter information into a patient’s chart. For example, we created templates for Mohs surgery that incorporate post-op notes and follow-up. Having this information in one place also helps us meet state guidelines for an ambulatory surgery center. Reporting capabilities within the EMR have also allowed us to improve patient safety. When warnings were issued about Accutane, for instance, the EMR’s prescription module enabled us to run a report to identify all patients who were taking the drug. We then used the system to generate letters to those patients. These reporting capabilities are also an asset for clinical trials. We use the system to run a report that identifies potential trial participants, allowing practice staff to quickly and efficiently contact prospective study participants. Peer review is also much easier with the EMR. To evaluate recent treatments for psoriasis patients, we can type the corresponding code into the system and generate a printout of all patients with that diagnosis. We also often use the system’s analysis capabilities to assist us with outcomes measurement. By far, one of the biggest benefits of using an EMR is that when I see a patient, I don’t worry about anything except that interaction. I’m not flipping through a paper chart or thinking about coding or dictation. I can focus on the patient’s problems, make the diagnosis, and move on to the next patient. Ultimately, we see more patients in the same amount of time. Dr. Anderson is with Dermatology Associates of Tyler in Tyler, TX.
