The High-Performance Physician

Two weeks ago, I described the hybrid EMR as a high-performance EMR, designed for and successful in high-performance practices. This has spurred conversations about the characteristics of high-performance practices, and why their needs for EMR technology differ so greatly from those of other practices.

There are two primary characteristics that differentiate physicians depending on their specialties—patient volume and total financial value of each office visit. Patient volume varies widely since the number of patients seen per day can vary from fewer than 15 for hospital-based, non-fee-for-service physicians to over 30 for pediatricians and dermatologists, and even far higher for many specialists such as orthopaedists and ophthalmologists. The total value of each office visit also varies widely, especially when adding in ancillary tests, procedures, and surgeries that may accompany office visits. Whereas the typical family practice physician generates less than $80 in total revenue per visit, ophthalmologists and orthopaedic surgeons can generate well over $200 per visit.

The High Performance Physician

This chart compares patient volume and revenue characteristics among different types of physicians. High-performance physicians are those who see a high volume of patients and/or generate significant revenue per visit. The orange shaded area of the chart highlights the high-performance specialties: orthopaedics and ophthalmology are high on both scales; OB/GYN is moderate in volume, but high in revenue due to in-house ancillary tests and surgeries; and cardiology is lower in volume but generates high revenue due to the battery of diagnostic tests that stem from many exams. It is these high-performance physicians who, despite having the financial wherewithal to purchase a traditional EMR system, have the lowest adoption rates of those systems.

This chart is by no means an evaluation of the quality or importance of the care physicians provide; rather, it’s a measure of the intensity of their practices, which is why their needs for electronic medical records solutions differ greatly. Traditional (CCHIT) EMR products have not gained a foothold in the orange-shaded, high-performance area because even a small decrease in productivity for these highly productive specialists is too great. On the other hand, CCHIT EMRs have found some success among lower-volume, lower-revenue specialties, which fall in the unshaded area of the graph. A thorough reading of the CCHIT Certification Criteria reveals CCHIT’s primary-care focus.

Productivity-driven, high-performance practices demand EMR solutions that are productivity-focused. Hybrid EMRs are the only EMRs to enjoy a proven track record of success in this marketplace.

What Is a Hybrid EMR?

The continued success of hybrid EMR has prompted extensive debate about what actually constitutes one. While the Internet is now filled with discussions about EMRs, the number of conversations regarding hybrid EMRs has exploded. People are always asking me what it is that makes hybrid EMRs work so well and how they are different from traditional (CCHIT-type) EMRs. This is the first in a series of 3 discussions that will address this subject.

A hybrid EMR is a high-performance EMR that is successful in high-performance practices.

In 1997, SRS created the first hybrid EMR, concentrating on performance-driven practices, where high-volume physicians demanded unencumbered productivity. As others have followed our lead, hybrid EMRs continue to be designed with efficiency and speed in mind. This emphasis on performance criteria contrasts sharply with traditional EMRs. As a reading of the CCHIT criteria reveals, traditional EMRs are constructed for lower-volume, primary care practices where speed is not a primary driver.

SRS has built the largest national network of high-performance practices that successfully use an EMR. Our development process is driven by these practices and we work to facilitate the sharing of best practices among them.

In the next segment of the series, I will share my thoughts on a key defining characteristic of high-performance hybrid EMR—high usability.

A Physician’s Voice

It is one thing for me to describe the limitations of traditional (CCHIT-type) EMRs. After all, I have a vested interest in a hybrid EMR. I have devoted 12 years of my life to developing a type of EMR that reflects the physician’s voice and that offers benefits for workflow and quality of patient care. I could be accused of being biased. I would therefore like to share with you an opinion piece published last week in the New York Times, “The Computer Will See You Now,” in which Dr. Anne Armstrong-Coben, a clinical professor of pediatrics at Columbia, shares her personal experiences with a traditional EMR. This one user has hit the nail on the head when she concludes that “the computer depersonalizes medicine.” Her comments support the conclusions presented in the New England Journal of Medicine article, “Avoiding the Pitfalls of Going Electronic.”

Dr. Armstrong-Coben struggles to keep the computer from interfering with her ability to connect with her patients. “I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me.” She describes a chart produced by her traditional EMR as “a generic outline, screens filled with clicked boxes.” She recognizes that these charts are incapable of capturing the nuances that are so important to high-quality diagnosis and treatment. Dr. Armstrong-Coben suggests that alternatives like a hybrid EMR might be a better solution.

I maintain that the computer is a wonderful tool, but for most users it requires a conscious effort. Dictating an exam or writing on a piece of paper is more intuitive and efficient for most doctors. Computers force physicians to tear themselves away from their patients, shift their focus to a computer screen and interface with a keyboard and mouse. Doing so requires deliberate effort to navigate oftentimes-complex screens containing a myriad of dropdowns, check boxes and text boxes. The computer distracts the physician and dilutes the physician-patient encounter—unless the EMR is designed to allow physicians to practice and document exams as they have always done and are comfortable doing. That is what distinguishes the hybrid EMR from traditional EMRs.

With precision, Dr. Armstrong-Coben has identified the crux of the EMR-adoption problem.

Challenge EMR Vendors to “Put Your Money Where Your Mouth Is”

Change has arrived. The government, through the Department of Health and Human Services (HHS), will provide an incentive if you purchase and meaningfully use a “government” EMR. The problem is that the HHS incentive will only pay for the type of systems that have a dismal track record with busy, high-volume physicians.

Landmark studies have demonstrated that government EMRs, (traditional, CCHIT-style EMRs), impose financial hardship on physicians. There does not exist a single landmark study that concludes otherwise. Just ask any government EMR vendor to prove otherwise with any landmark study that meets the “smell test”:

  • The study is either large in scale or by a venerable, nationally recognized institution.
  • The study is not vendor funded.
  • The study must specifically address physician productivity. Studies that claim benefits of EMR accruing to other industry stakeholders are not relevant.

Before embarking on an expensive and risky venture into the world of government EMRs, you owe it to yourself to be 100% sure that the system is usable and adoptable for your unique practice. If you are not able to prove to CMS that you are a “meaningful user” of the EMR technology, the entire cost of an expensive EMR purchase will rest on your shoulders.

How do you make sure that your investment in a government EMR will perform just as the sales rep promises and bring your practice into the digital world, while receiving payments from the government? Easy. Insist that the vendor puts its money where its mouth is.

Before investing heavily in a government EMR, know ahead of time whether or not you will be successful. Have the vendor prove to you that they can get 2 physicians in your practice live on their system. To be fair, no money should exchange hands—only time. The two physicians and their staff will invest their valuable time learning the system and the vendor will invest its valuable time implementing and training. If, after a 30-day trial period, you are happy and can see that practice-wide implementation of the government EMR is feasible, then you sign a contract with the confidence that the investment is worthwhile. If you feel that the government EMR is not right for you, then the government EMR vendor removes the system from your office and a financial disaster is averted.

The power of this arrangement is that the government EMR vendor, whose sales rep promises the world, actually has to back up its claims with a fair trial by you, the “real-world user.” If the product does not perform as you expect, then you will not suffer the loss of a substantial investment. Go ahead and make the government EMR vendor “put its money where its mouth is.”