The state of the electronic health record in 2005.

Like an expert surfer who has pivoted deftly and caught the curl, Mid-Carolina Medical Group in Charlotte, N.C., now nestles securely in the trough of the information technology wave--zipping along with ease and showing off impressive new moves. (See "Beyond Electronic Health Records" page 12.)

A few other surfers are spaced out widely along this wave front too: Big Kahunas, mostly burly practices of 50 or more physicians. There's a smaller sprinkling of middleweights of Mid-Carolina's size. (The Charlotte group numbers 30 cardiologists.) But only here or there does one glimpse the slight, grinning figure of a solo practitioner or a group of fewer than nine physicians.

Far to the rear, still bobbing tremulously on their boards, anxiously peering toward the horizon, shivering a little in the breeze, lingers the vast mass of would-be surfers. They come in all sizes.

But wait! The sea is surging again beneath them. And there go a whole rank of others now ... paddling furiously, scrambling upright ... some wiping out or bailing, others gamely mastering the momentum.

Eventually the sun will set. The last stragglers will surf or drift ashore. Mid-Carolina and its cohorts, mean-while, will have drunk all the beer and strolled off to the luau arm-in-arm with the most attractive spectators.

Size matters

That is one overripe analogy for the state of electronic health information systems among U.S. physicians in 2005. Three recent surveys sketch the picture in more conventional terms.

Among 1,061 early responders to a random sampling in January of members of the Medical Group Management Association, only one in five said they are now using an electronic health record (EHR).

However, 40 percent of those without one told the MGMA they plan to acquire the technology within the next two years. Not long ago, noted the MGMA, fewer than one in 10 member practices had adopted an EHR.

(Although the terms "electronic health record" and "electronic medical record" are sometimes used inter-changeably, there is growing consensus that the latter signifies a more limited documentation system. EMR data reside solely within a practice or medical facility, EHRs are more comprehensive and broadly linked. At the behest of the Department of Health & Human Services, the Institute of Medicine developed a set of criteria for a true EHR in 2003.)

Results of a second survey, a poll of physician leaders taken annually by Modern Physician magazine, were reported in late January. About two in five respondents said they have already adopted an "electronic patient record"--a usage that further blurs distinctions. However, significant differences existed between the prevalence of electronic systems in large and small practices.

Almost two-thirds of leaders of the largest medical groups comprised of at least 300 physicians said they have gone electronic; two others reported their organizations are planning to do so within the next 12 months.

At the opposite end of the spectrum were groups of fewer than four physicians. Only about one in four in this category have invested in electronic patient records, according to the Modern Physician poll. What's more, an almost equal number from this group said they had no plans to acquire the technology "any time soon."

Physicians who practiced at or were affiliated with a hospital were most likely to be using an electronic record. More than half said they are today, and another 18 percent said they expect to be doing so before the year is out.

Distinguishing among digital health information technologies, the Commonwealth Fund last December reported findings from a mid-2003 survey of 1,837 randomly selected physicians nationwide. The results looked like this:

* More than 75 percent use electronic billing routinely or occasionally but far fewer make use of IT to improve practice efficiency and quality or to communicate with other physicians or patients

* Fifty-nine percent access patient test results electronically, either routinely or occasionally

* About 27 percent use an EMR routinely or occasionally, most often coupled with electronic access to lab results, less so to other decision aids such as alerts to prevent drug ordering errors

* Twenty-five percent order tests, procedures or drugs electronically, but only 17 percent do it routinely

* Fifty-four percent send routine checkup or preventive care reminders to patients, but only 21 percent do it electronically

The breakdowns according to practice size were telling. Almost three in five physicians in groups of 50 or more practitioners belly up to an EMR at least once in a while, the Commonwealth Fund found. That compared to just one in four in solo practice.

Salaried physicians were also more likely to use a digital system than their non-salaried peers--35 percent versus 21 percent. Figure 1 shows how the surfers in that opening scenario would be arranged along the wave:

Help in choosing

What's the problem? Why aren't more doctors leaping to hang ten as the digital wave inexorably swells beneath them?

"The biggest stumbling block is cost," declares Kevin Fergusson, MD, medical director of the Virginia Health Quality Center in Glen Allen, Va. "A significant investment is required, and it takes time to recover that investment through the efficiencies gained--as much as 18 to 24 months.

"It also requires a change of workloads within the physician's office," he says. "And anything that reduces productivity for even a month or two is very difficult for most practices to handle."

In fact, observes orthopedic surgeon Eric Fishman, MD, of West Palm Beach, Fla., the price tag on electronic health record systems has dropped considerably and continues to do so. Still, he says, "to spend $10,000 to $50,000 per physician would not be uncommon--and that is a substantial amount of money."

Fishman is an expert on this subject. He has established a Web site, EMRConsultant.com, where physicians shopping for digital health information systems can submit a practice profile, describe the technology they already have in place and select the features they're seeking in an EMR or EHR. (Despite the Web domain name. Fishman agrees with the IOM's distinctions in functionality.)

The information is reviewed within 24 hours, says Fishman, and EMRConsultant.com offers a handful of recommendations of systems to investigate as most likely to be suitable. More than 200 vendors (as many as 400 sell this kind of soft-ware nationwide) are listed on his site, although only about 100, he judges, are "worth their salt." Fishman has referral fee agreements with a "subset" of those, he acknowledges.

The Healthcare Information and, Management Systems Society (HIMSS) offers a similar online EHR evaluation tool at http://www.ehrselector.com/emrtoolkit/ASP/Default.asp, that requires a $149 annual practice subscription fee. ACPE faculty have tested the HIMSS EHR Selector and found it quite useful.

