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The Pros and Cons of eMRs

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Delving Deeper into the Historic Origins of Debate

Dr. Mata

[By Richard J. Mata MD, CIS, CMP™]

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According to Wager, Ornstein, and Jenkins, in 2005, the perceived advantages of an EHR system include the following:

  •  Quality of the patient records (legible, complete, organized) — 86%
  •  Better access to patient records (available, convenient, fast) — 86%
  •  Improved documentation for patient care purposes — 93%
  •  Improved documentation of preventive services — 82%
  •  Improved documentation for quality improvement activities — 82%

Items viewed as an advantage by fewer respondents include the following:

  •  Administrative cost savings — 38%
  •  Improved efficiency — 61%
  •  Security of patient records — 64%

Nothing directly was said about cost savings or increased medical care quality. These topics have become more contentious issues during the past few years.

The Gurley Opinion

According to HIT expert Lori Gurley, in 2006, of the American Academy of Medical Administrators:

“The EHR provides the essential infrastructure required to enable the adoption and effective use of new healthcare modalities and information management tools such as integrated care,  evidenced-based medicine, computer-based decision support, care planning and pathways, and outcomes analysis” (Schloefell et al).  Although the benefits that support implementation of an EHR are clear, there are still barriers too, therefore the concept is still not accepted. “However, this could also be said of almost every other area of positive change and improvement within healthcare systems […]” (Schloefell et al).  There must be more involvement by the government and the private sector “to make changes where possible to instigate, motivate, and provide incentives to accelerate the development of solutions to overcome the barriers” (Young).

THINK: ARRA and HITECH, today. Of course, there are obviously advantages and disadvantages to both the paper medical record and the EHR.

Multi-Factorial Issues

Many factors must be considered before any healthcare organization or medical practice should implement an EHR.  The organization must first obtain as much information as possible about this new concept, and then the information must be carefully reviewed and the pros and cons discussed. Only then should the organization make their decision about this very important issue.

“The [EHR] as a part of a Clinical Information System (CIS) is a powerful tool which ties together documentation of the patient visit (clinical information), coding (diagnosis, and treatment procedures), which then translates into more accurate billing processes, reduces reprocessing of medical claims, and that translates into increased customer satisfaction with a provider” (Koeller). Although the technology is available, progress towards an EHR has been slower than expected. “Widespread use of [EHRs] would serve both private-and public-sector objectives to transform healthcare delivery in the United States” […] EHRs would also “enhance the health of citizens and reduce the costs of care” (Dick, Steen, and Detmer).

The MRI Study

According to a 2005-07 survey by the Medical Records Institute, the following factors are driving the push towards EHR systems within medical organizations:

Motivating Factors 2005 Ambulatory
The need to improve clinical processes or workflow efficiency. 89.3% 91.2%
The need to improve quality of care. 85.0% 85.3%
The need to share patient record information among healthcare practitioners and professionals. 81.1% 66.9%
The need to reduce medical errors (improve patient safety). 76.1% 69.1%
The need to provide access to patient records at remote locations. 67.9% 65.4%
The need to improve clinical documentation to support appropriate billing service levels. 67.1% 76.5%
The need to improve clinical data capture. 64.6% 61.0%
The need to facilitate clinical decision support. 60.7% 50.7%
The requirement to contain or reduce healthcare delivery costs. 54.6% 61.8%
The need to establish a more efficient and effective information infrastructure as a competitive advantage. 53.6% 53.7%
The need to meet the requirements of legal, regulatory, or accreditation standards. 50.0% 44.1%
Other 5.7% 5.1%
Totals 280 136
Margin of Error +/- 5.8% +/- 8.4%

Now, compare this with the results of the 2007 survey that focused on the factors driving hospitals to expand their use of EHR.

Driving Factors in a Hospital 2007
Efficiency and convenience, e.g., better networking to the medical community and patients and remote access 57.8%
Satisfaction of physicians and clinician employees 42.2%
The need to survive and thrive in a much more competitive, interconnected world. 41.0%
Regulatory requirements of JCAHO or NCQA. 35.6%
Savings in the Medical Record Department and elsewhere, including transcription. 24.0%
Value-based purchasing/pay for performance 17.7%
Pressure from payer groups, such as Leapfrog Group 15.2%
Possibility of subsidized purchase of HER, e-prescribing systems, etc. by purchasers/payers/large health systems. 8.8%
Totals 329
Margin of Error +/- 5.4%


How have these motivating and driving factors changed today; have they really changed in 2010?

