By Robert Anthony June, 2010 Physician Practice Magazine

Most of us have come to accept that an electronic health records system can make life a little easier. You can recycle all of those paper charts, save a fortune on filing cabinets, and free up all that office space you've been using to store paper records. Practices with multiple offices can even access patient information from every location.

But in the words of the old Peggy Lee song, "Is that all there is?"

A number of practices are starting to ask themselves that very question. With the high price tag of many EHR systems, practices want more than just a paperless office and instant access. They want to see a genuine return on their EHR investment, in terms of dollars and in terms of better patient outcomes.

So, can an EHR make you a better doctor?

Electronic patient management

Southeast Texas Medical Associates is a multispecialty practice founded in 1995. Headquartered in Beaumont, Texas, and with three offices, SETMA was an early adopter of EHR technology. They implemented their first EHR in January of 1999, and by May of that year a light bulb went off.

"I suddenly realized that we had spent a lot of money and gone to a lot of effort and were still going through a lot of pain to accomplish something that had little value," says CEO and founding partner James L. Holly, MD.

What the practice needed was not electronic patient records but electronic patient management.

"Our EHR was merely an electronic means of doing what we used to do by paper or by Dictaphone," explains Holly. "We suddenly realized that the complexities of 21st-century medicine could not be done with 19th-century methodologies, like pen and paper, or 20th-century methodologies, like Dictaphone and transcription. In the 21st century we needed to have electronic methodologies to accomplish the many different things that we needed to do."

Over the next few years, the practice customized their EHR to create different disease management tools. Their "digital dashboards" address areas such as diabetes, hypertension, and dyslipidemia, and allow them to review quality of care benchmarks for patients with these diseases. Not only can the practice physicians and staff compare the clinical values of individual patients to national quality indicators and standards of care, they can compare the progress of individual patients to other patients within the practice. And they can look within groups of patients (e.g., all patients with diabetes) to gauge the overall quality of care for a specific population.

It's been a fundamental shift in the way the practice delivers care, allowing them to look at the health of patients on a very high level and target specific ways the practice can improve outcomes. Over time SETMA has been able to use their EHR to not only track their own progress but see what initiatives have had the most impact. By tracking the average levels of HbA1c in their diabetic population, for example, they saw significant drops during the year when they implemented a diabetes self-management education program, and again when they recruited an endocrinologist for the practice.

That kind of data collection allowed SETMA to reallocate their practice's resources to maximize their return on investment. And it revealed a measurable improvement in patient care that would otherwise have been invisible or impossible to track.
"You can't do that without data," says Holly. "An EHR that is robustly used begins to expand and deepen, focus and sharpen, and strengthen the quality of care that's being given."

Let the EHR be your elephant

Nearly every practice interviewed cited this data-driven approach to care as critical in improving patient outcomes. Like SETMA, Village Health Partners, a 10-provider family practice in Plano, Texas, has made significant investments in technology - and reaped significant quality-of-care rewards.

To cite just one example, Village Health incorporated mammogram tracking into its EHR and now has 63 percent of the eligible population getting tested regularly. Some physicians in the practice have even achieved an 85 percent level of compliance.

"If you consider the fact that we don't provide mammograms in our office, that's an absolutely amazing figure," says president and family physician Christopher Crow.

Other practices have been equally successful: incorporating colonoscopy measurements, cholesterol testing, blood pressure monitoring, and any number of tests and indicators that are important contributors to future positive outcomes.

The secret? Not having to remember everything.

"We can address the clinical care and wellness and disease management gaps, because the EHR is a database that has information, and it will cue you when things are missing," says Crow.

Does the patient need an updated lipid test? The EHR will let the provider know it's time to schedule it. Has the patient been counseled to quit smoking? The EHR keeps track. Is the patient's HbA1c within normal target range? The EHR will let you know.

Holly cites the advantages of this last point for a practice with many providers. Every year the American Diabetes Association updates its Clinical Practice Recommendations, but not a single provider at SETMA needs to read this 100-page document. Holly updates the practice's EHR, and providers only have to check the EHR to see how an individual patient measures against the latest guidelines.

"We can instantly infuse into our practice that standard of care," says Holly.

Jonathan Bertman, a board-certified family physician and a clinical assistant professor of family medicine at Warren Alpert School of Medicine at Brown University, built a similar functionality into Amazing Charts, the custom EHR software that he developed and now sells to other practices. "The benefit of EHRs is that at the moment of care physicians are going to be gently reminded about some things they don't know or that they might forget. For example, I saw a patient who had gout. I forgot what the current recommended treatment for this acute case of gout was. In my EHR we have a 5-Minute Clinical Consult right at the point of care, so I clicked the button and it popped up and told me what to do."

The EHR can not only remind you what to do, but what not to do. Take the patient who comes in for a cold and is commonly prescribed an antibiotic, despite the lack of benefits. "It doesn't shorten the duration of the illness, it just adds expense for the medicine, plus there are risks for the patients, and resistance issues. But the way it works right now, physicians just do it," says Bertman. "They understand it's not necessarily good care, but they are trying to get through their 25 patients a day, so they might essentially do what is obviously an incorrect choice."

