THE 21ST CENTURY REVOLUTION

THE 21ST CENTURY REVOLUTION
EMRs and EHRs are Changing the Way ASCs Do Business

By Jennifer Schraag 

According to the Centers for Disease Control and Prevention (CDC)’s Division of Health Care Statistics, the latest data from the National Ambulatory Medical Care Survey (NAMCS) indicates that one-quarter of office-based physicians report using fully or partially electronic medical record (EMR) systems in 2005 — a 31 percent increase from the 18.2 percent reported in CDC’s 2001 survey.¹

EMR use was related to several practice characteristics including the number of physicians in the practice, the scope of services as measured by single- or multi-specialty practices, ownership, number of managed care contracts, and the percentage of practice revenue from Medicaid.

The CDC also breaks down the data by region citing physicians in the Midwest (26.9 percent) and West (33.4 percent) were more likely to use EMRs than were those in the Northeast (14.4 percent). Furthermore, physicians in larger, metropolitan areas (24.8 percent) were more likely to use EMRs than were those in smaller, rural areas (16.9 percent).

One shocking finding, especially in light of the Bush Administration’s push for widespread national electronic health records (EHRs), reflects that only 5.4 percent of the physicians surveyed report having electronic public health reporting capabilities.

Craig Veach, senior vice president of operations with Amkai™ Inc., says EMRs, EHRs and electronic clinical records are inevitable. “It’s come down to you are going to have to have these kinds of systems to meet the upcoming requirements for pay-for-performance, among other things,” he points out, adding that surgery centers are a year and half to two years behind acceptance than that of the practice management world.

“The challenge for ASCs is they do not have the huge choice of different systems that are available out in the practice management market,” Veach continues. “There has been a variety of misconceptions of what an EMR actually is. Some people think that just scanning paper documents and storing them on a disk is an actual EMR, where in reality that is just a different way of filing information.”

Veach explains that ASCs are unique in that it is the only healthcare market he has seen where someone else dictates what can be charged for their services. “It’s not even what the market will bear or what the market dictates for the services, it’s CMS,” he adds. “Many of the other insurance companies try to follow suit and keep as close to that as possible. A lot of ASCs are very limited, particularly in states with the certificate of need (CON) laws. It’s not like they can decide to say, ‘We’re just going to expand our hours to improve our revenue,’ or even build another operating room (OR). That, in some states, can be a four-year process just to be able to do that.”

He says that due to these restrictions and challenges, ASCs are really forced to look to other ways to improve profitability and growth. One of those ways is to become more efficient, he points out. “If you have a business management system, and then you have a separate electronic medical system, an EMR, and they don’t exchange or share information, than you have to enter information twice. That is very inefficient. If the two collaborate, you become more efficient and thus more profitable. It also reduces mistakes by less data entry,” he adds.

He gives another example, this time with drug interactions. He said clients will say drug interactions are a non-issue in their facility. “Then they are amazed that within the first couple of weeks how many they actually catch now that they have the system pointing that out to them.”

Tim Armstrong, vice president of document imaging with Surgical Notes Inc., advises ASC owners and operators to ask themselves one question: How many times do you touch a piece a paper and what are the costs associated with that?

“It’s a matter of efficiency,” Armstrong asserts. He agrees that ASCs are going to have to come up with better ways to conduct daily business and clinical operations, and he offers solutions. Armstrong says he runs his clients through a test where they have to take a document from within the organization and they have to put it on a board and chart out how many times it is touched in its lifespan. He notes that many times centers find it is 10, 15, or 20 times.

He does this to show that with the electronic process, you can move the information anywhere within the organization in a timely and efficient matter. He mentions this helps in such time constraint processes as off campus sites that require couriers to transport the paper documents or when awaiting the return of a physician for a signature.

“It’s efficiency through solutions — a noted reduction in manpower,” he reiterates. “Because right now, most processes are repeated over and over and over, whereas if [documents] were captured electronically on the front end they could very efficiently and very seamlessly be saving a lot of time and a lot of money.”

He mentions a client center he visited recently where one employee’s entire job was to pull down patient charts and put stickers on them. “It seemed kind of silly to me,” Armstrong says. “Here we have the best surgery in the world and we can have people out in a day for things that used to take weeks and months, but we can’t get a patient’s information on a piece of paper without putting a sticker on it.”

