Ready for prime time?
Electronic records technology offers real benefits for private practitioners, but the costs can be high
From the June 1995 ACP Observer, copyright © 1995 by the American College of Physicians.
By Edward Doyle
When it came to organizing his practice's medical records, Keith Michl, FACP, clearly needed some help. The general internist in Manchester Center, Vt., had tried everything from new filing systems to hiring medical records clerks, but nothing seemed to work. "My partner and I said, 'This is crazy,' " he explained. "We were falling all over each other trying to find our records."
So Dr. Michl decided on a drastic solution: computerizing his practice. Instead of fumbling for patient folders, Dr. Michl and his colleagues soon will refer to notebook computers for patient information. By plugging their tiny computers into special wall jacks they've installed in all their exam rooms, the physicians will be able to check patient notes and medication lists, as well as write prescriptions and order hospital tests--all while seeing patients.
In their quest to computerize the practice--and ultimately eliminate paper records--Dr. Michl and his colleagues count themselves among a growing number of private practitioners who are turning to electronic medical records for help. It's no wonder: Electronic records systems, which can help physicians save time and money, are poised to become the hottest medical computing tool since electronic billing systems were introduced in the late '80s.
But as physicians in small groups begin to embrace what is still a relatively new technology, they are encountering problems that raise questions about whether private practition- ers should be attempting to embrace electronic records software. Some, like Dr. Michl, ACP's Governor for Vermont, point to the benefits and say yes. But others, even some in the industry, point to issues such as cost and future con- siderations, and say that it's not yet time for private practitioners to computerize their records.
For now, the medical community appears to be taking a wait-and-see approach. While many physicians use computers in their practices, only a few use them for clinical purposes such as keeping patient records. For the most part, private practitioners have left sophisticated clinical information systems--and the hassles that often accompany them--to large organizations such as HMOs and academic medical centers.
For practitioners who have seen what these systems can do, however, electronic record technology is too good to pass up. For Dr. Michl, the biggest benefit is the ability to access patient information anytime. He and his colleagues, for example, will be able to tap into their patient records from the office or from home after hours. The computer that stores the information will be at the hospital that owns the practice, so the physicians will connect their computers to home or office phone lines. (The system will use passwords and other security measures to keep the information confidential.)
But electronic record packages do more than just provide round-the-clock access to patient information. Because they store patient information in a database, these programs can remind physicians when patients are due for procedures and tests. Sarah Corley, ACP Member, a general internist in Alexandria, Va., began using a records program when she opened her practice just over a year ago; today, all of the practice's 1,400-plus patients are logged in the computer. She said that using the program makes her and her partner better physicians. "When I've got the computer in the exam room, I can tell patients that they're due for a mammogram or a sigmoidoscopy," she said. "It makes us a little more vigilant with preventive medicine."
According to Dr. Corley, the program also allows her to interact with other physicians faster and easier. "When you need to send a record to somebody," she said, "you can just print the entire medical record instead of photocopying it. With one keystroke you can print all the progress notes. It's a great time-saver." And because she and her partner enter their own patient information, the practice has few transcriptionist bills.
And being more efficient, after all, is what physicians want from this software. "As managed care becomes more pervasive, physicians will have to become much more efficient in handling patient information," explained Edward Ambinder, FACP, an oncologist and general internist in New York City who is also a co-developer of Smart Clinic, a computerized medical record program. "If you're going to see more patients in a shorter period of time, you're going to have to have access to information in order to give patients the type of care that they should have. I can't see paper in any way helping."
Devil in the details
But such efficiency often comes at a high cost. While prices of electronic record systems have been falling (Dr. Corley bought a full practice management package that included electronic records for under $10,000), the overall expenses of implementing the technology can be daunting, particularly to small groups with limited resources.
In Dr. Michl's case, the hospital that owns his practice paid almost all of his computerization expenses, but he still found that some compromises were necessary because of budget problems. He and his colleagues would have preferred to have desktop computers in every exam room, for example, but instead settled on carting laptops from room to room. As a result, Dr. Michl and his colleagues will have to sign on and off the hospital's computer every time they go to a new exam room, adding 10 to 15 seconds--and some inconvenience--to each patient visit.