An EHR can provide a reminder at the moment of care that makes a provider think twice about a less-than-excellent treatment decision. It also can be used later to see how often those less-than-excellent decisions are made - and then help change behavior.

"It means that you can do a superb job every time, whether you're tired or alert, whether you're focused or you're thinking about this or not, because we've already sat down and gone through the algorithms," says Holly.

Seeing the big picture

If your EHR is the elephant that never forgets, it can also be the pack animal that does all your heavy lifting.

"There's actually no way without an amazing amount of time, resources, and dollars that you could ever pull off this type of information about yourself in the paper world," says Crow. "In 10 seconds I can tell you the number of Pap smears we've done in the last year. Imagine doing that in a practice with a bunch of [paper] charts. It would take you most of the weekend with a bunch of people pulling charts the whole time to make little check marks."

Family physician Robert Brenner, chief medical officer of Summit Medical Group in Berkeley Heights, N.J., saw the immediate implications of this versatility right away. "What if I want to find all the patients that are on a particular medicine because I need to recall that medicine? I could query the database and find all the patients that are on a particular medicine, such as Vioxx, and then send out an automated e-mail. In terms of patient safety, that's an immediate response."

Summit uses its EHR to identify high-risk patients, and then sends a list to its call center to schedule patient follow-ups and callbacks. It has been using Allscripts' Clinical Quality Solutions module to track quality-of-care indicators for its Medicare population and is now working on a fully implemented solution that will cover all of its patients.

"Things have gotten so complicated being a physician," says Brenner. "Here there is a consistent method that the group, managing 55,000 encounters a month, is able to control and chip away at, managing each disease entity the best that we can."

Not only has Summit seen marked improvement in the management of diabetes, hypertension, and mammograms, they've managed to make those improvements pay. Says Brenner, "We did get quite a return on our ability to capture Medicare dollars back from it."

Better call, better care

If data collection and population trends don't motivate you, maybe you should consider the more immediate applications of EHR technology. Barbara Morris is a pediatrician with an eight-provider practice in Saratoga Springs, N.Y., and chief medical officer of Community Care Physicians, a 180-provider multispecialty group practice. She and other providers in her office have been using a mobile app to access their EHR on their iPhones and Blackberries that is helping them to provide more complete care for their young patients.

Take the case of the 6 year old who had been complaining of knee stiffness and joint pain. Located in Upstate New York, Morris immediately thought of Lyme disease. She sent out blood work to start the evaluation process and prescribed antibiotics to be safe. In the meantime, the patient's symptoms worsened. Concerned that it might be secondary stage Lyme disease with encephalitis, Morris sent the child and parents to the emergency room.

Even though she was not at the office, Morris was able to access the patient's electronic records through her iPhone and send this data and a summary of what had been happening ahead to the ER specialist. The information arrived at the hospital before the patient.

"They were able to track down the labs and determined that, in fact, this was just a viral illness and not Lyme disease, avoiding this little girl having to have a spinal tap," explains Morris. "Of course I could have picked up the phone, but they never would have had all of the information. And I would have been relying on my memory to say there are these tests that are out, this is the lab they went to, this is what her exam was two days ago - I think."

Morris notes an additional advantage to using EHR and smartphone technology together. "Most physicians, I think, if you talk to them about their experiences on call, especially as they get those phone calls in the middle of the night, do a less than ideal job of documenting their contacts and what they actually told the patient. And if you talk to people who talk about medical liability, they will say that phone conversations and inadequately documenting are probably one of the worst things to encounter when you're involved in any kind of medical liability litigation."

Is it worth it?

With the cost of some EHR solutions reaching as high as $25,000, many practices, especially smaller ones, are asking themselves whether an EHR is worth the money. Nearly all of the practices interviewed said yes, with both Holly of SETMA and Crow of Village Health pointing to the EHR as a tool that actually has helped their practices grow.

Still the upfront costs of an EHR are considerable. If you're a smaller practice with a limited budget that still wants to reap the outcome and treatment benefits of an EHR, smaller vendors might be the way to go. Consider, too, that a number of large vendors are developing smaller, less expensive EHR software that will be on the market soon. Your practice may not realize all of the advantages of the large and expensive enterprise solutions, but it will certainly be easier on your bottom line.

Keep in mind, too, that money is not the only investment your practice will make. Physicians who think that implementing an EHR is like flipping a switch are in for a surprise. Not only will there be a significant initial training period for physicians and other staff, but ongoing training and development is essential to maximize the effectiveness of the EHR and create more efficient work processes.

"I will tell you that the vast majority of practices just implement and then they get stuck. They don't ever continuously improve," says Crow. "One of the secrets of our success is that technology is nice, but you have to have process and culture and training around it. We train twice a month still."

But if you're willing to put in time, effort, and money, an EHR can definitely help you provide better, more proactive patient care.