ASCs receive information in a variety of ways, he points out. He says that the requests he receives for improving efficiency generally begins with paper. There are space constraints, he points out. “I have a clinic I am working with that pays $10,000 a month to store their documents off site because they are just out of room. It’s the old adage that paper takes up space. It’s also subject to disaster (i.e. floods, natural disasters, and fires).”

Armstrong says paper is the easiest target for streamlining efficiency through electronic solutions. “This is because it is flying in and out of the door, it’s waiting on people’s desks and people are looking for it and they are grabbing it and they are faxing it and they are mailing it and they are filing it and they are pulling it back out and making notes on it ... this gives them a central repository to store it and gives everybody access to it. It can be anything from patient charts, to accounts payable, to materials management, to credentialing for the doctors, to doctor sign off, to charts; any process can be done there. More importantly, as we move into the digital revolution, people like Medicare and Medicaid are actually on the leading edge where they are sending patients’ EOB (explanation of benefits) information back electronically. This gives them a HIPPA and HL7 secure environment to pull this information back, store it, retrieve it, and work with it.”

HIPPA compliance is a very real concern when adapting to electronic capabilities in a healthcare facility. Veach says such systems will make organizations more HIPPA compliant. “If a patient chart is lying on a desk somewhere, there would be no real way to know if someone had looked at it,” he points out. “With EMRs, it records who has opened a chart, when they opened it, exactly what forms were viewed, etc.”

He says an electronic record is “much, much more secure” than a paper record, and that increased security is incorporated into electronic systems. For example, he says that if someone walks away from their desk for say a minute or two, the system automatically shuts down or locks itself so the person has to put their password back in to reopen the screen. “If an ASC implements a good system, it will make them HL7 compliant, HIPPA compliant, and keep them out of trouble with the government,” he says.

In terms of considering the return on investment (ROI) for such large-scale purchases, Armstrong advises that the first things you want to look at are: Can you approve efficiency and can you cut down on your labor costs?

“That is your biggest cost of doing business,” he says. “I recently did a project where by implementing a fully automated solution, they eliminated about four people. They cut one person that was putting stickers on the patient charts. They had two people scanning, and by using bar codes and some automation, they cut that down to one person. They had three people doing EOB processing, and by putting in an EOB module that made everything electronic, that eliminated two more positions. Basically, their return on investment was at least three people at $30,000 per FTE (full-time equivalent) or a total of about $90,000 by implementing an automated system.”

In addition, Armstrong says this particular center was able to lease everything that they needed for about $3,000 a month, “so basically the cost of one employee,” he adds.

Marion K. Jenkins, PhD, CEO of Englewood, Colo.-based QSE Technologies Inc., says leasing is an attractive option that helps ease the upfront “sticker shock.” “Many times it seems easier to add staff than to look at improved efficiencies through automation,” he offers. “The saving – or delaying of hiring – just one staff person can justify the purchase of a significant amount of technology and automation.”

Don Detmer, MD, president and CEO of the American Medical Informatics Association (AMIA) says ROI happens fairly quickly. “Generally speaking in a primary care office practice setting you can get your payback – if you do it right – in two to three years. I don’t know of data specifically to ASCs, to my knowledge that hasn’t been done.” Detmer says the No. 1 consideration when adopting a new system is connectivity. “Connectivity is critically important. The biggest issue as you go into this is to rethink communications, not just your records, per se. It’s both a way of communicating as well as a way of keeping a record of your communications.

“The biggest challenges by far are being able to get a system that will connect to the key providers in your areas and also have the capacity to communicate with your patients as well. Particularly if it is a freestanding surgery unit, it is going to be very key that you connect to other EHRs in your region; the referring physicians and so forth, as well as the other surgeons who use the facility.”

Detmer adds that interoperability is really a critical issue for ASCs. “They must not be thinking of this simply in terms of ‘How will we use a record for our own building or our own practice?’, but ‘How does it connect so that we can get records from referring sites and we can send records back to where patients come from?’”

