Debating the prose & cons of implementing EMR EHR.

1. No, Don't Buy an EMR Now! Yes, Buy an EMR Now!
Gregory A. Hood, MD;
Joseph E. Scherger, MD, MPH
No, Don't Buy an EMR Now!
Introduction
Electronic medical records (EMRs) evoke strong reactions, from anger to
enthusiasm. The US Government considers EMRs vital to controlling
healthcare costs and improving patient care, but adoption is lagging.
Doctors cite cost, work slowdown, potential problems and difficulties,
and other issues as reasons to avoid an EMR. Medscape invited 2 experts
to present their points of view on whether doctors should buy an EMR
now.
On "point," we welcome Gregory A. Hood, MD, internist with Drs. Borders
and Associates, PSC, in Lexington, Kentucky, and Governor-Elect of the
American College of Physicians, Kentucky chapter. On "counterpoint," we
have Joseph E.
Scherger, MD, MPH, Clinical Professor of Family & Preventive Medicine
at the University of California, San Diego School of Medicine
California, and Medical Director of Quality and Informatics at Lumetra
in San Francisco, California.
No, Don't Buy an EMR Now!
Point: Gregory A. Hood, MD
Everyone says that 2009 is the year that everyone should buy an
electronic health record (EHR). It slices, it dices, it fixes
everything that is wrong with healthcare delivery in the United States.
Not so fast. In spite of the fervor for EHRs in Government and the
press, now is the time to make sure that you have both feet planted
firmly on the ground.
before you purchase an EHR for your practice.
I have been using one EHR or another for about 12 years. They have
advantages and limitations, like any other instrument. I was driven to
use one because drastic circumstances in my practice required a
"failsafe" means of records retention. I also had a desire to document
more expansively and a natural inclination for technology. After 8
years of effort I was able to generate real-time completed office notes
during the face-to-face time with each patient.
This brings me to my first caution to you. If you expect "plug-and-
play"
technology, then this is not the time for an EHR purchase. You must be
ready to spend 4-6 months in preimplementation preparations, learning,
and data entry (scanning or manual data entry) and another 6 months of
diligent, daily, personal utilization of the system before expecting to
be proficient.
Furthermore, every single estimate of improved quality and reduced
quantity of redundancy in healthcare delivery is predicated on the
quality and intensity with which the conversion and day-to-day

2. management of data into the EHR is conducted. An empty EHR, one with
incomplete data entry, or one whose use is abandoned after a year of
trying to adopt it does nothing to improve quality, efficiency, or
national healthcare delivery.
If you believe that the EHR will guide you to more accurate coding and
boost practice revenue for you, paying for itself in the process, then
I must caution you again. Physicians are ultimately responsible for the
codes entered, no matter the method by which the coding level was
derived.
Do you expect the EHR vendor to stick up for you in an audit because of
what their coding module suggested? Think again. Rightly, it is the
physician, not the computer, who makes the code-level decision. The
main place where I have seen outright dollar savings from an EHR is in
the front office, where it is nearly invisible to the doctor in the
day-to-day practice of medicine. Not paying $8 for each new internal
medicine patient's manila chart and dividers
-- and not paying for staff to run around to each other's desks looking
for them -- are examples of savings that can be garnered.
Yes, it is possible that your practice may also see a bottom-line
difference if you purchase one now. The Government promises $44,000 for
each doctor when a qualifying system is purchased. However, caution is
warranted here again.
There are hurdles and heretofore unannounced qualifications to meet in
order to receive this money.
With the present economic woes and the uncertain outcome of the
national healthcare debate, this may not be a wise moment in history to
be saddling oneself with additional debt, unless your practice is in a
position to pay cash for the product.
Further, this is only for the upfront cost. Committing to an investment
of hundreds of thousands of dollars and hundreds of hours of both
physician and staff time in order to get a rebate is not a decision to
enter into lightly.
Also, if you are not prepared for the monthly IT bill for system
monitoring, maintenance, and replacement of broken or failing
equipment, terminals, and servers, then you may be in for a big shock.
Besides, don't forget that EHR programs go through periodic "upgrades"
and new releases, some of which may require more robust hardware than
previous editions. Such changes mandate payment for new, expensive
equipment to replace perfectly serviceable hardware which has been
rendered obsolete by your EHR partner's decisions on enhancement
priorities. These enhancements may or may not enhance your method of
patient care.
It is imperative that you obtain a full-total-cost quote IT service
contract from your proposed support company or you will have budgetary
shortfalls. Your IT partner and your practice must have contingencies
for when your EHR is down. You will experience power failures -- from
ice storms, for example. You will experience times when phone and
Internet services are down because cracked insulation on the 50-year-
old phone line that serves your building is letting rainwater into the
wires and degrading the signal. I've been there; trust me.