Does this deeper dive reveal any other truths; political, social, business or economic? Is this historical review helpful in understanding the reluctance or eagerness for EMR acceptance, or not?

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32 Responses

  1. Will Patient’s Read their Medical Records?

    In an increasingly electronic and accessible medical world, physicians and patients have more and more channels of communication available to them.

    But, when it comes to their personal medical records – particularly doctors’ notes – very few patients take the opportunity to read them even though they have the legal right to do so.




  2. Docs Slow to Adopt Advanced e-Prescribing

    Although electronic prescribing tools are widely available, they are not very widely used.

    According to the 2009 National Progress Report on E-Prescribing released in March by the electronic prescription exchange service Surescripts, about 68 million prescriptions—or 6.6% of the U.S. total—were transmitted electronically in 2008. This tripled to 191 million, or about 18%, in 2009, the Surescripts report noted.

    The Center for Studying Health System Change report acknowledged barriers to the use of these applications. It mentioned other studies’ findings that doctors suffer “alert fatigue” from the drug-interaction feature and often stop using it.

    The report also noted that many physicians are reluctant to rely on health-plan-supplied formulary information because they perceive this data to be incomplete or inaccurate and that patient pharmacies sometimes lack the capacity to receive electronic prescriptions.

    Source: Andis Robeznieks, Modern Healthcare [7/22/10]


  3. Doctors Quickly Moving to Electronic Health Records

    Healthcare providers are rapidly moving into the digital age for patient information. The financial incentive is too great to ignore, say experts. The federal government’s economic stimulus program last year called for hospitals and physicians to create an electronic health record for every American by 2014. Physicians qualifying under the Medicare incentive can receive up to $44,000, and those qualifying under the Medicaid portion can get up to $64,000.

    Records shouldn’t belong in a file cabinet, says Joseph Carr, chief information officer at the New Jersey Hospital Association. In the event of a natural disaster, such as a fire, the loss of paper records can be a scary reality. During Hurricane Katrina, for instance, many evacuees lost their paper medical records, he says. Consequently, they and their physicians no longer have documentation of their medical histories.

    Source: Carmen Juri, The Newark Star-Ledger [9/22/10]


  4. Perhaps Carmen Juri is right and the financial opportunities are hard to ignore (if one accepts Medicare patients anyway) … at least until the next CMS cutback in funding. So I’ll give her the benefit of the doubt. But when she claims eHRs are better than paper records in the event of a massive disaster, I think she steps in way over her head.

    First of all, how many records are lost by fire and flood each year? If the number were significant, then doctors would be purchasing digital records for their durability not free stimulus money.

    Secondly, the Internet is much more likely to be hit by a cyber attack than a hurricane. Which works better when the Internet is down – paper or digital?

    Finally, prolonged power failures are more of a problem in most of the US than hurricanes. Which is easier to read with a flashlight – paper or digital?

    Carmen’s ideas aren’t reasons. They are rationalizations.

    D. Kellus Pruitt DDS


  5. Dear Dr. Mata

    About eMRs and Today’s Medical Students

    Hospitals and physician practices take note – the next generation of doctors will expect a technology-laden environment when they get out in the real world.




  6. Richard,

    Great post; insightful and experiential. Now, did you know that even by 2010:

    • There is compelling evidence that the installation and use of information technology in your practice will certainly provide significant benefit to others like local, state, and federal government users of medical data.

    • There is no compelling evidence to prove that an implementation of electronic medical records necessarily has the same value to your practice.

    Fraternally, and with thanks.

    Dr. David Edward Marcinko MBA


  7. eMRs are Yesterday’s News?

    Providers and policymakers working hard to transition the healthcare sector to EHRs might not want to think about this, but at least one longtime observer of HIT is suggesting that EHRs have already had their day and it’s time to move on to something new.




  8. Coalition Will Collect Data on EHR Problems

    A coalition of medical societies and medical liability insurance carriers has announced the creation of a Web-based reporting system for physicians and other healthcare organizations to provide a centralized national repository of problems with electronic health-record system software.

    According to a news release, in addition to collecting information, the Web service, called EHRevent, will “create reports that medical societies, professional liability carriers and government agencies, such as the U.S. Food and Drug Administration, will use to help educate providers on the potential challenges that EHR systems may bring.”

