EMRs Positively Impact Neurology Practice, But Implementation Challenges Remain

With the American Recovery and Reinvestment Act (ARRA) designating $19 billion for healthcare information technology (IT), including $17 billion in financial incentives for physicians and hospitals to adopt electronic medical records (EMR) over the next five years, neurologists who currently don’t use this technology may be thinking about introducing it in the workplace.  While EMRs can provide neurologists and patients with many benefits, a number of challenges are also associated with these systems.  

Benefits of EMRs

Efficiency.  Improved efficiency over using paper records is one of the most immediate benefits of the technology.  For example, the Mayo Clinic’s EMR system, Centricity, allows for easy information exchange among physicians through the integration of chart notes, x-rays and lab tests, said Charles M. Harper, Jr, MD, vice chair of the Department of Neurology in Minnesota.  The EMR system also makes scheduling and billing much easier, he added.

Another advantage of EMR, which the Veteran’s Health Administration (VA), values is automatic prescription refill, a feature that reduces the need for patients to come in for office visits, said Robert Ruff, MD, the VA’s National Director for Neurology, located at the Cleveland VA Medical Center.  The system also reduces the need for duplicate tests because a VA facility in one geographic location will have the ability to access test results from another, he said.

Overall, EMRs improve the efficiency of collaborating with large groups of people to deliver care to patients, said Irene Katzan, MD, a neurologist at the Cleveland Clinic and Director of the Neurological Institute Center for Outcomes Research and Evaluation.  The ability to see what other physicians document for a patient is invaluable, she said of the clinic’s EMR system EPIC. 

Quality of Care.  “One of the advantages that we’ll see as we move toward the more widespread use of EMR systems is a positive impact on quality of care,” said Catherine DesRoches, DrPh, assistant professor in the Department of Medicine at Harvard Medical School and a researcher at the Institute for Health Policy at the Massachusetts General Hospital. 

Systems that incorporate sophisticated clinical decision support and guidelines will be especially useful, she explained.  

Data extraction and analysis to determine what type of treatment is best for a patient and the development of decision support tools that adhere to quality and safety standards can help guide care, agreed Dr. Harper.  With such systems, if an x-ray or MRI that has been indicated for headache finds a tumor or other complication, an auto alert is sent to the neurologist.

Another invaluable component of EMR that contributes to quality of care is being alerted to drug-drug or drug-disorder interactions, said Dr. Ruff, adding that the VA has a vast drug database that physicians can add to as they are prescribing new medications to patients.  

Patient Access to Information.  In addition to enhancing quality of care, EMR can improve patient communication.  For example, at the Cleveland Clinic, physicians can print out patient education materials right from the EMR and provide an after-visit summary that includes medication information and other instructions for care, said Dr. Katzan.  The clinic is also making EMR available to patients at home using an online system called MyChart, which allows them to request prescription renewals, schedule appointments, and view test results, she said.

The VA has a similar system called MyHealtheVet, which also alerts patients to tests, examinations and other medical procedures that need to be completed, noted Dr. Ruff.  

Web messaging with patients can also be a valuable part of EMR, said Vernon Williams, MD, a neurologist at Kerlan-Jobe Orthopaedic Clinic in Los Angeles who uses Allscripts.  The system allows patients to communicate with doctors at the clinic while complying with the Health Insurance Portability and Accountability Act, protecting patient privacy.

Potential Cost Savings.  Actual cost savings of having EMR systems implemented nationwide is based on a lot of assumptions and remain to be seen, said Dr. DesRoche. 

In the short run, implementing an EMR system may increase costs due to expenses associated with start-up, said Ashish K. Jha, MD, MPH, Associate Professor of Health Policy and Management at the Harvard School of Public Health. 

However, the technology also has the potential of identifying under-treated patients, which may help to offset expenses, he added. Using healthcare information technology to minimize redundancies should also help to reduce costs, “but this may take 3 to 5 to 10 years,” said Dr. Jha.

