Doctors charting high-tech path With computers, patient records are at their fingertips
By MEL HUFF Staff Writer | September 02,2007
When Dr. Bruce Bullock, a family practice doctor in Rutland, sees a patient, he opens her chart on his computer and at a glance notes her vital signs, the results of her laboratory tests and the medications she's taking. He can pull up a stress test she took five years ago along with the notes he made at the follow-up visit. He can automatically graph her blood pressure and weight between the time of the test and now and show her the relationship between the two.
Bullock's electronic medical record system lets him e-mail his secretary to make a referral to a cardiologist before the patient leaves the exam room. He can send himself an e-mail, dated in the future, reminding himself to tell her to get a colonoscopy.
When Bullock writes a prescription, the system will alert him if his patient is allergic to the drug or if there's a cross-reaction with other medications she's taking. He can view everything he has ever prescribed for her and see a list of the medications that were effective.
"This is absolutely the greatest quality tool," Bullock says.
The widespread adoption of electronic medical records, or EMRs, is a prerequisite for creating a secure statewide network for data exchange among health care organizations.
The use of electronic medical records, also called electronic health records, is the part of the Vermont Health Information Technology Plan, developed this year by Vermont Information Technology Leaders at the direction of the General Assembly.
Because EMRs can keep track of innumerable facts and present them in meaningful ways, they are considered indispensable tools for treating chronic conditions, which account for 70 percent of health care spending in the state.
"We knew it was the future," Bullock said. He and his partner, Dr. Seth Coombs, an internist, were "early adopters." They bought their system in 1999 when they left the Rutland Regional Medical Center to start Marble Valley HealthWorks.
"We didn't have the paper records any more. We simply started over. We had a lot of transition issues, but because we were starting from scratch, we designed things around the computer," Bullock said. They selected their system by reading articles on the Web site of the American Academy of Family Physicians.
The words "higher quality" pepper Bullock's observations about how the EMR system has changed patient care. "Faster" is the word that recurs when he talks about how Practice Partner, the system he uses, has affected his practice.
"It's highly tempting for me to give you lots of hyperbole about it," he says.
The integrated system includes scheduling and billing functions as well as electronic medical records, which he says makes it particularly well suited for use by doctors in small practices like his.
"It helps me organize my day and be in touch with other people," he says. And he can export the program to the laptop he takes on house calls. "In terms of it being a tool to do what I do, it's very versatile. I can tailor the program to do almost anything I want."
Bullock doesn't know whether the EMR has resulted in financial savings, but his nurse, Sally Beayon, observes that it makes the office run more efficiently.
"It saves a lot of filing because everything gets scanned now. Before, people had to actually pull the chart," she says. The staff also spends less time deciphering providers' notes.
A cost/benefit study published in the Journal of the American College of Surgeons this year looked at the financial impact of EMRs on 28 providers in five offices at the University of Rochester Medical Center. It found the systems produced an annual savings of nearly $10,000 per provider after costs were recaptured, which took 16 months. More than half the savings came from reducing the number of chart pulls.
In addition to helping him improve patient care, Bullock says the EMR has given him something else he prizes: "I can access this information from home, so even when I'm on call I'm able to function with full information. Or I can work at home," he says. "For clinicians, that's a really big deal, to be able to go home, have dinner, spend some time with our kids and then put in an hour from 9 to 10. That can make a big difference in your lifestyle."
But the improvements in patient care and lifestyle didn't come cheap. "This computer system in 1999 cost me roughly $70,000 between the hardware, the networking and the program," he says. "The maintenance cost is significant every year. I have to pay for each license we use there are scheduling, billing and clinical licenses."
Cost is the main barrier to the spread of the technology. Physicians in small, rural practices face rising costs and declining income.
"A 2005 survey conducted by the Bi-State Primary Care Association found that 67 percent of rural Vermont primary care practices identified cost as the largest barrier to EHR adoption," according to the Vermont Health Information Technology Plan. Another significant obstacle for 54 percent of rural practices in Vermont is the lack of broadband Internet access.
Health information exchange has become a national priority. In his 2004 State of the Union address, President Bush set a 10-year goal for creating a system of interoperable electronic medical records. Vermont is far from meeting that goal. This year, a survey by VITL showed that 69 percent of Vermont doctors are still using paper records. In five years, according to the Vermont Health Information Technology Plan, 55 percent of practices with one or two physicians are supposed to be using EMRs, up from 14 percent today.
One of the deterrents to EMR adoption is that physicians have to pay for the systems, and they see only 11 percent of the financial benefits.
