Physicians Practice has been asking physicians and practice administrators about their use of technology for over a decade. Now, many practices are on a second or third EHR system, and an increasing number use a cloud-storage solution for patient data.
Technology expert Derek Kosiorek, a consultant with the Medical Group Management Association, says "We see, especially [in] the healthcare sector, certain timeframes when there is a wave of technology adoption. … The big upgrade [for practices] was moving to the EHR." Chances are, your practice is somewhere in the process of implementing a new EHR, upgrading old systems, or adding new technology like a patient portal. If you are wondering where your peers are on the EHR adoption continuum, here's what we found out.
Hands down, EHRs are the largest piece of technology that medical practices purchase. Whether your practice is part of a large integrated delivery system or a small independent "shop," EHR is the scaffolding that supports all other technology use. According to our 2014 Technology Survey, Sponsored by Kareo, which asked over 1,400 physicians and practice administrators how they are using technology in their practices, 53 percent of respondents say they have a "fully implemented EHR," and another 17 percent use a system provided by a hospital or corporate parent. Only 20 percent of respondents say they do not currently have an EHR. When compared to past years, the trend is a slow but steady adoption of EHR: In 2010 (the year meaningful use became effective) 48 percent of responding practices had implemented an EHR, in 2014 that number was 70 percent.
John Squire, president and chief operating officer of Amazing Charts, says his EHR company, which caters to small primary-care practices (one to five docs), sees similar adoption patterns. Approximately "half of the practices we contact are coming from paper. We get about 30 percent of our business from 'switchers,' somebody who has adopted another EHR system or is getting off of it," says Squire. He notes that many non-adopters are finally deciding to purchase technology, a concept he calls "the last mile," because their attitudes on technology are changing and with the extended deadline for meeting meaningful-use targets, physicians can still take advantage of the financial incentives.
Even if practices decide to opt out of government programs like meaningful use, an EHR can support many practice operations like keeping clinical records and generating patient billing statements. Squire says his company also sees an increase in interest in patient portals for similar reasons. For those practices that are preparing to attest to the Stage 2 rules of meaningful use, it is a necessity to have a portal, but for those that don't the benefits to patients and practice alike are still very real — for instance, removing the burden of "call-backs" to answer routine patient questions.
Patient portals also give a competitive advantage to your practice. Kosiorek notes that patients have come to expect online access to services like banking. He predicts that, soon, practices won't really have a choice. "I think it is going to be a competition thing. Your competition down the street across town has that portal, so any patients are going to start migrating toward that, especially newer patients," he says.
According to our survey, attitudes about the challenges of technology adoption are also shifting. Three years ago, our survey indicated that "cost" was the primary concern for technology adopters. This year, that has changed: EHR adoption and implementation concerns came in first and cost slipped to third place. That dynamic is slightly different if the numbers are sorted by independent and hospital-owned practices. But not as much as one might think: Adoption and implementation of EHR is the primary concern for both groups, with interoperability and cost in a near tie for second place for independent physicians. For hospital-owned practices cost is much less of a worry.
When planning on acquiring an EHR, one way practices can address the twin issues of cost and technical support is by becoming part of a hospital or integrated delivery system; especially in rural areas that have fewer resources and large numbers of uninsured patients. Once abhorred by independent physicians, for some, the financials are proving hard to resist. Our survey indicates that 64 percent of respondents are in independent practice, while 36 percent are owned by a hospital. A slight majority of independent docs, 42 percent, say they are in solo practice and 33 percent practice with two to five physicians. That differs significantly when compared to the hospital-employed physicians, where there is a greater spread in practice size. On one end of the spectrum, 32 percent of respondents say they practice with two to five physicians, and on the other, 20 percent practice in a group with over 50 physicians.
Jo Orquia runs a small family medicine practice — located in a suburb of Atlanta — that consists of himself, a new physician partner, and a nurse practitioner. However, because his practice belongs to a large integrated delivery system, he's actually part of a multi-specialty group that has over 700 providers and is spread out over many locations. He's been in practice for over 20 years, and during that time he's vetted and partially implemented three different EHR systems, all with the help of his hospital network. Orquia firmly believes that his practice has benefitted from having access to hospital resources and IT support. He says that had he been in independent practice, he would have been pressured to pick a much less expensive EHR system.
Even though Orquia started his quest to adopt EHR in 2002, he's presently only a month into implementation of the hospital system's new EHR. While he says it has slowed down productivity, from prior experience he knows work flow will improve when he masters the learning curve.
However, he's less than pleased with the bureaucratic processes associated with his new system. "The frustration that I have now is simply, it takes so much time to do the things [EHR] requires me to do," he says, referring to his health system's requirement that as the physician, he must personally order tests and studies that previously he relied on his NP to order, with his supervision.
Forty-seven percent of respondents to our survey indicated that implementation of an EHR made their practice work flow more efficient; while 32 percent said they had not benefitted from new work flows. However, as Orquia notes, it takes time to fully implement and train staff members on a new system. Seventy percent of responding practices said that they had a fully implemented EHR (software/ hardware installed, and all providers and staff trained and using the system as needed) within one year of acquisition.
