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Removing obstacles to the paperless office

By Diane Lares

Many doctors dream of a “paperless office.” No paper equals no paperwork, right? The day will flow with interesting and satisfying patient clinical encounters without the hassle and aggravation of finding and reviewing mounds of medical records for each patient. Missing charts and misplaced labs will no longer exist.

In the past, the percentage of revenue invested for information technology in the health care industry has been significantly less than other major industries, such as financial services. With health care being an information intensive endeavor, the complexity of the information needs, and the reluctance of some physicians in health care to adapt effectively to applications have severely crippled the progress which has been made in medical computing.

There are a variety of physicians practice management software applications that were designed prior to managed care with subsequent “add-on” modules of software to handle the complexities of prepayment systems such as capitation. Now these same practice management systems are adding on medical record modules.

Sometimes in implementing new systems, the processes have not been analyzed so the information system is designed to replicate and record the paper process. This can lead to maintaining complicated and expensive paper processes now completed on the computer.

The use of electronic medical records has been slowly growing but is not expanding as quickly as many expected. There are several potential reasons for this:

It is not the way we do it. The paper chart is very comfortable for clinicians. Although there are difficulties in finding charts periodically (up to 30 percent of the time according to some studies) and finding information in the chart sometimes proves challenging, the thick chart has a strange allure to physicians. Having the information available in a “hard copy” is appealing. Some physicians, who have had little exposure to electronic medical records or computers, find that the transition from paper to electronic can be emotionally traumatic.

I don’t know where to start. Since the government and many insurers have begun penalizing physicians with delayed payments if they do not have electronic billing capabilities, there is a compelling pressure for electronic billing. Even with many options available for electronic medical records, the physicians appear paralyzed and inert when considering electronic medical records. Implementing an EMR system seems like an insurmountable project. Many times the physician support staff takes care of the other information systems for routine maintenance, problem solving and structuring. For electronic medical records, more physician involvement is expected.

It is too expensive. At a recent family practice conference workshop on medical informatics, the physician presenter actually apologized for the monthly cost of Internet access at $19.95. A participant noted that Internet access could be obtained for $13.95 per month and if used in the course of business, would be tax deductible. Equally with electronic medical records, the system cost can be an issue for physicians. Cost-effective options are available (such as options less than $500 for base software) and many are additional modules to the practice management system in the physician’s office. Additional costs may arise from voice recognition and fancy additional components. Unexpected costs are another concern. Even with a system priced moderately at $2,000 per physician, the additional hardware such as printers, computers, scanners etc. can quickly out-distance the moderate cost for the software itself. The software maintenance costs can also seem uncontrolled by physicians who prefer managing costs tightly. Quantifying the Return on Investment (ROI) has been of high interest to many parties, particularly the health information vendors but has been universally difficult.

It’s unreliable. Every clinician fears the nightmare of having a computer with a patient’s medical record totally crash and lock the information outside of the clinician’s access. Certainly, computers (like people) are susceptible to breakdowns periodically, though major portions of our society rely on computers for very critical functions. There are methods of getting around reliability issues through mirroring computers and doing fastidious backups of the data.

Confidentiality is compromised. In the last several years we have all lost a significant amount of our privacy. The concern about keeping medical records confidential is highly significant in a large integrated delivery system whether the record is paper or electronic. Concerns about confidentiality are a significant issue needing to be addressed in any electronic medical record plan.

The whole world is not doing it. Somehow, it seems everyone is waiting for everyone else to implement electronic medical records and then they will try them. The electronic medical records industry has had some growing pains and has advertised awesome capabilities but failed to have them fully developed. A growing cynicism has occurred about information technology capabilities.

The information systems cannot talk. Integration of information systems is another problem but mostly affects large systems. Stand-alone systems are less of a problem in a small or solo practice. Internal integration where the demographic updates in the billing system may be shared with the electronic medical record it is important to avoid duplication of data entry.

