Monday, November 8, 2010

Why We Delayed e-Prescribing for a Year

Come read this great article at

Tuesday, November 2, 2010

Monday, October 25, 2010

We have Moved to

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Please go to where I have a new post entitled, "Bedside Manner in the Information Age"

Mike Koriwchak, MD

We Have Moved to

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We have moved to Word Press at

Tuesday, October 5, 2010

The ROI of EMR Explained, Part 2: Show Me the Money

It’s time again to face the Doubters, those physicians who would dare question the benefits of EMR to the medical practice.  Incredibly, the Doubters are unimpressed by EMR product literature containing pictures of beautiful providers holding shiny tablet PCs taking care of happy, smiling (are they even sick?) patients.  They have the audacity to want to know their return on investment.

In the first part of this series I tried to explain how EMR uses parallel processing to liberate workflow, improve care and reduce costs.  But any good Doubter recognizes that those arguments are only theoretical.  The Doubter asks for real world examples and hard numbers.  So I gave it a shot.  For many of our perceived cost savings the hard numbers are much harder to find than I thought.  I am no expert at financial analysis…but few physicians are.

The examples are in 3 categories.   Direct savings clearly go straight to the bottom line.  Space savings have a well-recognized financial value.  FTE savings are by definition estimates; the effect on overhead (payroll) is difficult to measure. 

1.     Direct Savings. 
1.     Transcription Costs.  Our transcription cost for a busy physician was $750-$1000 per doctor per month.  With the cost of printing and filing transcribed notes in the paper chart, the cost was easily $1000 per doctor per month.  We were paying 10-12 cents per line not only for the content of the note but the patient name, date of birth, etc.  With EMR this cost disappeared.  We save $12,000 per doctor per year.   Over 4 years, 48,000 after tax dollars are worth far more than the 44,000 taxable dollars offered by the Medicare “meaningful use” incentives paid over the same period.

2.     Paper chart supplies.  A paper chart needs a manila folder, paper, labels, etc.   A rough estimate is about $1.20 per chart.  We see about 17,000 new patients per year.  Savings is thus about $20,000 per year, or $2200 per doctor per year.

2.     Space Savings.
1.     The empty file room.  After 2 years of EMR our paper charts were gone.  We have 5 offices each with a 100 square foot file room, which became available for other purposes.   Our rent is expensive, about $25 per square foot per year.  So 500 square ft x $25= $12,500 per year. ($1400 per doctor per year)
2.     Teleworking. Our surgery schedulers and some of our collectors now work from home; to do their job all they need is a cell phone and secure Internet access.  We have 3 schedulers and 2 collectors; each was using a standard cubicle 8 ft square, so roughly 300 sq ft or another $7500 per year ($833 per doctor per year).

3.     FTE “Savings”. 
1.     Paperwork Automation.  Shortly after getting settled with EMR we began to automate the process of preparing preoperative paperwork.  This includes the surgical consent, the preoperative history and physical (H & P) and some internal forms for routing data to our surgery schedulers.  A staff member needs 10 minutes (1/6 hour) to complete these forms by hand.  At an hourly rate of $20 per hour (including benefits) it costs about $6.50 per patient.  With 400 cases per doctor per year the total savings is $ 2600 per doctor per year. 

2.     Employee savings.  Our telecommuters come to work one day a week so their transportation costs go down 80%.  Assuming a 40 mile round trip to work with a variable cost of $0.30 per mile we get about $2400 after tax dollars saved per year per telecommuter, or $12,000 total.

3.     Workflow automation.  Our patient phone call protocol is a good example of how to re-engineer a workflow to leverage EMR technology.  This protocol uses 2 EMR workflow concepts that paper charts can’t offer:  remote access and parallel processing.

In our paper chart era phone calls from patients were handled in an unstructured, ad lib manner.  I received phone calls in many different ways.  Every office, every employee and every physician had his/her own personal preferences.  Training everyone in a new protocol would work for no more than a few weeks at a time.

Our administrator designed an excellent EMR-based protocol for patient phone calls:
1.     The phone system was configured to route all patient phone calls (except appointment requests) from all 5 offices to a single experienced, trusted staff member.  That is all she does.
2.     She triages each call in one of the following ways:
a.     Handles the call herself
b.     Forward the message via EMR to the appropriate physician’s staff
c.      Forward the message via EMR directly to the physician (copy appropriate staff)
d.     Call staff directly
e.     Call physician directly
3.     Regardless of triage method a phone note would be entered in the patient’s EMR chart and routed to the appropriate physician or staff EMR desktop for review.

