Thoughts on EMR

I plan to maintain a running commentary of Electronic Medical Record/Electronic Health Record musings on a semi-regular basis. If anybody is interested in these, please let me know so I will continue. If you find them useless, then please let me know that too!

Thoughts on 'Costs of EMR and who should pay for EMR'.

Some years back, while working on the COMPETE project (www.compete-study.com) I conducted a study on how much physicians are willing to pay for EMR. In doing this type of study, you have to have a clear idea of the benefits of the product to get valid data about willingness to pay. Being somewhat new to this area at the time, I assumed that physicians would be interested in drug look-up tools and medical information look-up tools. I was quickly put in my place when I found out that the #1 benefit physicians are expecting from their EMR is an improvement in their CLINICAL efficiency. They were asking, 'how do I manage to see all my patients and more, while maintaining or improving the quality of my care?'. Other benefits from EMR included 'improving patient care', 'faster charting', 'decreasing costs', 'participating in research' and 'staying abreast of developments'.

My biggest insight during this study was that physicians don't at all doubt that EMRs can provide the benefits that they envisage. What they do doubt is that anybody can actually deliver those benefits to them at a reasonable cost, with minimal impact on their time and energy.

The study results, for those of you who want me to get to the point, was that physicians were willing to pay somewhere between $255 and $415 per month for the software --if you could deliver their top 3 benefits --improve clinical efficiencies (fewer charts lost, labs available at all times, drug look-up on the computer), better patient care (drug-drug interactions checking, more legible charts) and faster charting (little typing, point and click interface). Two things stood out from the study: First, in 1997 when the study was done, only 21% of physicians would have bought an EMR at the low price of $255. (It would be interesting to find out how many would purchase one today.) Second, physicians didn't seem to make a distinction between leasing a system on a rental basis vs. a lease to own basis. They were more sensitive to the impact of the monthly payment amount (a cash flow consideration) than they were on whether they owned the equipment at the end or not. Thus, physicians have indicated that they value the benefits of EMR only somewhere betweeen $255 and $415.

Clearly, the cost of an EMR system today is closer to $855 than it is to $255.

If the only value from an EMR went to physicians, then very few would buy the system and the whole market would collapse (as it should, if the costs of the system exceed the value it generates).

However, people generally believe that the value of an EMR to society exceeds the costs of the system. A recent study done in the US showed that an EMR system generated over $85, 000 of value over five years for the health organization that implemented it.

The question becomes, who will pay for the other $600 of cost that generates a huge value to society? I leave the drawing of the conclusion to you.

REFERENCES:

You can find the references to the Willingness to Pay study at www.compete-study.com and the EMR cost-effectiveness study at EMRCostBenefit.pdf .

Comments

[Alan Brookstone]

Karim, I think you have summed up years of work and insight in a couple of paragraphs.

If physicians were still willing to pay in the range of $255 - $415 per month and the cost of an EMR in 2004 is closer to $855 per month, then the amount that would need to be susidized (? by government) would be between 50% and 70% of the total monthly cost.

[Dr. Michael Pray]

Karim, I would hate to think that your well thought out, groundbreaking work sets a precedent for the payment for EMR. I would like to look at it from another point of view. The ophthamologist using the laser in the hospital or any other surgeon operating in the hospital for that matter has all that equipment provided at no cost.

EMR is an essential tool in family practice and will become even more important in the future in order to acquire and manage the increasing amount of information we have to deal with. Government should provide this tool to family physicians.

[Karim Keshavjee]

Mike, I really like your analogy of EMR to surgical equipment. Much better imagery and communication of an important concept than my long-winded academic rant.

You're absolutely correct.

[Martin Dawes]

We developed our EMR in the UK iteratively over 5 years. First prescribing only using a central machine (1987-9) then using a desktop system (1999 onwards) . We just took the patients on multiple medications. That was it - we were hooked. The ability to print 12 items within 20 seconds.
Next came pap smears - a company entered all demographic data for our 7000 patients and then a nurse entered all the pap smears. Suddenly we started using it to code a few chronic problems.

laboratory data downloaded into the EMR overnight with dial up and dial back moved us a step further. By 1992 about 80% of consults were bing put on the computer. BUT - in 1996 when we were looking at a new system we were put off by being given all the bells and whstles (full text, graphics, x-rays, etc etc). We moved to this system but only so we could have the appointments system.

What I am trying to say in my clumsy way is that computerisation was an iterative process - and possibly the slow uptake in N America is because it is being promoted as big bang.

Maybe we should have a system that is really really really slick at prescribing - and sell that first for $100. Then have optional modules to add as the user wants.
Nice site - great conversations.
Nice to know I am not alone............
Martin

[Karim Keshavjee]

Iterative and incremental vs. Big Bang. This is an excellent point.

I and colleagues of mine have just completed a review of the literature to look at predictors of successful EMR implementatons. (We are hoping to present it at e-Health in May.)

