EMR Yes- No

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Debating the prose & cons of implementing EMR EHR.

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EMR Yes- No

  1. 1. No, Don't Buy an EMR Now! Yes, Buy an EMR Now! Gregory A. Hood, MD; Joseph E. Scherger, MD, MPH No, Don't Buy an EMR Now! Introduction Electronic medical records (EMRs) evoke strong reactions, from anger to enthusiasm. The US Government considers EMRs vital to controlling healthcare costs and improving patient care, but adoption is lagging. Doctors cite cost, work slowdown, potential problems and difficulties, and other issues as reasons to avoid an EMR. Medscape invited 2 experts to present their points of view on whether doctors should buy an EMR now. On "point," we welcome Gregory A. Hood, MD, internist with Drs. Borders and Associates, PSC, in Lexington, Kentucky, and Governor-Elect of the American College of Physicians, Kentucky chapter. On "counterpoint," we have Joseph E. Scherger, MD, MPH, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine California, and Medical Director of Quality and Informatics at Lumetra in San Francisco, California. No, Don't Buy an EMR Now! Point: Gregory A. Hood, MD Everyone says that 2009 is the year that everyone should buy an electronic health record (EHR). It slices, it dices, it fixes everything that is wrong with healthcare delivery in the United States. Not so fast. In spite of the fervor for EHRs in Government and the press, now is the time to make sure that you have both feet planted firmly on the ground. before you purchase an EHR for your practice. I have been using one EHR or another for about 12 years. They have advantages and limitations, like any other instrument. I was driven to use one because drastic circumstances in my practice required a "failsafe" means of records retention. I also had a desire to document more expansively and a natural inclination for technology. After 8 years of effort I was able to generate real-time completed office notes during the face-to-face time with each patient. This brings me to my first caution to you. If you expect "plug-and- play" technology, then this is not the time for an EHR purchase. You must be ready to spend 4-6 months in preimplementation preparations, learning, and data entry (scanning or manual data entry) and another 6 months of diligent, daily, personal utilization of the system before expecting to be proficient. Furthermore, every single estimate of improved quality and reduced quantity of redundancy in healthcare delivery is predicated on the quality and intensity with which the conversion and day-to-day
  2. 2. management of data into the EHR is conducted. An empty EHR, one with incomplete data entry, or one whose use is abandoned after a year of trying to adopt it does nothing to improve quality, efficiency, or national healthcare delivery. If you believe that the EHR will guide you to more accurate coding and boost practice revenue for you, paying for itself in the process, then I must caution you again. Physicians are ultimately responsible for the codes entered, no matter the method by which the coding level was derived. Do you expect the EHR vendor to stick up for you in an audit because of what their coding module suggested? Think again. Rightly, it is the physician, not the computer, who makes the code-level decision. The main place where I have seen outright dollar savings from an EHR is in the front office, where it is nearly invisible to the doctor in the day-to-day practice of medicine. Not paying $8 for each new internal medicine patient's manila chart and dividers -- and not paying for staff to run around to each other's desks looking for them -- are examples of savings that can be garnered. Yes, it is possible that your practice may also see a bottom-line difference if you purchase one now. The Government promises $44,000 for each doctor when a qualifying system is purchased. However, caution is warranted here again. There are hurdles and heretofore unannounced qualifications to meet in order to receive this money. With the present economic woes and the uncertain outcome of the national healthcare debate, this may not be a wise moment in history to be saddling oneself with additional debt, unless your practice is in a position to pay cash for the product. Further, this is only for the upfront cost. Committing to an investment of hundreds of thousands of dollars and hundreds of hours of both physician and staff time in order to get a rebate is not a decision to enter into lightly. Also, if you are not prepared for the monthly IT bill for system monitoring, maintenance, and replacement of broken or failing equipment, terminals, and servers, then you may be in for a big shock. Besides, don't forget that EHR programs go through periodic "upgrades" and new releases, some of which may require more robust hardware than previous editions. Such changes mandate payment for new, expensive equipment to replace perfectly serviceable hardware which has been rendered obsolete by your EHR partner's decisions on enhancement priorities. These enhancements may or may not enhance your method of patient care. It is imperative that you obtain a full-total-cost quote IT service contract from your proposed support company or you will have budgetary shortfalls. Your IT partner and your practice must have contingencies for when your EHR is down. You will experience power failures -- from ice storms, for example. You will experience times when phone and Internet services are down because cracked insulation on the 50-year- old phone line that serves your building is letting rainwater into the wires and degrading the signal. I've been there; trust me.