Phone calls were delivered much more efficiently.  Patient complaints about unreturned phone calls disappeared.  Responses to phone calls were much easier since the chart was always available to everyone, all at once. 

Our guess is that we saved about one FTE across our 9 physician, 5 office practice, saving about $40,000 per year including benefits, or about $4500 per MD per year.

We have similar processes in place to automate outbound faxing and our patient web portal.

The totals:
1.     Direct savings:  $14,200 per MD per year.  Take it home.
2.     Space savings:  $2233 per MD per year.  Grow your practice without paying extra rent.
3.     FTE savings:  $8500 per MD per year.  Intuitively, we are convinced that the FTE savings are by far the greatest financial benefit from EMR and are far greater than this figure would suggest.  We have barely scratched the surface of workflow automation.

This remains a work in progress.  I welcome all comments including corrections, better estimates, omissions…anything.  And if anyone can help me nail down the FTE savings better I would be most grateful.

Thanks again for reading.

Friday, September 17, 2010

Physicians vs. Health IT: The EMR Culture War

The recent financial incentives offered by the government (HITECH) for EMR implementation are somewhat helpful but are also misleading.  Most fail to recognize that the biggest obstacles to EMR implementation are not financial, but are cultural.  EMR adoption will require cooperation between two disparate cultures:  the Health IT (HIT) culture and the medical culture.  One needs only to read a few of the EMR debates in any health care blog to discover that these two cultures view the health care system differently.  Until the differences are reconciled, EMR implementation will continue to struggle despite the HITECH incentives.

Buoyed by its success digitizing other parts of the economy, the HIT industry sees in health care an untamed wilderness of inefficient workflows and slow, outdated data exchange.  HIT folks envision a world where standardized workflows and rapid data movement ensure, for example, that a patient never has to wait 30 minutes in an exam room for test results and where day-to-day management of chronic diseases can be done remotely.  An IT revolution in medicine would bring lower costs, better efficiency and improved care.

But there is a dark side to the HIT perspective. After successfully bringing so many other parts of our economy into the information age, some believe they have learned all they need to know to do the same for health care.  The benefits are so clear and so obvious that anyone who would oppose EMR must be either clueless or just “protecting their turf.” I have heard HIT consultants brag about walking out on their physician the minute they saw a paper prescription pad.  They mistakenly believe that health care is no different than banking or grocery stores – that there is nothing else to health care besides documentation, workflow and data exchange.

The medical culture sees it differently.  To us health care is all about the doctor-patient relationship.  In the physician’s world workflows and data exist only to support and execute the decisions patients and doctors make together regarding care.  The art and science of medicine defy, to some degree, traditional software structure and data capture techniques. Our decisions may depend as much upon the look on a patient’s face as on any objective data.  That is how it should be.  The type of personality who is attracted to this kind of work is interpersonal, not technical. We got into medicine to interact with people, not machines.

The doctor-patient relationship gets attacked from all sides. Since the doctor-patient relationship drives one-sixth of our economy that comes as no surprise. The government just passed a huge piece of legislation that will have profound effects on the doctor-patient relationship.  Pharmaceutical companies tell us we need to use their latest drug.  Device manufacturers push the next great Magic Wand for performing a tonsillectomy, sinus surgery or other operation.  Consultants tell us to run our practice like a business.   When we make sound business decisions, we are accused of abandoning our moral obligation to medicine.  To us the folks trying to sell us EMR are no different.  They are just another group that thinks they know how to do our job better than we do.

But the medical point of view has its dark side as well.  We act as if the doctor-patient relationship is so sacred as to be perfect and infallible, privileged from the need to evolve and improve, immune to the economic and performance pressures lurking just outside the exam room door.  If the treatment we prescribe is not the most cost effective choice, let the system deal with it.  If our paper prescription is illegible or non-formulary, that’s the pharmacist’s problem.  If EMR is too inconvenient because of the learning curve, then it doesn’t matter how much more efficiently the system would run with EMR in place.

Bringing information technology to health care will be slow and painful until these 2 points of view are reconciled.  The first step is to realize that both doctors and Health IT are right – and they are both wrong.  Both sides need an attitude adjustment.

Health IT must acknowledge that the doctor-patient relationship is a major part of the health care machine.  Workflows and data are the means, not the end.  Nothing like the doctor-patient relationship exists anywhere else, so the experience gained bringing IT to other parts of the economy is not enough to write good software for physicians.  Little wonder that doctors find EMR software “clunky”, inefficient and difficult to use.   As one physician responding to a survey stated, “in order to contain the subtleties of the medical thought process, these systems have to be complex, flexible, and very nimble.”  Health IT needs to invest time and effort developing a greater understanding of how doctors and patients interact and make decisions.  Only then will the software get better.