Veach says ASC operators are quickly realizing the fact that technology is really going to make them a viable product. It will also offer more efficient services for their patients. For example, Detmer advises centers to take these new information technology (IT) capabilities as a way to really look at reinventing the way a center delivers its care. “This is more than something you just put in in order to go from paper to electronics,” he asserts. “In other words, the EHR, done right, can help them actually be a more efficient and effective deliverer of care and of information to the patients and so forth. But if they aren’t thinking about that going in, if all they think they are going to do is just get something and plug it in and basically not use it for decision making and efficiency, they are missing a great opportunity.”

Ideally, Detmer adds, an EHR will allow centers the capability of interacting through email with their patients, for one thing. He warns that centers do need to be careful when bringing patients onboard the EHR system to include a clear description of the small, but potential risks of the information not being totally secure when transmitting electronically to patients. “So you need to be honest and open about that, but overall, patients love it,” he says. “They’d like to be in sufficient contact with their surgery center, if they could pull that off. So an EHR would have the ability of actually integrating the patient to the system as well as the medical dimension of it.”

“This is all part of being able to reinvent aspects of your work,” Detmer continues. “So instead of paper surveys and such, many of the things that you had done, you can start doing electronically. I think what you would find is that some patients actually would prefer to get care there than at a place where this is not one of the capabilities. I think EHRs offer some market advantage, but I do not have data to prove that, but it’s going to be a great patient satisfier. Again, you have to make sure you get the permission right, but if you do that, it turns out that a great number of patients love it.”

In any case, Detmer strongly advises educating all staff and management personnel when shifting to such systems. “They would be very wise to make sure that they actually put in a little time to get educated about this,” he asserts. “If not, they run the risk of spending a lot of money and not really having much to show for it.”

Armstrong points out that these systems are a work in progress and that it can be a very time consuming and lengthy ordeal to implement. “It’s an elephant,” he says. “You’ve been running your business for ten years with paper. You can’t really go overnight to electronic, so you want to take it in phases.” He offers that going department by department is the best way to roll such a system out. “Same way you eat an elephant — one bite at a time,” he says.

Insuring a successful implementation takes a lot of patience and a lot of teamwork. Detmer also offers that increasingly, regions around the country are developing networks to be able to help hospitals, ASCs, and other healthcare entities to get into a community network. He advises “to check in your back yard” relative to those sorts of sources.

Veach points out that more than anything else; the thing that can assure a successful implementation is management involvement. He says he has witnessed both sides of this fence and management involvement is key to a seamless implementation. However, management can not do it alone. Detmer says it presents a “great challenge” getting the clinicians to go through the behavior change that it will take to actually get into this new status of operations, at least until it becomes sort of the new norm. “They have to have the respect of the clinicians and the attention of the clinicians or they won’t be able to succeed,” he asserts. “This is because there is a change management associated with this. In fact, it is more of a change management behavior issue than it is anything else.”

“More and more, patients are equating good technology with quality healthcare outcomes,” Jenkins adds. “Payors are requiring electronic interfaces, not paper/fax. Business office and clinical staff need more advanced tools to do their jobs; and the lowered cost of bandwidth, processing power, and data storage has made things like imaging and complete case documentation feasible.”

Jenkins adds that the most requested new technology features revolve around mobility, such as WiFI, remote access, and tablet PCs. “We used to implement these features about half the time,” he says. Now, “they are now becoming standard — everyone wants the increased capabilities and efficiencies that accompany these features.”

Detmer reminds us that the thing that makes ASCs so successful is that they have the rapport and the satisfaction with their patients that they serve. He says that if a center keeps this aspect at the forefront of thought when implementing these systems, they are sure to succeed in improving business and clinical efficiencies.

“I think this really adds another major key dimension to that if they do it in such a way that they can have secure communications to their patients as well. I think yes, you absolutely need to have the communications open among the clinicians — both inside and outside of the organization — but I also think this capacity of also being able to relate to the patient themselves is really terrific.”

Detmer’s last piece of advice on jumping onto this 21st century revolution bandwagon: “Come on in, the water’s fine.”

1. Burt, CW, et. al. Electronic Medical Record Use by Office-Based Physicians: United States, 2005. CDC Division of Health Care Statistics.

