EHRs and Productivity Loss: How Can This Be Acceptable?

The purpose of automation is to increase efficiency and productivity. Every industry that has undergone the transformation from paper to digital has realized these benefits immediately . . . every industry, that is, except the EHR industry. Why is this acceptable?

Even the AMA acknowledges this failure—and yet seems to accept it. Toward the end of its newly released, and otherwise very helpful, video on how to select an EHR is the test question: “What is the ‘best practice’ in terms of the number of patient visits to schedule during the first week of operation with your new EHR?”

Why does the AMA think that the correct answer “A”?:  “Reduce the number of patient visits by up to 50% for the first week to allow you and your staff to learn how to use your new EHR.”

Why isn’t it “D”?:  “Your new EHR was carefully selected to fit into your practice smoothly and seamlessly. There should be no impact on patient volume that first week.”

Why does the typical EHR implementation follow the bottom line of the graph below, when it should look like the top one? Dr. Jacqueline Fincher’s testimony at last week’s HIT Policy Committee’s hearing on “Experience from the Field” is representative of the all-too-common experience.

Dr. Fincher reported an “absolute requirement to drop patient volume by half for the first three months [due to] an exponential learning curve,” and that she and her partners “have never gone back to the previous volume of patients,” even after 5 years of EHR use.

Some argue that the medical business is different from other industries like banking and shipping. That is very true. The type of data collected is different, and the level of employee responsible for inputting much of the data is also very different. In most industries, it is the lower-level, less costly employees (such as bank tellers and UPS truck drivers) who input data, while in medical practices, it’s actually the CEOs (i.e., the physicians) who do it. This makes productivity all the more critical for an EHR. According to the recent MGMA study on EHR adoption, fear of productivity loss is the primary barrier to EHR adoption—a concern justified by reports from experienced users, as illustrated below.

For the EHR industry to evolve as necessary for widespread adoption to become a reality, choice “A” must be rejected as totally unacceptable by physicians and the professional organizations that represent their interests. Physicians should expect more from their EHRs—they should demand that vendors deliver productivity, not merely fancy features and functionality. The truth is, they can get both, but only if they do their due diligence.

7 thoughts on “EHRs and Productivity Loss: How Can This Be Acceptable?

  1. What is efficiency?
    The number of patients that you see?
    The amount of money that you make?
    Or is it delivering quality care and better outcomes?
    If your EHR cannot collect structured data which can be mined in order to evaluate clinical decisions and see what works and what doesn’t work, you are not moving the delivery of healthcare forward.

    Some physicians are not in this just to be efficient and make money. Some actually want to use the power of EMRs to document quality and outcomes.

    You, on the other hand, will be left behind in your “efficient” fee for service model.

    That’s straight talk.

    [From Evan Steele:]
    Efficiency and quality are inextricably tied together. Any business that runs more efficiently will takes better care of its customers (patients in a medical practice).

    Agreed that if an EHR cannot collect structured data to be mined, then it will be difficult to realize the goals of higher quality and lower cost.

    There are EHRs that do both well (i.e., collect discrete data and increase physician and practice efficiency).

  2. Hospitals openly brag that emr will increase the non patient time a doctor spends per patient

  3. I think the question you raise is as frustrating as the problems being experienced by the industry. When any business is “forced” to move to a space not of its choosing, on a timeframe it did not decide (EMR is clearly an accelerated schedule for the large majority), serious issues are looming.
    Think about it, if today you discovered your industry must (will) completely change all its processes, regardless of its current efficiency, use a technology which is unproven with many know issues, regardless of cost to you, doesn’t it scream you should expect a hit in efficiency and productivity regardless of solution chosen?
    I just find it amusing that after all this time we still wonder why this is happening…expect the worse, and you will be pleasantly surprised in the end!

  4. “Every industry that has undergone the transformation from paper to digital has realized these benefits immediately . . . every industry, that is, except the EHR industry.”

    Okay, i’ll bite…Name another industry which was forced to operate completely paperless…I can’t think of a single one!

    [Evan Steele says]
    I can’t think of an industry that is completely paperless. Even if every physician has an EHR, there will still be paper in medical offices.

  5. HISTALK fan is missing a central issue- If the charts are virtual in SRS even if they are images of what the doc wrote, chart pulls take no time, and chart audits are easy.
    What data do you really want discretely to track? Diagnoses, immunization dates, dates seen, medications prescribed- all of which I have access to with my combo of SRS and PCC/Partner.
    If you can explain to me when you really want to run reports on “green ear discharge from the left ear instead of yellow ear discharge, I will concede that doctor-data-entry is better. (Although you will probably have that info with ICD 10)
    But I will let you in on a secret- docs are _terrible_ data entry clerks. The boilerplate spew that I have to read from most doctor data entry EMRs bills great, but tells me almost nothing about what is going on with the patients. I am so tired of the little girls who have normal male genitalia according to their EMRs…. So if your data stinks, your attempts to improve Quality will not get far.
    Yes, if Google was doing analytics of free text EMR HPIs and patient plans, that might lead you to interesting hypotheses– Maybe an increased percentage of children with a dog named Rover have asthma? But until the feds/public health/ were to give me a “free” EMR (not just purchase price but not hurting my productivity) I am not willing to subsidize fishing trip research hypotheses everyday as I see patients, when I can spend time with existing tech finding kids getting too many Rxs for steroids and asthma, or missed opportunities to vaccinate.
    My barriers to QI are finding the time, not the technology.
    Lots of issues, none of them simple- but to imply you can’t do quality improvement, assurance, and population management without doctor-data-entry EMR is _absolutely_ untrue.

  6. Histalk Fan asks “what is efficiency?” One must also ask “what is quality and outcome.”

    Whether locally or nationally, “patient satisfaction scores” have become more weighted in quality and outcome measures. In 15 yr of practice, the only factors that have negatively impacted patient satisfaction scores in our practice are “access” and “time spent with the physician.” Wait time for appointments, wait time in the office, and time spent with the physician are the things patients care about most. I rarely, if ever, receive a negative comment on decision making or performance.

    Efficiency means spending more time on those things that patients care about, and less time on minutia that matters to no one. In the eyes of my patients, timely service defines quality, and efficiency directly impacts timeliness of service. Any EHR that results in longer wait times or less time to spend with patients also produces a direct drop in quality. I have yet to ever hear a patient accept poorer daily service on the basis that some beaurocrat has an easier time data mining months or years from now.

  7. I wrote an analysis of EMR’s in the November discussion site here. Forgot to mention one thing which has already happened several times at my 700 bed urban hospital: failure of the system – due to in one case a general power failure in this part of my city and several times due to internal bugs in the software for the hospital as a whole. I am not talking about lack of back up which we have, but when you cannot enter the system, given the dependence upon the EMR which we now have, do you imagine that patient care is enhanced. We all have had computer failures in our offices and this will happen in your office EMR. And now I have seen it personally in a system wide failure. Do EMR software writers have a solution for this?

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