EMR Straight Talk Centennial Blog—It’s Still About Productivity

This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.

There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.

Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.

When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.

Thank you for reading and commenting!

EHR Success: What is the Reality?

With the constant barrage of meaningful use success stories in the media—number of providers enrolled, dollars of incentives earned, and case studies about practices that have already received their money—it pains me to see that the experience on the ground quite often does not reflect this reality. Although they are only anecdotal, let me share two recent personal stories that I fear are representative of all too common EHR implementation failures.

I recently visited my dermatologist, whose practice purchased an EHR approximately 2 years ago (not my company’s product). When I arrived, I saw to my dismay that the office looked and operated exactly as it had before they bought the EHR—there were walls of charts; no computers in or around the exam rooms; and my physician walked in grasping my paper chart in his hand, with loosely assembled documents protruding from the edges. When I asked why they were still using paper charts, I was told that “it takes a long time to switch over to computers!” No one in the office—not the front desk staff, not the clinical staff, and not my physician—could even tell me the name of the EHR they had purchased. Clearly, little—if any—progress had been made on the implementation front in the 2 years since the purchase decision, and yet they seemed to think this lack of a transition was normal. All that money invested, and no return!

A visit to my primary care physician was equally disturbing, but from another perspective. His practice had implemented an EHR (also not my company’s product), and several of the physicians were, in fact, using the software—but not happily. He complained that he was seeing fewer patients each day, as well as staying a half hour longer to catch up on his documentation. Will he earn a meaningful use incentive? Likely yes, but at what cost?

I have always maintained that government incentives should not be the motivation for adopting an EHR. Practice improvement—cost reduction, increased productivity, and better patient care—should be the driver. With the rapidly increasing demand for care and the growing shortage of physicians, the need for easily implementable, productivity-enhancing EHR technology is indisputable, and yet so many EHR implementations are still failing. How do we as an industry address this shortcoming?

Physician EHR Productivity: Vital to Meet Spike in Demand for Care

Half of the physician group practices recently surveyed expected to buy an EHR system within the next 2 years. In the rush to purchase, however, it is imperative that physicians take the time to carefully assess how each of the EHRs they are considering will impact their productivity. Productivity has always been a major concern in EHR adoption, but demographics and financial factors now conspire to make it increasingly critical. Physicians can no longer afford even the slightest decrease in productivity. Consider the following projections that affect specialists:

  • The demand for joint replacement surgery will soon outstrip the supply of orthopaedic surgeons available to provide it, according to studies presented to AAOS. This is partly the result of an aging population with increasing rates of obesity and arthritis, but the growing demand will also come from a younger population. A full 50% of joint replacements will be sought by people under 65—the physically active baby boomer generation with a high level of physical activity. Not only will first-time joint replacements increase astronomically (rising 673% to 3.48 million knee replacements, and 174% to 572,000 hip replacements by 2030), but the demand for revision joint replacements, (i.e., repair or replacement of artificial joints) will also increase—doubling by 2015.
  • The situation is similar for ophthalmologists. Higher life expectancy will create a demand for 30 million cataract surgeries by 2020. Combined with the downward pressure on Medicare reimbursement rates that will lead some ophthalmologists to limit their practices to medical ophthalmology, the result will be a greater caseload for the remaining surgeons—but these physicians will need a high-volume, highly productive practice to remain financially viable.
  • Dermatologists will see a two- to three-fold increase in skin cancer patients as the population ages, and the demands for their medical services will grow rapidly. Not only will dermatologists be called upon to perform more surgical procedures in their offices, but increased awareness will lead to a higher demand for screening and preventive-care services.

Physician productivity will be critical in the office as well as the operating room, since the number of surgeries performed is directly proportional to the number of office visits conducted. A physician-focused, specialist-oriented, efficient EHR will be key to a physician’s ability to meet the increased demands, satisfy patient needs, and run a financially successful practice. Given the above statistics, it would be fiscally and socially irresponsible to implement an EHR that negatively impacts physician productivity. Now, more than ever, productivity is king.

EHR Usability – Let Physicians Decide

Usability has become the focus of a great deal of attention in the EHR world. The HIT Policy Committee has talked about making usability a component of meaningful use—recognizing that spending $36 billion to incentivize and support physicians to adopt EHRs means that we can no longer close our eyes to the historically high rate of EHR failures. Fears about lack of usability, and the resulting impact on productivity, have contributed to physicians’ reluctance to move forward with implementation, and EHR incentives will not sustain adoption beyond the first payments if physicians find their EHRs unusable.

To address these issues, the Committee held a day-long hearing on usability, and on June 7, NIST (National Institute for Standards and Testing) convened a workshop to discuss the state of EHR usability. Significant work is being done by NIST, as well as by academic institutions, research and trade groups, and vendors, to determine how to measure, evaluate, and improve the usability of EHRs.

I hope that those involved in the efforts to advance EHR usability will consider the following points:

  • The only people who can truly define usability are the users—i.e., physicians and other providers. Usability relates to the comfort, ergonomics, and acceptability of a particular application interface to its users. As such, it is the experiences and feedback provided by those users that must be the driving force behind any shift toward greater usability.
  • Usability can be measured, but not legislated. Because personal subjectivity will always be an important factor in each individual user’s judgment about what is ergonomic, comfortable, and generally acceptable, there will always be room for a variety of approaches. Attempts to legislate the best way will inevitably accommodate only a narrow range of users, leaving those with varying preferences and workflows without software to satisfy their usability requirements.
  • Usability must be evaluated not only from the perspective of primary care physicians, but also that of specialists. Specialists provide different types of care and have very different expectations of their EHRs. Treating specialists as an afterthought—as happened in the initial formulation of the meaningful use requirements—would be a major disservice and undermine the serious work being done to define usability.

