What's Plaguing E-health?

March 26, 2007 Computerworld Thomas Hoffman

The new electronic medical records system at Harbin Clinic has the strong support of its CEO, board of directors and chief medical officer. Its technology can improve patient outcomes while saving physicians money. But cultural issues, including resistance from some of Harbin’s physicians, have stretched the implementation from two and a half years to four.

Welcome to the world of EMR, where the best technology and the best intentions come smack up against the inertia of human nature.

Advocates of EMR contend that melding these systems with the work processes of physicians, nurses and administrators can dramatically improve the quality of patient care and cut waste out of health care costs. For instance, by using an EMR system, a doctor can view a patient’s entire medical history, use a rules-based engine to pinpoint potentially harmful drug interactions and receive suggestions for new tests and medications.

Studies have shown that the use of EMR systems can help reduce medical errors, including misdiagnoses and unintentionally harmful prescriptions, leading to fewer accidental patient deaths.

But to date, EMR adoption has been a big challenge in the health care industry. Rome, Ga.-based Harbin Clinic is a case in point. Georgia’s largest privately owned, multispecialty medical clinic has 135 physicians spread out across 20 locations in northwest Georgia and northeast Alabama. With 33 different medical specialties under its roof, ranging from endocrinology to ophthalmology, Harbin has had a tough time getting various specialists to adapt their work processes to accommodate the EMR system from Chicago-based Allscripts LLC that it’s installing. Indeed, the cultural and work process differences among these specialists has made the EMR implementation “more difficult than I would have imagined,” says Harbin CIO Tom Fricks.

However, primary care physicians at the clinic immediately embraced the EMR system, since they found it easier and cheaper to key in patient information than to pay a third party to transcribe dictation, says Fricks. But high-end specialists, such as cardiologists, have been considerably more resistant to learning and using the Allscripts TouchWorks EMR system, says Fricks. Cardiologists “don’t want aggravation in their lives,” he explains.

Despite strong support of the EMR system from Harbin’s CEO, the board of directors and its chief medical officer (who happens to be a cardiologist), the project has dragged on.

“It’s been a long process for us,” says Fricks of the estimated $2.5 million to $3 million effort, which Harbin expects to complete in June.

The clinic’s difficulty implementing EMR is not unusual. According to a study released last July by the National Center for Health Statistics in Hyattsville, Md., just 9.3% of all physicians in the U.S. use complete EMR systems. “It’s a field strewn with the carcasses of broken promises,” says Mark Frisse, professor of biomedical informatics at Vanderbilt University in Nashville.

That’s why Medicare and a handful of health insurers, such as Blue Cross and Blue Shield of Massachusetts Inc., have begun to sweeten the deal for doctors by offering “pay for performance” incentives that are aimed, in part, at enticing physicians to adopt and use EMR systems to improve their quality of care.

Pain Point

But physician resistance isn’t the whole problem. Cost constraints, the lack of dedicated IT staffers at smaller physician groups and the disruptive impact that EMR installations can have on a health care organization have also limited adoption rates.

Installing a full-blown EMR system at a large hospital can cost up to a few hundred million dollars, says Frisse. That’s a big chunk of change, especially for cash-strapped hospitals. Plus, roughly 3,000 of the nation’s 5,000 hospitals are not-for-profit institutions, notes Eric Brown, an analyst at Forrester Research Inc. in Cambridge, Mass. Unlike for-profit hospitals, those organizations don’t have shareholders “clamoring for profits” through improved technology, says Brown, so there’s less pressure to invest in EMR systems.

EMR investments can be even more daunting for small physician practices of, say, two to six doctors. The average cost per physician for EMR system evaluation, installation and training runs about $40,000, says John Halamka, CIO at Beth Israel Deaconess Medical Center in Boston. He is also chairman of the Healthcare Information Technology Standards Panel, an ANSI-backed initiative that’s aimed at facilitating interoperability among health care applications.

