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.

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.

Usability: Can Every EHR Be Above Average?

Usability is the key differentiator between the long-term success and failure of an EHR implementation. The findings of the recent MGMA study lead to the inescapable and troubling conclusion that too many physicians do not consider their EHRs “usable.” A bad EHR choice is costly for the particular physician(s) and, while it might suffice in the short term for the purpose of earning meaningful use incentives, it will do nothing in the long run to foster sustained EHR adoption. Recognizing this, the HIT Policy Committee’s Adoption and Certification Workgroup convened an 8-hour hearing last week on the subject of how to define and measure usability. Recommendations were offered that mirrored my EHR reform proposal, and various groups/studies are already working on usability testing. One such group is CCHIT, which has introduced a usability rating tool into its commercial certification (not to be confused with government-certification) process. In her testimony, Karen Bell, M.D., Chair of CCHIT, discussed the results (Chart 1) and her recommendations.

So what’s wrong with this picture?

What’s wrong is that, to be useful to physicians, it has to look like this:

This is not meant as an indictment of CCHIT—the organization is to be commended for having taken an important first step in defining usability and creating a process for measuring it. The problem—which Karen Bell did acknowledge when challenged about it—is that if this rating scale were an accurate reflection of usability, there would be many fewer complaints about EHRs and, in my opinion, many fewer failures.

To provide physicians with the objective information that will be valuable to them in EHR purchase decisions, the ratings must be comparative and follow a normal distribution, as illustrated in Chart 2 above. Because achieving this distribution would require more aggressive usability criteria, it would distinguish those EHRs that have the greatest positive impact on productivity and cost savings from those that have a lesser, or negative, impact in these areas.

Even more important, this more challenging evaluation will create a market in which vendors are forced to compete on usability and how to better meet the needs of physicians. Physician satisfaction levels will increase. It will elevate quality across the board and raise the level of the entire EHR industry. Perhaps, as Dr. Ross Koppel testified at the Usability Hearing, if health IT were more usable, we wouldn’t even need incentives to spur EHR adoption!

MGMA Study Reveals #1 Reason Physicians Fear EHRs

The evidence is indisputable: the fear of lost productivity associated with EHR implementation is uppermost in the minds of physicians, and their fears are justified by the actual experience of the majority of EHR adopters to date. The titles of two articles about the recently released MGMA EHR survey say it all: “Survey: EHRs Often Don’t Increase Doc Productivity” (Health Data Management) and “HITECH Drives Docs to EHRs, but Cost, Productivity Issues Remain” (Healthcare IT News).

MGMA is to be commended for the size and scope of this important survey (4,588 practices representing 120,000 physicians), for the multiple ways it segmented the survey population, and for the detailed analysis of the results. One important segmentation was missing, however—that of physician specialty, or, at a minimum, of primary care versus specialist. The EHR experience of orthopaedists or ophthalmologists, who may see as many as 60 patients a day, is dramatically different from that of a family practice physician who sees 20.

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

  • Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
  • While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
  • What accounts for the loss of productivity?
  • When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

The MGMA report did not tie satisfaction and productivity to the particular EHR being used, but there were clearly some successes, so it is important to understand what differentiates these implementations. It all comes down to usability. According to a recent HIMSS Task Force Report on why adoption has been so slow, “A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.” I maintain that lost productivity and lack of usability are one and the same.

Meaningful Use Stage 2—So Many Opinions

While providers are still struggling with the details of meaningful use Stage 1—and as of yet, no one has actually demonstrated meaningful use of their EHR—plans for defining Stage 2 requirements are moving ahead at full speed. A preliminary set of recommendations was released by the Meaningful Use Workgroup of the HIT Policy Committee in January, along with a Request for Comment by February 25. And comment they did!

Major organizations representing the various stakeholders submitted lengthy letters detailing their recommendations. While the specific concerns they express differ slightly, a clear consensus is emerging:

  • Rushing providers to do too much too quickly in the next stage will be counterproductive to the end goal of successful and widespread EHR adoption, as well as have a negative effect on patient care.
  • The proposed timelines are too aggressive in several areas.
  • Expectations should not exceed the existence of a sufficient information-exchange infrastructure, e.g., syndromic surveillance is identified as unrealistic.
  • Stage 2 requirements should be based on an objective evaluation of the experience in Stage 1 and the value of individual measures.

The last point above reveals a sense of frustration over the fact that the existing timetables create pressures that do not allow for this approach. Without taking into consideration the successes, failures, and physician participation rate in Stage 1—including, I would add, the rate of participation by specialists—Stage 2 could lay the groundwork for failure.

The AMA’s letter on behalf of 39 medical societies reiterates those societies’ initial concern about the excessive burden being placed on physicians. The letter argues for increasing flexibility, expanding the ability to opt out of measures that are not relevant to a physician’s routine practice, retaining a menu set rather than making all measures core and therefore required, and limiting physicians’ responsibility to what is within their control and not subject to compliance by other parties (e.g., patients’ use of portals for access to health information).

MGMA identified many of the same concerns, adding a request for harmonization of government programs to eliminate duplication of effort. (See discussion of this topic in my last EMR Straight Talk post.) Premier, Inc., a provider alliance, urged that new no clinical quality measures should be added until Stage 1 performance can be evaluated.

