Infotech tipping point? (HIMSS meeting)

It seems that momentum and physician interest in electronic medical records are getting bigger than ever. But doctors at a major information technology conference don't know if the technology has really hit the mainstream.

By Tyler Chin — Posted March 14, 2005

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Paul Tang, MD, an internist and chief medical officer of the 600-doctor Palo Alto (Calif.) Medical Foundation, stood up before a physician symposium at a major medical information technology conference to make a declaration.

"We're really near the tipping point" of adopting electronic medical records, he told the crowd on the first day of February's Healthcare Information and Management Systems Society Conference & Exhibition in Dallas. Rather than EMRs being a rarity in practice, he and other speakers said, they are reaching the critical mass necessary to make physicians use them.

But audience member Jonathan D. Leffert, MD, a solo endocrinologist in Dallas, was unmoved.

"I'm a solo physician in private practice. My big concern is how physicians like myself and others in small and medium practices can afford an EMR," Dr. Leffert said afterward. "[Dr. Tang] is from a practice that probably has several hundred physicians whose decision-making is very different than if you're in solo practice and have to pay it out of your pocket."

The comment underscores the disconnect between the physicians who generally pound the table for clinical automation and those who are supposed to feel their vibrations. The former typically are from deep-pocketed large practices while the latter are small and medium practices with little change to spare. But smaller practices are being heavily courted, because the goal of improving patient safety and reducing costs through automation can't happen without them.

The Chicago-based HIMSS, which historically has geared its annual conference toward senior management and technology executives at large hospitals, started reaching out to small practices in 2003.

This year, it drew more than 21,000 attendees, including 588 physicians, though not all of them are practicing or in private practice. The technology symposium attracted 250 attendees, up from 180 in 2004.

But the increased physician visibility at HIMSS does not mean doctors will buy an EMR anytime soon, even with President Bush pushing to have electronic medical records implemented nationwide within a decade. Although EMRs have been on the market for years, sales remain limited to a select group referred to as early adopters, who are estimated to be up to 15% of all physicians.

Recent studies have estimated that fewer than 10% of physicians use EMRs.

The conventional wisdom is that until powerful EMRs sell for $10,000 or less per physician, demonstrate that they save time and money, or are mandated, physician adoption of the technology will continue to just inch forward.

"The reality is that many people are very fearsome of computers, especially in medical offices," said Armand A. Gonzalzles, MD, a solo pediatrician in Chicago, whose practice was one of four small- and medium-size practices honored at the HIMSS conference for their implementation of EMRs.

Even physicians interested in using EMRs aren't necessarily ready to buy them.

Unless a hospital, insurance company or the federal government offers a $10,000 bonus or grant, Dr. Leffert says he's not buying. "EMRs are absolutely the right thing to do, but for me the barriers are cost, time and energy [EMRs impose on me when most of the benefit accrues to insurers]," he said. "They are not insignificant."

For Sally M. Knox, MD, a surgical oncologist in Dallas who also attended the HIMSS conference for the first time so she could research EMR products, the tipping point will come when the technology gets really good, which she believes is starting to happen. "If it saves doctors cost, if it saves them time, you won't be able to keep doctors away," she said. But systems costing $30,000 per physician are "not going to fly."

"It really comes down to economics more than anything else," said Robert J. Lamberts, MD, an internist and pediatrician at Evans (Ga.) Medical Group, a four-doctor primary care practice that has an EMR. "Nobody had to convince an ophthalmologist to do LASIK surgery; they all spent the money to learn to do that because there was a financial incentive. If there was the same financial incentive for [an EMR], it'd be a done deal."

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Award-winning technology usage

The following four physician groups won the Healthcare Information and Management Systems Society's 2004 Davies Primary Care Award for excellence in implementation of electronic medical records. The two-year-old award is named after Nicholas E. Davies, MD, an Atlanta internist and cardiologist who was part of an Institute of Medicine committee that coined the term "computer-based patient record."

North Fulton Family Medicine

Location: Cumming, Ga.
Number of physicians: 8
Details: In 1998, as a four-doctor practice, the group paid $180,000 to buy and implement an EMR from A4 Health Systems, Cary, N.C., reaping an estimated return on investment of $253,000 in the first year. The group estimates its return on investment now is $2.5 million based on eight doctors and eight physician assistants seeing more than 350 patients daily. "Now, we're not seeing [all of] that in our pocket because we're spending money on other things" such as salaries, benefits, hardware and additional software licenses, said family physician James R. Morrow, MD, vice president and CIO.