Electronic Health Records: An Overview

By Jennifer Schraag

It’s inevitable. Every healthcare provider e-v-e-r-y-w-h-e-r-e is going to have to jump on the EHR bandwagon. It’s going to be a confusing, challenging and expensive endeavor, but if you arm yourself and your center with the proper tools and education you can easily transform with a smooth and simple operation.

The idea behind electronic health records (EHRs) is to develop a nationwide health information infrastructure to allow information to be more portable – moving with consumers from one point of care to another – and to aid in achieving secure and seamless information exchange. The EHR ideology also focuses around patient safety and reducing medical and medication errors.

Don Detmer, MD, president and CEO of the American Medical Informatics Association (AMIA), says there is no question concerning the inevitability of EHRs. “It is something that everyone will get to do – and it’s not good to be the last one,” he warns. He adds that the United States is past the era of this as a research application, and past the era of the early adopters. “We are now into general implementation,” he asserts.

According to the report, “U.S. Electronic Health Records 2005 – 2015: Spending Forecast and Analysis” published in August, total information technology (IT) spending for the EHR market in the U.S. will increase to $4.8 billion by 2015, reflecting a compounded annual growth rate of 15.8 percent. ¹ Current spending in that market is estimated to have hovered around $1.1 billion. Moreover, according to Lynne Dunbrack, the lead author of the report, payors will invest earlier in EHR systems than will providers “because they currently have more digitized health information than other stakeholders in the health ecosystem,” she writes.

The adoption of such systems could produce efficiency and safety savings of anywhere from $142 billion to $371 billion, according to a study published in the journal Health Affairs.² In a model assuming that 90 percent of all U.S. hospitals and outpatient practices will have adopted EHRs by the end of a 15-year period, cost savings from improved efficiency were estimated to be $77 billion per year. Overall cost savings associated with widespread EHR use was estimated to be primarily dependent on productivity gains. Furthermore, costs savings to the U.S. healthcare system as a whole were estimated to be $81 billion. The quality of care and patient safety outcome reflected positive results as the researchers cite that health benefits are estimated to come from improved disease management for chronic conditions and improved safety and preventive care.

Another aspect important to mention was documented in a separate Health Affairs study that found that physician specialty was associated with EHR use.³ Cardiologists and orthopedic surgeons were more likely to use EHRs and psychiatrists and dermatologists the least likely, according to the researchers.

EHR adoption was tossed onto the frontburner by both the disasterous 2005 hurricane season and by the Bush Administration. President Bush has set the goal for widespread national adoption of EHRs for 2014. Through an Executive Order, Bush established the Office of the National Coordinator for Health Information Technology and designated a Department of Health and Human Services (HHS) official to serve as the national health information technology coordinator.

Bush pointed out in his announcement that the “21st-century healthcare system is using a 19thcentury paperwork system.” He also notes that national implementation of EHRs could reduce healthcare costs by as much as 20 percent and that such records could “help change medicine and save money and save lives.”

The ongoing transformation of healthcare IT received another shot in the arm when on July 27 the U.S. House of Representatives passed H.R. 4157, the Health Information Technology (HIT) Act of 2006. The Healthcare Information and Management Systems Society (HIMSS) says that if this legislation is passed, it “could have profound effects on the healthcare industry.” This action follows similar action by the Senate last November when it passed S. 1418. Both H.R 4157 and S. 1418 codify the Office of the National Coordinator for Health Information Technology into law, and both pieces of legislation codify the American Health Information Collaborative/Community (AHIC).

The Wired for Health Care Quality Act of 2005, which passed the Senate on November 18, 2005, directs HHS to recommend uniform technology standards for the federal government. The legislation also establishes grants to hospitals and other providers for technology use, to regional entities for the development of health information networks, to states for the creation of revolving loan funds to support IT adoption by providers, and to educational centers to train healthcare professionals to use technology.

HHS Secretary Mike Leavitt announced in August that the first round of ambulatory EHR products have been certified by the Certification Commission for Healthcare Information Technology (CCHIT). HHS awarded CCHIT a contract last fall to develop certification criteria and a certification process for ambulatory EHR products. This CCHIT certification indicates that EHR products meet baseline levels of functionality, interoperability and security in com pliance with CCHIT’s published criteria. This collaborative effort was set to ensure the adoption of health IT products by limiting the risks associated with investing in them.