3. What's more, a typical EHR may boast a 99.8% "up time." This sounds
impressive, but it means that almost 18 hours a year you won't have
your EHR, even if you have electricity and phone service.
Again, now is not the time for an EHR purchase if you expect (as many
patients
assume) that data from hospitals, labs, and other doctor's offices will
flood into your system automatically from all over the galaxy. Each
interface requires programming, testing, verification, and periodic
updates and revisions. This can be tedious, time consuming, and at
times impossible due to incompatibilities. Evolving Government
standards for systems may force you to scrap presently functional
systems and implement others in order to qualify for stimulus monies
and avoid penalties.
The future does include EHR technology. The picture could be much
clearer in
6-12 months. Now is the time to investigate, to strategize, to start a
comprehensive plan to review options. Now is not the time for a hasty
decision.
Because compliance with the meaningful EHR use in 2012 still qualifies
for $44,000 from Medicare over 5 years, and compliance in 2013 only
lowers this figure $5000 a year, it is more important to take the time
to make the best decision you can, rather than make a rushed "now"
decision. Unless and until you have full answers with complete
confidence about each issue discussed here and about other issues
unique to your personal circumstances, an EHR won't help you to live
long and prosper.
Yes, Buy an EMR Now!
Counterpoint: Joseph E. Scherger, MD, MPH
If you have been waiting to buy an EMR until now, you have made a good
decision. I and other early adopters of EMRs struggled through initial
versions of these records and didn't any great return on the
investment.
However, my EMR successes have improved over the years. I launched an
EMR back in 1994 in a teaching practice in San Diego, and that practice
is now on its eighth version of the record. I have also been part of a
health system conversion to a leading EMR started 5 years ago, and it's
been a real success.
For small-to-medium private practices, waiting until now has been a
very reasonable decision, while the industry and its products, pricing,
and standards has been getting its act together and improving. But the
waiting period is over. It is now time to act.
There are 3 compelling reasons why now is the time to begin the
strategic planning to buy an EMR and to install it later this year or
in 2010. The first is to take advantage of the stimulus dollars that

4. are available for this purpose. The second is that EMRs are now
affordable for any medical practice.
Third, in a few years, the standard of care will require the benefits
of an EMR for improving the quality of care. You will be at a major
disadvantage in medical practice without one.
1. Take advantage of stimulus dollars: The passage of the American
Recovery and Reinvestment Act (ARRA) this year included the Health
Information Technology for Economic and Clinical Health (HITECH) Act,
giving $19 billion for the adoption of EMRs. The opportunity is there
for every physician to collect $44,000 over 5 years for "meaningful
use" of a certified EMR.
This amount of money would cover the cost of any leading EMR and its
maintenance over the next 5 years. The federal government wants to
cover your costs of an EMR! There will be penalties in lower
reimbursement from Medicare for not having an EMR by 2015.
This is a no-brainer! As the details become clearer, can you imagine
the rush to install the best EMRs? Act now, act carefully and wisely,
and beat this rush while plenty of help is available. At some point,
manufacturers' training staffs could become so overscheduled that they
will not be able to supply adequate training on a timely schedule.
2. EMRs have become more affordable for a private practice. Amazingly,
Wal-Mart stepped up to the plate and has challenged physicians to stop
complaining about the cost of an EMR. eClinicalWorks is one of the
leading small-practice EMRs and Wal-Mart has contracted with this
company and with Dell to cut in half the cost of installing an EMR.
Instead of $30,000 per physician, it is now about $15,000. Borrow the
money if you need to and take advantage of such a price. You will get
it back from the government.
Better yet, Congressman Pete Stark (D-Calif), watchdog over any deals
struck between hospitals and doctors, led a Congressional exemption to
the "Stark rules" to allow hospitals to subsidize the cost of an EMR
for members of its medical staff. This allows the physician to install
the same system that the hospital uses and to take advantage of
interoperability with the hospital and other physicians in the same
medical community.
If your hospital is not taking advantage of this historic means of
connecting the hospital with its physicians, you need to meet and
encourage this. Some of the best EMRs are only available to large
systems, and by teaming up with your hospital you may be able to get an
EMR that you could not buy otherwise.
3. Improve the quality of care. In the long run, this is the most
important reason to get an EMR. Having the patient's data available
when making decisions, such as when on call, improves care.
Applications of an EMR, such as electronic prescribing, reduce errors
and improve patient safety.
All of the leading EMRs are imbedding in their record current medical
knowledge to guide clinical decision making, such as drug-drug
interactions, drug-disease interactions, and the latest clinical
guidelines for preventive services and the management of chronic

5. diseases. Physicians with an EMR have their care guided by the medical
record. Those without an EMR are "winging it"
off the top of their heads.
When it comes to avoiding errors in diagnosis and in disease
management, physicians with EMRs will be at a distinct advantage. As
having an EMR becomes the standard of care over the next 5 years, you
will have trouble defending yourself in a medical malpractice case
working without one if an EMR could have prevented the error in
diagnosis or treatment.
Don't suffer from "mural dyslexia," difficulty reading the writing on
the wall. Now is the time for all physicians to begin the conversion to
EMRs. The federal government has stepped up and supported physicians.
The carrots and sticks are being put into place. You do not need to act
hastily right now, but form a leadership team in your office that
studies the EMR options carefully and presents a plan. Act on that plan
so you beat the rush. Get your EMR this year or in 2010 at the latest.