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.

EMR References: Cast a Wider Net

Client references and site visits can be a rich source of valuable information when you’re shopping for an EMR—but only if approached critically and after conducting your own due diligence. The graph below illustrates the limitations of relying on vendor-supplied client references to make an informed EMR purchase decision.

Impact of EMR on Physician Productivity

This graph represents the effect of EMR adoption on physician productivity, given the acknowledged 50–80% failure rate of traditional EMRs—specialists being on the higher end of the range. Immediately upon adoption, physicians experience a significant reduction in the number of patients they can see, and over time, they hope to regain their productivity. Some are able to achieve their pre-EMR levels, and a small number see an increase above that level—the latter are the physicians in the orange-shaded section. These are the physicians whom vendors will identify as references and whose practices will be offered for site visits.

Every vendor will have a few good references and can take potential customers to visit a “show site” client, but this is not necessarily representative of the experience of the majority of users—the experience that you can likely expect.

If this graph instead portrayed the results of a clinical trial for a new drug, would a physician prescribe this medication based on the fact that 100 (of the 1,000) patients in the study showed positive effects? Clearly not!

Ask the vendor for—and insist on—at least 10 to 15 references of practices in your specialty and at least a few that are close in size to yours. If a vendor cannot provide this, there is reason to question whether its EMR is right for your practice. Call a physician of your choosing in the reference practice(s)—selecting at random from the group’s website is most likely to yield an objective evaluation. Don’t be fooled by one reference, one hand-picked physician, or one “show site” visit.

Healthcare Reform: Get Ready for the Crush!

Against what seemed to be insurmountable odds, President Obama has signed a healthcare reform bill. While the full impact of the bill won’t be known for a while, two things are already clear about this legislation’s effect on physicians. There will be a sharp increase in demand for their services, and they will get paid less for the services they provide—making physician productivity vital.

By 2014, all Americans will be required to have health insurance. A whopping 32 million people will be added to the rolls of private health insurance plans over the next few years with the help of government premium subsidies. Because these people have not had health insurance in the past and many have medical problems for which they have not received treatment, they can be expected to seek care in greater-than-average numbers. Compounding this demand will be the seismic shift in demographics caused by the aging of the 79 million baby boomers, the first of whom turn 65 next year. Their naturally increasing demands for medical care will further stress our healthcare delivery system. Given the current, and growing, physician shortage, physicians will be deluged with patients.

With a projected cost of $938 billion, much of the funding for the legislation will come from cuts to Medicare, which will include payment reform—a euphemism for reduced payments for the services provided by physicians.

Physician productivity has always been important, but the healthcare reform legislation has made it critical. To meet the crush of demand for care, and to grow—or even maintain—their current incomes, physicians will have to see a greater number of patients and do so more efficiently. Now—more than ever—it is important for physicians to invest in software that is physician focused and designed with physicians’ workflows in mind, to ensure that it will increase, rather than decrease, their productivity.

Reminder: to find out what your time is worth, try the physician productivity calculator.

MGMA Confirms Productivity Loss with Government’s EMR Program

What struck me at last week’s annual meeting of HIMSS (Health Information and Management Systems Society) was the conspicuous absence of conversation about the effect of the ARRA legislation on physician productivity—there was hardly a mention of the subject throughout the conference. Jeffrey Belden, M.D., of the HIMSS Usability Taskforce, did point out that documenting patient exams in an EMR takes 10 times as long as documenting by dictation, but offered no solution to that problem. Admittedly, the audience contained few, if any, physicians. However, once again, it struck me that physician productivity was the elephant in the room—the topic that no one was discussing, even though physicians are the very people upon whom the success of the program is so dependent.

I arrived home to the release of the results of a new MGMA study (conducted last month), which concluded that practices expect that the operational changes required to meet the proposed meaningful use criteria will cause a significant decrease in productivity. Nearly 68% of the respondents anticipate such a decrease, with 31% projecting that the decrease would exceed 10%—and this was likely based on only the impact of Stage 1 meaningful use criteria.

This productivity loss is what I described in last week’s EMR Straight Talk post, where ARRA meaningful use requirements compound the reduction in productivity that is already associated with the “point-and-click” EMRs themselves. Before ARRA, physicians estimated that traditional EMRs reduced their productivity by between 20% and 40%, as documented in testimonials posted on the Government’s FACA blog and included in the Voice of the Physician Petition. Others are speaking out about this issue as well; Paul Roemer reported that his cardiologist puts the productivity loss at 30%, due to the amount of time that he “wastes” performing clerical—i.e., data entry—tasks. (Read his comments in “Healthcare IT, How Good is Your Strategy: A Scathing Rebuke of EHR.”) Added together, this means that physicians face a 40% reduction in productivity at the outset. Imagine what will happen to productivity when the more stringent Stage 2 and 3 meaningful use criteria are implemented!

The conclusion is clear. Physicians should not be considering EHR adoption for the incentive money; they should be looking at what will help them address their business and patient-care needs. The HIMSS keynote address by chairman Barry Chaiken, M.D., charged the EMR industry with “creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them.” Systems like that already exist—they just don’t interest the government, which appears to be more interested in data collection than EHR adoption.