The medical culture must understand that while the doctor-patient relationship is unique and special, it is not entitled to be rigid and inflexible.  Over the past several decades the way we do our job has evolved; the evolution must continue.  The doctor-patient relationship is not perfect.  The shortcomings we impose on the rest of the system play a part in the inefficiency and the waste.

Remember when managed care came along 20 years ago?  We dug our heels in and fought against it.  We declared our methods and our high price tag to be above criticism.  So the rest of the health care system created managed care without us.   We are still living with the consequences.

With the impending IT revolution in health care we face a similar choice. If we refuse to accept change, the result will be the same as it was 20 years ago.  If we want a better result this time we must take a leading role.  We must voluntarily leave our comfort zone and bring EMR to the practice of medicine.

Can both cultures admit their shortcomings and meet in the middle?

Monday, September 6, 2010

The ROI of EMR Explained

Some of the toughest obstacles to EMR are the “Physician Doubters.”  These people say, “My charts are going to be on a computer.  So what?  All I know for sure is that it will take longer for me to finish my charts every day and we will have another component in fixed overhead.  Why this is a good idea?” 

The concerns are valid.  When my practice chose to get EMR 6 years ago we made a decision of faith and vision, not from an ROI analysis.  But for most practices, faith and vision are not good enough.  We need a return on investment (ROI) rationale that justifies EMR adoption to the Doubters.  The IT experts talk in vague terms about workflow and re-designing your practice to take advantage of EMR, but these arguments are not concrete or specific enough.  Yet after 5 years of EMR no one in our group has ever suggested that our EMR investment was unwise.  I am convinced the ROI argument exists.  My next few posts will attempt to make the case.

Let’s start with an unusual example.  Your car needs new tires.  You live in a beautiful rural area but there is only one car shop, staffed by a single mechanic.  He is glad to put on new tires but the job will take all day.

Why so long?  How many steps does it take to put on new tires?
1.     Remove the first wheel from the car
2.     Take the old tire off the wheel
3.     Put the new tire on
4.     Balance the wheel
5.     Put the wheel back on
6.     Repeat the above with other 3 wheels, one at a time.

Any interruptions such as other cars needing work, a phone call, emergency, etc. will make the job take longer because these events interrupt the work on your car.  Our solo auto mechanic must operate by sequential processing – defined as one operation at a time.

Now consider the other extreme.  You are an Indy racecar driver going 180 miles per hour around the track.  You need new tires fast.  You pull into the pits and the pit crew changes all 4 tires at the same time.  You also get mechanical adjustments, a full tank of gas, and the windshield cleaned.  A pit stop that takes more than 8 seconds is considered a failure.   This is parallel processing – defined as multiple operations taking place simultaneously.  Thanks to parallel processing the Indy pit crew can do in 6 1/2 seconds what takes the solo mechanic all day.

Now go to the doctor’s office.  The physician sees a patient with a suspicious nodule in his thyroid gland that needs surgery.  How many steps does it take to get that patient to the operating room?
1.     Create a chart note that supports the need for surgery
2.     Schedule the operation with the surgical facility
3.     Preoperative labs, imaging, EKG
4.     Specialist clearance (i.e., cardiology)
5.     Precertification with insurance
6.     Generate and complete documents
a.     Surgical consent
b.     History and Physical
c.      Preop and Postop orders
7.     Communication with the referring physician
8.     Handle the unexpected – patient calls with questions, abnormal lab values, scheduling conflicts, etc

How does the paper chart office handle these tasks?  In all but the smallest practices these tasks are each handled by different individuals.  Every step requires access to the paper chart, which can only be in one place at a time.  The chart won’t be available to anyone for at least 24 hours until the transcription comes back and is filed.  The paper chart office must therefore accept the slowness and inefficiency of sequential processing.  Workflow is defined by stacks of paper charts – stacks waiting for transcription, stacks waiting for labs, waiting for scheduling, etc.  And if the patient scheduled for surgery calls with a question…what stack is the chart in?  Will the chart find its way back to the right stack after the phone call is handled?  Everyone competes with each other for access to the chart.  Not only is the process slow and inefficient, it carries a high risk of workflow failure.