Robert Hodge, MD, FACPE, CPE says the EHR Selector is not only useful for finding a suitable vendor, but it also helped him figure out what features were not offered by a current vendor.

Also, a group of medical societies including the American Medical Association, the American College of Physicians and the American Academy of Family Physicians have formed a coalition to publish general EHR specifications and perhaps user reviews later this year.

Finally, HIMSS, the American Health Industry Management Association (AHIMA) and The Alliance (formerly NAHIT), have launched a Certification Commission for Healthcare Information Technology intended to do for EHRs what Underwriters Laboratories, Inc., does for consumer electronics.

CCHIT, says president and CEO Scott Wallace, "was created specifically to lower the risk and uncertainty of EHR adoption." The organization's seal of approval, based on thorough tests of security, functionality and interoperability, "will lower the overall purchase price of these products," he maintains. "As a result, the commission's work should lower resistance to EHR adoption by making the financial and emotional costs of system failure less likely."

Fear factor

As much as cost, Fishman agrees, sheer terror has been a major holdup to widespread EHR adoption.

"Physicians can be bewildered by the number of systems out there," he says. "They're like a deer caught in the headlights. For fear of making a mistake, they take no action."

But no decision is a bad decision, he maintains. To be sure, "time-consuming inefficiency is inherent at first in the implementation of an EHR. Under almost all circumstances, that's very likely at first. For a 25-physician practice that installs an EHR--not a Rolls-Royce, but a fully functional system--it would be appropriate to expect 25 percent fewer patients for a period of three months," he says.

Driven by short-term performance goals, American business executives would be horrified at such a prospect.

"This is the most important quarter of my life," Fisher quotes a common boardroom mantra. But a Japanese executive takes a longer perspective. And that, he emphasizes, is the point of view physicians should embrace when they contemplate riding the digital wave.

"Maybe it'll take till the 93rd day, but eventually you'll find you're seeing more patients than you ever were before," promises Fisher. "And by the end of the year you'll be happy you made the decision."

Fergusson concurs. "I don't think there's any question about the return on investment," he says. "But EHRs are not plug-and-play. The physicians and the staff have to invest themselves in it and learn to use it. Getting the benefit is kind of a progression."

Successful implementation, Fergusson says, requires "a physician champion--leadership that can get consensus. And it requires project management. The vendor plays a big role, of course, but it's like remodeling your house--the contractor doesn't live there, you do. So there has to be someone, usually the office manager, who's making sure the project is on time, on focus and on budget."

If fear can paralyze it can also motivate--like the fear of being caught on the ebb that finally kicks the laggard surfer into action. Or, for that matter, the fear of becoming a puupuu for the sharks.

"The physician who's in the second half [of EHR adopters] is clearly putting himself at risk," warns Fisher. "There's a flex point at which adoptions accelerate, and I think we're getting close to that point right now."

Specialists without EHR capability will be particularly vulnerable to wired competitors, he believes--especially if the primary care practices in the referral base go electronic.

"If a family practitioner has a system that's interoperable with one of four other local surgeons," he proposes, "that will be a tremendous motivation to refer to the surgeon who has interoperability."

Surf's up

Clearly, electronic storage and exchange of health data represent the wave of the future. President Bush has said as much, and appointed a new national coordinator for health information technology, David Brailer, MD, to make sure the surfboards are more widely available and affordable.

For small primary care practices and office sites (no more than eight physicians), the Centers for Medicare and Medicaid Services sponsors the Doctors Office Quality-Information Technology initiative. DOQ-IT programs in every state--Fergusson runs Virginia's--help neophytes lay the groundwork for EHR adoption, including assisting with vendor selection and implementation.

Another CMS program, the VistA-Office EHR, will bring to the public domain this summer an EHR software platform for the grand license fee of $50.

There is still, laments Eric Zimmerman, senior vice president of marketing for RelayHealth, in Emeryville, Calif., a yawning "digital divide" among doctors. A provider of Web-based patient-physician communications system. RelayHealth even uses that gap as a sales pitch. Getting comfortable with e-mail provides a foundation from which technophobic physicians can ease into the demands of a full-blown EHR, argues Zimmerman.

And customers like Eric Liederman, MD, medical director of clinical information systems at the University of California, Davis, back him up on that. "Every year the number of adoptions is going to increase," forecasts Liederman. "There's going to be a sea change."

Better grab your board if you're not already out there paddling. Surf's up.

David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at [e-mail]

RELATED ARTICLE: 8 Core Capabilities for EHR

As defined by the Institute of Medicine, an electronic health record, or EHR, should have the following eight core capabilities:

1. Health information and data. Having immediate access to key information--such as patients' diagnoses, allergies, lab test results, and medications--would improve caregivers' ability to make sound clinical decisions in a timely manner.

2. Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.

3. Order management. The ability to enter and store orders for pre-scriptions, tests and other services in a computer-based system should enhance legibility, reduce duplication and improve the speed with which orders are executed.

4. Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions and facilitate diagnoses and treatments.

5. Electronic communication and connectivity. Efficient, secure and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.

6. Patient support. Tools that give patients access to their health records, provide interactive patient education and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes.

[ILLUSTRATION OMITTED]

7. Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.

8. Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state and private reporting requirements, including those that support patient safety and disease surveillance.

Figure 1. Current Use of Electronic Access to Patient Test Results,
EMRs, and Electronic Ordering by Practice Size

Percent who currently "routinely/occasionally" use the following:

                                  2-9         10-49        50+
                            Solo  Physicians  Physicians   Physicians

Electronic Access to Test   37    62          67           87
Results
Electronic Medical Records  13    23          35           57
Electronic Ordering         14    25          37           46

Source: The 2003 Commonwealth Fund National Survey of Physicians and
Quality of Care

Note: Table made from bar graph.