    The portal also can be integrated into the websites of participating medical societies, liability insurance carriers, and EHR vendors, among others.

    Link: http://ehrevent.org/

    Source: Joseph Conn, Health IT Strategist [11/15/10]


  9. Hold Harlmes HIT Vendor Clauses

    For more on HHCs, from eMR vendors, visit this link:

    The doctor pays – the doctor takes his/her chances.

    AKA: “blanket indemnity clauses”



  10. Revise Unfair e-prescription Policy, Doctors Say

    The American Medical Association and more than 100 other state and specialty medical societies are urging the Dept. of Health and Human Services to revise a Medicare e-prescribing policy that slaps doctors with a financial penalty in 2012 if they don’t meet specified e-prescribing criteria during the first six months of 2011.

    The medical organizations are dismayed with a new regulation from the Centers for Medicare & Medicaid Services that uses e-prescribing activity during the first six months of 2011 as the basis for imposing penalties in 2012. In addition, the government would look at the entire 2011 calendar year to determine the 2013 penalties physicians would pay.

    Source: Chris Silva, AMNews [12/20/10]


  11. Ann and ME-P Readers,

    An interesting ID Experts press release was posted on FierceHealthcare yesterday titled “Experts Forecast Top Seven Trends in Healthcare Information Privacy for 2011.”


    Darrell K. Pruitt DDS


  12. Names, Emails Stolen in Massive Data Breach

    Personal information on customers of Citigroup Inc., JPMorgan Chase & Co., Best Buy Co., Walgreen Co., and other major U.S. companies was stolen by hackers, in what may be one of the biggest data breaches in history.


    And so doctors, if it could happen here ….. ?



  13. Those who find it necessary to discount the dangers of breaches of Protected Health Information [PHI], from eHRs, often point out the safety of credit cards.



  14. e-RX Update

    An estimated 36% of office-based physicians were sending their prescriptions to the pharmacy electronically at the end of 2010, up from 26% the year before, according to Surescripts, which attributes the continued rise in e-prescribing in large measure to 2 federal programs that reward physicians for adopting the technology.




  15. Linkedin HIT group discussion

    Though I’ve been a member of the Health IT and Electronic Health Records group on Linkedin only a short time, it looks to me like it mostly consists of cohesive HIT stakeholders who pass happy notes about technology to each other and viciously discourage messengers with bad news. I like the action and am increasingly drawing fire from recognized informatics leaders for reminding them of concepts like common sense, simplicity and the Hippocratic Oath that have been trained out of them.

    I’ve surprised more than one overconfident professional. Who would have thought that a dentist would know so damn much about electronic dental records and HIPAA, as well as sport classy grammar skills?


    Here is my reply:

    Your response was well-written, Philip Magistro, but wrong. Quite frankly, since you hold the position of Director of Health Informatics at Quality Insights of Pennsylvania, your insensitivity to patients’ rights to privacy frightens me and others as well.

    You write: “Not to minimize either [financial or medical identity theft], but I’ve never had data taken but do have friends that have had their identity taken from a financial institution. The headaches and embarrassment that they had in cleaning up the mess was, to me, much more troublesome than if someone found out that I had my tonsils out or what meds I could be taking.”

    – You are fortunate to have an uninteresting health history that would never get you turned down for a promotion, job or loan. If you have children, your DNA that even their children’s children will share could also become part of your boring medical history soon. What about their privacy rights?

    Talk about headaches and embarrassment: If one’s medical identity is comingled with an identity thief’s – which is happening more frequently, Tom Gomez – the HIPAA Rule prevents the rightful owner from accessing his or her own health history because HIPAA protects the thief’s privacy as well.

    Considering the possible life-threatening risks of medical identity theft, patients who have EHRs should always take a few minutes to review the medical histories of their own and those of their children before visiting paperless healthcare providers – be especially sure to review the allergies … No time saved there. On the other hand, if one’s medical history is written on paper, dangerous 3rd party alterations can’t be hidden – if they occur at all.

    “I seriously doubt that the patients will determine the success of interoperable EHRs. They don’t have a clue.”

    – That will change soon enough. After all, this is America.

    “If the patients do raise any alarm it will likely be due to prodding from those that have a problem with moving to electronic record-keeping.”

    – True

    “Please don’t overlook that some of the largest breaches were not by providers but occurred as a result of electronic claims processing. I surely hope that nobody thinks we should go back to paper-based claims.”

