Since the dawn of meaningful use, questions have swirled about how the money, the incentives, are being spent by those who receive them. In fact, it’s a question I’ve asked several colleagues, practicing physicians and healthcare leaders.
The answer typically depends on the person giving it. As such, no two answers are ever really the same, but there are some general responses offered.
The most common, from my perspective have something to do with responses such as “work to ensure better patient care,” “take steps to be more efficient” and “better meet our goals.”
A new report suggests that the average physician lost just as much as would have been gained had he or she received the full meaningful use incentive payment for the last five years — $44,000 – by implementing an electronic health record, which basically makes the whole thing null and void.
There’s a caveat, though. The practice that has implemented and is using the EHR, needs to make a few changes to the way the practice runs or else the saving is lost. Somewhat of a no brainer, according to study that’s published in Health Affairs, only 27 percent of practices achieved a positive five-year return on investment by implementing the electronic systems.
The trouble, according to the survey, is that practices “failed to make operational changes to realize the benefits of EHRs such as doing away with paper records after implementation of the electronic systems, adoption, as well as dictation, billing services and positions or staff members who were performing services no longer required after EHR adoption.
A reduction in the required workforce at the practice after the implementation of an EHR is a common problem. I’ve spoken with several practice leaders who cited it as such, and in many cases, staff whose positions were eliminated because of the software have been re-assigned to other areas. There are only a few practices in which I’ve spoken where employees were laid off because of the systems. I expect this number to grow as more systems come online.
According to MedPage Today, which published the results of the study, the study sought “pre- and post-adoption financial cost/benefit data from practices such as total revenue, total operating costs and total labor costs. Researchers also asked for information on areas that were impacted by EHRs, such as the cost of paper medical records, dictation services, and billing services.”
Their results of the study showed that the average physician lost $43,743 over five years. Primary care practices fared better than specialists. Practices that saw a positive return on EHR investment increased revenue by more than $114,000 per physician over five years, results showed. In comparison, practices with a negative return on EHR investment saw revenue increase by an average of only $9,200 per physician in five years.
“Even when adding federal incentives to use EHRs, the majority of doctors would have lost money,” MedPage Today reports.
Other results from the study include:
38 percent of practices with six or more physicians achieved a positive return on investment, compared with 26 percent of practices with one or two physicians
55 percent of practices reported a reduction in the cost of paper medical records after EHR adoption
22 percent of practices reported the most common ongoing cost was additional hours of practice time
10 percent of practices noted improved efficiency, allowing them to see more patients each day
18 percent increased revenue through improved billing
This is a bit surprising: Practices with a practice management system prior to EHR implementation in place to help with billing functions benefited less on average.
Seems like some of the unexpected consequences of EHR use are finally working their way to the top and a bit of the actuality of the situation is coming out; just because a system is implemented, doesn’t mean everything is going to be great. “Wide usage of EHRs was supposed to help doctors increase revenue through improved billing and efficiency gains that would allow them to see more patients per day. However, doctors have complained that EHRs are cumbersome and cause physicians to spend more time documenting patient visits,” the magazine states.
Another day, another study, but this one – about the EHR user’s satisfaction levels with their systems – seems to have some teeth. According to the survey, “EHR Satisfaction Diminishing,” which was administered by the adept AmericanEHR group, users of EHRs are becoming ever more disenfranchised with their EHRS.
According to the AmericanEHR, data was collected over a two-year period of time, from 2010 through 2012. After two years of use, and in some cases longer, practice leaders and caregivers who have time to figure out their electronic collection systems and who are past the test-drive phase say they are not happy with the technology.
I’ve made this case before, but this is one of the primary reasons I strongly recommend physicians not getting locked into extremely long-term contracts. For example, some vendors require seven years. That’s way too long. Stay away.
Nevertheless, this could just be a standard response to the technology as a whole, but let’s get to the results of the survey. For brevity’s sake, I’ve cut what I don’t find to be significant. Some of the results noted here are amazing and eye opening; you decide.
