Participating in the government's meaningful use program may be a costly proposition for specialists. Integrating software that may have been designed for a primary care practice into a radiology
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Stamatia Destounis, M.D., a radiologist who practices at the Elizabeth Wende Breast Center in Rochester, N.Y., said that the biggest problem her practice faced when looking to implement an EHR system was balancing the needs of her practice against the requirements of the government's meaningful use program.
There is an inherent tension between the two considerations, Destounis said. In order for a practice to qualify for incentive payments under the meaningful use program, it must select software that has been certified by the Office of the National Coordinator for Health IT (ONC). All certified EHRs must have certain functions the regulatory authority mandates. However, a radiological practice like Elizabeth Wende is not likely to use many of these required functions, which Destounis said were intended to improve care quality in primary care practices. This means the specialty practice must essentially pay for features it doesn't intend to use.
For example, Destounis said her practice's EHR had to include functionality to record immunizations, transmit prescriptions, and track patients' vital signs. In her practice -- which administers radiological treatments to women with breast cancer -- immunizations and prescriptions do not play a role in standard care, and most patients come to the office with vitals primary care doctors already recorded.
"A lot of the programming that we had to pay for is for criteria that we're never going to use, but we had to possess it in order to get certified," she said.
Destounis said her practice has already invested the entire amount it expects to receive in meaningful use incentives, and the practice is still working to finish implementation. With more costs to come from things like additional staff hours and software updates, Destounis said she expects the office to spend far more on EHR implementation than it could receive in incentive payments. Over the length of the meaningful use program, an eligible physician may receive an average of $44,000 in incentives.
Specialists must find the right EHR
Aside from regulations that may be geared mostly toward primary care practice, specialists must deal with the fact that many vendors produce systems for general practices. When selecting an EHR specialists may struggle because of this.
Jay Alexander, M.D., a cardiologist with the North Shore University Health System in Evanston, Ill., said that specialists need to do some research to make sure that the vendors they are considering offer systems that complement the workflow of their specialty. Finding a system that is customizable and has a proven record of use by physicians in the same field helps ensure that the overall impact on workflow will be positive.
"[EHRs] will all change your workflow to some extent, which will impact productivity," Alexander said. "But you're trying to get it to do so as little as possible because every physician I know has different workflows. The ability for a system to not alter those workflows dramatically is important."
Alexander said that he previously practiced as part of a private group that was able to select its own EHR. The practice opted for WebChart from Medical Informatics Engineering, which Alexander said was customizable and could be made to fit the office's existing workflow. However, when the practice joined North Shore University Health System, it had to switch to an Epic system. Alexander described the change as going from a maneuverable sail boat to an ocean liner. Overall, he is happy with Epic, but feels it lacks many of the customizable options of WebChart, which went a long way toward making the system a good fit for his specialty practice.
EHRs don't always slow down specialists
The key to making sure an EHR implementation does not wreak havoc on a specialty practice's workflow productivity is to find a vendor that understands the demands of the specialty, experts say. When practices identify and implement an EHR that was designed specifically for their field of medicine, the effect doesn't have to be negative.
The ability for a system to not alter those workflows dramatically is important.
Jay Alexander, cardiologist, North Shore University Health System.
Evan Steele, the CEO of EHR vendor SRSsoft, said specialists who implement a primary-care-based system are likely to see a negative impact on their productivity, but a practice may actually experience significant gains in efficiency when it chooses a vendor that matches its needs.
For example, he said that an orthopedic surgeon or ophthalmologist might be able to save 15 seconds per patient by using an EHR system that is designed for their specialty, as compared to using a primary-care-optimized system. In a busy practice where physicians see up to 60 patients each day, the difference in seconds may help doctors save up to 15 minutes, allowing them to see one or two extra patients, Steele said.
Additionally, he pointed to the benefits of clinical decision support. This functionality can help identify patients who should receive further tests, which can enable doctors to spot potential health problems early, when they are more treatable. In the case of an orthopedic practice, decision support may help doctors identify patients who are at risk for osteoporosis, which may prompt the physician to conduct a bone density test.
However, doctors only realize these benefits when they have a system that suits the needs of their practice. For this reason, Steele recommended that doctors ask prospective vendors for up to 20 references that are relevant to their specialty.
"It's not a one-size-fits-all world," he said. "It's very tempting to go out and buy a name [vendor] -- and they may have good references -- but not in their specialty. Doctors really need to check references and find software that's appropriate to their specialty."
Specialists should be ready to invest
EHR implementation can certainly take a toll on a practice's productivity. A 2011 study published in the Journal of Risk Management and Healthcare Policy showed that practices' productivity tends to drop 20 percent in the first month after implementation, 10 percent in the second month, and 5 percent in the third month, with productivity levels recovery by month four. This crash in productivity can cost up to $11,200 per full-time physician.
While specialists may eventually be able to achieve meaningful use and implement EHR systems without negatively affecting productivity, the process may still require more effort than it would for primary care doctors. Destounis said she and her staff attended workshops, participated in webinar, and hired a consultant to help in the EHR selection process.
Eventually the medical office chose to have the vendor that provides its practice management software design an EHR system that was customized to the practice's needs. This may be an expensive route to take, but Destounis said it was necessary to ensure the system would fit the office's workflow.
With all the time and money the Elizabeth Wende Breast Center invested in selecting and implementing its EHR system, the financial incentives the government offered through the meaningful use program are unlikely to defray the cost of adopting the technology. Destounis said the payments will only help her practice recoup a small fraction of what it invested.
At this point in the implementation process, Destounis said the practice has not seen patient volumes drop. Most of the work so far has been done behind the scenes. But she believes that front desk staff will eventually have to spend more time entering data. Dedicating extra staff hours to implementation has been an additional cost.
Both Destounis and Alexander said they hope future stages of the meaningful use rules will include provisions that make the program more relevant to specialists. In particular, Alexander said he is eager to see greater support for data exchange between specialists and other health care providers. He sees this as being the greatest benefit of the technology.
"I'm hoping that in the future meaningful use will be meaningful to specialists, but to primary care physicians as well," Alexander said. "The power of EHRs is the ability to share data with colleagues, whether they are in the same health system or on the same EHR as you or not."
For the time being, however, the experts agreed that specialty physicians should do plenty of research into available options and find a vendor with a track record of providing software to physicians in their area of medicine. They may help to minimize the pain of participating in a government program that was not designed to accommodate specialists, but with which specialists must comply nonetheless.
This was first published in August 2012