    – Good point. If a clumsy, stupid or dishonest employee of an insurance company hundreds of miles away breaches 500 or more of an innocent provider’s patients’ financial and medical identities, those mostly former patients not only have to be notified by mail within 60 days, but HIPAA/HITECH also demands a press release in the local media reporting the name and location of the local healthcare facility affected. As a dentist, I can assure you that it won’t take many unfortunate press releases and subsequent bankruptcies before concerned dentists and other specialties tell insurers to either accept paper claims or make their clients pay in full at the time of visit. As long as dentistry can be purchased with cash in a free market economy, dental insurers will always need dentists more than dentists need insurers. That arrangement is always in patients’ best interests.

    And Tom Gomez, Founder & Executive Director at Transformations at the Edge (TATE): In the future, if I make any statements you believe are deceptive, before blanketing everything I say as “half-truths,” please give me a fair chance to provide links to the source in question. I have to say I am at least as surprised as you are. I’ve said nothing that isn’t common knowledge elsewhere in the HIT industry.

    D. Kellus Pruitt DDS


  16. EDR Interoperability hopes fade before our eyes

    A provider’s freedom to avoid wasteful costs is a consumer-friendly benefit of the free market in healthcare. If HIPAA compliance becomes too expensive, dentists will simply abandon computerization. The telephone, fax and US Mail have served the profession cheaply and safely for decades. There’s no reason common sense can’t prevail for a few more years.

    Yesterday, Kelly Soderlund, American Dental Association news staff, posted “Upgrade systems to HIPAA version 5010 by March 31, CMS urges health providers.”


    Soderlund lists 6 questions for vendors that dentists who have paper records don’t have to worry about:

    – Have you upgraded your system to meet Version 5010 standards?

    – How much will it cost?

    – What will be the cost for each upgrade?

    – What versions of your software will be upgraded and will these upgrades require any hardware upgrades to maintain system performance?

    – How are issues logged and how will they be addressed? For example, if a batch of claims bounce because of noncompliance with the 5010 standard, how will you log the incident, when will you fix the problem and how will my office receive notification of the problem and its resolution?

    – Is there training available for new system changes and/or functionalities?


    As anyone can see, for dentists who have already volunteered for permanent NPI numbers and unwittingly accepted HIPAA’s bankruptcy-level liabilities, the tedious, costly demands like Version 5010 will never end. What’s more, coding does nothing to improve dental care.

    As long as 3rd parties continue to profit from using HIPAA to complicate insurance payments to providers, maintaining compliancy will only grow increasingly expensive and fines steeper. Even now, only 15% of dentists have EDRs, and I’ve heard the failed installation rate for EHRs is up to 70%. Software designed to satisfy government mandates reminds me of Soviet automobiles, but without the user comfort.

    Unless paper dental records become a lot more expensive really soon, the comparative lack of a return on investment for EDRs will remain a strong disincentive for interoperability with dentists. As we’ve seen this week, ROI is looking less likely elsewhere, even with stimulus help.

    D. Kellus Pruitt DDS


  17. Finally – A response from the ONC

    “On behalf of the Office of National Coordinator (ONC) for Health Information Technology I would like to thank you for speaking candidly about your feelings towards EHRs.”

    Christy Choi, Web Manager, ONC, on Linkedin.


    Her salutation appeared after I publicly demanded that HIT stakeholders take more responsibility for the epidemic of data breaches from their software. It was followed by links to several government sites – none of which were helpful. They never are.

    Ms. Choi didn’t offer much, but she offered purchase. Here’s my response:

    Dear Christy Choi:

    As I recall, before President Obama took office, he promised us transparency in his administration. Today, you proved that he didn’t let me down after all. I am sincerely grateful for your response, Christy, and look forward to our conversation. Outside the ONC, you wouldn’t believe how difficult it is for practicing dentists to get straight answers from dental industry leaders concerning HIPAA, the NPI number, and even the safety of electronic dental records.

    For example, in the last few months, my office has been warned by an anonymous recorded message from Aetna that if I don’t “volunteer” for an NPI number, when their clients ask me how much Aetna will pay, HIPAA/HITECH will prevent Aetna employees from revealing details of the insurance coverage they sold to their trusting clients.

