Do Small Practices Provide Better Patient Care?

Leigh Page

Disclosures November 19, 2014

Small Practices Do Many Things Well

Just when small primary care practices seemed headed for the dust heap, recent studies are saying "not so fast." Large practices, with their phalanxes of employed physicians, are rapidly becoming the norm, but the research suggests that small practices offer a viable alternative and can even produce better clinical outcomes.

Large practices thrive on the team approach and economies of scale, but small practices benefit from a personal style of care and allow physicians to practice the way they would, without interference by a large, impersonal organization.

"When you work closely with patients and empower them, they are going to make better choices," said Craig C. Koniver, MD, a solo family physician in North Charleston, South Carolina. He said a team of caregivers at a large practice will not have the same impact, because none of them are as close to the patient as he is.

A study[1] in the August issue of Health Affairs seems to bear this out. Focusing only on small primary care practices—those with fewer than 20 physicians—researchers looked at "ambulatory care-sensitive admission rates," covering such conditions as congestive heart failure, which can be prevented by high-quality primary care. The study found that practices with 1 to 2 physicians had ambulatory care-sensitive admission rates fully 33% lower than practices with 10 to 19 physicians.

This isn't the only evidence of small practices' clinical superiority. A 2013 study[2] showed that small practices in general had slightly lower hospital readmission rates than large practices, and a 2012 study[3] looking at practices ranging from 5 to 750 physicians found that the smaller ones had fewer ambulatory care-sensitive admissions and lower overall costs of care for diabetes.

All three studies turned a piece of conventional wisdom on its head: that large practices, with their care management teams and sophisticated clinical information systems, produce better clinical outcomes. The findings of the Health Affairs study "were unexpected, since small practices presumably have fewer resources to hire staff to help them implement systematic processes to improve the care they provide," the authors wrote.

Is It Too Late to Revive Small Practices?

The news that small practices deliver better care may be arriving a bit too late. For many years now, physicians have been fleeing from small practices, and the solo practices in particular. The Center for Studying Health System Change reported[4] that the percentage of physicians in solo and partnership practices plummeted from 40% in 1997 to just over 32% in 2005, and the number continues to drop.

There are a lot of doctors in small practices, including Dr Koniver, who don't see a pretty future. "This time, the solo practitioner is really going away," he said. What with larger groups and "team" care, "there is really no room in the environment for the solo practitioner anymore."

The key problem for small practices is low reimbursement. Rather than pay these doctors more for better outcomes, insurers actually pay them significantly less than doctors in larger groups. "In a small practice, you really can't negotiate for terms and fees," Dr Koniver said. "That's just the way it works."

Dr Koniver is not alone. Douglas A. Gerard, MD, a solo general internist in New Hartford, Connecticut, believes in small practices. Larger practices often employ nurse practitioners to do the workup, but "in my practice, I do the history taking," he said. "It's a chance to find out more about the patient."

However, Dr Gerard also thinks small practices are headed for extinction. He is age 60 and works in a town of 6000 people. "When I leave this practice, there'll be no one to take my place," he said. Merritt Hawkins, the physician search firm, reported that requests for searches for soloists fell from 22% of all requests in 2004 to 1% in 2012.[5] "Nobody wants to be Marcus Welby anymore," declared James Merritt, founder of Merritt Hawkins.

"I can't see anyone wanting to come out here and do this," Dr Gerard said. Medical students who rotate through his practice on clerkships don't show much interest in "entrepreneurialism," he said, and they tend to end up in large practices or hospital employment. The Graduate Questionnaire,[6] which all graduating seniors fill out, showed that less than 2% of 2013 graduates planned to go into full-time solo practice.

Dr Koniver said the decline of small practices has institutional roots. Many medical schools don't teach practice management, which is essential when you have to run a practice. A 2013 poll[7] of medical students showed that 37% of them were dissatisfied with their training in practice management and ownership. Dr Koniver added that when they enter residency training, new physicians are taught to work in groups. "It's a confidence issue," he said. "You don't want to be on your own."

Are Small Practices Still Relevant?

The Health Affairs study did not identify what aspect of practices with 1 to 2 physicians gave them better outcomes, but the lead author, Lawrence P. Casalino, MD, PhD, professor of healthcare policy and research at Weill Cornell Medical College, has a few theories.