To further aid in compliance, legislation introduced by Congressman David Wu (D-OR), the “10,000 Trained by 2010 Act,” calls for a trained workforce. The proposed legislation would authorize the National Science Foundation to award grants to institutions of higher education to develop and offer educational and training programs for healthcare workers and professionals in applied health and medical informatics. The Act comes on the heels of a 2005 AMIA initiative called the “10x10” program. This program aims to realize the goal of training 10,000 healthcare professionals in applied health and medical informatics by 2010.

The American Health Information Management Association (AHIMA) and AMIA jointly hosted a summit in 2005 to develop strategies to address EHR-related workforce challenges. The two organizations produced targeted recommendations for preparing the existing healthcare workforce to use the tools and recommended federal support for health IT adoption and training.

In addition, the Office of the National Coordinator for Health Information Technology contracted with AMIA to create a roadmap for a national approach to clinical decision support as part of EHRs. Clinical decision support includes such additions as electronic reminders, alerts for things such as drug-drug interactions, dosage calculators, and imbedded intelligent agents to support the management of respirators and other devices. These innovations are thought by AMIA to offer significant improvements in safety and quality, according to an AMIA press release.

AMIA is also working with the American College of Surgeons (ACS) in educating surgeons on EMR and EHR use, according to Detmer. As a result, ACS will increasingly be offering programs and courses that relate to the use of EMRs and EHRs in surgical environments.

HHS, in August, announced a final rule from the Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG) that creates new exceptions and safe harbors to two key federal fraud and abuse laws for arrangements involving the donation of certain electronic health IT and services.

The CMS rule creates two new exceptions to the physician self-referral law. Similar to the CMS rule, the OIG rule establishes two new safe harbors under the federal anti-kickback statute. Arrangements involving the provision of items and services that meet the requirements of the safe harbors are exempt from enforcement action under the federal anti-kickback statute related to electronic prescribing as well as EHR systems.

The rules finalize an exception and safe harbor for the provision of EHR information that is more expansive than the exception and safe harbor proposed by CMS and OIG on Oct. 11, 2005.

“These important regulations will help promote the adoption of essential health information technology while protecting the federal healthcare programs and beneficiaries from fraud and abuse,” HHS Inspector General Daniel Levinson said in a press release.

The exceptions and safe harbors establish the conditions under which:

• Entities furnishing HHS (and certain other entities under the safe harbor) may donate to physicians (and certain other recipients under the safe harbor) interoperable EHR software, IT and training services 
• Hospitals and certain other entities may provide physicians (and certain other recipients under the safe harbor) with hardware, software, or IT and training services necessary and used solely for electronic prescribing 

The scope of donors and recipients under the final rules is broader than in the proposed rules. Among other conditions, the final rules for arrangements involving the donation of EHR technology include a cost-sharing requirement. Recipients are required to pay 15 percent of the cost of the EHR technology items and services. In addition, consistent with the President’s goal of adoption of EHR technology by 2014, the exception and safe harbor protecting arrangements involving the donation of EHRs will sunset on Dec. 31, 2013.

1. U.S. Electronic Health Records 2005 – 2015 Spending Forecast and Analysis, Health Industry Insights. www.healthindustry-insights.com. 

2. Hillestad, R., et.al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff, 2005 Sep-Oct, vol 24, pp 1103- 17.

3. Burt, C. W., Sisk, J. E. Which physicians and practices are using electronic medical records? Health Aff, 2005 Sep-Oct, vol 24, pp 1334-43.

EMRs and EHRs, What’s the Difference?

Many use the terms electronic medical record (EMR) and electronic health record (EHR) interchangeably. However, these terms describe completely different concepts, both of which are crucial to the success of local, regional, and national goals to improve patient safety, improve the quality and efficiency of patient care, and reduce healthcare delivery costs. EHRs are reliant on EMRs being in place, and EMRs will never reach their full potential without interoperable EHRs in place. It’s important to understand the differences, and to reduce confusion in the market.

The EMR is the legal record created in hospitals and ambulatory environments that is the source of data for the EHR. The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payors/insurers, including the government.

Before the move to effective EHR environments can be implemented, provider organizations must first implement complete EMR solutions.