    Since I choose not to endanger my patients’ identities by filing claims electronically, I’m not required by law to obtain the arbitrary 10-digit identification number. Surely the ONC recognizes that Aetna officials are simply leveraging their clients’ rights to informed consent to maximize profits – driving their clients away from paper-based practices like mine, and using HIPAA as the tool. After all, when the claims I mail containing my patients’ identities, arrive safely, Aetna employees have to be paid to manually upload the data onto Aetna’s computer system. On the other hand, HIPAA covered dental practices with NPI numbers which file Aetna’s claims electronically send identities and other data over the internet to Aetna’s computers for free. What makes Aetna’s tyranny especially aggravating is that dentists accept assignment of benefits from insurers like Aetna as a favor to patients, not Aetna.

    Aetna is clearly using the NPI to bully small business owners like me into volunteering for an arbitrary number that nobody other than you seems willing discuss. Why else would they force dentists and patients to guess at Aetna’s secret deductibles and maximums? My questions to Aetna concerning their harmful NPI policy were repeatedly ignored before I gave up. That’s why it pleases me so much to finally have the opportunity to actually ask an ONC representative a question no American Dental Association official will touch: What is the true purpose of the NPI number and what does it have to do with dentists’ “report cards”?

    Aetna’s abuse of the HIPAA Rule for profit and/or power is far from an isolated incident in the dental industry. And it’s not the most egregious. Only days ago, a BlueCross BlueShield of Texas client fruitlessly showed up at my office for an appointment – unaware of BCBSTX’s NPI requirement that applies to plans covering federal employees. Starting four years ago, my office manager was told by BCBSTX that without an NPI, it is impossible for my paper claims to even be “entered into the system.” Since nobody wants to waste time like the clueless federal employee and I did last week, before scheduling appointments, we try our best to warn them that even if they pay the dental bill in full, and we give them a receipt, BCBSTX will not reimburse to them the benefits they are owed. In other words, if a federal employee mistakenly racks up a huge dental bill with a dentist who isn’t a HIPAA covered entity, BCBSTX pockets the money. No wonder BCBSTX keeps the NPI requirement a secret. It saves BCBSTX from having to pay for uninformed clients’ dental work, and like Aetna’s NPI scheme, BCBSTX’s also drives clients away from safe, paper-based dental homes – even though the NPI number does nothing to improve dental care.

    On Wednesday of last week, shortly after BCBSTX’s NPI requirement wasted their client’s time as well as mine, I complained on the BCBSTX Facebook. Instead of answering my question, the anonymous moderator provided a less-than-helpful link to CMS… Sort of like the one you provided me that bluntly affirms who is responsible for the security of EHRs:

    “Your practice, not your EHR vendor, is responsible for taking the steps needed to protect the confidentiality, integrity, and availability of health information in your EHR and comply with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Rules and CMS’ Meaningful Use requirements.”

    The frequency of data breaches of patients’ PHI doubled between 2010 and 2011, and is expected to double again in 2012. Data breaches cost healthcare $6.4 billion last year. 96% of healthcare organizations have experienced data breaches of PHI in the last 2 years, and thieves are increasing seeking medical identities, which when imperceptively altered, can lead to sudden death for victims.

    Please, Christy Choi, tell me there’s a Plan B.

    D. Kellus Pruitt DDS


  18. Unheralded benefits of paper health records defy extinction

    Yesterday, the widely-respected HIT blogger John Lynn broke rank with the politically-correct HITECH crowd when he invited discussion on his EMR and HIPAA blog about meaningful but largely unappreciated advantages of paper health records over digital. He is one of the very few in the HIT industry who has the courage to publicly address unpopular truth.

    “Paper Has Healthcare Spoiled,” explores a few advantages with paper that young doctors may never have the opportunity to appreciate.


    John begins, “As I was thinking about the radical invention of something called paper, I realized that we’re really quite spoiled by paper and its amazing benefits. Let me just list a few of the radical benefits that paper provides a doctor using a paper chart.”

    1. Immediate response to pen. John says, “You just pick it up and start using it. It’s beautiful.”

    2. Never a delay when flipping pages. “Paper has the unique ability to flip pages with instant display of the next page.”

    3. Instant On. “A paper chart is beautiful in its ability to immediately be available for you to work.”

    4. No training needed. “You hand a new doctor some pen and paper and they can start documenting their visit.”

    5. Multiple page view. “If you need a quad page view, you’re only limited by the amount of desk space you have or you could even move to the floor if needed.”

    6. Fast page switching. “With 5 fingers you can even instantly ‘bookmark’ up to 5 locations in the chart which you can switch to and back very quickly with zero load time.”

