Though making the switch to electronic technology may generate some built-in efficiency, is it a reach to suggest its use boosts quality of care? One expert explores the costs and factors.
Listen to John Thompson, MD's presentation at the 2014 meeting of Current Concepts in Ophthalmology at the Wilmer Eye Institute/Johns Hopkins University in Baltimore.
Take-home message: Though making the switch to electronic technology may generate some built-in efficiency, is it a reach to suggest its use boosts quality of care? One expert explores the costs and factors.
By Stephanie Skernivitz
Baltimore-It’s no secret that many in the health-care arena-insurers, patients, governmental regulators, lawyers, and physicians-are tired of handwritten records.
Thanks to the push behind the Health Information Technologyfor Economic and Clinical Health Act passed several years ago, it provided strong incentives for pursuing electronic health records (EHRs), according to one expert. Though making the switch to electronic technology may generate some built-in efficiency, is it a reach to suggest its use boosts quality of care?
“The basis of this discussion is that the U.S. government and regulators are convinced that EHRs can improve the quality of care given the patient,” said John Thompson, MD, a partner with Retina Specialists, Baltimore, and a member of Greater Baltimore Medical Centers ophthalmology department and its Advisory Committee chairman.
The thought is that it is also going to decrease the cost of medical care by saving complications and reducing unnecessary testing and more, Dr. Thompson added.
“If your practice switched to EHRs by July 2014 you were eligible for a $24K bonus,” he said. “If you didn’t achieve meaningful use by July 1, you were to be penalized 1% this year.”
The requirement was for physicians to have it done by July 2014, but if a vendor couldn’t produce the 2014 version in time there were exemptions, if done by January, according to Dr. Thompson.
“The interesting thing many people don’t know is that if less than 75% of eligible professionals achieve this, by 2018, the penalty is going to ratchet up to 5%,” he said.
“To qualify, you need $55K in Medicare collections over a 5-year period, you need to fill out a form, and make sure your EHR vendor is certified for the particular stage that is required,” Dr. Thompson said. “For Stage 1 you have to do all 13 items and have to do at least five of the 10 menu set items.
“Also as of 2015, you have to do nine of 64 clinical quality measures,” he said. “Once you do Stage 1, you have two years to get to Stage 2, which has 17 core objectives and is more rigorous. Then you have to do three of the six menu measures.
As for Stage 3, “We don’t even know what Stage 3 is going to look like. You’re signing onto this but you don’t know what’s going to be required a couple years from now,” Dr. Thompson said.
The IRIS (Intelligent Research in Sight) Registry spearheaded by the American Academy of Ophthalmologists allows physicians to report quality measures.
“It’s basically pulling this quality data from your medical records, but you have to report it properly to get this data,” Dr. Thompson said. “The IRIS registry is an approved Physician Quality Reporting System (PQRS) registry for 2014 and will likely be approved in future years.”
According to Dr. Thompson, IRIS is one of the reasons you should consider using EHR. It’s going to be necessary for the quality component.
For practices “on the fence” about whether to pursue the electronic record route, the reality is that PQRS is also likely going to require EHR in the future, so there will be additional penalties if they don’t do this, he said.
But the question remains: “Does EHR improve quality?” Dr. Thompson asked.
He cited a recent report analyzing peer review literature that found no evidence that hospitals with EHR systems delivered better quality of care for key indicators, for example, myocardial infarction or pneumonia.
Aside from quality, there’s also a great cost noticed even by regulators in Medicare who acknowledge how use of EHRs is costing more.
“People with EHRs tend to charge more for their office visit on average,” Dr. Thompson said. “Medicare is very concerned about this.”
Nevertheless, use of the systems is not going away.
Once the decision has been made to pursue the EHR route, there are two basic platforms from which to choose-server-based, where computer hardware and software is housed in the office; and cloud-based, where hardware and software is at the company or another third-party site and the office connects via application service provider via Internet.