How is the same process handled in a doctor’s office that has EMR?  With the power of parallel processing:
1.     The chart note, including the diagnosis codes, is immediately available to support preoperative workflow. 
2.     The chart note is paperless faxed to the referring physician the same day, sometimes before the patient leaves the office.
3.     The staff is immediately notified of the new workflow via the EMR system
4.     Consent, H & P, and orders are all generated with a single button click
5.     All workflows are performed simultaneously, greatly improving speed and efficiency and reducing the risk of a workflow failure.

With parallel processing there are no stacks of charts and no competition among staff for access to the chart.  Copying and faxing charts within the practice is eliminated.  The chart is everywhere, all at once.  Any phone call regarding a patient is easily handled without having to search for a paper chart and without the risk of killing a workflow because the chart was not put back in the right stack.

So where is the ROI?  The same work gets done with fewer people, fewer resources and less space.  These initial benefits happen without having to “re-engineer the practice” or change anything else about how things get done.  After electronic documenting becomes second nature it will be time to employ the concepts of remote access, computerized provider order entry, workflow design / automation and  “e-patient” functions like secure e-mail and patient portals to really get things cooking.  I will cover those in detail in a future post.

Thanks again for reading and for your thoughtful comments.  The response so far has been very strong, far better than I had hoped.


Monday, August 30, 2010

Documentation Requirements are the Enemy of EMR

After 5 successful years with electronic medical records (EMR) I am convinced that the promise of EMR to improve physician practices and to improve the health care system is real.  If that is true, why is adoption of EMR currently limited to only 5 - 10% of medical practices?  Why is there so much resistance?  As folks who work in heath care IT so often ask, why don’t doctors “get it?”  I don’t mind the question but I do object to some of the sinister explanations that are offered.  Physician resistance to EMR is legitimate.  This post will explore one of the reasons for doctor resistance to EMR.

A few years ago one of our best referring physicians came to see me as a patient.  After we took care of his medical issues, I asked him how he liked our new EMR and the notes we were sending him through it.  His answer floored me: "I hate it."  That is NOT what you want to hear from one of your best referring physicians.  After a moment of drop-dead silence he added, "nothing personal.  I hate all the EMRs out there, including the one our practice just bought."

He went on:  "Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you.  I have to wade through lines and lines of empty verbage to finally find a meaningful sentence or two that tells me what I need to know.  Our own EMR notes are no better.  But there's nothing we can do about it, we just have to accept it."

Except for that last part, he is absolutely right.  Why did things get so bad?  

Doctors used to document their work with concise handwritten notes.  (See my last blog).   Then came CPT codes, which brought elaborate documentation requirements that medical records must fulfill in order to receive payment from the insurance provider.  These requirements measure the documentation, not the care itself.   Fear of documentation errors often force providers to code and bill at a lower level than their work truly deserves.  Physician revenues are thus limited not by the amount of real work performed, but by the sheer number of words one must write to properly document that work.  As long as chart notes had to be handwritten or manually dictated and transcribed, CPT effectively limited physician billing.  Providers became as much servants to documentation as they were caregivers.

This situation inspired the first marketing efforts by EMR vendors to physicians.  Recognizing the need, vendors promised improved, automated documentation and monitoring of charts for CPT compliance.  Doctors could finally bill safely at the appropriate CPT level.  With just a few mouse clicks the chart note can fulfill all the requirements to be CPT-compliant.  Now the physician can concentrate on the patient again.  In my experience this has worked well. 

But sometimes it's the side effects that kill.

EMR shows us what fully CPT-compliant documentation looks like. And it's awful. The folly of carrying CPT documentation requirements into the information age has been exposed. The relevant data are buried in a sea of white noise - patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  Each mouse click generates a bland, repetitive phrase in order to hit a CPT-mandated "bullet point."  The result is a multipage, single-spaced, small font monster of a chart note with very little substance relative to its size.   This obsession with documentation is distracting both EMR vendors and users from pursuing the real benefits of EMR - automation of workflow, rapid data exchange, reduced costs and improved efficiency.

Want a real incentive for docs to get EMR?  Forget HITECH.  Few doctors I know believe those incentive payments will ever happen.  All but the largest practices and major institutions will be defeated by "meaningful use" criteria.  Instead offer EMR users freedom from CPT documentation requirements.  Replace CPT with a system that is appropriate for the information age.  Leverage the power of EMR and create a system that rewards quality of care rather than volume of documentation. 

Easier said than done.  But recognizing the problem is the first step.

Thanks for reading.


Saturday, August 21, 2010

From Notecards to RAC’s: The Evolution (and Nightmare) of Medical Records

Medical record keeping used to be simple. 