Old Harding Pediatric Associates

Location: Nashville, Tenn.
Number of physicians: 14
Details: The practice, which in 2002 spent about $500,000 to buy and install an EMR from Cleveland-based Noteworthy Medical Systems, won the award in part because every member of the practice from physicians down to office staff has "fingertip access" to the system, said executive administrator Brenda Plunkett.

Pediatrics @ the Basin

Location: Pittsford, N.Y.
Number of physicians: 2
Details: The practice spent less than $15,000 in 2002 for an EMR from Docs Inc., Springdale, Ariz., including hardware and implementation costs. Pediatricians Alice Loveys, MD, and Janet Cranshaw, MD, share call and weekend care with five doctors at two other pediatric practices in suburban Rochester, N.Y. They decided to implement an EMR because they have young children and wanted to balance their personal and professional lives. "At 5 p.m., I'm done, as opposed to having to sit there and chart and be home later at 6 p.m. or so. If I need to leave early for a chess club [engagement] at 4 p.m., I can work that in," Dr. Loveys said.

Riverside Pediatrics

Location: Chicago
Number of physicians: 1.5
Details: The group paid $7,000 to $10,000 in 1999 for an EMR from Atlanta-based JMJ Technologies. They've kept costs low by buying used hardware on eBay.

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What hospitals are doing

More than half of U.S. hospitals plan to add electronic medical records in the next two years, according to an HIMSS survey of 253 information officers representing more than 550 hospitals.

Top applications planned Hospitals
Electronic medical records 62%
Bar-coded medication management 55%
Clinical information systems 52%
Computer-based physician order entry 50%
Enterprisewide clinical information sharing 44%
Digital picture archiving 42%
Clinical data repository 42%
Point-of-care decision support 37%
Technology adoption Hospitals
PDAs 59%
Bar code 59%
Speech recognition 59%
Automated alerts to clinicians 57%
Data warehouse 51%
Wireless information appliances 51%
Extranet 50%
Web-enabled clinical process 45%
Data security technologies 45%
Most significant barriers Hospitals
Lack of financial support 20%
Vendor's inability to deliver product 18%
Lack of staffing 13%
Proving return on investment 10%
Lack of clinical leadership 10%
Difficulty achieving end-user acceptance 8%
Lack of top management support 7%
Lack of strategic IT plan 4%
Lack of data standards 3%

Source: Healthcare Information and Management Systems Society

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Can we talk? Maybe later

A major concern that physicians have about EMRs is the risk of buying a system that isn't compatible with -- can't "talk" to -- other systems used by colleagues or a hospital. It's a legitimate fear: From what was demonstrated at the Healthcare Information and Management Systems Society conference, systems won't have much to say to each other for a while.

It will be a decade before physicians will be able to buy EMRs that will be compatible with each other, according to some experts at HIMSS.

Although 40 health care technology vendors at the HIMSS conference showed that their systems can transfer information across different outpatient settings, real interoperability is "not there yet," said Mark Leavitt, MD, PhD, HIMSS' director of ambulatory care. "If you want one that can transmit the whole electronic medical record to another doctor's, it may be 10 years [away]."

Lack of standards is to blame, said Michael Glickman, president of Computer Network Architects and a member of Integrating the Healthcare Enterprise. IHE is a volunteer organization composed of vendors and others who are collaborating to make their systems compatible and promote interoperability in health care.

Because it's not a standards-setting organization, IHE must wait for standards to be developed and approved, he said.

IHE has tested interoperability at the annual meeting of the Radiological Society of North America for several years, but 2005 is the first time it tested ambulatory interoperability at HIMSS. RSNA and HIMSS founded IHE in 1997.

The AMA has official policy supporting the development of standards for interoperability. It also is working on the National Health Information Infrastructure, an HHS-led effort to develop standards.

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External links

Healthcare Information and Management Systems Society (link)

Integrating the Healthcare Enterprise initiative (link)

AMA's Physician Consortium for Performance Improvement (link)

The National Health Information Infrastructure project (link)

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