The VA’s EMR system, which has been in place for more than 10 years, has helped to reduce costs by curtailing redundant tests and procedures, said Dr. Ruff, adding that this is especially important being that the VA operates as a large health maintenance organization.

The Mayo Clinic is currently studying how its EMR system has impacted costs, and the Cleveland Clinic describes cost assessment as “an ongoing process.”   

Smaller clinics or solo practitioners may be able to better pinpoint where cost savings might occur. For example, Audrey Halpern, MD, a solo practitioner at Manhattan Headache and Neurology, notes that her Web-based EMR system, Bizmatics, helps her save on transcription and paper costs and reduces insurance billing errors, saving both time and money. Dr. Williams also noted that his practice saves on transcription.

Barriers to Implementation

While EMR has a number of advantages over paper-based medicine, implementing a system can be challenging. 

Start-up Costs.  Finances are one of the biggest barriers, said Dr. Jha, adding that start-up costs at a hospital can be $20 to $100 million. 

Moreover, the efficiencies that the initial investment is supposed to create may not result in revenues that go directly to the hospital, said Dr. Jha.  For example, a new EMR system may provide emergency department doctors with information about patients indicating that they do not need to be hospitalized.  “If data in the ER says they don’t have to be admitted, this is lost revenue,” he said.

Physician offices may also face some financial hurdles. Implementing EMR costs about $40,000 per doctor, said Dr. Jha.

Dr. Halpern notes that she purposely looked for a lower-cost solution to implementing EMR. Start-up fees were about $5,000, and she pays a monthly subscription fee of about $500. With the Obama administration’s plan to have all physicians and hospitals using EMR in the near future, “neurologists should know there are low-cost options to getting started,” she said.

 The ARRA provides a good start to funding EMR systems, noted Dr. Jha.  “It might be enough for most physician practices, and it’s a down payment on what hospitals need,” he said.  

Learning Curve and Physician Resistance.  In addition to cost, EMR systems come with a learning curve. “You can’t just put [EMR] on a desk and plug it in and have it work,” said Dr. DesRoches. “It takes a lot of learning and upkeep.”

Many doctors efficiently practice with paper records, noted Dr. Jha.  “They may not be excited about switching over, and they have sway in hospitals and certainly in their own practices,” he said.

Additionally, some doctors are concerned about how EMR might impact their interaction with patients, noted Michael Segal, MD, PhD, a pediatric neurologist in Chestnut Hill, Massachusetts, who founded SimulConsult, which produces diagnostic decision support software.  

“If you are pointed away from the patient and typing, it reduces the quality of the interaction,” he said.  “Both the physical position of pointing away from the patient and the intellectual exercise of filling out checkboxes can give the patient the idea they are being put into pigeon holes.”  

Lack of Interoperability.  Yet another obstacle to implementation is interoperability.  “Most systems aren’t interoperable in any meaningful way,” said Dr. Jha. “They may not be able to communicate with a physician who works in the community, or they may not be able to transmit key information to another hospital.”

The Mayo Clinic Health Manager, a Web-based system supported by Microsoft’s HealthVault, allows patients to manage their health records from a variety doctors and facilities, and will eventually be incorporated into the clinic’s EMR system, allowing for greater interoperability, said Dr. Harper. 

At the Cleveland Clinic, a pilot program with Google Health will eventually extend the clinic’s online patient services, enabling the portability of data so “patients can take their information with them wherever they go—even outside the Cleveland Clinic Health System,” according to a clinic statement. 

Some physicians at smaller clinics are relying on traditional communication methods for information exchange outside the practice. “We have not done a lot of electronic transfer to other facilities,” said Dr. Williams. “We generally revert back to traditional ways of doing things and print out documents and send them by fax or mail.” 

The ARRA provides funding for finding solutions to facilitate the exchange of information between institutions, noted Dr. DesRoches. “This is a technical problem that I’m sure is solvable,” she said.

