John T. Kihm, MD, FACP

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by John Kihm, MD, a full-time solo concierge internal medicine physician in Durham, North Carolina. 

The views expressed in these blogs are those of their respective contributors and do not represent the views of 

	Acquiring a horse may be inexpensive or even free-then the expenses mount: vet bills, boarding, training, new equipment, not to mention all time dedicated to your new pet.  Similarly, your EHR may be cheap or free, then IT fees, hosting fees, hardware, update fees and user training all have to be paid for.  Now, imagine the government telling us we all need to buy a horse and keep it for life-great for the horse industry, but perhaps not for you. Horses and EHRs are expensive animals after purchase. More importantly, your irreplaceably precious commodity, time, overshadows all other EHR financial expenses. EHRs can absorb your valuable time, hurt your bottom line and lead to burnout and a tragically foreshortened career.

	Balance your time and keep your priorities straight.  Stark figures warrant looking before leaping into EHR. If you haven’t already jumped, there may be a solution.

	As a solo internist managing my own office, I make business decisions every day, and here’s how I see the EHR:  2.61 hours per day spent entering EHR notes and orders.

 Assuming six weeks off per year, that’s a staggering 731 EHR hours, or three months of busy-work annually.  What’s that worth to you? Primary care doctors earn an average of $230,000 annually working an average of 45 hours per week, or roughly $100 per hour.

	At that hourly rate, EHR costs you an eye-opening $73,100 annually in your time. This doesn’t even factor in actual EHR expenses, such as hardware, implementation, upgrades and maintenance, IT consulting time, licenses and office personnel overhead. If you earn more, the time-cost of EHR clerking increases proportionately. No, I do not own an EHR or horse, but I do like horses.

	Knowing your time and money costs will make for easy business and life decisions. What about Medicare penalties for not having an EHR? The math is simple: look at that total revenue, then subtract 4-9%. That’s the amount you will lose not adopting an EHR as part of MACRA/MIPS.  Your time cost will likely dwarf the penalty, but if time/costs penalties approximate, then add the thousands in hardware, software, tech and training fees to the time-money you are losing, not to mention the hours you work to pay that overhead. If you are a physician-employee working for a group or health system and are paid for EHR time (earning $100/hour to scribe), you may rather earn $100 per hour as a doctor, helping people, rather than as a clerical worker.

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	Or, if you presently scribe after-hours, “donating” time to your employer and insurance companies, you may prefer to donate your time and money to charities. Life is short, though, so if you prefer typing versus practicing medicine, make that choice. Either way, prevent burnout by doing what you enjoy.

Next: Good business decision foster happiness

	Your good business decisions should foster happiness. While converting my hamster-treadmill traditional practice to concierge, I explained to my patients that a burned-out doctor who retires ASAP is good for neither his patients nor himself. Ten years into concierge medicine, I only wish I had converted five years earlier. I enjoy working hard, seeing half as many patients per day and doing a great job for them while reversing my burnout trajectory. With a slight income gain, working 25% fewer hours per week, I have more time for family and personal activities. Don’t take your time for granted, life is too short to spend it unhappy.

	For physician-employees, consider an alternative to being the $100 per hour clerk-hire a scribe for $12 per hour, the median hourly rate.

 Full time, with benefits and taxes, that’s about $32,500 per year. Tell your manager you could generate an extra $73,100 per year of revenue by hiring a scribe. Subtracting the scribe expense, that’s still $40,600 per year of pure profit for your company, even in primary care.

	The more earning potential you have, the better you will do with a scribe. The financial math is simple, and so is the burnout math. That’s why smart managers hire scribes. In my medical community, scribes are multiplying.

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	The only EHR stress I have is in tracking down and trying find the relevant information in consulting specialist EHR notes. I usually find the answer to my referring question in the last two lines of the six-page note. I am sure there is someone, somewhere, who appreciates all that prose and the work behind those pages.

	Assess your life’s balance:  professional, personal, physical and spiritual. If the professional part is dragging you down, take action. If you don’t wish to, or can’t afford to, quit medicine, and an EHR is unavoidable, hire a scribe. If you are in the tiny minority of us without an EHR, hopefully this blog affirms your decision. Life with an extra three months per year spent with family and hobbies, anyone?

	1.     Arndt, A. (September/October 2017). 

 Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. 

http://www.annfammed.org/content/15/5/419.full

Relationship between Clerical Burden and Characteristics of the Electronic Environment with Physician Burnout and Professional Satisfaction. 

http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-4/abstract

	3.     Grisham, S. (April 5, 2017). 

Medscape Physician Compensation Report 2017. 

https://www.medscape.com/slideshow/compensation-2017-overview-6008547#31

	4.     Paysccale.com (November, 11, 2017). 

https://www.payscale.com/research/US/Job=Medical_Scribe/Hourly_Rate

	Dr. Kihm practices full-time solo concierge internal medicine in Durham, in Durham, NC. He is a member of the board of directors, American College of Private Physicians, 

.  Active in volunteering, Dr. Kihm sees patients at the homeless shelter medical clinic in Durham, NC, and regularly flies medical missions to the Outer Banks of North Carolina and Appalachians. 

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EHRs can absorb your valuable time, hurt your bottom line and lead to burnout and a tragically foreshortened career.

Author | John T. Kihm, MD, FACP

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