I was born in the early 1960's and saw my pediatrician for regular checkups and common illnesses until going to college in 1980. The first 18 years of my medical care were completely summarized on five 5 X 7 notecards contained in a manila packet. Each of my visits was documented by a 1 to 5 line handwritten note.  There were no wasted words.  My pediatrician also set the standard for illegible doctor's handwriting!

How could my pediatrician get away with such a thing? In those days medical records served only one purpose: they were the physician's personal notes taken to assist him or her in future care.  The only outside request for my medical records was made to show I had my immunizations.

Things began to change in 1966 when the American Medical Association created Current Procedural Terminology codes, or CPT codes. The original set of codes addressed medical procedures only and did not include office visits.  A physician's bill to an insurance company for an office visit instead contained a narrative of the patient's symptoms and the care that was given.

Over the next three decades events conspired to make medical records far more complex. The emergence of comprehensive health insurance, including Medicare and Medicaid, separated the consumer of health services (the patient) from the payor of health services (the insurer). Because the payor for health services no longer directly witnessed the patient encounter, the medical record became a necessary instrument of proof that service was delivered. A single phrase record such as “severe tonsillitis” no longer sufficed.  CPT was revised to include codes that covered office visits ranging from simple level 1 visits to complex level 5 visits. Each level specified a set of documentation criteria that medical notes had to meet in order for the doctor to bill at that level.

Then medical liability was created.  The medical malpractice lawsuit, once considered inconceivable, became commonplace. Physicians were compelled to add even greater detail to their medical records in order to defend themselves against potential accusations of inadequate care. In training I was taught, “if you didn't document it, you didn't do it.”  Thus defensive medicine and defensive record keeping was born.

Next came managed care.  Under the guise of cost control insurers came up with a variety of tricks in order to delay and decrease payments to physicians. One of the most popular games was to use the minutia of CPT coding requirements as a means to reduce and/or deny payments. A physician can spend 45 minutes working up a complex, very ill patient, compose an extensive clinic note, and have payment denied because the “review of systems” in the note was technically (but not clinically) inadequate.   In more recent times CPT coding and the supporting medical record documentation have become so complicated that an entire industry has formed for the sole purpose of understanding CPT coding and training / certifying individuals in this new body of knowledge.

Another popular managed-care technique, still in use today, is pre-certification. In most insurance plans a surgeon cannot expect to be paid for an operation unless he gets prior approval from the insurer prior to performing the procedure.  Pre-certification is often not given unless the medical record documents the need for the procedure. This puts yet another burden on the medical record.

Finally, we have the ever-increasing threat of practice audits coming mostly from the federal Office of the Inspector General.  An audit includes an exhaustive review of the physician's billings to Medicare and a comparison of those billings to the corresponding medical records to be sure the records support the level of billing. Even the most conscientious physician fears the OIG audit, knowing that even the best documentation occasionally fails to meet the minutia of CPT coding requirements.   In some states these audits are now being performed by privately contracted firms (called recovery audit contractors or RAC's) that are incentivized to find problems and levy fines.  RAC auditors are not held accountable for their actions.

The future promises further obligations on medical record keeping.  Pay for performance, benchmarking, outcomes research and other similar plans will raise the bar even higher.
What began in the mid-20th century as simple professional note keeping has grown into a regulatory and liability behemoth, creating a burdensome obligation for the 21st century physician.  The medical record serves not only as the provider's reference but also as documentation of service, support for billing, support of proposed future care, defense against lawsuits and as a data capture instrument for outcomes research and future pay for performance initiatives.  The medical record must often face hostile audiences such has malpractice attorneys seeking liability or managed care providers looking for reasons to deny payment to the physician.  With the possible exception of RAC audits I don't regard any of the above concepts as inappropriate.  But they do make record keeping much more difficult. 

Into this complex and rapidly changing environment comes the electronic medical record (EMR), trying to hit a poorly defined, rapidly moving target.  And EMRs have additional hurdles made just for them, including CCHIT certification and the ever changing / growing "meaningful use" criteria.

In the next post I will review how the regulatory burdens on medical record keeping distract the EMR from its best, most noble goals: improving efficiency, lowering costs and improving quality of care.

Thanks for your time and interest.  Comments and corrections are welcome.


Saturday, August 14, 2010

Why did I create this blog?

Electronic medical records is getting lots of attention these days, especially with the Federal Government's incentive program regarding "meaningful use" implementation of EMR.  In our practice, ENT of Georgia we are in our 6th year of EMR, so we are far ahead of most.

Over the past 5+ years we have learned a great deal about bringing a medical practice into the information age - not just EMR but a host of other functions as well.  I hope to share what we have learned.