COMMENTARY

EHR: Forget Billing and Go for the Registry

Robert W. Morrow, MD

Disclosures

April 19, 2012

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Hi. This is Dr. Bob Morrow of the Transparent Medical Practice blog on Medscape. Welcome. I am a family physician in the Bronx, and today I am going to talk to you about the question of whether electronic health records actually save any money.

It is an interesting question. You are saying, "I am buried under this electronic record. I am not getting my work done. I can't get out of the emergency room. I can't get out of my office. How could this possibly be saving anybody anything?"

I am very sympathetic, of course. I have a small practice in the Bronx, consisting of myself and a nurse practitioner, and we have had many adventures with different electronic records. I have been an electronic prescriber for more than 10 years and have thrown out more than I have kept in terms of programs and health information technology.

When we talk about electronic records, a few things are important. The first is, if you have a record that is connected to an institution-based system, the institution is really eager for you to order things: MRIs, CT scans, physical therapy, home care, or whatever is in their business model. They are going to have a check box so you can get there quickly. When this type of situation has been studied, particularly the integrated practices, it has been found that these systems are driving up costs rather than dropping costs. It is not an information highway; it is branding. Many large institutions brand their electronic records so that they don't "talk" to each other. In New York, where we have at least 10 institutions that are the best in the world, their systems don't talk to each other. If my patient goes to the hospital with which I am associated, then I can get information. If the patient goes to another hospital, I can get no information, and the hospital gets none from me.

Therefore, these internally branded electronic health records, which push business, are not going to drive down costs, and that is a problem. It comes back to the question of what these systems do to our practice. Is everybody in the back room typing notes instead of seeing patients? That tends to be true, particularly for the billing records, which is what most of these systems are built around. Most of these systems are structured so that everything comes back to billing. They are not built for patients, and they are not built for the people who use them, who are looking for ease of use, speed, and getting the work done.

I am a big fan of what I call the "patient-centered medical record." This is a record that is built around registries, in which we record the structured things that are important in the care of patients. The rest is not terribly important when a patient with diabetes comes in and is having some belly pain. You evaluate it and it is not urgent, but you have done some tests. That doesn't have to be structured into your record except as a visit. But you do have to structure in the things that you might have forgotten, and with a good registry-based record, you can have the rest of your team do things for you before you even see the patient. For diabetes, the team can order the patient's A1c, or they can give an immunization that might be needed. They can do the foot examination, and so on -- whatever you decide based on the structure of your practice.

In studying registry-based records in different practices, we have found a tremendous improvement in patient outcomes and we are capturing important data. For example, the percentage of patients who don't have a low-density lipoprotein (LDL) test done at the start of the study will be 50%, and by 6-8 months, every patient who has diabetes will have had an LDL drawn, because the registry prompted that action. It gives you a real-time feedback.

Why can't we do this in general and make life easier? Why can't we be more proactive with patient care? The answer is, we can. There are records like this. They tend to be modular. When you have a modular record, each module can talk to others and therefore can talk to other practices. We can integrate our practices. We can meet meaningful-use requirements. In my practice, I used our registry data to become a National Committee for Quality Assurance diabetes recognition office. When I got my certificate for that, it turns out that I passed part 4 of my boards automatically, which was a surprise but a pleasure.

A registry system also fits into the data collection you need for the Physician Quality Reporting Initiative and meaningful use. It doesn't help much with your billing, but it doesn't need to, because you are really centered on the patient activities and the billing part can follow that. Such records in my office are now costing $180 per provider per month -- with no upgrades and no licensing fees. One example is the portal AMAGINE™ which is run by the American Medical Association, who is spreading the idea of registry-based, patient-centered records. Do these records save money? In the long run, they save money by reducing the number of admissions and by reducing the amount of missed care. They do appear to save money if we extrapolate from what we know. However, at least these systems don't interfere with patient care flow, they don't interfere with your cash flow, and they meet all the new requirements of meaningful use.

These are just a couple of thoughts about the issue of electronic health records, a topic that can be quite contentious. When you look at very expensive systems installed in large enterprises, you will not see any savings. You will see expenses. Unless we balance that with financing from the government or amortization, we will find electronic records being more of a weight around our necks than a benefit to the patients.

I encourage you to think about a patient-centered electronic record, and I would like to hear your comments.

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