    7. Flexible to an infinite number of documentation methods. “Paper has the ability to morph to every medical specialty’s documentation needs.” (Except 3D views).

    8. Easily supports text and graphic input. “In the same input area you can easily add text or graphics. In fact you can easily link the text and graphics in whatever way you see fit.” Such as notes in margins and arrows.

    In closing, John suggests: “I’m sure there are other areas where paper spoils us that I’ve missed, but this is a good start. Hopefully you’ll add any areas I’ve missed in the comments. Watch for future posts in my ‘Healthcare Spoiled’ series.”

    So I added:

    9. Most importantly, paper records are much more secure than electronic.

    This morning, Rick Weinhaus MD, added:

    10. Differences in handwriting between individuals immediately indicate who contributed what to the record.

    11. Different line width, color, and other characteristics of the marks made on paper can indicate emphasis, authorship, appended data, or other information not conveyed by the text itself.

    12. Different colors and textures of paper can indicate different components of the paper chart.

    13. The design of the chart binder constrains the order in which new documents are appended to the existing ones, so that the physical order of the pages serves as an intuitive metaphor for the chronological order of health events.

    Dr. Weinhaus concluded: “It is also interesting to think about which advantages of paper carry over and which are lost when paper documents are scanned into an electronic record.”

    I added:

    14. Even the wear of the exterior of a patient’s chart subtly brings to the doctor’s attention how long the person has been in the practice.

    Dr. Weinhaus:

    15. Yes, and its thickness also gives you some idea of the duration and severity of a patient’s health issues.


    Providers are already given far too many tedious choices to select from in an effort to satisfy Meaningful Use click quotas. But we can never be given too many subtle, instantly-grasped details about our patients that don’t require us to click on anything. It could be argued that instant communication through tactile paper in a small practice not only helps prevent misdiagnoses, but it also helps prevent misidentification of patients intuitively.

    So far, John Lynn’s request has elicited 15 suggested benefits of paper health records that will be lost with universal adoption of less sensitive, less personalized digital health records. If the mandated change is indeed inevitable for even the smallest of practices like I’ve been told many times, it’s a good idea to document paper’s disappearing benefits. Otherwise, someone will re-invent the file cabinet and charge way too much for them.

    D. Kellus Pruitt DDS


  19. More on Paper Health Records’ Advantages

    Today, an EMR and HIPAA blog reader named A. Davis responded to John Lynn’s article, “Paper Has Healthcare Spoiled,” in which the benefits of paper records were explored for perhaps the first time ever, even as they are being replaced by digital:


    There’s no doubt that for one patient, in one office, paper is the absolute leader over EMRs in terms of ease of use. When considering multiple patients in multiple locations, the potential advantage of the EMR is easily seen.

    The challenge is to transfer the benefits of paper to the EMR. That challenge has gone largely unmet, and it is the primary reason why uptake of EMRs among physicians has been so poor.

    Medicine is a very personal undertaking. Physicians treat patients one at a time, and that’s how patients want it. That treatment is detailed, can be very personalized/customized, and documentation of that treatment varies to meet those individualized demands. EMRs, in their current state, are not user friendly to that type of documentation. While the government, insurers and hospitals are interested in aggregate data, physicians are not – at least not in the exam room, where their documentation occurs.

    For an ever-shrinking number of physicians, typing is a problem. The problem is self-resolving over time.

    For every physician, the “hunt and peck” mode of documentation is a problem. There are many variants – check boxes, radio boxes, drop down lists, “type ahead” automatic completion, etc – but there are hundreds, if not thousands, of locations in any EMR where the physician is required to choose among multiple options in a list. And there is no efficient way to do it. In a paper chart, the required entry simply flows from the tip of the pen. In an EMR, the physician’s attention must shift to the appropriate entry field, the mode of selection must be determined, the proper entry must be found and selected and, often, it must be confirmed, by clicking, by tabbing to the next field, etc. It takes a few seconds longer than simply writing the word and, when multiplied by the dozens or hundreds of times it must be done in a single patient encounter, the time lost becomes significant. Despite this limitation, it isn’t the method of data entry which is the primary problem.

    The issue is how much data is required. Because hospitals and physicians are forced to accept fixed payments from the government and insurers, the natural evolution of EMRs as patient care tools has been altered. Rather than innovating to meet the needs of doctors and patients in the exam room, EMR vendors were forced to focus on the billing aspects of the EMR in order to justify their fees in a fixed-price economy. Therefore, EMRs are designed to elicit the information needed to justify the highest allowable payment rate from any given patient encounter. This is good for office and hospital economics, but is actually counterproductive to patient care.