One of the factors that seems to predict success is exactly what Martin proposes: gradually implement parts of the record. The literature suggests that starting with things that are read-only, like labs and x-ray reports allows the EMR to be immediately useful to physicians without any effort on their part. Once they get used to that, they can start doing simple things like prescribing medications and ordering lab tests. They can then graduate to maintaining their CPPs and documenting their encounters. This gradualist approach is an excellent one, although I have not seen in work in Canada simply because there are no external drivers for it.

For example, lab reporting systems have been available in this country for over 5 years, yet most physician print them off and look at them on paper.

To a great extent, it has been because there has been no concious movement toward EMR. Physicians have not viewed the development of various modules as a move toward EMR simply because nobody told them that it was!

We need a lot better communication about EMR implementation and all stakeholders need to get involved --especially our medical assocations and the medical colleges. Until they get involved and promote this, it will not appear on the clinical radar screen and will continue to be ignored by rank and file physicians. An encouraging development has been the American Academy of Family Physician's recent Nov 2003 announcement that they were partnering with 9 vendors to make EMRs more accessible to physicians. Hopefully we will see a similar move in Canada.

[Galen]

Our medical group in the US will be making the transition to EMR in the office within the next few months. Interetingly, it is expected to pay for itself in 18 months based on decreased storage, paper, and personel costs. We're looking at it as a way to save money, not an added cost.

[Karim Keshavjee]

I would be very interested to hear of your experience with the implementataion and what cost savings you realized. Clearly, there are many benefits from EMR implementation. Unfortunately, here in Canada physicians don't have the option of increasing their top line (i.e., revenues) when they implement an EMR. Also, traditionally, Canadian costs for administration of healthcare are less than 50% of those in the US --so there are fewer incentives for they type of cost savings you describe.

The way health care is funded in the two countries is also sufficient to make a huge difference in the incentives to use EMR.

[John Fernandes]

Great comments!

I've been searching in vain for an EMR that I can implement in my office. I’ve actually installed and used several of them, but have been unable to find anything as reliable and easy to use as paper. I’m a retired computer systems analyst and am appalled at the relatively low quality of software our there – when I compare to what is available for other industries (like insurance companies, dentist’s offices, etc.).

I have created my own system with tablet PC’s on a wireless network for quickly looking at online CT’s, and X-rays with my patients in the rooms. I also use the tablet pc to fill out forms, etc. for patients. But to actually record medical information…..it just doesn’t seem reliable or quick!

My nurse installed and used Wolf to try to book a patient appointment……it took her about 30 seconds to do this (with numerous keyboard and mouse clicks).

Then she did it with her pencil and paper (as is our normal system)….it took her about 5 seconds and she was able to do it while triaging patients in front of her, answering the phone and addressing one of my questions.

I suspect that these EMR’s will only be successful if we employ numerous people in our clinics that do not do any multitasking. As a solo practitioner, I’ve been unable to get the attention I need from an EMR company in order to address my software concerns. They are obviously concentrating on the bigger fish group practices that will pay them thousands per month. This is not a criticism….I certainly can’t blame them. But solo practitioners like me see this as a disincentive to go ahead and become electronic.

I even won that POSP lottery in Alberta….my funds have been sitting for almost 2 years now without being used – simply because I cannot find a vendor with suitable reliability, suitable software and suitable support. My colleagues are amazed by this, as I am widely regarded as a very techie Physician (ie. I have a stethoscope that records heard sounds and beams them wirelessly to my tablet pc – which I can keep for my medical students as part of my lecture or I can email to a cardiologist as part of a consult).

These EMR systems – no matter which way I look at them – end up costing more that they save. I’m very positive about the future of these systems, and I’ve thought of some amazing solutions (one of them, I’m actually using in the office now)…but I am leery to implement any of the systems currently for sale.

Ultimately, however, as Karim has pointed out - installing an EMR is a business decision, and business-savvy Physicians seem to be wise to shy away from them until they are able to deliver the top three desired returns that Karim has discussed.

[peter richards]

I have started using Amazing Charts from the US to write my scripts. it is fast and very functional and all I need at this stage. Writing scripts for me is the ideal application and has been very easy and simple to implement and that's how I like my life. I would worry about what happens during the patient interview. in fact I recently talked to a patient who was thinking about switching from her previously revered GP as he recently got a computer in his office and now he is more interested ion the computer than me.

[Alan Brookstone for Doug Redwood]

The following comment was sent to me by Doug Redwood - Fraser Health Authority. He makes some interesting points from a health management perspective. If you would like to contact Doug, his e-mail address is included below the comment:

"Buying an information system because someone else will fund the initial purchase is the wrong reason. Information systems are business assets to support care delivery processes to achieve some goals (patient care and practice management). Your practice goals and objectives should drive your investment decision. I like to challange people with thinking about information systems as commodities - "80% of the cost is acquiring and setting it up (including loading data) - then plan on modifying it the rest of its useful life until you throw it out". It is the inability to sustain this last 20% that erodes the initial value proposition. A continuous pursuit of productivity gains and patient integration into the EMR will maximize return on investment in the end. "

Doug Redwood
doug.redwood@fraserhealth.ca

[John Fernandes]

The true cost of running an EMR as a solo practitioner is much higher than $855 per month! The hardware costs alone put the price through the roof, when you run a properly designed redundant system (ie. backup computers continually running and imaging hard drives that you can immediately switch to in the event of a system crash). The IT support costs to run a mission critical system like this is also prohibitive. My solo office with 4 examination rooms with a properly designed EMR with redundant system planning cost more like $3500.00 per month - which is about the same as my rent!!!