71 percent of respondents were in practices of 10 physicians or less;
The average length of time that survey respondents had been using their EHRs was more than three years at the time of the EHR satisfaction survey;
Satisfaction and usability ratings are dropping. This holds true regardless of practice size, specialty type and across multiple vendors;
Overall, EHR user satisfaction reveals a 12 percent drop in satisfied users from 2010 to 2012 and a corresponding increase in very dissatisfied users of 10 percent for the same period;
In 2012, 39 percent of clinicians would not recommend their EHR to a colleague (I’m not surprised by this, especially given my experience with vendors);
Average satisfaction level with the ability to improve patient care decreased from 2010 through 2012 for all specialty groups;
Satisfaction with ease of use dropped 13 percent between 2010 and 2012 and 37 percent reported increased dissatisfaction in 2012;
34 percent of users in 2012 were very dissatisfied with the ability to decrease workload compared to 19 percent in 2010.
Why is this happening (according to AmericanEHR)? The following hypotheses may explain some of these findings:
With Meaningful Use, users may have lost some of their workarounds or have new ones that they have to do e.g. clinical visit summary that now takes 10 clicks and as a result workflow may feel more cumbersome;
The difference between cognitive versus procedural specialists. If one asked the majority of physicians how they would rate the quality of care they provide, most would likely say very good to excellent. Unless these physicians regularly use dashboards and reports they do not know whether they are doing better using an EHR. This is more challenging with procedural specialists such as a thoracic surgeon or orthopedic surgeon. It is not clear how the EHR helps with improving quality of care for proceduralists;
As we have further analyzed the data in related to satisfaction with the ability to improve patient care by duration of EHR use prior to completing the EHR satisfaction survey, there appears to be a strong correlation between length of use an EHR and ability to improve patient care especially in those who have been using an EHR for 5+ years. This could suggest that there is a minimum period of time that someone has to use an EHR before beginning to demonstrate improvements in patient care;
Dissatisfaction may also be a result of being asked to do something with an EHR that previously was not required (prior to Meaningful Use);
There continues to be an inability to complete certain tasks electronically despite having an EHR. For example, ACOs that require a paper form to be completed for registration of each patient in a pay-for-performance program, resulting in increased workload and decreased productivity/satisfaction.
Additional observations (which are amazingly insightful):
The speed of change in relation to the Meaningful Use program may be too much too fast for many practices who are unable to cope the demands and workload;
Different populations have different expectations. The pioneers and early adopters have a greater tolerance for the problems and challenges of implementing an EHR vs. those in the mid or late majority;
EHR systems clearly have usability issues which need to be addressed even with respect to basic functionality.
Recommendations (here’s the real gold):
Training is a significant deficiency. Training is required at all stages of adoption, both at time of implementation and as more advanced functionalities are required or integrated with EHRs. Almost 50 percent of respondents in a 2011 AmericanEHR report on the correlation of training duration with EHR usability and satisfaction reported receiving less than three days of training to use their EHRs or no training at all;
Dissatisfaction levels with basic EHR functionalities highlight the need to improve existing technologies rather than just focus on adding new features and capabilities;
Clinician workload within the practice must be re-balanced. Providers are working harder and face numerous additional challenges including the impact of payment reform and the need to comply with multiple incentive/penalty programs.
In closing, according to AmericanEHR: “If these issues are not recognized and addressed, the alternative is that clinicians will do the bare minimum in order to meet meaningful use requirements.”
I’ve always been a sucker for trivia. In most cases, the information that sticks in my head is useless and, well, trivial. People — including those that know me best — often shoot me quizzical looks and wonder where the hell I came up the crap that pops out of my mouth. Most of the time I shrug and respond with the I’m-so-stupid-sorry-for-breaking-the-silence, “What.”
But, in healthcare, this kind of mindset set has a place; maybe it’s just a data place of mind sort of thing. Nevertheless, I’m comforted by all of the (sometimes) useful technology information floating around, and today, I’m proud to share a kindred spirit at HIT Consultant, who posts an incredible plethora of devourable data worthy of sinking your teeth into in the piece, “80 Mind Blowing EMR and Meaningful Use Statistics & Trends.”
Feel free to check out the full course, but for a primer, let’s dig in here.