Independent practice concerns
Brandon Peters' solo practice, Northeastern Family Medicine, has been providing care to the citizens of Elizabeth City, N.C., since 1872. It is truly a family practice: before Peters, his father ran the practice, and before him, his grandfather and great uncle did. Elizabeth City is a small town about 50 miles south of Norfolk, Va., where 28 percent of the population lives below the poverty line. For Peters, that means a negative impact on his practice revenue.
"Unfortunately, some folks that make the commute up to the tidal area to have service have insurance, but we have a large uninsured population," Peters explains. That was part of the impetus for him to abandon his standalone practice management system two years ago and to adopt a new EHR system. He feels strongly that newer reimbursement models will depend heavily on reporting quality patient-care measures.
Squire sees the same trend in terms of practices adopting and using data systems that will not only document patient visits and facilitate automated billing tasks, but are also integrated with regional healthcare delivery networks. "[Primary-care physicians] see a little bit of everything," says Squire, "… they are basically the triage for the healthcare system. And they've got to interact with all these delivery systems; hospitals and larger [integrated delivery networks] and ACOs … and want the data portability and the ability to fit into all those systems."
Even for those physicians who are not wholly connected to data networks, Squire says the majority of physicians he talks to are embracing technology like e-prescribing and automating lab orders. "There's a clear payback there. If you look at one screen and see all your lab results come in, it's very convenient vs. a pile of faxes."
Another benefit to practices that adopt EHR will come through better transitions of care; for instance being notified when a patient is discharged from the hospital. Squire says that process is not as smooth as it should be, but CMS is working to automate it — and provide for greater provider reimbursement. New procedural codes for transitions of care will "allow the physician to basically make more money [for] follow-up care," Squire notes.
Peters does believe there is value in collecting and reporting patient data, but he's not convinced that translates into better patient care or improved work flow. He's even changed the structure of the questions he asks his patients during the office visit, so that he can better enter the data into the EHR. He fears that change will tarnish the patient-physician relationship. He likens the EHR-directed patient visit to driving 70 mph on the interstate, where changing direction is not an easy maneuver.
Peters also says he struggles with completing patient notes and often stays late at night trying to finish up. In that regard he is not alone. A third of respondents to our survey said EHR made their work flows more difficult. Peters says he cannot afford to hire someone to help him enter patient data. "I know some people have scribes … so you are not trying to collect [data] in real time while the patient is right there in the office. But the value, the charge for each one of our visits is so low … we're only getting $35, $40 per patient," he explains.
Using a medical scribe may be a concept before its time: Only 21 percent of our survey respondents indicated that they used a scribe to help enter patient data.
Since his practice consists only of himself, a receptionist, and a nurse, Peters must wear multiple hats — which make further drains on his time and pulls him away from patient care. "If we had somebody in-house to run the system, to customize the system, to keep it running, to do the updates, to make sure the printers worked, to make sure everything ran together [it would be better]."
New tech tools
If you contrast the hospital-owned group versus the independent practice contingent, it is clear that goals like implementation, access to new technologies, and IT support are more easily attained with the help of an integrated delivery system.
Robert Goldszer is chief medical officer at Mt. Sinai Medical Center in Miami Beach, Fla. Mt. Sinai is a 600-bed teaching hospital that also has five multi-specialty satellite clinics located within a 10-mile radius from the main campus.
The hospital uses an EHR that is accessible to providers on inpatient, outpatient, and teaching services. It can also be accessed remotely through laptop, tablet, smartphone, or whatever device is convenient. Goldszer says that physicians who treat patients at satellite clinics carry no patient charts. "I [the provider] just drive there, I log in to the desktop or my iPad, and I can do all the computing and look at every chart, write my notes, and see all the results I need," he explains.
Goldszer notes that Mt. Sinai has implemented several of the newest healthcare technologies: a HIPAA-compliant texting application; a heart-rhythm monitoring and reviewing application that uses telemetry; a diagnostic imaging application that can be viewed on mobile devices; and a patient portal.
The hospital also supports its residents' technology use by giving them an education allowance — which many use to buy an iPad.
"In this hospital on … teaching rounds, there's an attending, two interns, and three of the people have their iPad out. One of them is reading something from UpToDate or technology that they have online; the other person is looking at the X-ray; and the other person is writing the orders," says Goldszer.
While most practices have adopted an EHR, concerns about implementation are still front and center. Here are some ways to make technology work for your practice:
• Use hospital/laboratory data networks to share/transmit patient records electronically;
• Write and transmit prescriptions electronically;
• Avoid printing and faxing reports, lab results, and prescriptions;
• Select EHR systems that allow remote access to patient data on mobile devices; and
• Use a cloud solution to store patient data — reducing expenses for upgrades, maintenance, and support.
Erica Sprey is an associate editor at Physicians Practice. She can be reached at firstname.lastname@example.org