  3. 3. What's more, a typical EHR may boast a 99.8% "up time." This sounds impressive, but it means that almost 18 hours a year you won't have your EHR, even if you have electricity and phone service. Again, now is not the time for an EHR purchase if you expect (as many patients assume) that data from hospitals, labs, and other doctor's offices will flood into your system automatically from all over the galaxy. Each interface requires programming, testing, verification, and periodic updates and revisions. This can be tedious, time consuming, and at times impossible due to incompatibilities. Evolving Government standards for systems may force you to scrap presently functional systems and implement others in order to qualify for stimulus monies and avoid penalties. The future does include EHR technology. The picture could be much clearer in 6-12 months. Now is the time to investigate, to strategize, to start a comprehensive plan to review options. Now is not the time for a hasty decision. Because compliance with the meaningful EHR use in 2012 still qualifies for $44,000 from Medicare over 5 years, and compliance in 2013 only lowers this figure $5000 a year, it is more important to take the time to make the best decision you can, rather than make a rushed "now" decision. Unless and until you have full answers with complete confidence about each issue discussed here and about other issues unique to your personal circumstances, an EHR won't help you to live long and prosper. Yes, Buy an EMR Now! Counterpoint: Joseph E. Scherger, MD, MPH If you have been waiting to buy an EMR until now, you have made a good decision. I and other early adopters of EMRs struggled through initial versions of these records and didn't any great return on the investment. However, my EMR successes have improved over the years. I launched an EMR back in 1994 in a teaching practice in San Diego, and that practice is now on its eighth version of the record. I have also been part of a health system conversion to a leading EMR started 5 years ago, and it's been a real success. For small-to-medium private practices, waiting until now has been a very reasonable decision, while the industry and its products, pricing, and standards has been getting its act together and improving. But the waiting period is over. It is now time to act. There are 3 compelling reasons why now is the time to begin the strategic planning to buy an EMR and to install it later this year or in 2010. The first is to take advantage of the stimulus dollars that
  4. 4. are available for this purpose. The second is that EMRs are now affordable for any medical practice. Third, in a few years, the standard of care will require the benefits of an EMR for improving the quality of care. You will be at a major disadvantage in medical practice without one. 1. Take advantage of stimulus dollars: The passage of the American Recovery and Reinvestment Act (ARRA) this year included the Health Information Technology for Economic and Clinical Health (HITECH) Act, giving $19 billion for the adoption of EMRs. The opportunity is there for every physician to collect $44,000 over 5 years for "meaningful use" of a certified EMR. This amount of money would cover the cost of any leading EMR and its maintenance over the next 5 years. The federal government wants to cover your costs of an EMR! There will be penalties in lower reimbursement from Medicare for not having an EMR by 2015. This is a no-brainer! As the details become clearer, can you imagine the rush to install the best EMRs? Act now, act carefully and wisely, and beat this rush while plenty of help is available. At some point, manufacturers' training staffs could become so overscheduled that they will not be able to supply adequate training on a timely schedule. 2. EMRs have become more affordable for a private practice. Amazingly, Wal-Mart stepped up to the plate and has challenged physicians to stop complaining about the cost of an EMR. eClinicalWorks is one of the leading small-practice EMRs and Wal-Mart has contracted with this company and with Dell to cut in half the cost of installing an EMR. Instead of $30,000 per physician, it is now about $15,000. Borrow the money if you need to and take advantage of such a price. You will get it back from the government. Better yet, Congressman Pete Stark (D-Calif), watchdog over any deals struck between hospitals and doctors, led a Congressional exemption to the "Stark rules" to allow hospitals to subsidize the cost of an EMR for members of its medical staff. This allows the physician to install the same system that the hospital uses and to take advantage of interoperability with the hospital and other physicians in the same medical community. If your hospital is not taking advantage of this historic means of connecting the hospital with its physicians, you need to meet and encourage this. Some of the best EMRs are only available to large systems, and by teaming up with your hospital you may be able to get an EMR that you could not buy otherwise. 3. Improve the quality of care. In the long run, this is the most important reason to get an EMR. Having the patient's data available when making decisions, such as when on call, improves care. Applications of an EMR, such as electronic prescribing, reduce errors and improve patient safety. All of the leading EMRs are imbedding in their record current medical knowledge to guide clinical decision making, such as drug-drug interactions, drug-disease interactions, and the latest clinical guidelines for preventive services and the management of chronic
  5. 5. diseases. Physicians with an EMR have their care guided by the medical record. Those without an EMR are "winging it" off the top of their heads. When it comes to avoiding errors in diagnosis and in disease management, physicians with EMRs will be at a distinct advantage. As having an EMR becomes the standard of care over the next 5 years, you will have trouble defending yourself in a medical malpractice case working without one if an EMR could have prevented the error in diagnosis or treatment. Don't suffer from "mural dyslexia," difficulty reading the writing on the wall. Now is the time for all physicians to begin the conversion to EMRs. The federal government has stepped up and supported physicians. The carrots and sticks are being put into place. You do not need to act hastily right now, but form a leadership team in your office that studies the EMR options carefully and presents a plan. Act on that plan so you beat the rush. Get your EMR this year or in 2010 at the latest.

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