    For a given patient problem, the EMR doesn’t change the physician’s diagnosis and treatment decisions, but it does slow down the visit process by asking, typically, for more information than the physician needs for those decisions in order to get the required billing justification info needed to maximize the “billing code” for the patient encounter. This process is not only counterproductive to efficient care, but also increases the cost of medicine overall.

    This problem is not inherent to the difference between paper and EMRs; rather, it is the result of the development of EMRs in a government-constrained environment. But it matters, because it is the basis of the very real fact that most physicians would prefer to use paper over an EMR. Until EMR vendors are able to innovate with the goal of improving the documentation needs of patients and their physicians, rather than government and insurers, paper will remain the medium of choice in the exam room.

    Darrell K. Pruitt DDS


  20. eHRS


    The good and the bad.



  21. EHR Exemption for Small Practices?

    There is no governmental requirement to implement EHR systems. There is an incentive for adopting EHR and meeting meaningful use.
    If you don’t adopt:

    1 – you will not get the meaningful use incentive.
    2 – in 2016, you will start getting penalties.
    3 – you will not be able to receive e-referral requests; you will get fewer referrals for new patients; you will not be able to e-ommunicate with other doctors and patients.

    If you do not adopt, you are doing your practice and your patients a great disservice.

    Dr. Micheal L. Brody DPM

    Source: PMNews #4,505


  22. Dear Ann:

    Dr. Brody’s offensive sales pitch for EHRs is even more threatening to Americans’ civil liberties than the Affordable Care Act’s individual mandate – which barely squeaked by the Supreme Court a few days ago as a “tax.” As a dentist, I still find it difficult to imagine how such tyranny can deprive me of my rights as small business owner – as long as I never choose to become a HIPAA-covered entity.

    I think most of us know that the primary purpose of HIPAA/HITECH has never been about the needs of providers and patients. HIPAA/HITECH has always been intended to be used to control doctor-patient relationships according to cost-effectiveness and other interests of healthcare stakeholders. Unfortunately for physicians, their practices are so complex that computerization is virtually a must if one wants to get paid for their time.

    Since dentists rarely if ever need lab reports, and since they have only thousands of active patients compared to physicians’ tens of thousands, and since dental bills are miniscule compared to hospital bills, some dentists have already moved to cash only businesses. It’s going to be much more difficult for HHS to “legally” wedge itself between dentists and their patients than it was to have their way with physicians.

    Physicians are in a hole. They are so far down that they’ve become defenseless against oppressive government intrusion into their businesses, like that which Dr. Brody describes.

    Darrell Pruitt DDS


  23. 5 ways to turn your EHR cost center into a revenue generator

    I just read the above article that caught my eye.


    Great title – terrible content.



  24. EMR selling points

    EMRs have selling points for everyone

    The question of whether EMRs will increase or decrease physicians’ billings depends on who is asked. Kelly Kennedy, writing for USA Today suggests that better oversight by insurers and government will help eliminate unnecessary charges:

    “Also, the [2010 health care] law and 2009 stimulus act will change payment incentives and allow physicians to use electronic records to limit unnecessary medical testing. Private insurers will also be able to work with government agencies to combine billing data to spot trends in overused procedures.” (from ”Health care law may cut down on excessive procedures,” August 8, 2012).


    On the other hand, if one asks Alok Prasad, the President and CEO of RevenueXL, an EMR and Practice Management consulting firm, he tells physicians:

    “Electronic Medical Record Software improves charge capture: When traditional paper charts are used, many services performed in a physician’s office are lost and never billed. The billing staff may either completely leave out an E&M Code or may erroneously enter fewer units, all resulting in lower billing and therefore lower reimbursements to a physician. Electronic Medical Record software can increase revenues by facilitating capturing of charges for all services provided by the physician thereby avoiding lost revenues. In a case study (Nick Fabrizio, July 2005, QIO Presentation quote), a family medicine physician while seeing same number of patients increased revenues by $3000 per month due to timely visit documentation and automated charge capture.” (from “Does an Electronic Medical Record / Electronic Health Record Software system increase revenues?” February 13, 2009).


    Bottom line: Will the improvements in government and insurance oversight enabled by EMRs save more money than improvements in charge capture will cost?