"I don't want to romanticize small practices," said Dr Casalino, who started his medical career in a partnership. "One problem is that no one is looking over the doctor's shoulders. You don't know whether he's doing a terrible job." Still, these physicians are more likely to take responsibility for their patients and know them well enough to understand when they are truly sick, he said.

When a patient with a health problem calls up a small practice, Dr Casalino said, the call goes to the doctor or the nurse, who knows the patient very well, and they can tell by the tone of the patient's voice whether he needs to come in. Even on a very busy day," he said, "the doctor will say, 'Sure, I can squeeze him in. I'll just stay a little late.'"

In a large group, on the other hand, no one really knows the patient, and patients might even be seeing a different doctor each time. When they call in, their calls go to a scheduler who may never have met them. If it's a busy day, "the doctor will say, 'I can't see him, I'm full,'" Dr Casalino said. And if the doctor is getting a paycheck rather than paying himself, "he's not going to stay late to see this patient."

Not everyone, however, believes that small practices have much of a future. Greg Mertz, a practice management advisor in Virginia Beach, Virginia, agrees that it's possible for small practices to have better outcomes. "The patient-provider bond is much tighter," he said, "but it's not a function of being better clinicians. It's a function of being little. However, little practices are often inefficient."

In a small practice, he said, "there is not enough volume to hire a full-time employee for functions like care management," he said. "You can't hire half a person." Sure, the physician can take on the care management function, but that means extra hours of work. To do this work, the physician "has to go through patients' records and see who hasn't come in for check-ups," he said.

"Why do doctors become soloists? In some cases, it may be because they don't work well with others," Mertz said. He added that small practices are less likely to have electronic health records (EHRs). And even when they do have them, they're less likely to take advantage of all their features. This puts them at a disadvantage in reporting outcomes, which is needed to prove that they deserve higher reimbursements.

On the other hand, Mertz thinks large practices can learn from small practices and mimic their advantages. For example, he said, large practices can make sure that a patient always sees the same doctor.

Rosemarie Nelson, a healthcare consultant in Jamesville, New York, added that large practices can organize into "pods" of 4 to 6 physicians, each with its own set of nurses, and behave like small practices. Each pod knows its patients intimately, and unlike really small practices, they can take advantage of economies of scale in scheduling, billing, buying supplies, and negotiating with insurance plans, she said.

Nelson does not see much necessity in saving small practices. "It's really hard to give up the freedom of running your practice just the way you want to," she said, but in the face of mounting pressure on their income, "they might not see independence as an option anymore. It's either consolidate with other practices or retire."

Many physicians in small practices disagree that they can be so easily replicated by large practices. John Brady, MD, a solo family physician in Newport News, Virginia, loves his autonomy. "Every day I feel this sense of accomplishment that I can't imagine in a group practice," he said. "There is this entrepreneurialism that I didn't expect I would care about when I chose this model."

He concedes that he works somewhat longer hours than employed colleagues. However, he has a great deal of freedom in the way he spends his time. When he plays the role of care manager for his patients, he can draw from his deep experiences treating each of them. He doesn't have to fall back on specific process requirements, as a nurse care manager in a large practice would do, he said.

Dr Brady doesn't think that any large practice could truly mimic what he does. He feels that because he's involved in virtually all of the clinical care in his practice, it makes him more effective. "Continuity is high because it's basically just me," he said. "Every time you add an employee to a practice, you create new lines of communication, which increases the chances that some aspect of care won't get done. Things can get dropped because people think, 'This isn't my job; it's your job.'"

Creating a New Model for Small Practices

For small practices to survive in a new era of tight reimbursements and greater regulations, the old Marcus Welby practice had to be updated, Dr Brady said. He uses a model called the Ideal Practice, which reduces staff and adds a computer to the traditional small practice.

The model was developed by L. Gordon Moore, MD, about 14 years ago, when he was a quality improvement officer at the University of Rochester in New York. "I wanted to create the solo practice of the 21st century," said Dr Moore, now senior medical director for 3M Health Information Systems.

To test the model, Dr Moore opened a solo practice and ran it successfully for many years. He believes that a solo practice is the optimal model of quality and efficiency because all processes are observable to one physician. "You can see your own patient flow, message and information flow, and know that each event and task was associated with your work," he said. Even in a practice with just a few doctors, "you can't attain this level of efficiency."

In addition, the low overhead allows the physician to see fewer patients, which further improves outcomes. Before going solo, Dr Brady had been in a four-physician practice that emphasized productivity, and he didn't like it. "I wasn't able to connect with patients like I wanted to," he said. "There was more than one occasion when I felt that I was leaving the room before I got what the patient was trying to say."

