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Deborah Leyva

Tom, thank you for your insightful and comprehensive analysis and reply. I agree with your assertions and find it to be well written and clear on the points you make.

Indeed, use of an EMR has potential to eliminate inefficiencies in practice management, although education is a key factor in its use since many providers are unfamiliar with technology use. The "younger generation" of physicians are apt to be more comfortable with the technology as you clearly pointed out - they grew up with it.

In addition, for EMR use to become mainstream to a practice, I believe it will evolve as a culture change in the way healthcare is delivered.

Thank you for sharing your insightful comments, experience, and perceptions on use of technology in healthcare.

Tom Anthony

Deborah: I worked in IT management (CIO) of two large medical groups for most of the last thirteen years. In each case, we installed a first generation clinical repository and began implementation of full EMR features. From the standpoint of the physician owners of a medical group, there is usually a very clear-eyed examination of cost and benefit. At least for the systems we examined, the software and maintenance costs of acquiring the systems where not the prime cost concern. I think for most providers, the biggest concern was about the loss of productivity and the possibility of having to see a few patients less each day to make up for the documentation tasks that would fall on their shoulders. Most of the providers had many years of experience with dictation as their primary source of charting and were quite proficient with this process. Managing transcription well could hold the cost per patient down to a manageable figure compared to the cost of physicians’ time if they now had to spend substantial time doing their own data entry.

Setting nursing staff resistance aside (not a minor consideration in an environment where each clinic or physician office can often be somewhat autonomous), there has to be a compelling economic benefit to overcome the inertia of “the way we have always done it”. Physicians are by no means technology adverse, they will rapidly move to the imaging and surgical technologies that will improve the quality of care and reimburse their practice for the cost of the technology.

I think there has always been a healthy skepticism among physicians that EMRs can improve the quality of care they provide. It is felt that medication alerts are often suspect as a being unnecessarily sensitive and usually not applicable to their patient/order. I think it has been greatly appreciated that lab results, diagnostic images, and transcribed reports were available so much faster in automated systems but most had access to these repository features without the full documentation EMR.

What has been getting more practices to commit is a combination of economic factors. First, financial incentives for chronic disease management would be very difficult to earn across a group practice without online documentation and a system that can provide reminders for the conditions being monitored. There have been small financial incentives from malpractice carriers for the adoption of EMRs. The ability to do some of the “office work” at home on their own schedule (or better yet be completed before they leave the office) has been a significant lifestyle improvement as well.

Widespread adoption will follow EMR systems that are evolved enough to truly improve workflow within a practice (avoiding some of the extraordinary amounts of telephone tag for test results, prescription questions from pharmacies, records from other practices, and consultant reports). As documentation demands are reduced through interfaced diagnostic equipment, voice recognition, and more intuitive user interfaces, the productivity toll on the mid and late career providers will be lessened. The 20-something providers and those now in training will expect nothing less than systems as intuitive as the systems they have lived with since their pre-teens. The physician recruiting factor becomes a more important EMR driver each year.

I do not mean to seem crass that quality has been a more minor driver. As said earlier, physicians care a great deal about the quality of patient care but are skeptical that we have yet reached that tipping point that EMR=better quality. Larger groups and academic practice plans with dedicated quality improvement functions are beginning to realize the powerful value in data mining to understand variations in care and the impact on patient outcomes. Evidence-based logic will become continuously better and more accurately targeted to provide greater degrees of patient safety.

Deborah Leyva

Gosh, how could I forget usability? Pamela, thanks for the reminder!

As a former technology and software developer, I spent a great deal of time in the trenches learning how people go about their business on a daily basis to identify requirements and specifications for development of custom software. Part of those specifications included the workflow process to ensure that the software worked in concert with existing processes. But that is custom software.

The EHR market and Health IT in general, seems to have a myriad of vendors who are most likely going to support at least 80% (but not 100%) of the market's needed functionality. Unfortunately this means that an EHR software selection may require considerable effort when implemented, requiring the need to adapt workflow processes to the software, rather than the other way around.

Software usability is a key foundation, perhaps even one of the most important considerations, for any software application. Ease of use for any software may determine how well it is used.

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