From the IT industry, AHIMA (an organization of healthcare IT professionals) cautioned about the impact of the overwhelming number of complex initiatives that practices will have to incorporate at the same time—ICD-10, Healthcare Reform, and meaningful use. EHRA, the EHR vendor trade organization, not surprisingly expressed its concern about the time needed to develop the software updates that will be required, particularly in light of the impending regulations identified by AHIMA. It therefore recommended that Stage 2 be limited to increased thresholds for Stage 1 measures with no addition of new measures. EHRA specifically identified clinical decision support as an area in which the government’s expectations go well beyond the scope of an EHR. As an overarching recommendation, EHRA urged a delay in the start of Stage 2 and the extension of certification to three years instead of two.

A somewhat different perspective comes from consumer organizations. The Consumer Partnership for eHealth and the Campaign for Better Care, on behalf of a number of other groups such as AARP and several unions, argue for a significant raising of the bar and accelerating of the program. For example, they ask that all menu measures become core measures, patient and family engagement via use of portals be emphasized, and clinical decision support rules be defined and adherence required. Deborah C. Peel, MD, Founder and Chair of Patient Privacy Rights, submitted a letter expressing her disappointment that “the current MU Stage 2 criteria and schedule for MU Stage 3 criteria completely ignore/omit privacy rights and protections in existing privacy law . . .“ It is not surprising that these groups would take a more aggressive stance and have higher expectations—these are the people who are paying for this program.

How will all of the above positions be reconciled? Based on the experience of Stage 1, in which the HIT Policy Committee and CMS revised the initial requirements to make meaningful use more achievable, I believe that they will do the same for Stage 2 and create a set of rules that are beneficial to the overall healthcare system and patients, while not overly burdening physicians.

Blumenthal and EHR Program: Time Will Tell

In the aftermath of Dr. Blumenthal’s departure announcement, he has received abundant praise for his accomplishments, his leadership, and his commitment to EHR adoption. There is a general consensus that the groundwork has been laid and that sufficient organizational structures are in place to move the EHR adoption program forward smoothly, despite the upcoming change in command at ONC.

Most writers have attributed Blumenthal’s departure to his need to return to Harvard—which had granted him its standard two-year leave of absence—since his option to retain a tenured position expires at the end of that period. According to Secretary Sebelius, this schedule was incorporated in the HHS plan from the outset.

Some people are more cynical regarding Blumenthal’s reasons for departing, like one of the commenters on last week’s EMR Straight Talk post, who suggested that he is getting out “before the roof collapses.” They cite recent studies that question the link between EHRs and quality of care, the loss of confidence among some providers regarding their ability to meet the meaningful use requirements, and the recent (albeit unsuccessful) attempt by House Republicans to repeal unspent funding that would have included the EHR incentive program. These commenters express doubt as to whether the momentum toward health IT adoption will continue.

Others say new leadership will be a good thing. John Moore of Chilmark Research posits that the EHR program is at a turning point—and that as it transitions from the development phase into the operational phase, it should be led by someone with operational experience rather than by an academician.

No doubt, top PR people were involved in the orchestration of the Blumenthal announcement. What still concerns me is why it was not accompanied by the naming of his replacement—a sentiment that has been echoed by many industry pundits, (Ken Terry, for example). This begs the question: What does it really mean? Time will tell.

Blumenthal’s Departure: Odd Timing

Yesterday morning, in a podcast interview with Neil Versel, a respected HIT journalist, I was asked to compare the mood at last year’s HIMSS meeting with my expectations for this year’s assembly. In 2010, I listened as David Blumenthal, head of ONC, spoke to a standing-room-only crowd, whipping up a frenzy of excitement about ARRA and its EHR incentives in what I can only describe as a pep rally. I told Neil that I anticipate a more subdued and somewhat anxious atmosphere at this year’s meeting, since the practical realities and challenges associated with the complexities of meaningful use have set in. A recent survey of hospital CIOs, for example, revealed reduced confidence in the ability of their respective institutions to successfully meet the requirements within the allotted timeframes, and a resulting skepticism about whether they would earn the incentives. Similarly, at the recent 2-day hearings conducted by the Adoption and Certification Workgroup, the generally positive sentiment was tempered by concerns about operational issues, timing, IT workforce challenges, and the multitude of government programs on the plates of practices.

Then, yesterday afternoon, the news broke that David Blumenthal is stepping down from his post as the national leader of the EHR adoption and incentives program. Although we all know that no single individual is ever indispensible, the timing of his departure struck me as quite odd. The program is at the precipice—its launch is just underway and the first attestations of meaningful use are expected in April. Initial success or failure will be evidenced imminently. One would think that this would be the time to demonstrate stability and unwavering commitment from the top down—a time to rally all of the forces to ensure the program’s success.

I cannot help wondering the following:

  • Why is Blumenthal stepping down now, when the program is at such a critical juncture?
  • Why is HHS Secretary Sebelius just now “conducting a national search for the right successor” even though she reports that it was always the plan that Dr. Blumenthal would end his term at this point?
  • What are the implications for the EHR incentives program?
  • Will his departure affect the likelihood of its success?
  • How will provider confidence in the program be impacted?
  • Should we expect changes in the program? What kind of changes?

Please share your thoughts on David Blumenthal’s departure by commenting below.