He calculated that based on Medicare reimbursement levels at that time, he'd need to see just seven patients a day to bring home $150,000 a year in pay. Now that the practice has been established, he has exceeded that level.

Dr Brady said a computer is essential to Ideal Practice because it creates automated systems that can replace work that had to be done by hired staff and thus keeps overhead low, and low overhead is the watchword of a modern small practice. He can do his own billing with the aid of an EHR system. Although he concedes that many physicians wouldn't want to do the billing, he doesn't mind the task. "Billing is not so hard to learn," he said. "I consider it part of the job."

Even physicians who don't know about Dr Moore's model have developed similar approaches to keep overhead low and reduce the number of patients. When Dr Koniver was starting his practice and had very few patients, he worked out of the back of a converted ambulance and used it to make house calls. But he said he stopped using the ambulance and found office space because he couldn't use his cell phone or email while on the road.

Both Dr Moore and Dr Brady improvised on the original model and brought in nurses to provide health coaching and perform some other functions. A few years ago, Dr Moore passed the leadership of the Ideal Practice network over to Dr Brady. Physicians who join the Ideal Practice community can share ideas on the Internet and attorney meetings, which helps reduce the isolation of being on your own, he said.

Dr Brady said hundreds of doctors have adopted the model, but he doesn't know how many have kept with it. "It's not for everybody," he said. Physicians have to be well organized so they can deal with many distractions, and they should not have debts because it can take several years to build a patient base. He added that the model might not work in areas with unusually low reimbursements, high malpractice premiums, and high costs of living.

More Buzz Around Small Practices

The burgeoning dominance of hospital employment has, curiously enough, spawned new interest in small practices, particularly solo practice, according to Mary Pat Whaley, a practice management advisor in Durham, North Carolina. After a few years of employment, some physicians have become very disenchanted and decide not to renew their contracts. "Most of all, they don't like the productivity requirements of hospital employment," Whaley said.

About 4 years ago, she began to get a couple of calls a month from physicians asking about switching to solo or small practice. Now she gets 3 to 5 calls a week. They are of all ages—new physicians as well as physicians who opted for employment in mid-career. While many of the older doctors came into employment as members of a group, they usually leave employment on their own.

Whaley offers them 12 different solo practice models to choose from, including time-share offices, outsourcing staff and administrators, dropping Medicare, and refusing to accept insurance altogether and opting for concierge or direct-pay practice.

Meanwhile, physicians already in small and solo practices can improve their chances of survival by banding together in independent practice associations (IPAs) that share administrative services. Or they can even become clinically integrated, sharing the same tax ID number but keeping separate offices. Or they can choose some arrangement in between.

Jennifer Brull, MD, a solo family physician in Plainville, Kansas, shares services like billing and collections with four other physicians, three advanced practice nurses, and one physician assistant in the same county, but they all have different tax ID numbers. "We very much have something that looks like a group practice," she said. "When I leave town, I know there will be people to cover for me." But she doesn't share reimbursements. "The number of dollars I bring in is entirely dependent on the number of patients I see," she said.

In Connecticut, Dr Gerard is part of a much larger arrangement with a 50-physician group that takes care of billings and collections, a 401(k) plan, and group health insurance. But he hires his own staff and can opt out of certain insurers.

Barriers to Being Paid More for Quality

Dr Casalino said he hopes that his research findings will prompt insurers to consider rewarding small practices higher reimbursements for better outcomes. Currently, however, insurers pay small practices less than larger ones, and everyone agrees that it won't be easy to get them to change this preference.

Thirty years ago, when small practices were king, physicians could largely choose their "usual and customary" reimbursement rates. Now most medical care is tied up in preferred provider contracts. Insurers negotiate these contracts with large practices, allowing them to raise rates, but rates are assigned to small practices on a take-it-or-leave-it basis.

Things have been changing in recent years as insurers inch toward the concept of rewarding value of care. Pay-for-performance programs pay practices for meeting certain quality goals, but the payments are comparatively low and usually involve meeting process measures rather than clinical outcomes. What's more, practices often need EHRs to participate, and solo practices in particular have been much slower to adopt EHRs than larger practices.

Lately, however, they've been catching up to larger practices. A new survey[8] shows that solo practices' EHR adoption rate jumped from 42.3% in 2013 to 53.7% in 2014.

