No, Don't Buy an EMR Now! Yes, Buy an EMR Now!

Gregory A. Hood, MD; Joseph E. Scherger, MD, MPH

Disclosures

August 05, 2009

In This Article

Introduction

Electronic medical records (EMRs) evoke strong reactions, from anger to enthusiasm. The US Government considers EMRs vital to controlling healthcare costs and improving patient care, but adoption is lagging. Doctors cite cost, work slowdown, potential problems and difficulties, and other issues as reasons to avoid an EMR. Medscape invited 2 experts to present their points of view on whether doctors should buy an EMR now.

On "point," we welcome Gregory A. Hood, MD, internist with Drs. Borders and Associates, PSC, in Lexington, Kentucky, and Governor-Elect of the American College of Physicians, Kentucky chapter. On "counterpoint," we have Joseph E. Scherger, MD, MPH, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine California, and Medical Director of Quality and Informatics at Lumetra in San Francisco, California.

No, Don't Buy an EMR Now!

Point: Gregory A. Hood, MD

Everyone says that 2009 is the year that everyone should buy an electronic health record (EHR). It slices, it dices, it fixes everything that is wrong with healthcare delivery in the United States.

Not so fast. In spite of the fervor for EHRs in Government and the press, now is the time to make sure that you have both feet planted firmly on the ground. before you purchase an EHR for your practice.

I have been using one EHR or another for about 12 years. They have advantages and limitations, like any other instrument. I was driven to use one because drastic circumstances in my practice required a "failsafe" means of records retention. I also had a desire to document more expansively and a natural inclination for technology. After 8 years of effort I was able to generate real-time completed office notes during the face-to-face time with each patient.

This brings me to my first caution to you. If you expect "plug-and-play" technology, then this is not the time for an EHR purchase. You must be ready to spend 4-6 months in preimplementation preparations, learning, and data entry (scanning or manual data entry) and another 6 months of diligent, daily, personal utilization of the system before expecting to be proficient.

Furthermore, every single estimate of improved quality and reduced quantity of redundancy in healthcare delivery is predicated on the quality and intensity with which the conversion and day-to-day management of data into the EHR is conducted. An empty EHR, one with incomplete data entry, or one whose use is abandoned after a year of trying to adopt it does nothing to improve quality, efficiency, or national healthcare delivery.

If you believe that the EHR will guide you to more accurate coding and boost practice revenue for you, paying for itself in the process, then I must caution you again. Physicians are ultimately responsible for the codes entered, no matter the method by which the coding level was derived.

Do you expect the EHR vendor to stick up for you in an audit because of what their coding module suggested? Think again. Rightly, it is the physician, not the computer, who makes the code-level decision. The main place where I have seen outright dollar savings from an EHR is in the front office, where it is nearly invisible to the doctor in the day-to-day practice of medicine. Not paying $8 for each new internal medicine patient's manila chart and dividers -- and not paying for staff to run around to each other's desks looking for them -- are examples of savings that can be garnered.

Yes, it is possible that your practice may also see a bottom-line difference if you purchase one now. The Government promises $44,000 for each doctor when a qualifying system is purchased. However, caution is warranted here again. There are hurdles and heretofore unannounced qualifications to meet in order to receive this money.

With the present economic woes and the uncertain outcome of the national healthcare debate, this may not be a wise moment in history to be saddling oneself with additional debt, unless your practice is in a position to pay cash for the product.

Further, this is only for the upfront cost. Committing to an investment of hundreds of thousands of dollars and hundreds of hours of both physician and staff time in order to get a rebate is not a decision to enter into lightly. Also, if you are not prepared for the monthly IT bill for system monitoring, maintenance, and replacement of broken or failing equipment, terminals, and servers, then you may be in for a big shock.

Besides, don't forget that EHR programs go through periodic "upgrades" and new releases, some of which may require more robust hardware than previous editions. Such changes mandate payment for new, expensive equipment to replace perfectly serviceable hardware which has been rendered obsolete by your EHR partner's decisions on enhancement priorities. These enhancements may or may not enhance your method of patient care.

It is imperative that you obtain a full-total-cost quote IT service contract from your proposed support company or you will have budgetary shortfalls. Your IT partner and your practice must have contingencies for when your EHR is down. You will experience power failures -- from ice storms, for example. You will experience times when phone and Internet services are down because cracked insulation on the 50-year-old phone line that serves your building is letting rainwater into the wires and degrading the signal. I've been there; trust me.

What's more, a typical EHR may boast a 99.8% "up time." This sounds impressive, but it means that almost 18 hours a year you won't have your EHR, even if you have electricity and phone service.

Again, now is not the time for an EHR purchase if you expect (as many patients assume) that data from hospitals, labs, and other doctor's offices will flood into your system automatically from all over the galaxy. Each interface requires programming, testing, verification, and periodic updates and revisions. This can be tedious, time consuming, and at times impossible due to incompatibilities. Evolving Government standards for systems may force you to scrap presently functional systems and implement others in order to qualify for stimulus monies and avoid penalties.

The future does include EHR technology. The picture could be much clearer in 6-12 months. Now is the time to investigate, to strategize, to start a comprehensive plan to review options. Now is not the time for a hasty decision.

Because compliance with the meaningful EHR use in 2012 still qualifies for $44,000 from Medicare over 5 years, and compliance in 2013 only lowers this figure $5000 a year, it is more important to take the time to make the best decision you can, rather than make a rushed "now" decision. Unless and until you have full answers with complete confidence about each issue discussed here and about other issues unique to your personal circumstances, an EHR won't help you to live long and prosper.

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