Government EHR Program: Unintended Consequences (continued)

Last week’s EMR Straight Talk, “Government EHR Program: Potentially Harmful Unintended Consequences,” seems to have struck a nerve with readers—based on the number, source, and intensity of the comments. The elevated level of concern is palpable. What I find rewarding is that blogs like EMR Straight Talk are creating a community of physicians who find support for their concerns—concerns that they might have thought were unique to themselves. Several of last week’s comments came from physicians who are not even on our mailing list, which means that their colleagues are sharing the blog, seeking to build support for their beliefs. Most of the comments were submitted by specialist physicians who are getting our message and beginning to speak up about why they do not consider the government’s EHR program relevant for their practices.

Those commenting identified several additional unintended consequences and voiced other concerns, including:

  • Dissatisfaction with templates and the utility of the notes they generate;
  • Failure of the government program to consider the needs of providers;
  • Effect of traditional EHRs on physician productivity;
  • Failure of physician organizations to speak out on behalf of their constituents; and
  • Difficulty of finding the right EHR for a practice.

An interesting comment came from Paul Roemer, who directed concerned readers to his post on HealthsystemCIO.com, in which he suggests that the “meaningful use” dates will be pushed back. He maintains: “Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.” His contention is that very few providers will be ready or able to take advantage of the incentives, including those who already have implemented a traditional, point-and-click EHR.

What do you think the government should do with its program that is clearly meeting significant and vocal resistance—particularly among specialists and other high-volume physicians? Submit your comments below, and let’s keep the conversation going.

The Elephant in the Room

The search for the perfect EMR involves an extensive list of criteria related to features and functions, cost, hardware requirements, certification, references—and since February, the potential to obtain government incentive money. Search committees are assembled, consultants are engaged, RFPs are solicited, presentations are made, and references are checked. But there is a big elephant in the room that everyone is ignoring—physician productivity.

The effects of productivity are enormous. Changes in physician productivity dramatically and directly impact the practice’s bottom line. You can calculate the cost for yourself using the Productivity Calculator discussed in a prior blog. Physician productivity has broader societal impacts as well. Decreased productivity means fewer patients seen in the face of higher demand for care by aging baby boomers and the massive numbers of newly insured patients under proposed health care reform legislation. This is further compounded by the shortage of physicians.

Why is no one looking at productivity? Why aren’t physicians and medical societies insisting that productivity information be made available and be the focus of the EMR selection process? Why do RFPs—typically written by consultants—contain no questions about productivity? CCHIT certification has never included any evaluation of productivity, and neither does the government’s “meaningful use” matrix. Even at the recent MGMA Annual Conference there was no mention of productivity in a session on implementing EHR technology. A reasonable explanation might be that objective information about comparative productivity is not available. However, this problem could be remedied by EMR Reform—but that proposal is meeting with resistance within the industry.

Some of the answers to the questions above are less surprising than others. I believe that vendors are afraid of what comparative benchmarking would reveal about their products’ performance under close scrutiny of productivity. It is not in the vendors’ interest to yield control of the EMR evaluation process—not when scripted presentations permit skirting the productivity issue entirely. Consultants don’t feel confident that they have the tools to effectively compare productivity, particularly if vendors are not supportive of productivity measurement. What confounds me, however, is the lack of concern being expressed by physicians and their representative professional groups. I can only assume that it is due to the fear-based marketing efforts to which they are being subjected. Physicians are being told that they must buy an EMR because the government requires it and because everyone else will buy one—neither of which is true. What physicians should be fearful of is the loss of productivity that they will suffer if they do not consider productivity as a primary factor in the EMR selection process.

At next week’s HIT Policy Committee meeting, defining “meaningful use” for specialists will be a primary agenda item. We will advocate that meeting the government’s goals for widespread EHR adoption requires that physician productivity—the elephant in the room—be addressed.

Here’s Proof: Your Time is Worth More Than You Think

When I speak with physicians and share with them this calculator, they are astonished to see the true value of their time.

Physician productivity is a major driver of practice revenue and profitability. Today’s rising practice costs, a more challenging reimbursement environment, the looming payment reform, a physician shortage, and the aging baby-boomer population make productivity increasingly critical. Whether you are comparing an EMR to paper charts, one traditional EMR to another, or a point-and-click EMR to a hybrid EMR, seconds count.

Last week, I suggested benchmarking to compare the relative effects on productivity of the different EMRs a practice might be considering. My EMR Reform plan includes “click” comparisons as a “report card” measure of efficiency. It may sound trivial—a few clicks more or less, or a few seconds here and there, couldn’t have much of an impact. But they do.

Consider this: approximately 80% of clinical workflow consists of the repetitive performance by physicians and medical assistants of 20% of their tasks. If generating a prescription requires 8 clicks in one EMR and 3 clicks in another, and each click takes just one second of a physician’s time, every prescription written has a potential impact—positive or negative—of 5 seconds on physician productivity. Add in the differential for other common workflows such as reviewing chart notes, sending a message, or reviewing and signing a test result (number of clicks, number of screens that must be navigated, etc.), and it is reasonable to assume that you can increase—or decrease—productivity by 30 seconds per exam, depending on the technology you choose.

For a typical orthopaedic surgeon who generates $1.1 million in revenue by seeing 125 patients per week, conducting office hours 20 hours per week, and taking 5 weeks of vacation, this 30-second-per-exam increase in productivity would enable this physician to generate an additional $57,000 per year (or $285,000 over 5 years). Conversely, an EMR that decreases productivity by 30 seconds per exam would cost this physician $285,000 over 5 years. Because this represents marginal revenue, it goes straight to the bottom line as almost entirely profit (or loss).