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.

MK

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.

MK