Implementation isn't the only thing that you need to do to successfully use an electronic health record system. Here's a look at what you need to do to measure productivity.
Before you implement an electronic health record (EHR) system, it’s important to analyze and document your practice’s procedures. To get the most out of your system once it is in place, you’ll want to examine your staff’s performance and analyze key metrics. The insights you gain will help you ensure that practice productivity continues to increase and stabilize.
Here, Robert Rowley, MD, Shahid Shah, and Rosemarie Nelson-three healthcare industry experts in the areas of health information technology implementation, EHR development for primary care, and practice management-share their knowledge in easy-to-follow steps that you can apply immediately to ensure the health and longevity of your practice post-EHR implementation.
Predicting the EHR pay-off
By Robert Rowley, MD,
Health information technology consultant
An electronic health record (EHR) system, which replaces the use of paper charts in your medical practice, affects everything that touches a patient’s chart. In other words, it affects just about everything.
How can you tell whether it is worth it? How can you measure the effect on productivity, overhead, and general quality of life brought about by EHR adoption? By having some useful measurement tools.
The best way to assess the effect of an EHR is to look at three domains:
For the purposes of this discussion, we will include the effect on quality of care under the heading of productivity.
In a practice that relies on fee-for-service income as the mainstay of its compensation, the effect of an EHR on productivity can be measured in several ways:
If part of your compensation comes from achieving clinical quality measure (CQM) goals (some practices, especially primary care practices, can have as much as 25% of their income come from performance-based compensation), then the measures can be either simple, or more sophisticated:
Many reports in the literature conclude that the biggest monetary advantage from EHR implementation is not so much from increasing revenues but from reducing overhead. It is important to measure these savings, because they may offset the cost of implementing and maintaining the EHR in the first place. Calculate the overall overhead before the EHR, including:
After the EHR is implemented, the number of FTEs may change. This potential is especially true in larger clinics, and the reduction mainly occurs in the form of medical records personnel. In smaller practices, these FTEs may be re-assigned to other duties newly needed as a result of the EHR (such as scanning outside documents into the EHR). Calculate the post-EHR overhead, including:
Measure the overhead at various intervals after EHR implementation and at 1 month, 3 months, 6 months, and 12 months.
Quality of life
Quality-of-life effects of EHR use are more difficult to quantify. Healthcare professionals spend much time and effort maintaining their documentation, that is, completing their charts. This task is an uncompensated burden that is simply part of life for a practicing physician. Hours spent “catching up on charts” after the practice is closed is a familiar part of a clinician’s life.
One approach to quantifying this task would be to create a log consisting of two columns, hours and location. Each row represents a specific day. For a trial period of time (I would recommend 1 week), write down, for each day (including weekends), the hours spent completing charts after the office is closed, and where those hours were spent. Typically, in a paper-based environment, those hours were spent at the office, because you do not want to take home incomplete charts. In a post-EHR environment, those hours may be spent in part in the office and in part at home (where the EHR can be logged into remotely and the charts completed).
It might even make sense to include a third column in the log: time arrived home. That way, you can see whether you are, in fact, getting home earlier after an EHR is installed.
It is important to quantify the effect of an EHR on your practice. Review the effect on productivity, on overhead, and on quality of life at intervals after EHR implementation: 1 month, 3 months, 6 months, and 1 year.
Armed with your own data, you can realistically assess your EHR and answer the question, “Is it worth it?” with facts, not just gut-based conjecture.
Anatomy of a successful EHR adoption
By Rosemarie Nelson, MS
Principal consultant, MGMA Healthcare Consulting Group
How do you measure success? Some would suggest that we must determine the return on investment before we sign a vendor contract for an EHR acquisition. That task may be overwhelming considering that we don’t often understand the costs of our current operations.
Greg Spencer, MD, chief medical officer of Crystal Run Healthcare, a group practice in New York with about 200 physicians, says, “Paper costs money, too, but that feels more like a ‘normal’ expense.”
And therein lies the dilemma: What is the new normal?
Let’s look at the story the data tell us.
Looking at the table “Orthopedic surgery, median per FTE physician, 2010 report” (numbers rounded), at first glance, we might point our fingers at the higher head count for orthopedic surgery practices using an EHR. Look further, however, and the EHR practices produce more relative value units (RVUs) and generate a higher percentage of medical revenue after operating costs than practices in the paper environment or those that are operating in a hybrid setting.