Dr Brull said her small group has purchased its own EHR system partly because the doctors wanted to show compliance with quality improvement measures under the Healthcare Effectiveness Data and Information Set (HEDIS). The group meets or exceeds national averages and "we will show the data to anyone who asks." But so far, insurers haven't been interested in paying extra for this, she said. Moreover, HEDIS goals are mostly process measures, so the group cannot take advantage of better clinical outcomes.

Reaping rewards for outcomes, however, won't be easy. Dr Brady said it's not possible for his small practice to demonstrate better outcomes. To do so, he would need to get data from insurers on the total cost of tests, hospital admissions, and other services that his patients have incurred.

But insurers don't want to share that data with him, he said. And even if they did share it, the volume for one solo physician—or even a small group—at one insurer would be too small to be a reliable measure. "You need at least 5000 lives to have accurate data," he said.

Dr Brady is also worried about the impact that accountable care organizations (ACOs) might have on his practice. The local hospitals and a large multispecialty group in his area have each launched an ACO, and most practices in the area are aligned with one of these systems. Dr Brady is still on the sidelines. "The anxiety is that I'll be squeezed out," he said.

"We're in a period of great transition," Dr Brady said. What happens in the next few years will have a great impact on the future survival of small practices, he said. "There are all kinds of questions about the viability of practice models in the long term. We'll have to see how this unfolds."

Latest in Family Medicine/Primary Care



Medscape EHR Report 2014

Leslie Kane; Neil Chesanow  |  July 15, 2014



  1. US Department of Health and Human Services. Doctors and hospitals' use of health IT more than doubles since 2012. May 22, 2013. Accessed June 26, 2014.

Contributor Information

Leslie Kane
Executive Editor
Medscape Business of Medicine

Neil Chesanow
Senior Editor
Medscape Business of Medicine

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Medscape EHR Report 2014: Physicians Rate Top EHRs
Electronic health records (EHRs) have changed the way physicians practice medicine. Medscape invited physicians to participate in a survey of current EHR use; 18,575 physicians across 25 specialties responded during the period from April 9, 2014, through June 3, 2014. They answered questions about their use of an EHR and rated their systems in terms of overall ease of use and other performance traits, as well as their satisfaction with the EHR vendor. Physicians also described how their EHR affects practice operations and patient encounters. The results give an eye-opening portrait of how EHRs are affecting medical practices.

Are You Using an EHR?
EHR use has penetrated the physician market to the point where physicians who don't use one are an increasingly dwindling group. Over 80% of physician respondents say they now use an EHR. This is in line with what the Centers for Disease Control and Prevention (CDC) reported in 2013: that 78% of office-based physicians use an EHR.

If one adds in the 4% of our respondents who are currently installing or implementing an EHR, and the 6% who plan to purchase or start using an EHR in the next 1-2 years, that should bring EHR market penetration to over 90% in the near future. Only 7% of our physician respondents have no plans to buy or use an EHR in the next 1-2 years.

Are You Using an EHR (vs 2012)?
In Medscape's 2012 EHR Report, 74% of participating doctors said they were currently using EHRs, and another 20% said they were either in the process of installing or implementing an EHR, or planned to purchase or start using an EHR in the next 1-2 years. In our 2014 report, the percentage of current users climbed to 83%, with another 10% of soon-to-be users of EHRs.

The percentage of physicians who have no intention of switching to an EHR has remained fairly constant. In 2012, 7% of respondents had no plans to buy or use an EHR in the next 1-2 years; in 2014, the percentage dropped slightly to 6%. They say they're avoiding EHRs because they interfere with the doctor-patient relationship, are too expensive, and/or the incentives and penalties aren't worth the trouble.

Who's Using an EHR?
More than half of respondents (56%) using an EHR are part of a hospital or health system network using their institution's EHR. This partly reflects the fact that a majority of hospitals are now using EHRs. As of 2013, more than 80% of eligible hospitals have demonstrated meaningful use of EHRs.[1]

It also relates to the fact that many doctors are leaving the financial headaches of private practice to become salaried hospital employees. Hospitals have been purchasing physician practices, and the number of employed physicians has risen in recent years.

Only 39% of physicians using an EHR are in independent practice using their own EHR. This partly reflects the fact that independent practices are declining in number, and also that many such practices are run by older physicians nearing retirement, for whom the cost of investing in an EHR, and the steep learning curve, aren't worth it.