“What’s nice about the server-based system is that you own your data and computer-it’s all in the office,” he said. “You just have to access the local area network to get to your records.”
The disadvantage is that it’s more costly. It is necessary to buy hardware, software, maintain it, and upgrade it, as well as the need to have I/T support around the clock and rapid replacement of broken parts.
Conversely, with the cloud-based system, the start-up costs are minimal. There is an initiation fee of several thousand dollars, then a monthly fee of $700 to $1,000 per physician per month.
According to Dr. Thompson, there are few hidden costs since the company does maintenance of upgrades as part of these costs. These companies usually have sophisticated back-up systems and redundant servers to keep the system running.
“But the disadvantage (with cloud-based) is that if the product is unreliable, you cannot access your medical records,” he said. “They also control your data. All that medical information sits on their servers not in your office.
“You’re also totally dependent on the reliability of your internet connection, which can be expensive,” Dr. Thompson said. “And you have to have back-up Internet in case your primary Internet goes down.”
When ready to choose a system, Dr. Thompson advises involving the staff in reviewing what is available.
“It’s important to have a vendor do a demo in your office with staff present,” he said.
Before committing, seek outside input. Talk to users of the software you are considering. How good is customer service?
Once you’ve chosen a vendor, Dr. Thompson said it’s necessary to negotiate a contract and terms and determine whether it will hook up with other imaging devices.
“If you choose a cloud-based system you want to insist on monthly downloads of data to your office so that you have your data and it’s not just at the company,” he said. Also you need to have an exit strategy should the system fail.
When up and running, it’s crucial to have a nonphysician become the project manager.
“That person needs to become the super user who’s going to help physicians deal with EHR problems,” Dr. Thompson said. “That person also needs to get expedited support from the EHR vendor whenever they have a problem.”
Expect the transition to EHR to take from 3 to 9 months.
“It’s disruptive to virtually every medical practice,” he said. “Careful planning helps to reduce severity of disruption.”
Not only is it disruptive, but also EHR implementation can sabotage productivity. According to Dr. Thompson, many practices that have transitioned from paper to EHR have found physician productivity decreases from 20% to 40% during implementation. Practices also end up needing more staffing.
Further, a drawback to EHRs can involve data input. Entry of patients for the first time in an EHR system takes 10 to 30 minutes per patient.
“If the physician is going to input data, often the patient is going to feel ignored while the MD struggles to input relevant information such as history, exam data, etc., ” he said.
How do you begin to implement? Start entering a couple patients per day, according to Dr. Thompson, then increase rapidly over weeks and months until every patient is entered. Tablet or PC-compatible devices can be very helpful for MDs to enable the physician to have eye contact with the patient while talking with them.
What about ROI for your practice?
“We did a back-of-the-napkin calculation and it was about $70K per physician for personnel costs and $20K per physician for EHR system on a yearly basis, but saved about $20k in transcription costs,” Dr. Thompson said. “Net is $70k per year. If you add the 5% penalty, that’s not going to cover the $70K per year. It’s an added cost to you.”
What about start-up cost? According to Dr. Thompson, it’s about $30K per physician for entering/pre-entering charts.
“The only way your ROI for EHR is positive is if you see more patients per day or bill higher levels for service,” he said. “Otherwise, it’s never going to make sense economically.”
Where are the advantages? For one, there’s an ability to carry exam data forward via copy/paste. EHRs also can help improve documentation to build a level 3 or level 4 visit; can enable you to access patient information from anywhere; do away with paper; and can give the patient a completed exam when they leave.
EHRs are going to be essential to participate in quality measures, he noted.
“Eventually, ophthalmology EHR systems will improve documentation,” Dr. Thompson concluded. “It might improve quality of care, but will not save you or insurance companies any money.”
John Thompson, MD
This article is adapted from Dr. Thompson’s presentation at the 2014 meeting of Current Concepts in Ophthalmology in Baltimore. Dr. Thompson has consulted for Kaleidoscope.