The Legislature created an Interim Technology Fund last session with the goal of raising $1 million through contributions from hospitals and the public and private insurance companies who pay for claims. The principal beneficiaries of EMR systems are insurers, who reap savings through reduced duplication of tests and automated record-handling, a study by the Center for Technology Leadership found. VITL argues that insurers' savings could serve as a "foundation for contributions."
The $1 million fund will be used for a pilot project to equip 12 providers in small, independent primary care practices with EMRs and maintain them for three years. The systems will be chosen from two or three systems evaluated by VITL, and the sites will be chosen from practices that serve low- and middle-income patients.
The $1 million includes $32,000 per provider for hardware, software and short-term loss of productivity, and $10,000 per provider annually for three years of maintenance and support. To this $744,000 in direct costs, VITL has added 25 percent to pay for staffing to implement the project. Practices and vendors are to be selected by the end of the year.
"We are running this as a pilot to try to figure out how to serve the entire state long term," explained Gregory Farnum, VITL's president. "We're really focused on using this as a learning ground to understand what is it going to take, what are the barriers, what are the tools we need to have in place to help this practice transformation happen."
Building on what is learned through the pilot project, VITL plans to roll out EMR systems for the state's 318 primary care physicians who work in practices not owned by hospitals. The three-year cost of that project is projected at $24.7 million.
Dr. Chris Bean and Dr. Christopher Meriam use a different system in their Berlin practice, Green Mountain Orthopaedic Surgery. Unlike Bullock, Bean admits he is not especially adept with technology, but he says the EMR saves time on paperwork time that he can now spend with patients.
Bean and Meriam previously adopted a digital system for storing X-rays and other images. They saw that medicine was evolving in the direction of electronic records, and they were relocating to a much smaller office where they wouldn't have space to store X-rays and files. "That," Bean observed, "was what tipped the balance."
Another factor, Bean said, was that "we weren't going it totally alone." Medical Business Associates, who handles their billing, did the research for them and found a system that was "relatively easy to incorporate."
As Bean walks around his office, he holds a tablet PC and a microphone built into a mouse that he carries with him from one exam room to the next.
"I like to be mobile," he explains.
The tablet holds about 20,000 patient charts, displays his schedule, test results, workers' compensation forms, holds physical therapists' notes, records of patient's phone calls, notes on operations and consultations with other doctors and pictures from previous surgeries. And it provides Bean with alerts and reminders.
"I am not a super computer geek," Bean says, "but I use the system. I like it."
Rather than typing, he uses speech recognition software, he says. He begins to dictate a note and his words appear as type, unfurling across a text screen. He dictates in front of patients it gives them an opportunity to hear his comments again.
Bean sees many people who have workers' compensation claims and whose care he has to coordinate with other physicians. He signs his notes electronically, and when patients get to the check-out desk, his secretary prints a copy for them. The patients can fax the copy to their workers' compensation case manager or give it to their family physician or take it to another doctor for a second opinion. And they can reread the notes at home to better understand their conditions and treatment options.
"There's no waiting for two or three days waiting for it to go to transcription," Bean says. "My notes are usually all done by the end of the day."
Bean particularly appreciates the fact that the system cuts through the chore of coding procedures for insurance reimbursement.
"The kind of coding that's painful is trying to look up the code for something you don't see every day. Rather than having to go to a book and look it up or write it down and have somebody else look it up ...," he says, then speaks the name of a condition into the mic. The computer finds the code in seconds.
"Does that actually help the patient?" he asks. "No. It just helps me get through the insurance rigmarole. The billing and coding is our nightmare. Treating the patients isn't so bad. It's treating the charts that's a pain in the neck."
Bean describes the transition from paper to electronic records as "painful. There were days when the computers would stall or crash, and although there were back-ups, it slowed the office down.
Bean doesn't think the EMR system has saved the office money, although he says the speech recognition software has eliminated thousands of dollars in transcription costs. He does think it has enhanced "safety and accuracy and the ability to keep track of things that can get lost between the cracks in medicine sometimes."
"It's worked well for us," Bean says. "It's still a process where you have to find your own groove."
Indeed, finding your groove may be the greatest challenge in making a successful transition to EMRs.
Angela Barnett, a nurse with a degree in clinical microsystems whom VITL recently hired to help practices with the conversion process, observes that adopting EMRs involves a fundamental change in workflow for everyone in the office.
Whether an organization can absorb such a top-to-bottom change successfully depends on its culture on things like whether everyone is included in the decision-making process, whether the staff gets ongoing training and how thoroughly the change is planned for, she says. It's not "just adding software and flipping a switch."