Most Widely Used EHRs
Epic and Cerner, two of the earliest EHR vendors, were first and second among our survey participants in usage in 2014 (23% and 9%, respectively). Both focus on hospitals, health systems, and large physician practices.

However, the difference in usage for other widely used EHRs is not large. eClinicalWorks, for example, is used by 6% of our respondents, Practice Fusion by 3%, Amazing Charts by 1%, and e-MDs by 1%, suggesting a tight horserace for market position in the small to medium-size physician practice sector.

Almost a quarter (22%) of respondents use systems other than those listed. More than 500 EHR vendors offer certified EHRs. Among those cited more regularly by respondents were Aprima, Quest Diagnostics' Care 360, CureMD, DocuTap, HealthFusion's MediTouch, Kareo, and Medicat.

Top Five Most Widely Used EHRs vs 2012
There were no dramatic changes in the five most widely used EHRs since Medscape's 2012 survey. In 2012, Epic was the most widely used EHR (22%); in 2014, Epic stayed on top (23%).

Allscripts was rated second in usage in 2012 (10%); in 2014, Allscripts' two EHRs (Enterprise and Professional) garnered 8% of usage, putting it in third place. Cerner claimed the same percentage of users over 2 years (9%), as did eClinicalWorks (6%).

Most Widely Used EHRs by Practice Situation
Epic dominates the EHR market for hospitals and health systems, with 37% of users, nearly three times as many as Cerner, its next-largest competitor, with 13% of hospital users.

Ronald Sterling, CPA, MBA, Principal of Sterling Solutions in Silver Spring, Maryland, is a national EHR expert and the author of Keys to EMR Success. "The lack of diversity is basically due to the fact that a number of hospitals, and even health systems, require use of specific products by their employee doctors," he says. "The decision is not up to the doctor. Therefore, they are going to have a tendency to use a more limited set of products."

Independent private practices with their own EHRs, including many smaller practices, generally use a different set of products. More than a third (34%) use "other systems." eClinicalWorks rated first in usage (10%), and NextGen and Practice Fusion tied for second place, with 8% each.

Most Widely Used EHRs by Practice Situation (cont'd)
Although many EHRs are less widely used, it's worth noting that several were rated highly in categories such as ease of use and overall physician satisfaction.

The Top Rated EHRs
Survey participants were asked to rate their EHRs by several key criteria, including ease of use, vendor support, overall satisfaction with the product, how well it connects with other systems, and usefulness as a clinical tool. We used those scores to develop the ratings shown in upcoming slides. In this and forthcoming slides, a rating of 5 is excellent, 4 equals good, 3 equals average, 2 is below average, and 1 is poor.

The highest-rated EHR, with a score of 3.9, is the Veterans Administration EHR: VA-CPRS. It's regarded as one of the best overall by our physician respondents. Practice Fusion and Amazing Charts tied for second in the ratings for overall user satisfaction (3.7). Medent and e-MDs tied for third place in the ratings (3.5).

Five Top Rated EHRs vs 2012
The same 5 EHRs that physicians rated highest in Medscape's 2012 report are again the top 5 in our 2014 report. Amazing Charts, rated number one in 2012 (with a score of 4.2), slipped to the number-three spot in 2014 (3.7). Some EHRs rated higher in certain attributes — for example, ease of use, user satisfaction, and clinical usefulness — than others, so a similar overall score doesn't necessarily mean that the EHRs performed equally well in the various EHR attributes measured.

Why such variation in ratings? One reason is that earlier products focused on creating an acceptable E&M note, says Ronald Sterling. When care and clinical management, quality, and meaningful use became important, older EHRs had to be retrofitted to deal with the new issues, with varying degrees of success.

Top Rated EHRs by Practice Situation: Hospitals and Health Systems
Among survey participants who are part of a hospital or health system network and are using that entity's EHR, the Veterans Administration EHR, VA-CPRS, led the pack in overall ratings, with a score of 3.9.

No EHRs had an overall score of 4 or higher. Several reasons are possible, says EHR expert Ronald Sterling. "EHRs have basically been focused on creating E&M-acceptable documentation for office visits, but physicians want better tools to manage care and track patients," he says. "Meanwhile, EHR vendors have been overly focused on meeting the demands of meaningful use rather than addressing the focused needs of doctors."