Regardless of interoperability or the other challenges associated with EMR, “can we really imagine a healthcare system that is high quality, effective, efficient and doing what we want it to do, but is still paper-based?” concluded Dr. Jha. AN  

Heather Lindsey

With the American Recovery and Reinvestment Act (ARRA) designating $19 billion for healthcare information technology (IT), including $17 billion in financial incentives for physicians and hospitals to adopt electronic medical records (EMR) over the next five years, neurologists who currently don’t use this technology may be thinking about introducing it in the workplace.  While EMRs can provide neurologists and patients with many benefits, a number of challenges are also associated with these systems.  

Benefits of EMRs

Efficiency.  Improved efficiency over using paper records is one of the most immediate benefits of the technology.  For example, the Mayo Clinic’s EMR system, Centricity, allows for easy information exchange among physicians through the integration of chart notes, x-rays and lab tests, said Charles M. Harper, Jr, MD, vice chair of the Department of Neurology in Minnesota.  The EMR system also makes scheduling and billing much easier, he added.

Another advantage of EMR, which the Veteran’s Health Administration (VA), values is automatic prescription refill, a feature that reduces the need for patients to come in for office visits, said Robert Ruff, MD, the VA’s National Director for Neurology, located at the Cleveland VA Medical Center.  The system also reduces the need for duplicate tests because a VA facility in one geographic location will have the ability to access test results from another, he said.

Overall, EMRs improve the efficiency of collaborating with large groups of people to deliver care to patients, said Irene Katzan, MD, a neurologist at the Cleveland Clinic and Director of the Neurological Institute Center for Outcomes Research and Evaluation.  The ability to see what other physicians document for a patient is invaluable, she said of the clinic’s EMR system EPIC. 

Quality of Care.  “One of the advantages that we’ll see as we move toward the more widespread use of EMR systems is a positive impact on quality of care,” said Catherine DesRoches, DrPh, assistant professor in the Department of Medicine at Harvard Medical School and a researcher at the Institute for Health Policy at the Massachusetts General Hospital. 

Systems that incorporate sophisticated clinical decision support and guidelines will be especially useful, she explained.  

Data extraction and analysis to determine what type of treatment is best for a patient and the development of decision support tools that adhere to quality and safety standards can help guide care, agreed Dr. Harper.  With such systems, if an x-ray or MRI that has been indicated for headache finds a tumor or other complication, an auto alert is sent to the neurologist.

Another invaluable component of EMR that contributes to quality of care is being alerted to drug-drug or drug-disorder interactions, said Dr. Ruff, adding that the VA has a vast drug database that physicians can add to as they are prescribing new medications to patients.  

Patient Access to Information.  In addition to enhancing quality of care, EMR can improve patient communication.  For example, at the Cleveland Clinic, physicians can print out patient education materials right from the EMR and provide an after-visit summary that includes medication information and other instructions for care, said Dr. Katzan.  The clinic is also making EMR available to patients at home using an online system called MyChart, which allows them to request prescription renewals, schedule appointments, and view test results, she said.

The VA has a similar system called MyHealtheVet, which also alerts patients to tests, examinations and other medical procedures that need to be completed, noted Dr. Ruff.  

Web messaging with patients can also be a valuable part of EMR, said Vernon Williams, MD, a neurologist at Kerlan-Jobe Orthopaedic Clinic in Los Angeles who uses Allscripts.  The system allows patients to communicate with doctors at the clinic while complying with the Health Insurance Portability and Accountability Act, protecting patient privacy.

Potential Cost Savings.  Actual cost savings of having EMR systems implemented nationwide is based on a lot of assumptions and remain to be seen, said Dr. DesRoche. 

In the short run, implementing an EMR system may increase costs due to expenses associated with start-up, said Ashish K. Jha, MD, MPH, Associate Professor of Health Policy and Management at the Harvard School of Public Health. 

However, the technology also has the potential of identifying under-treated patients, which may help to offset expenses, he added. Using healthcare information technology to minimize redundancies should also help to reduce costs, “but this may take 3 to 5 to 10 years,” said Dr. Jha.

The VA’s EMR system, which has been in place for more than 10 years, has helped to reduce costs by curtailing redundant tests and procedures, said Dr. Ruff, adding that this is especially important being that the VA operates as a large health maintenance organization.