No matter how I crunched the numbers, there was absolutely NO WAY the $3500 monthly investment would pay off....so I installed my EMR...ran it for a while...and pulled it out and went back to paper! The paper works wonderfully and is actually more efficient than the EMR system (I tried three in all).

J.

[Dale Taylor]

I'm planning on using an EMR in the next few months. I find the comments in Canadian EMR very helpful. I'm past worrying about the cost benefits of paper vs EMR. GP practice has become so hectic that my chart notes are becoming illegible. Every time I have a patient come in for a renewal of four or more prescriptions I think of what a waste of time it is to have to re-copy script after script into the chart. Or trying to find the cream the patient was prescribed a few years ago. I search page after page wasting valuable time. After over twenty years in practice I see an EMR as something refreshing for my practice. I know the first six months will hold many headaches but I also know from reading all your comments that there will be a payoff down the line in being able to practice better medicine. Facing the first year that I have been unable to obtain a locum for the summer I can see the benefit of having a colleague who doesn't work in my building be able to access my records electronically. Many of us like to practice solo but a virtual group allows us the best of both worlds.
I have been scheduling electronically for years (I would argue electronic scheduling is far more time efficient than a paper appointment book). Fortunately my software supplier (Osler) has included the EMR in the same package as my scheduler. Slight cost savings there. More important is not having to relearn a new system from square one or having to get billing and appointment information transferred to another program. However, I can see the new computers loaded with XP Pro and Microsoft word are going to put a dent in my budget.
I'm glad I will be able to get private lab information for the past two years dumped into my program from pathnet. It would be great if a similar system could dump hospital information into the file. Talking to specialist colleagues many of them seem ready to send consults by email if requested.
I see a momentum building regarding EMR's. I can see that in ten years they will be mandated if you want to receive full payment. I expect there will be cash incentives down the line which early adopters might miss out on but I prefer to go at my pace rather than be forced into it. I am excited about the prospects of my new EMR.

[Alan Brookstone]

Dale, great comments. I agree with much of what you have said. Although there are no guarantees regarding how financial incentives evolve or are paid to physicians to support the uptake of EMR, I believe that the early adopters should not be penalized by the funding formula that is implemented. The proviso is probably going to be the fact that if a physician is to receive funding support for EMR, they will need to purchase an accredited system in the province in which they practice. This has already been put into place in Alberta with the VCUR process (Vendor Conformance and Usability Requirements). So the risk one might face as an early adopter is that you could purchase a system that does not meet the equivalent requirements in BC (when we have a similar process in place). The key is to ensure that your data is transferrable from any vendor system to another and so this question must be discussed with a vendor. How will they ensure that your data will be transferrable to another system if you should choose to move in the future? The investment in hardware will pale in comparison to the investment that is made entering data into a system, scanning in documents and entering isolated labs etc. if that information is 'locked' in a system and is not transferrable at a future date.

[Dale Taylor]

I am wondering how offices deal with signing consult reports, insurance reports, etc. I want my consultants to send me reports in electronic format. How do they sign these reports so medico-legally it can be shown the specialist actually authored the report? Hospitals use electronic signatures that rely on us digitally signing in when we dicatate. Does the same hold true in our offices when we sign on to our computer? I'm sure if you have a tablet pc it is simple to put in a signature. I expect it will be some time before insurance companies will accept our reports without a written signature. What is your experience?

[Norman Yee]

I'm still a bit old fashioned about signatures. I like to sign them in blue ink for official signature and authenticity. However, I have used a scanned image (in black and in blue)in some official documents...although not my EMR generated ones, as my EMR is too stupid to put a scanned signature in the correct spot...ironic that it allows me to sign a signature box (doesn't end up looking like my signature at all)!

In terms of electronic signatures, which can simply be a name/date/time stamp, they are considered legal in the sense that the user has to sign on in an authenticated manner and sign off the documents. The e-signature is a reflection of the captured user sign off in a system that has been 'certified' or 'recognized' as authenticating and auditing. Reports do not so much show who authored them, but rather, who signed off on them (and therefore, accepts legal responsibility for them). In practice, the author and the signator is the same. But, not always. Sometimes, my staff starts a note/message, or my residents enters a clinical note. Ultimately, I review and sign off on it...not the author, but the responsible person.

Technically speaking, e-signed reports generated by a trusted authenticating system can be considered legal, and should be acceptable as legal documents to any third party. Practically speaking, they may balk at the idea, for lack of understanding. Makes me think of retailers that refuse to accept $100 bills for fear of counterfeits...however, since a genuine $100 bill is legal tender, they cannot legally refuse to accept a bona fide transaction.

Have a nice and prosperous week.

Norm

[K. Jones]

My community is just beginning the process of researching to implement EMR. I am wondering are any of you sharing information from office to office (i.e., specialists to PCPs, hospitals to PCPs, etc) and how are you monitoring security?