Transcript Document

Small Practice Physician EMR
Adoption
Helga E. Rippen, MD, PhD, MPH
Chief Health Information Officer
Vice President, Clinical Services Group
October 2007
Seminole County Medical Society, Florida
Agenda
 National Directions
• The Physician: EMR Adoption in the Small Physician
Practice
• Summary
Disclaimer: This presentation does not represent the views or policies of any agency in the U.S. government
National Directions in HIT
Nation-wide interoperable health information
infrastructure and electronic health record (EHR)
available for most Americans within ten years.
President George W. Bush, 2004
Executive Order:
• Vision of developing a nationwide interoperable infrastructure
• Incentives for the Use of Health Information Technology
• Establishing the Position of the National Health Information
Technology Coordinator within the Department of Health and
Human Services, Office of the Secretary
Leavitt’s 500 Day Plan
•
Transform Health Care System *
•
Modernize Medicare and Medicaid *
•
Advance Medical Research*
•
Secure the Homeland*
•
Protect Life, Family and Human Dignity
•
Improve the Human Condition Around the World
* HIT as part of the plan
Success Is Dependent on Physician
Adoption and Consumer Acceptance
What factors are important for small
practice physician adoption?
Agenda
• National Directions in HIT
 The Physician: EMR Adoption in the Small Physician
Practice
• Summary
Findings Presented Are Part of a Series of
Studies Being Commissioned by the
Department of Health and Human Services
Most Physicians are Not Using
EMRs, Especially in Small Practices
•
•
•
Practices between 1-9 physicians account for over 80% of physicians
In practices larger than 9 physicians, adoption rates are significantly
higher
For example (Burt and Sisk, 2005):
Practice Size (# of
Physicians)
% Using EHR
% Distribution of Physicians in
Sample (n=3,360)
1
13.0
35.3
2-4
16.2
39.9
5-9
19.9
12.8
10-19
28.7
7.1
20-above
38.9
4.9
Many Factors Such as Size, Type of
Practice, and Compensation Important
to EMR Adoption
Practice Characteristics
Burt and Sisk
Audet et al.
Gans et. al
Legend:
+ (s)*
+ (s)*
+
Type of Practice
Primary care vs. specialist
0
+ (s)*
NE
Scope of Practice
Single vs. multi-specialty
0
NE
NE
+ (s)*
0
NE
0
NE
NE
NE
+ (s)*
NE
0
NE
NE
+ (s)
NE
NE
Size of Practice
Ownership of Practice
Source of Revenue (Influence
of different payers and
managed care contracts)
Mode of Compensation
Salary vs. non-salary
Metropolitan Status
Geographic Region of US
Northeast, Midwest, South, and
West
NE = characteristic not examined in survey
0 = no correlation
+ = pos. correlation, with no stat.
significance
- = neg. correlation, with no stat.
significance
+ (s)* = pos. correlation, with stat. sign. at
95%
- (s)* = neg. correlation, with stat. sign. at
95%
Specialty and Age are Related to
EMR Implementation
Legend:
Physician Characteristics Burt and Sisk
Specialty of Physicians
Specifically defined
specialty
Gender of Physician
Age of Physician
+ (s)*
Audet et al.
Gans et. al
NE
NE
0
0
NE
- (s)*
0
NE
NE = characteristic not examined in
survey
0 = no correlation
+ = pos. correlation, with no stat.
significance
- = neg. correlation, with no stat.
significance
+ (s)* = pos. correlation, with stat. sign.
at 95%
- (s)* = neg. correlation, with stat. sign.
at 95%
Adopted EMRs Have Broad Range
of Functionalities
Systems
Characteristics
Uses of EHR
Gans et. al
Patient demographics
+
Visit/encounter notes
+
Patient medications
+
Past medical history
+
Problem lists
+
Laboratory results
+
Radiology/imaging
results
+
Tracking
immunizations
+
Drug interaction
warnings
+
Drug reference
information
Legend:
+ = pos. correlation, with no stat. significance
Literature Review and Synthesis:
EMR Definitions and Functionalities
•
Gans’ survey describes the functionalities physicians have adopted and
correlates them to practice size
EHR Feature/Capability
Percent Adoption by Practice Size
≤5
6–10
11–20
21+
Patient demographics
99
99
99
100
Visit/encounter notes
98
96
99
98
Patient medications
96
97
98
98
Past medical history
95
95
99
95
Problem lists
94
93
94
96
Laboratory results
89
87
94
97
Radiology/imaging results
75
72
87
89
Tracking immunizations
80
72
64
75
Drug interaction warnings
79
75
81
84
Drug reference information
76
80
78
79
Drug formularies
62
64
67
68
Clinical guidelines and protocols
64
62
71
64
Benefits Identified As Important to
Physicians Relate to Patient Quality,
Revenue Enhancement and Efficiency
Benefits of Adoption
Patient Quality
Audet et al.
Gans et. al
Improved Decision Making
+
+
Improved access to info.
+
+
Reduce Medical Errors
+
Clinical Guidelines
Increase Immunization Rates
Revenue Enhancement
Improve Charge Capture
+
+
Reduce Transcription Costs
+
Reduced Staff Expenses
+
Increase Patient Volumes
Increase Revenue
Improved Workflow
Efficiency
Improved Drug Refills Capabilities
Eliminate/Reduce Chart Pulls
Decrease phone call turnaround time
Patient and Physician & Staff
Satisfaction
Legend:
Improved customer service
Increase time with patient
+ = pos. correlation, with no stat. significance
+
+
+
Barriers to Adoption Included Lack of
Capital, Usability, and Productivity Losses
Barriers to Adoption
Audet et al.