The Mayo Clinic is currently studying how its EMR system has impacted costs, and the Cleveland Clinic describes cost assessment as “an ongoing process.”   

Smaller clinics or solo practitioners may be able to better pinpoint where cost savings might occur. For example, Audrey Halpern, MD, a solo practitioner at Manhattan Headache and Neurology, notes that her Web-based EMR system, Bizmatics, helps her save on transcription and paper costs and reduces insurance billing errors, saving both time and money. Dr. Williams also noted that his practice saves on transcription.

 

Barriers to Implementation

While EMR has a number of advantages over paper-based medicine, implementing a system can be challenging. 

Start-up Costs.  Finances are one of the biggest barriers, said Dr. Jha, adding that start-up costs at a hospital can be $20 to $100 million. 

Moreover, the efficiencies that the initial investment is supposed to create may not result in revenues that go directly to the hospital, said Dr. Jha.  For example, a new EMR system may provide emergency department doctors with information about patients indicating that they do not need to be hospitalized.  “If data in the ER says they don’t have to be admitted, this is lost revenue,” he said.

Physician offices may also face some financial hurdles. Implementing EMR costs about $40,000 per doctor, said Dr. Jha.

Dr. Halpern notes that she purposely looked for a lower-cost solution to implementing EMR. Start-up fees were about $5,000, and she pays a monthly subscription fee of about $500. With the Obama administration’s plan to have all physicians and hospitals using EMR in the near future, “neurologists should know there are low-cost options to getting started,” she said.

 The ARRA provides a good start to funding EMR systems, noted Dr. Jha.  “It might be enough for most physician practices, and it’s a down payment on what hospitals need,” he said.  

Learning Curve and Physician Resistance.  In addition to cost, EMR systems come with a learning curve. “You can’t just put [EMR] on a desk and plug it in and have it work,” said Dr. DesRoches. “It takes a lot of learning and upkeep.”

Many doctors efficiently practice with paper records, noted Dr. Jha.  “They may not be excited about switching over, and they have sway in hospitals and certainly in their own practices,” he said.

Additionally, some doctors are concerned about how EMR might impact their interaction with patients, noted Michael Segal, MD, PhD, a pediatric neurologist in Chestnut Hill, Massachusetts, who founded SimulConsult, which produces diagnostic decision support software.  

“If you are pointed away from the patient and typing, it reduces the quality of the interaction,” he said.  “Both the physical position of pointing away from the patient and the intellectual exercise of filling out checkboxes can give the patient the idea they are being put into pigeon holes.”  

Lack of Interoperability.  Yet another obstacle to implementation is interoperability.  “Most systems aren’t interoperable in any meaningful way,” said Dr. Jha. “They may not be able to communicate with a physician who works in the community, or they may not be able to transmit key information to another hospital.”

The Mayo Clinic Health Manager, a Web-based system supported by Microsoft’s HealthVault, allows patients to manage their health records from a variety doctors and facilities, and will eventually be incorporated into the clinic’s EMR system, allowing for greater interoperability, said Dr. Harper. 

At the Cleveland Clinic, a pilot program with Google Health will eventually extend the clinic’s online patient services, enabling the portability of data so “patients can take their information with them wherever they go—even outside the Cleveland Clinic Health System,” according to a clinic statement. 

Some physicians at smaller clinics are relying on traditional communication methods for information exchange outside the practice. “We have not done a lot of electronic transfer to other facilities,” said Dr. Williams. “We generally revert back to traditional ways of doing things and print out documents and send them by fax or mail.” 

The ARRA provides funding for finding solutions to facilitate the exchange of information between institutions, noted Dr. DesRoches. “This is a technical problem that I’m sure is solvable,” she said.

Regardless of interoperability or the other challenges associated with EMR, “can we really imagine a healthcare system that is high quality, effective, efficient and doing what we want it to do, but is still paper-based?” concluded Dr. Jha. AN  

Heather Lindsey

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