The table “Multispecialty, not hospital-owned, median per FTE physician, 2010 report” addresses the question: Do multispecialty practices using an EHR with more support staff per FTE physician use their staff more effectively as represented by more RVUs per FTE physician? The increased production would support a higher percentage of medical revenue after operating cost, and that includes the cost of the additional support staff.
The table “Multispecialty by years EHR in practice, median per FTE physician, 2010 report” points to experienced EHR practices realizing the most significant benefits in the form of a higher percentage of medical revenue after operating costs and increased production as measured by total RVUs. The efficiencies of the EHR allow us to see more patients and provide more services, a win-win situation for the patient and the practice.
The table “Family practice, median per FTE physician, 2010 report” (again, numbers rounded) depicts family practice data that raise the question of staffing to support the provider. Do practices enter into the EHR implementation without appropriate staff to support the transition and adversely affect production?
It would appear that billing and collections operations are significantly enhanced with the use of the EHR in family practice. It is clear that a hybrid approach increases cost without supporting a better bottom line. The take-away says, “If you’re going to do it, do it all the way.”
In the table “Surgical specialty, median per FTE physician, 2010 report,” it is not surprising to find a mixed message. The EHR can improve the coding and charge capture (more RVUs) for surgical specialties, but it may be more difficult to transition the physician from a dictation model to a point-and-click-template for documentation (more support staff to scribe).
The table “Pediatrics, median per FTE physician, 2010 report” shows that practices using EHRs see similar trends as the family practice groups-fewer support staff and lower production (as measured in physician work RVUs) than those practices using paper records. EHR pediatric practices, however, produce a higher percentage of medical revenue after operating costs (lower staff head count may be a factor) and
collect it very effectively (as do the family practice EHR adopters).
Can the data help us more effectively define a successful EHR adoption? They certainly provide direction. Know your pre-EHR data points.
A 12-provider family practice group in Newport Beach, California, on implementing its EHR experienced:
Be patient with your implementation. It takes time to fully integrate a new tool into the nursing and provider workflow. The EHR will deliver a better bottom line, but not without a strong, ongoing effort at integrating the technology tool into the clinical operations.
How to tell whether your implementation was successful
By Shahid Shah
Founder and chief executive officer,
Netspective Commmunications LLC
Many initial implementations of EHRs cause at least minor or in some cases major productivity declines, and most cause physicians to be able to see fewer patients after the install than they could before the installation. That sounds counter-intuitive, especially because technology always is supposed to make things faster and easier. The “old” technology of paper records is infinitely flexible, however, and allows variations in workflow, procedures, training, and other conveniences that computer software still can’t manage.
So, reviewing productivity carefully after an EHR installation is key to ensuring no loss of clinical effectiveness and that problems in billing and receivables don’t linger.
In the post-2009 era of “meaningful use” (MU), it seems everyone is thinking that if you meet MU requirements and get your incentive check, you’ve achieved EHR success. Because incentive payments currently are paid based on the honor system and you won’t be tested for compliance, you should be wary of thinking of success in MU terms.
If MU payments don’t determine success, what does? Most practices that started their implementations without pre-install metrics in place and expectations set appropriately find that they don’t know when they’re done. Consider putting some productivity metrics in place before you implement your EHR and then measure the same ones afterwards. For example:
Keep a close eye on chart access time. You will want to know how patient charts are indexed, found, and stored on paper compared with your EHR. The time from knowing a patient ID or name to getting into his or her chart should be less than 10 to 15 seconds (based on typing speed).
Once you have identified some simple workflow metrics, focus on questions related to disruption-generating tasks:
Disruption can occur when basic computer literacy is lacking. Just as you wouldn’t buy a car for someone without driving skills, don’t bother implementing an EHR unless each user who will be involved has at least these minimum skills that you can measure before and after an implementation:
Once you’ve looked at the key disruption generators, start to consider data quality and the system effects of an EHR. Look for the following specific benefits after installation, and try to quantify them:
If you don’t like the metrics you’re receiving, be willing to disengage from your vendor and get your money back. It seems like silly advice, but if you don’t have metrics and your vendors know that you’re scared of change, then you won’t have any power. If you know what you want and you have measures to prove your requirements, then tell the vendor that unless it meets your needs, you’re going to toss the vendor.
That way, you’re always in the driver’s seat. Otherwise, you’re in the back seat as a terrified passenger.