In addition, "ease of use is still a significant stumbling block, with physician productivity a continuing problem," he says. "If you cannot get the EHR to support doctors at their speed, then they are not going to consider their EHR any better than average."

Doctors may also use one EHR in the office and another at the hospital. "Doctors are recording information in the hospital EHR that should be in their own records but may be difficult to transmit," he says.

Top Rated EHRs by Practice Situation: Independent Practices
Among independent practices using their own EHR, VA-CPRS scored highest (4.1), with Amazing Charts, Practice Fusion, and Epic tied for second place in the ratings (3.7). Epic is among the EHRs in longest use (over 20 years), reengineered versions of which have been adopted by Kaiser Permanente, Geisinger Health System, and other integrated delivery systems.

Amazing Charts and Practice Fusion, popular in smaller practices, also appear popular with respondents in hospitals and health systems using their entity's EHR. However, EHRs designed for smaller practices aren't used by hospitals. Rather, physicians who are part of a hospital or health system may use EHRs for smaller practices, even though the entity itself may use a more heavy-duty system such as Epic or Cerner. A hospital may not want the expense of installing its EHR in a physician practice, Sterling notes. "Epic for doctors is not cheap!"

Top Rated EHRs for Ease of Use
Ease of use, the most important category for many physicians, is measured by several factors: "easy to learn," "ease of data entry," "ease of EHR implementation," "reliability," and "overall ease of use." For many physicians, "ease of use" determines their overall perception and experience with the EHR, affecting patient interactions and time spent documenting.

Amazing Charts, which is not used by hospitals and health systems but is more popular with smaller practices, was rated most highly, with a score of 4.0 for overall ease of use. Practice Fusion and VA-CPRS tied for second (3.9 each) in ease of use; both also scored highly in those attributes in 2012.

Top Rated EHRs on Satisfaction
Satisfaction with EHRs includes various key attributes that are critical to the EHR experience.

Value for the money is related to, among other factors, the complexity of the system compared with what it offers. Some EHRs for large hospital systems contain far more extensive features than do some EHRs for smaller practices, and consequently cost much more, particularly in terms of software and installation.

"Sometimes it takes years for older products to update their look and operation to take advantage of new technology," EHR expert Ronald Sterling points out. "It can be difficult to retrofit a new capability into an older piece of software. For example, the way e-prescribing works in older EHRs may not be as cool as newer implementations. Some older products don't even do as good a job with the Microsoft Windows interface or images."

Practice Fusion, which rated highly on "value for the money," is billed as a "free" EHR with an "ad-supported model."

Top Rated EHRs for Vendor Support
Vendor support is a key to satisfaction with one's EHR. Some physicians have reported that after their EHR was installed, the vendor was difficult to reach, and the practice lost time trying to work around or solve EHR problems. Not surprisingly, the top five EHRs in overall satisfaction also head the list of top rated EHRs for vendor support.

Practice Fusion was highest rated both in "adequacy of vendor training program" (3.7) and "vendor continuing customer service" (3.8), followed by Amazing Charts (3.5 and 3.8, respectively), VA-CPRS (3.5 and 3.6, respectively), e-MDs (3.4 and 3.3, respectively), and Medent (3.3 and 3.6, respectively).

It's worth noting that Practice Fusion, Amazing Charts, and e-MDs are cloud-based systems that are intrinsically easier to support than installed, office-based systems. With the former, the vendor's tech staff can immediately troubleshoot an EHR problem remotely via the Web. With office-based systems, a tech must often physically visit a practice to troubleshoot, a more complicated and costly operation. The three systems rated lower in vendor support — McKesson (2.7), Meditech (2.7), and NextGen (2.6) — are office-based.

Top Rated EHRs for Connectivity
Medscape asked about EHR connectivity across four domains: with diagnostic devices (eg, ECGs, laboratory information systems); practice management systems; reference and hospital labs; and other physicians (especially in supporting electronic referrals).

The Veterans Administration's VA-CPRS rated highest, scoring 4.0 or better in all domains measured. Epic came in second in three of four domains (3.5-3.7), although third-rated Athenahealth outscored it in the "works with my practice management system" domain (3.9 vs 3.6, respectively).

Connectivity becomes increasingly more important as concepts of "care coordination" take hold, and also as hospitals and private practices work to make their operations more efficient.

Scores in the last domain, "connectivity with other physicians," were not typically high. According to the Office of the National Coordinator for Health Information Technology (ONC), only a minority of physicians with EHRs from different vendors are exchanging clinical summaries of patient visits with other physicians.