And not all costs can be measured in dollars and cents. For physicians who don't type--or don't want to--there is the issue of how to get patient information into the computer. Some high-tech solutions promise to allow physicians to enter patient information by dictating notes directly into a computer with voice recognition technology or by using an electronic pen to choose from templates that contain lists of symptoms and other patient complaints. But the technology is still relatively new, so most practices settle on lower-tech compromises and use a combination of computerized templates and transcriptionists, who type patient information into records programs for physicians.
Other problems have less obvious solutions. How, for example, is a practice using computerized records supposed to handle the flood of paper (consult letters from other physicians and lab reports from the hospital) that comes from non-computerized organizations? One solution is to have someone type it in, but that is time-intensive and costly. Another is to scan the materials into the computer electronically, but errors are still common, a factor that could be critical when scanning numbers such as lab values.
Again, the typical solution is something of a compromise. Clerical staff at Dr. Corley's practice take the time to type in some reports (she doesn't trust the accuracy of scanners yet) and also file paper copies into the patient chart in others. This may represent the biggest compromise that Dr. Corley has made; while the practice is computerized, she and her partner still maintain paper charts in case they are sued. (It is not yet clear whether courts will accept electronic records as valid in malpractice cases.)
Waiting and hoping
The range of problems that users of electronic records systems must face has discouraged some physicians from using the technology. George Dichter, MD, an internist in a multispecialty group in Simi Valley, Calif., for example, already uses sophisticated software to manage his practice's managed care contracts, but is waiting until records software better integrates voice recognition technology that allows physicians to dictate notes directly into the computer.
Some physicians concerned by technology's shortcomings have chosen a middle-of-the-road approach. Pamela Fennewald, ACP Member, a general internist in Libertyville, Ill., uses a $400 program to enter patient information into a database and check for drug interactions. While she acknowledges that the system is far from perfect, she said, "I can see patients every 15 minutes, and I can get a quick summary of their problem list and current medications to get me oriented before I go into the room. I feel like I'm much more organized when I see patients, that I haven't forgotten any of their medical problems because I have it right in front of me."
While such solutions may help physicians individually, they may do little for practices in the long run. Ronald Brown, MD, a family physician and medical computing consultant in Cumberland, British Columbia, Canada, who uses electronic records, said that such limited types of software will be unusable in the future. "They only give you one very small part of the patient record and don't integrate with a computerized medical record and scheduling," he said.
And even if you go with a full electronic records package, explained some experts, there is no guarantee that it will survive any more than such fragmented programs. "If I was a physician in practice right now, I wouldn't be developing my own online records," explained Barry Blumenfeld, ACP Member, director of product development for First Data Bank, a San Francisco firm that produces medical software. "There would be a good chance that some time in the next two to three years the PPO I'm part of or the hospital where I'm an attending will reach out and link me into their system. That would negate the work I had done."
Tough choices
All of which leaves private practition-ers interested in using computers with some hard questions. Should they search for an electronic records program that is complete but hard to handle and possibly difficult to implement? Or should they hedge their bets and go with a product that is easy to use but that may be of limited value five years from now?
It's a tough choice. While there are hundreds of electronic records systems on the market to choose from, experts agree that none yet qualify as "killer apps" (industry lingo for software that users can't live without). But that does not mean that physicians should sit back and wait for the perfect system to be handed to them on a silver platter.
"Physicians need to try things out and make their opinions known," said Randolph Miller, FACP, president of the American Medical Informatics Association. "PhDs in computer science who have never seen an outpatient clinic may be designing systems that they think are good for physicians but that just won't work because they don't know about clinical medicine. Physician feedback that we provide now will determine whether the systems are usable or not in five years."
Dr. Miller said physicians need to prepare themselves to enter the information age so they can make sure that organizations such as hospitals choose the best systems for them. "The idea of how you can link your office to sources of information about your patients is critical," he said. "Often the community hospital will buy a closed lab system when they could have bought an open one, where the physicians could be finding out Mrs. Johnson's potassium yesterday but instead have to wait a week for the paper report to come in the mail."
That type of thinking is exactly what led physicians like Dr. Corley to embrace electronic records software in the first place. Since she began using her records program, the hospital she is affiliated with has considered using the same software to link itself to other physicians in the area.
But even if that doesn't happen, Dr. Corley said, the system's advantages--being able to get patient information from home when she is on call, for example--outweigh any difficulties she has faced. "When I get home at night, if somebody calls me up from the ER and wants information on one of my patients, I can dial into the system with a PC anywhere and I can look up what their last lab was or what their last note said or their last prescription," Dr. Corley explained. "I couldn't be happier with the system."
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