Gans et. al
Lack of Support from Physicians
+
Lack of Capital for Investment
+
+
Concern, Technical Ability to Use
+
+
Concern, Loss of Productivity
(To include lack of time)
+
+
Inability to Evaluate and Select EHR
+
Lack of Uniform Standards
+
Maintenance Costs
+
Concerns over Privacy
+
Lack of Evidence of Effectiveness
+
Legend:
+ = pos. correlation, with no stat. significance
The More Advanced the EMR the
Greater the Benefits
Basic EHR
On line chart with:
- Clinical note
documentation
- Results viewing
($18,200)
Net Cost
* Wang et al. (2003)
Intermediate EHR
Advanced EHR*
Basic plus:
- Electronic
prescribing with:
- Adverse drug
prevention capability
- Alternative drug
suggestion
Intermediate plus:
- Lab order entry with testing
guidance
- Radiology order entry with
test guidance
- Electronic Charge Capture
$44,600
Net Benefit
$86,400
Net Benefit
There are Many Components of Cost in
Implementing an EMR
Factor*
Financial Costs / Benefits per FTE
Provider per Year
Year 1 Costs
Software, training, and installation
$22,038
Hardware
$12,749
Productivity loss
$7,473
Other implementation costs
$1,145
Total Year 1 Costs
$43,405
Average Ongoing Costs
Software maintenance and support
$2,439
Hardware replacement
$3,187
Internal IS/external IS contractors
$2,047
Other ongoing costs
Total Ongoing Costs
$739
$8,412
Miller (2005) – costs in this study are higher than those found in Gans study
Net Benefits Are Realized After the
First Year in One Study
Benefits
Benefits per FTE Provider per
Year
Increased coding levels
$16,929
Personnel savings (excl. transcription
savings)
$6,759
Transcription savings
$5,334
Paper supply savings
$1,051
Increased revenue from increase visits
$2,664
Total Benefit
$32,737
Net Benefit (Benefits less Ongoing Costs)
after Year 1
$24,324
Source: Adapted from Miller, 2005, pg. 1130-1131.
Note: Subtracting the above costs from benefits will not equal the author’s annual net benefit figure because
some of the above costs are one-time installation costs and will not recur on an annual basis.
Agenda
• National Directions in HIT
• The Physician: EMR Adoption in the Small
Physician Practice
 Summary
Summary
• Federal activities focusing on EHR adoption and
consumer empowerment
• Many challenges to overcome
• There is a return on investment within 1-2 years
• Accelerating the adoption of EMRs at the small physician
office is critical
– Model being developed to understand factors critical to
implementation to support policy makers
• HCA is moving forward in providing affiliated physicians
with options for EMRs
Overview of EMR Implementation
Guidance for Physician Offices
Con
duct
Inter
nal
Prep
arati
on
Develop
Understanding
of EMR
Functionalities
► Gain
familiarity
with common EMR
terms
► Explore
functionalities
defined by IOM,
CCHIT and others
► Understand
functionality levels
and associated
benefits
► Conduct
internal
assessment to
assess baseline
► Plan
for budget and
strategy alignment
► Map
capabilities to
goals and
requirements
► Consider
using
assessment tools
(e.g., checklists,
RFPs)
Ident
ify
and
Eval
uate
Pote
ntial
Vend
ors
► Research and
prioritize vendors
based on ratings,
compatibility, history
with small practices,
longevity and other
factors
► Test-drive
top 3-4
choices for hands-on
experience
► Consult
with
colleagues and
conduct site visits
Sele
ct
Ven
dor
and
Neg
otia
te
Con
trac
► Contract should
explicitly state:
t type,
term, products &
services included,
current & future costs,
vendor role and time
commitment and other
contingencies
► Consider
hiring IT
consultant or software
contracts lawyer
► Develop
timeline for
implementation
Implementation
and Beyond
► Train
and troubleshoot
before going live
► Transition
from paper to
electronic records
► Develop
historical data
migration plan
► The
process is not over: the
landscape is dynamic, and
needs will evolve
► Practices
should celebrate
small victories and foster
open communication to
share lessons within the
practice and the community
Questions?
[email protected]
615 344 8128
References
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Executive Order: http://www.whitehouse.gov/news/releases/2003/01/20030124.html
ONCHIT web site http://www.hhs.gov/healthit/
American Health Information Community Potential Breakthroughs, October 7, 2005
http://www.hhs.gov/healthit/breakthrough.html
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California Healthcare Foundation Survey http://www.chcf.org/topics/view.cfm?itemID=115694
Assessing the Economics of EMR Adoption and Successful Implementation in Physician
Small Practice Settings http://aspe.hhs.gov/sp/07/adoption/index.htm
Audet AM, Doty MM, Peugh J, Shamasdin J, Zapert K, Schoenbaum S. Information
technologies: when will they make it into physicians' black bags? Medscape General Medicine
2004;6(4). (Accessed October 17, 2005, at www.medscape.com/viewarticle/493210)
Burt CW, Sisk JE. Which physicians and practices are using electronic medical records?
Health Affairs 2005;24(5):1334-43.
Ford, E. W., Menachemi, N., Phillips, M. T, Predicting the adoption of electronic health records
by physicians: when will health care be paperless? in the J Am Med Inform Assoc, 2006 JanFeb, vol 13, pp 106-12
Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health
records and information systems. Health Affairs 2005;24(5):1323-33
Miller RH, West C, Brown TM, Sim I, Ganchoff C. The value of electronic health records in
solo or small group practices. Health Affairs 2005;24(5):1127-37.
Wang SJ, Middleton B, Prosser LA, et al. A cost-benefit analysis of electronic medical records
in primary care. American Journal of Medicine 2003;114:397-403.