Another problem is that the primary benefits that EMR systems generate — higher-quality care and improved patient outcomes — are skewed toward fattening health insurers’ profits and helping patients, says Halamka.

“The individual who receives the least economic value is the physician,” says J.P. Little, chief operating officer and acting CEO at RxHub LLC, a nationwide information exchange in St. Paul, Minn., that connects physicians, patients, pharmacies and pharmacy benefit managers. That’s where pay-for-performance incentives may tip the scale, Little says. “If a doctor got a bonus of ten or twenty grand to improve quality of care, they’re going to adopt the technology,” he says.

Operating Room

Another barrier to EMR adoption is the disruptive impact that these implementations can have on a health care organization’s short-term operations, especially for smaller entities. It’s a tough sell to persuade physicians to buy EMR systems that can force them to cut back on their patient loads (and revenues) by as much as 25% for up to a month during the implementation transition.

“If you’re a four-person practice, you can’t afford to take four weeks off and tell patients to come back and see you when you’re ready,” says Frisse.

These constraints have led to the emergence of application service provider (ASP) type EMR applications aimed at lowering the costs and burdens associated with on-site installations. Cerner Corp., a Kansas City, Mo.-based health care software provider, has been offering hosted support of its PowerWorks clinical and practice management software to individual and group physicians for the past two years at a flat rate of $595 per month, says Michael Ash, a vice president in Cerner’s community health organization.

Still, some physicians are leery about having a third-party entity store confidential patient information, says Dianne Koval, director of physician services at MedAllies Inc., a health care consultancy in Fishkill, N.Y., that’s just starting to roll out ASP services for two EMR applications to 25 health care providers in New York’s Hudson Valley region.

To ease those concerns, MedAllies’ salespeople demonstrate to physicians that under a hosted model, “they don’t have to worry about employees or patients tampering with records,” says Koval. “They realize it’s more secure.”

Nonetheless, the ASP-style approach isn’t a cure-all. For instance, Evanston Northwestern Healthcare in Illinois implemented an EMR system from Verona, Wis.-based Epic Systems Corp. in late 2003 for its 500 doctors. The $35 million effort has been viewed as a success and has generated a three-and-a-half-year return on investment, says CIO Tom Smith.

Still, it has been challenging to install the system in the practices of the other 40 independent physicians who work part time at one or more of Evanston’s three hospitals, says Smith.

“A lot of [these] physicians don’t have computers,” he notes, and even those who do would have to have LANs installed in their offices to link the various partners. To install the Epic system for these independent doctors, implementation work would have to be done before and after regular work hours so as not to disrupt office operations and patient care, Smith says.

“It could easily cost $50,000 for an office of two or three [physicians] under an ASP-type setting with us,” says Smith. “It takes a lot of work.”

Yet the EMR implementation, which Evanston broke down into several discrete projects, has otherwise been a success for the company. Part of the reason is that Smith and his team worked closely with nurses and physicians to address workflow changes that the system required and to set clear payback expectations, he says.

The results have been worth it. “It’s so much faster to do business this way,” says Smith. For instance, the time it now takes to turn around lab results electronically for a patient “is like the difference between sending e-mail and regular mail,” he says.

It’s important for health care organizations to recognize that an EMR implementation requires significant business process and workflow changes and isn’t simply a plug-and-play application, Smith says.

Allina Hospitals & Clinics in Minneapolis realized that early. It’s in the final throes of a four-year, nearly $250 million effort to install an Epic EMR system throughout its 11 hospitals and 65 clinics in Minnesota and western Wisconsin. Because the implementation is so comprehensive, the company decided to run the project out of its operations group instead of IT, says Kim Pederson, vice president of the EMR implementation.

“This really wasn’t about implementing software,” says Pederson. “This represents work that the vast majority of our 23,000 employees do every day. This was, as much, if not more, about process redesign and change management than about delivering the software. So we deliberately positioned it outside of IT for those reasons.”