Top Rated EHRs on Usefulness as Clinical Tools
The use of an EHR as a clinical tool is one of its most important functions. Physician participants rated their EHRs in four domains. VA-CPRS scored the highest in all aspects of use as a clinical tool, including appropriateness of clinical content, ability to support the physician's workflow, patient services, and patient portal.

EHRs' Effect on Your Practice Operations
Despite complaints that EHRs make documentation too burdensome, 63% of our respondents said that an EHR improves documentation; only 27% disagreed. Among participants, 39% felt that EHRs improve collections; only 9% disagreed.

Responses overall showed that physicians are somewhat split in whether they like or dislike their EHRs. Thirty-four percent of participating doctors maintained that an EHR improves clinical operations, yet 35% said it worsens them. Thirty-two percent felt that an EHR improves patient service; 38% said it worsened patient service.

Ten percent of respondents listed other ways that the EHR affects practice operations. A representative sample includes: "E-prescribing is awesome"; "More organized"; "Legibility"; "Accessible from home after hours"; and "Saves all my data in one place."

EHRs' Effect on Patient Encounters
One of the most dramatic differences since our 2012 survey shows up in how physicians feel that an EHR affects the doctor-patient relationship. In 2012, 36% of respondents said the EHR had a positive impact, 30% said it had a negative impact, and 34% said it had no impact on patient encounters.

This year, however, some responses were significantly more negative. For example, 70% of respondents said the EHR decreases their face-to-face time with patients, and 57% said it decreases their ability to see patients. Still, about a third (35%) said the EHR improves their ability to respond to patient issues, and 33% said it allows them to more effectively manage patient treatment plans.

Satisfaction With EHR Vendor
Dissatisfaction with EHR vendors has been a perennial sore spot for many physicians. Our survey pointed out encouraging news, although there's still room for improvement. Fully 42% of respondents said they were either very satisfied or somewhat satisfied with their vendor. Less than a fifth (17%) were neutral, and a third (33%) were either somewhat dissatisfied or very dissatisfied.

A small percentage of respondents (9%) don't interact with an EHR vendor, most likely because they are employees or work in large group practices, where vendor interaction is handled by a site administrator or other staff member.

Has Your EHR System Become...More Comfortable to Use Over Time?
Familiarity seems to be vital in using an EHR. While physicians new to EHRs often find them hard to use, use over time appears to make a big difference.

In our 2014 report, 81% of respondents agree that their EHRs have become easier and more comfortable to use over time; only 19% disagree. The likelihood is that practice may not make perfect, but it does enhance the experience.

And as far as managing one's staff, EHR expert Ronald Sterling says that "'managing staff' includes being able to assign them tasks, move issues and messages around the office, and document the completion of patient service items, as well as allowing doctors and supervisors to follow up on when a given item was completed and which items are still open and need to be addressed or upgraded."

Just over half of our respondents (53%) feel that their EHRs do not help with these issues. "The reason," explains Sterling, "is that some EHRs do not have workflow tools to meet all of these requirements." Office workflow and staff management capabilities, he adds, are not requirements for certified EHRs.

Will You Keep or Switch Your EHR?
Despite the fact that many physicians dislike their EHRs, there's no mass migration to new systems among our survey respondents.

Fully 84% of participating physicians say that they plan to keep their EHRs. Many physicians, particularly those who are employed, don't have a choice in whether or not to keep their current system.

This year, 16% of physicians are planning to switch EHRs for a variety of reasons, some by necessity: 5% are switching because their job has changed; 2% because the vendor was not certified for meaningful use Stage 2; and 1% because the vendor went out of business.

Do You Have Patient Privacy Concerns?
What a difference two years makes!

In our 2012 EHR Report, patient privacy concerns were barely on the radar screen of respondents. At that time, fully 77% of participating physicians said they had no patient privacy concerns.

However, in 2014, only 17% of survey participants said they had no EHR-related patient privacy concerns.

"I think this greater awareness is from hospital training, as well as physicians who had to return their EHR incentive money, since they did an inadequate security risk assessment," says EHR expert Ronald Sterling.

"The real risk for small practices," Sterling observes, "is that they do not have appropriate policies and procedures and fail to train their staffs in HIPAA privacy and security requirements."

