The implementation of electronic health records, though purported to provide longterm benefits to physicians and practices, is associated with significant short-term challenges. As evidence of the potential negatives associated with implementation of EHRs, the Federal government has had to institute financial incentives to entice physicians to embrace electronic records. Coinciding with this surge in EHRs, numerous guidance documents have been published. Among these is the AAD-sponsored Dermatology Electronic Health Record Manual (dEHRm, see sidebar, next page) that essentially acknowledges the challenges of electronic records, indicating that physicians and their practices will have to change to accommodate EHRs, rather than vice versa. These guidelines advise physicians/practices to, “Instill the necessary culture change to gain adoption of the EHR throughout your practice.”
Although “changing workflow” sounds relatively benign, the reality is that physicians/practices are being asked to change well-established personalized ways of treating patients. With EHR systems, all aspects of patient interaction and tracking—bringing them back to the exam room, documenting the exam, preparing for biopsies, signing consent, taking photos—are to be managed and recorded via the same input device. In a very true sense, the electronic interface dictates the course of the exam from initial patient registration to check out.
Given the costs associated with EHR software and hardware, it would seem that systems should adapt to physicians/practices, not vice versa. These changes to the workflow are not simply a potential nuisance to the physician and staff; Patients will experience the differences in our interactions with them. Use of EHR has made patient interactions somewhat impersonal.
Typing patient notes typically requires more work and time than writing in the chart, and it is much more difficult to maintain eye contact with the patient while looking at a screen. Without a scribe, I will spend more time looking at the computer than talking with the patient.
The EHR concept essentially shifts personnel duties, with the physician performing more administrative tasks previously performed by medical assistants, nurses, or the front office staff, such as “writing” all prescriptions, completing electronic referrals, and ordering labs, X-rays, and tests. This represents a significant change in function for physicians who are used to simply checking boxes on a superbill.
Reduced Patient Load?
This change in work for the physician, which should ostensibly streamline practice operations, may actually lead to reduced patient load for the practice. The additional time needed to manipulate the computer, compared to documenting on paper, means that each patient encounter takes longer. Spending more time per patient means fewer patients can be seen each day.
While the degree to which patient numbers are reduced will vary from physician to physician, assume an average reduction of 10 percent. In this case, a physician with annual net receipts of $300,000 would translate to $30,000 lost. To reduce the administrative demands on the physician and preserve the patient load and billings, the practice could hire a medical assistant, but average annual salary for a medical assistant is about $28,000. Either way, the practice loses about $30,000 from the bottom line.
To be fair, there are potential cost savings associated with EHRs. Elimination of paper charts yields a savings on paper costs. In addition, conversion to all electronic records could permit a reduction in office space and associated reduction in rental costs. There should be a reduction in transcription costs, as well as billing costs, such as postage, envelopes, and other related charges. Plus, the billing software included in most EHRs may facilitate more accurate, streamlined coding. As such, there could be fewer denials from bundling or human error, thus potentially increasing collections, and perhaps producing a benefit to the bottom line.
However, while EHRs are associated with some financial savings for a practice, there are at the same time notable costs associated with incorporating a system. These include costs for primary and ancillary hardware and devices. For my practice of a 50-physician multispecialty group, that included the purchase of four servers (three for EHRs, one for fax), installation of a T1 line, installation of a wireless network, a storage area network (for scanned charts and EMR data), a digital scanner, and PC Tablets for each doctor.
Moreover, there are initial costly investments in choosing a software (selecting the “right” system is a topic unto itself), as well as yearly costs associated with software upgrades, support, data protection, security, and privacy protection. These annual costs can vary tremendously based on providers, but they are significant.
Once the EHR is integrated, the practice may find it possible to reduce staff. This could mean the elimination of a medical assistant scribe (not likely, in my opinion), a collections clerk, or maybe a filing clerk. But the EHR alternately brings other personnel costs, including those for full-time or consulting information technology staff.
Weighing the Intangibles
In my experience thus far, the incorporation of EHRs has led to a reduction in patient load and subsequently lower collections. However, advocates of EHRs point out potential intangible benefits that may offset this financial impact. For example, some say that the better documentation that electronic records facilitate could reduce medicolegal risk and costs associated with any possible legal action. Others tout features of systems, such as auto detection of drug interactions and programs that ensure that doctors review and followup on tests ordered, that they say also minimize medico-legal risk.
These purported benefits could be disadvantages, though. Some EHR interfaces appear cluttered, increasing the possibility that the physician or the consulting physician receiving the report will overlook positive or negatives findings. There is also a chance that the physician could get used to ignoring regular pop-ups and auto-alerts, treating the software system like the boy who cries “wolf,” leading him or her to overlook an important alert. Also, with the touch of a button a physician could inadvertently switch to and use an improper template, thus rendering the documentation of a particular visit useless or worse, put himself at risk for a legal quagmire.
Further, there is the argument that while one is relentlessly inputting the information requested by the system, the physician could be distracted from the physical exam and potentially miss something. Finally, and perhaps most worrisome to some clinicians, electronic records will create a vast and easily navigated body of data that a lawyer could efficiently scan in search of information that would support a malpractice suit.
What About Incentives?
When it comes to cost savings associated with EHRs, government “incentives” invariably garner attention. The Physician Quality Reporting Initiative, e-prescribing incentives, and other programs all directly or indirectly encourage or reward the adoption of EHRs. In reality, these relatively small financial incentives are a way to entice physicians to more quickly and voluntarily adopt EHRs in anticipation of a time in the near future when electronic records will be mandatory, and those not using them may actually suffer penalties.
Pros and Cons
While there remains some skepticism and indeed a great deal of uncertainty related to EHRs, it is clear that adoption is inevitable for all physicians. Electronic records provide benefits and drawbacks. The most significant benefit is for patients, who may have improved access to their own health data, who can have their medical data shared easily between providers, and who will enjoy the convenience and possible improved safety or e-prescribing and paperless test ordering and reporting. Unfortunately, these benefits come at a cost—in time and money—for physicians. At least for now, many of the highlighted benefits of EHR are offset by the negative impact of systems on patient flow and collections. Physicians and practices may benefit from a cautious approach to EHRs: wait until systems are more efficient and more user friendly, interoperable standards have been developed, and government regulations are established.
Dr. Suchniak has no relevant disclosures.