There is a great opportunity here for the government to provide advice and education regarding EHR usability—this could go a long way to furthering successful EHR adoption. It would be a major mistake, however, for the government’s role to extend to legislating or mandating usability standards. That would sap innovation, push creative vendors out of the market, and turn EHR adoption back to where it was before the meaningful use incentives.

EHR: Great Expectations?

It’s so interesting how the same statistics can be interpreted through different prisms to arrive at opposite conclusions. In a past post, I wrote about the recent comprehensive MGMA study that explored the EHR experiences reported by over 4,500 professionals, representing 120,000 providers, focusing on the effect of EHR implementation on providers’ operating costs and productivity.

In this month’s issue of MGMA Connexion, David Gans, MGMA vice president, discusses the results of this study. He points out that EHR benefits to providers increase as they increase training and optimize their EHRs—“optimize” being defined as allocating sufficient time for physicians and staff to become familiar with the system—not a surprising finding. The tone of the article leads the reader to view as good news the fact that 37.7% of the respondents who claimed that they had optimized their EHRs reported productivity gains.

This statistic lends itself to a glass-half-full versus glass-half-empty analysis. Shouldn’t we look at this result with considerable concern since it means that 63.3% of optimized EHR users are not experiencing improved productivity? As the shaded area of this chart illustrates, if we did nothing to change these results, the vast majority of EHR users would never realize productivity benefits.

This is not a condemnation of EHRs, but rather a caution that physicians must evaluate their EHR options carefully to ensure that they purchase a system that is designed for their particular specialty and workflow—one that they can implement easily and optimize quickly, and that delivers increased productivity from the outset.

Meaningful Use Retrofit: Unintended Consequences

Question: What do you get when you try to retrofit a primary-care-focused government program to be relevant to specialists?
Answer: Unintended consequences.

In response to the outcry from specialists about the primary-care nature of meaningful use, CMS implemented some exclusions to make the program more workable for them—but these changes did little to make it more “meaningful.” In fact, there were some significant—and, I have to believe, unintended—consequences that will actually create challenges for many specialists:

  • Some physicians will have to add what they consider non-relevant vital signs to their workflow. Acknowledging that vital signs are not within the scope of practice for some specialties, CMS provided a potential exclusion for this measure. However, to take advantage of the exclusion, providers must attest that all three vital signs (height, weight, and blood pressure) do not apply to their practice. This leaves physicians who routinely record just one or two of the vital signs without a way to satisfy the measure, other than to add the non-relevant measurement, too—blood pressure for orthopaedists, height and weight for ENT specialists, etc. (For an explanation, read The All 3 Vital Signs Dilemma.)

Is it the government’s intention that orthopaedists take blood pressure on every patient? Perhaps—but if so, are these physicians then responsible for treating this condition? Some would argue that orthopaedists need to know their patients’ blood pressure if they are going to perform surgery—likely true, but why should this requirement also apply to non-surgical patients? It should not, but let’s remember: this is a primary-care-focused program, designed by primary-care physicians, and this type of analysis was never performed.

  • Some specialists will have to report on clinical quality measures (CQMs) that have no relevance to their practices—and in doing so will provide meaningless data. The accommodation for specialists in regard to reporting on CQMs was originally intended to allow them to identify non-relevant measures by reporting zero as the denominator. However, the meaningful use measure requires physicians to report CQMs using data that is directly generated by the EHR. This results in the inclusion of patients in the denominator of CQMs that are outside the scope of the reporting physicians’ specialties. Physicians will be forced to report on problems for which they did not treat the patients, reporting zeros as the numerators, but not the denominators. (For further details, see Clinical Quality Measures: Who Defines Relevance?)

This raises several issues. First, physicians are reluctant to go on record as not addressing a known problem, even when that problem is outside their specialty. In this litigious medical environment, this is not an unreasonable concern. Second, the data generated in this manner will be meaningless since numerous specialists will provide data on the same patients and on the same problems as are being treated by primary-care physicians—making it will appear that, on average, very little care is being provided for these problems. Some physicians will be trapped into providing data on measures that are not relevant to their practice, even though valid measures exist. For example, any pediatrician with even a few patients over 18 will have to report on those few older patients—using the core measures meant for adult populations—rather than report on his/her entire pediatric patient base, using the alternate core measures that were specifically added to capture valuable information regarding the pediatric population.

CMS acknowledges that the purpose of this particular requirement during Stage 1 is merely to get people comfortable with automated reporting—specifically stating that the government is not looking to gain valuable information about medical practices or the state of care being delivered. I am concerned, however, that the discussions to date about reporting on CQMs in Stage 2 do not advance us towards producing data that will be any more meaningful. To accomplish that, the entire structure would have to look more like PQRS, where physicians report only on measures directly relevant to their practices.

For meaningful use to be meaningful to specialists—beyond the financial value of the incentive money—the program needs to be restructured to fit their needs and practices. It is quite evident that trying to apply primary-care requirements to specialists is not effective.

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.