Where Do You Stand on Meaningful Use?
In 2012, 44% of respondents said they had already attested to meaningful use, 31% said they planned to attest within the year, and 11% said they planned to attest sometime after 2012. In our 2014 report, 78% of participating physicians said they were attesting to meaningful use Stage 1 or Stage 2 in 2014.

On the other hand, the number of physicians who say they will not attest is growing. In 2012, 14% of survey respondents said they wouldn't bother to attest. In 2014, 16% said they will never attest to meaningful use requirements, and another 6% of participants said they are abandoning meaningful use after meeting the requirements in previous years.

Thus, 22% of physicians surveyed this year are opting out of or disregarding the meaningful use program.

Web-Based or Installed EHR?
The percentage of doctors using installed EHRs is declining as the percentage of those using Web-based EHRs is growing.

In our 2012 survey, 46% of the respondents said they had installed EHRs; 21% had Web-based EHRs. In our 2014 survey, 36% of participants said they use an installed EHR; 29% had Web-based EHRs. Those percentages are likely to widen in the years to come. (A large percentage of physicians [34%] didn't know whether their system was Web-based or installed.)

"In a lot of respects, cloud-based systems are less problematic," says Ronald Sterling. These systems have fewer security problems, he says, because a server isn't physically in the office. Another issue is updating an EHR's drug compendium, which can take months with in-house systems, whereas "the cloud-based systems are much faster at posting changes," Sterling says.

Type of EHR System by Practice Size
In Medscape's 2014 report, just over one third (35%) of practices with one to nine physicians in the practice used an installed EHR. In our 2012 report, that number was 30%.

Among larger practices, there's a significant difference in use of Web-based or installed EHRs. In groups of 25 or more physicians, 38% had an installed EHR, but only 20% had a Web-based EHR.

Cost per Physician to Purchase and Install
Are EHRs getting less expensive? Despite a growing number of relatively economical Web-based alternatives, the overall answer appears to be no. In 2014, for example, only 8% of doctors paid less than $10,000 per physician for their EHRs, according to survey participants, and only 7% paid $10,000-$34,999. In our 2012 survey, the percentages were 5% and 8%, respectively.

In 2012, only 7% of respondents said their EHR system cost over $50,000 per physician to install. In 2014, almost a quarter (23%) of respondents said their EHR system cost that much.

More than half of the respondents are unaware of the cost of the EHR, reflecting the large percentage of employed physicians who are not privy to cost information.

Monthly Fees per Physician for a Web-Based EHR System
A benefit of Web-based EHRs is that they are generally less expensive than installed systems. Software upgrades, drug compendium updates, and other changes are all done online, EHR expert Ronald Sterling points out.

The costs, however, are creeping up.

In 2012, only 4% of survey respondents said they were paying over $700 per month for monthly fees; in 2014, 12% are paying that amount.

Why You Don't Use an EHR
The number-one reason that physicians say they won't use an EHR is that EHRs interfere with the doctor-patient relationship (40% of responses). Few physicians, even ardent EHR users, would disagree with that.

Number two on the list is that EHRs are too expensive (37% of responses). Besides the cost of the EHR, there are expenses involved in switching all current paper records to electronic records, and there is also lost work time during the transition and switchover. For doctors nearing the end of their careers, the cost and effort are not worth it. (Note: Respondents were allowed to choose more than one answer.)

The third-most-cited reason — that the incentives offered and penalties levied by the Centers for Medicare & Medicaid Services (CMS) aren't worth the hassle of adopting an EHR (32% of responses) — is something that a number of doctors have concluded.

Advice From Other Physicians
In our 2014 survey, we asked respondents to offer advice to other doctors based on their experiences with EHRs. Over 11,500 physicians did. A common theme: Many doctors don't do enough homework prior to purchasing an EHR and then are unpleasantly surprised.

Homework, our respondents say, consists of visiting the offices of your colleagues to see how their EHRs work; attending specialty society conclaves where you can test-drive many EHRs and speak with attendees about their experiences; and visiting online chat rooms for EHR users to view their comments and pose your own questions.

Another common observation: Many physicians aren't sufficiently trained in EHR use before going live — a key reason why practice workflow often suffers. In addition, if you plan to customize your EHR, you should be thoroughly versed in how it functions, because an error made on one screen may create systemic errors.

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Authors and Disclosures


Leigh Page, Freelance healthcare writer, Chicago, Illinois

Disclosure: Leigh Page has disclosed no relevant financial relationships.


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