Kevin, Nice post. Comments / support in-line below.
Kevin Toppenberg wrote: > Hello all, > > In Tennessee, our medical malpractice company is > hosting an EMR conference this December (and why it is > them is interesting) . I hope you'll let us know what they say their reason is. More on this below. > This will be an business expense, not an > investment, because there will be little > (and I suspect no) financial return on this > expendature. > > But frankly, I worry that this will be an expensive > wild goose chase. I believe the power of an EMR > will not be realized unless there is interoperability. I absolutely agree. But while I think your example of lab data interchange is a good / valid one, I believe there are even stronger reasons for the interoperability requirement. /snip/ > > So after AAFP and other organizations push doctors > into coughing up the $100-200k needed to get a new > system up and running, The costs for the EMR systems I've looked at recently (GE, A4, NextGen, and Misys) are in the $30-60K per physician range. It's a little dangerous, IMO, if you're going to use numbers like this to be specific WRT what size practice you're talking about. It's important not to set yourself up for strawman arguments against your case. > will patient care be better? I'm not convinced it will. EMR's have very little to do with improving patient care per se. They are mostly touted in an error-avoidance setting. > I have heard that thought leaders feel that a good > EMR could achieve a 20% reduction in health care > expendatures. These numbers are nonsense as they relate to community-based physicians. They come from institutional settings where, for example, there are entire groups of employees devoted to nothing but record retrieval, *large* amounts of room devoted to paper record storage that can be converted to revenue-producing uses, etc. In the seven practices I worked for last year, not one of them predicted that they would be able to reduce staffing levels or convert space to revenue producing uses. In fact, given that servers couldn't realistically be kept out in the open like the file cabinets, some worried whether adopting an EMR system might have the opposite effect. None of this, of course, dissuades the evangalists. > But unless my EMR will somehow let me instantly > access a lab/study ordered by another physician in > another city, I don't see how this could happen. How often does this happen? And how much money does it save each time? 20% is a big number if we're talking about reductions in the "average." This example won't get it anywhere close. > And now system I have seen addresses this > issue. You're right about this. Some of the major vendors do have a product offering that will allow you to exchange data between installations of their own systems under a very limited set of circumstances. It tends to be an expensive option though, based on what I saw last year. > With HIPPA nervousness abounding, no one > will release records without a written signature from > a patient, and I not heard of any quicker electronic > solution to this problem. This is another one of those circumstances where I'd recommend you use this argument with caution. HIPAA definitely allows the circumstance you outlined above. But you're right, the legal vultures have created such an environment of fear, uncertainty, and doubt that many physicians are reluctant to even do what the law, including the preamble, clearly says they can do. > I keep a relatively well organized paper chart with > tabs etc. It is fast and complete. It easily stores > the carbon copies of scripts that I write, letters > that patients write me, copies of their advance > directives etc etc. All these things would have to be > scanned in an EMR, and then possibly lost in a shuffle > of filenames (i.e. "image1462"). My charts are > portable: they can travel in the car with me, or I can > take them to the hospital when admitting a patient. > They're flexible: I could have a visit in a patient's > home if required (i.e. I don't have to have a computer > station set up.) They're "hi-res": Most computer > screens have to magnify the image so that a scanned > image is readable. Thus a full scanned page often > won't fit on a screen and still be legible. So you > have to scroll around. Paper doesn't have this > problem. You're right about these technical issues too. > As one who has put in a significant amount of time > working with VistA, I don't want to sound like a > Luddite anti-technologist. But I am seriously > concerned that physicians are being pushed into making > a sudden technology change away from a system that has > withstood the test of time. In my mind, there's only one reason for community-based physicians to an EMR system: ROI. That could take several forms. 1) getting paid faster for services rendered 2) getting paid more for services rendered (CMS is actually talking about this) 3) reduced expenses (As discussed above, the typical justification along this line is bunk WRT community-based physicians. BUT... reduced malpractice premiums are an obvious possibility. Unlikely, but obvious. I say unlikely because a) the data I've seen re: reduction of errors relates to errors in a hospital setting, not a office-based setting, and b) the way the insurance market works in general) 4) business growth (i.e., patients decide which physician they use at least in part as a function of whether or not the physician uses an EMR system) In my mind, number 4 is the most likely scenario on the horizon. And I'm working a plan to try to accelerate that scenario. > I'm also concerned about a "lock-in" issue. > I suspect that none of us use the same word > processor that we did 10 years ago, but > rather technology has progressed and we regularly > purchase the latest and greatest. But will physicians > be willing to purchase system after system the way we > do computers now? I doubt it. If our group buys a > non-VistA EMR, I imagine we will keep it at least 10 > years. We'll be locked into 2004 technology until > 2014. (Our current system is 1980's technology) This is going to happen to some extent independent of the "cost" of the system chosen. More on this below. > So what do I think the solution is to all this? Well, > VistA goes a long way. First, it is easily > conceivable that VistA could be established in an > office for ~$10-20k, one-tenth the cost of a > commercial system. I think your numbers are probably close, but it's probably closer to $20K than $10K per Doc. The "one-tenth" number is problematic though. The initial cost of a system, at least the ones I looked at, is roughly 1/3 software license, 2/3 other. Choosing VistA isn't likely to change the "other" for the better. Best case, it's probably safe to predict a net "no impact" result. > (And my goal is to make the cost > much less than this). This will make it much less > painful for small practices, and still quite > attractive for vendors (multiply the "272,428 > practices" below by $10,000 makes for a nice > retirement plan.) To your "lock in" comment above, the software cost, while relevant is not the main reason "lock in" occurs. It's the "other" costs including installing/configuring the new system, migrating data, training, productivity decreases as everyone climbs the learning curve again, etc. > And if we have a critical mass of physicians on > the same system, we have more chance of > interoperability. Interoperability does not require physicians to be on the same system. In fact, as it stands today, *everyone* could be using VistA and they *still* wouldn't be able to exchange patient records in electronic form. Interoperability depends on flexible yet rigorously defined, computer-readable formats for the EMR. > So in summary, I support getting EMRs into physicians > offices, but I think we need to have realistic goals. > We need to provide inexpensive solutions, and plan for > gradual transitions. And VistA has a great potential > meeting some of these goals. Agree and concur. > Hope to see you all at the WorldVistA conference. I, unfortunately, will not be there. But I look forward to some lively conversations here afterward as a result. Hope you all have an enjoyable and productive time of it. Best regards, Bill ------------------------------------------------------- This SF.net email is sponsored by: IT Product Guide on ITManagersJournal Use IT products in your business? Tell us what you think of them. 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