It decreases productivity. There is little debate that the implementation of a new system will temporarily slow processes. In a private practice where losing time means wasting money, it is imperative to get the practice back to full efficiency as soon as possible. The goal of the electronic medical record is to improve efficiency. Practices with systems implemented several years ago are now showing the improvement of the work processes.

Support for the network issues is difficult. This issue is the same with billing systems, but if the model of electronic medical record implementation is one with full client/server, there will be additional network issues. If the practice has several sites, this requires more planning and money.

How do we get the information into the computer? The physician interface has many options, including hand-held devices, a mouse, a menu-driven screen format, touch screen or transcription. Transcription of dictation seems to be the easiest answer to the concern of losing patient rapport in the examination room. The transcription can develop provider-specific templates that can allow information to be dictated to complete the template. Allowing the flexibility for the provider’s choice in documentation style may lead to more acceptance of the technology.

However, we would need to change. The change factor is a very significant one since we naturally tend to resist change. A well-designed implementation of an electronic medical record system involves reviewing current processes and modifying them if they do not make sense.

I will wait for voice recognition. An alluring promise of just talking and having written words appear on a page can delay many physicians. The cost is high and the technology marginal. The training for voice recognition systems can be a test of patience. Some physicians seem pleased, but voice recognition is not yet the mainstream.

Nevertheless, there does appear to be light at the end of the tunnel. The vendors appear to have recognized the need to design more simplified applications that have considerable flexibility in how the physician can interact with the technology. Keeping it simple and affordable should be a mantra for software vendors at this stage of the technology development.

Of particular interest are the wireless devices that can go to the patient’s bedside in the physician’s pocket. These personal digital assistants (PDAs) can allow for accurate data capture in a less bulky way than a personal computer. Physicians are expressing an interest in these devices possibly because they seem less intimidating and easier to learn and use. In addition to the physician schedule and contacts list, these devices can capture charges, act as a reference resource in medication dosage and interactions, draft e-mail and generally improve the physician’s efficiency. The possibility of decreasing medication errors using electronic prescribing drives physicians and administrators toward these technologies. Reportedly, many residency programs are purchasing PDAs and providing them to all their physicians in training. These physicians will likely find acceptance of using technology easier.

The physician’s ideal interface would be a voice recognition system that would not be overly burdensome to train. Again, physicians express interest in the advancements in this technology and seem interested in integrating its use as soon as voice recognition is ready. Most physicians seem to agree that the technology is not practically useable today.

The use of an Application Service Provider (ASP) for practice management functions and electronic medical records can also address many of the physicians’ cost and support issues. With an ASP, the physician can subscribe to an Internet-based application and only pay a monthly amount. The chief advantages are lower capital costs, strong support in a “turn-key” fashion and a much more rapid implementation time. One of the primary concerns about such a model is the transition or ownership of the data at the end of the term of the contract. Nevertheless, the potential to ease the physician’s start-up costs and frustration can be improved through an ASP model.

Hopefully, within the next five years electronic medical record systems that can be unified in inpatient and outpatient information should be in wider use. The future vision is seamless communication, probably over the Internet, so physicians could send information to other physicians and the patient’s critical medical information could be available to an authorized user at any point-of-service. We see a slowness to development of truly integrated information systems or even access, except within health systems.

Privacy and system security are major issues and deserve immediate attention. The modern society appears to have accepted the “invasion of privacy” necessary for some level of technology. The example is our acceptance of Internet white pages, mega databases, Internet resume posting, and worldwide access to a map to our home based on a mouse click. A common thought is, “You have no privacy, so get used to it.” However, the potential misuse of health information at an individual level is a more serious concern. Others counter the loss of privacy with the potential harm of a physician treating with incomplete information in emergency or even non-emergency cases because we have overprotected the information. Which is worse?

Nevertheless, the future is bright. We will get there—or at least significantly closer than we are now!

Diane Lares is consulting manager of PMSCO’s Western Pennsylvania region.

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