• According to the list, 75 percent of patients are willing to go online for health information. Not surprised by this one bit. I’d argue the number is low. Check out this article by American Medical News for more on the subject. We spend our lives online wherever we can get online. If we have access to the web, we’ll be on it; this isn’t necessarily mind blowing, just trivia, and a reality.
• Next up, financial troubles at the practice level. Interesting topic, but given the conversations I’ve had with physicians I’m not surprised. More than 40 percent of physicians have financial troubles, and given the overwhelming reform practices face, it’s no wonder the private practice is being ambushed.
• More than 70 percent of hospitals employ full-time staff to scan charts into their electronic systems. WOW! Seriously? This doesn’t sound efficient to me. Someone please explain.
• “Solo practitioners are particularly unlikely to be using EHRs or to have plans to implement them. Also, older physicians are less likely to be pushing for adoption of HIT.” Again, no surprise, though, it’s sad. Truth is, both of these segments will be out of private practice in the next three years under the current healthcare structure. No joke.
• Just a bit more than 20 percent said their EHRs made them more efficient and only 6 percent said their making more money with their systems. Again, not surprised by this data. These are PR talking points EHR vendors push to sell their systems. Pay attention, you’ll probably see some CEO on this site talking the same points sometime soon.
• Apparently, according to a study reposted by Becker’s Hospital Review, 91 percent of physicians want/are interested in mobile EHRs. I don’t buy it. I’d like to see the data, but I bet it’s a flawed report. Physicians are too concerned with their in-practice solutions, mandates and reform. We haven’t tipped that far in the mobile direction yet. Not possible; just another PR talking point from a vendor.
• “Each patient visit requires approximately 10 to 13 pieces of paper.” That is shocking.
• Top 5 EMR vendors by number of users are: o eClinicalWorks o Epic o McKesson o Care 360 o Allscripts Care 360 is in the Top 5? Hmmm.
• The feds believe they’re on the hook for more than $20 billion of taxpayer’s money for meaningful use before the program wraps. This is one of those facts that I’m not surprised by, but I am, if you know what I mean. It just makes me look side ways.
And the list goes on and on, some shocking pieces of trivia, some less so. The point is there’s much to consume, some more positive than others. But, HIT Consultant does make a great point: a lot of the data available doesn’t point to a land of milk and honey. On the contrary, there’s a lot of disappointment in health IT.
There’s apparently much to learn and much to improve. Everything is yet to be perfect, while some things are wonderfully, wonderfully good.
According to the latest Centers for Disease Control and Preventions’ National Center for Health Statistics survey of 2011 EHR adoption trends, released on July 17, use of EHRs is up to 55 percent of practicing physicians. That’s a 5 percent increase from 2010, also according to a CDC survey.
The survey of 3,180 physicians was funded by the Health and Human Services Department’s Office of the National Coordinator for Health Information Technology. More than 55 percent of all physicians use and EHR (and more than 86 percent of physicians in practices with 11 or more physicians use an EHR). Physicians also value their current EHRs more compared to past iterations of the systems and, finally, respondents said the care they provide to patients is better than in the past because of the EHRs.
Problem: there’s no data in the survey to support this final claim.
Obviously, EHRs are intended to improve care, whether at the individual level or at the practice level. However, physicians accessing patient data through the records should be tracked and made quantifiable.
Practices using EHRs have the power to change lives for the better, manage care and ensure proper care is provided throughout a patient’s care plan. Practices can and should track how care initiatives have changed with the implementation of an electronic health record and how their patient populations’ health benefits.
Simply stating that patient care has improved when a practice uses an EHR is an immeasurable statement. Innovative practices find ways to track these outcomes whether it means there are fewer chronic conditions among their patients or that their patient populations’ life expectancy actually increased over a period of time (as can be measured and in some cases has been done).
The ONC needs to do more to encourage physicians to move beyond meaningful use stimulus, which is driving the increased use of EHRs. And while the data collected from surveys such as this are important, as I continue to say, they don’t tell the whole story of how technology can improve healthcare.
And throwaway statements indicating immeasurable “facts” does nothing more than generate misleading headlines.