    D. Kellus Pruitt DDS


  25. EHR investment: AMA vs ADA
    [The American Medical Association versus the American Dental Association: A comparison of EHR investment]

    Today in the USA TODAY: “Survey: Doctors mixed on electronic medical records – The federal government’s push to get doctors and medical providers to use electronic health records rather than paper is not getting universal approval from physicians,” by Jonathan Ellis and Jon Walker, January 6, 2014.


    On the other hand, a month ago the ADA published an article titled: “EHRs provide long-term savings, convenience,” (no byline), ADA News, December 6, 2013. Unlike the AMA, evidence-based research supporting ADA’s claims of “long-term savings and convenience” was not offered.


    AMA: “It just takes a lot more time and is much more cumbersome” – Dr. Steven Stack, an emergency physician in Lexington, Ky., and a member of the AMA’s Board of Trustees.

    ADA: “… the investment can provide tremendous savings over the long run,” – Brett Lindstrom, director of The Dental Record, an ADA Business Resources™ business partner, and the only ADA-endorsed EDR vendor.

    “[The AMA] has lobbied the federal government for more flexibility with EHR mandates.”

    On the other hand, in 2008, the ADA capitulated: “The electronic health record may not be the result of changes of our choice. They are going to be mandated. No one is going to ask, ‘Do you want to do this?’ No, it’s going to be, ‘You have to do this.’”

    http://www.ada.org/members/resources/pubs/adanews/081006_findley.asp (The ADA President-elect’s interview was deleted, but the article can still be found in paper editions of the October 2008 ADA News).

    The AMA funded the recent RAND study which reveals that a significant number of HIPAA-covered providers are very dissatisfied with EHRs. “The technology was not mature enough to be deployed in this broad based way,” Dr. Stack said.

    On the other hand, in Dr. Robert Ahlstrom’s 2007 testimony before the National Committee on Vital and Health Statistics, Subcommittee on Standards and Security, he presented the ADA’s list of 11 increasingly dubious reasons EDRs are an improvement over paper dental records.


    1. Dental office computer systems will be compatible with those of the hospitals and plans they conduct business with. Referral inquiries will be handled easily.

    2. Vendors will be able to supply low-cost software solutions to physicians/dentists who support standards-based electronic data interchange. Costs associated with mailing, faxing and telephoning will decrease.

    3. All administrative tasks can be accomplished electronically. Dentists will have more time to devote to direct care.

    4. Dentists will have a more complete data set of the patient they are treating, enabling better care.

    5. Patients seeking information on enrollment status or health care benefits will be given more accurate, complete and easier-to-understand information.

    6. Consumer documents will be more uniform and easier to read.

    7. Cost savings to providers and plans will translate in less costly health care for consumers. Premiums and charges will be lowered.

    8. Patients will save postage and telephone costs incurred in claims follow-up.

    9. Patients will have the ability to see what is contained in their medical and dental records and who has accessed them. Patient records will be adequately protected through organizational policies and technical security controls.

    10. Visits to dentists and other health care providers will be shorter without the burden of filling out forms.

    11. Consumer correspondence with insurers about problems with claims will be reduced.


    Similar to an overly-optimistic 2005 RAND study that even RAND finally disowned a year ago – which wrongfully promised savings of 77 billion dollars and 100,000 lives a year from EHRs – Dr. Ahlstrom’s “selling points” for EHRs are so feeble that even rookie salespeople have ignore them. Sit back and watch dental history confirm that the ADA’s overly-optimistic federal testimony about EDRs favoring The Dental Record, doesn’t age well at all.

    D. Kellus Pruitt DDS


  26. EHR Assessment

    This spring, David Blumenthal M.D., the former national coordinator for health information technology, gave his assessment of savings from EHRs: “… from the provider’s perspective, there are substantial costs in setting up and using the [EHR] systems. Until now, providers haven’t recovered those costs, either in payment or in increased satisfaction, or in any other way.”

    (See: “Why Doctors Still Use Pen and Paper -The healthcare reformer David Blumenthal explains why the medical system can’t move into the digital age,” by James Fallows, for The Atlantic, March 19, 2014).


    D. Kellus Pruitt DDS


  27. EHRs – Good News and Bad News

    Both good news and bad news has appeared on the internet recently concerning electronic health records. The good news first:

    “President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems.

    The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood.” (See: “Hazards tied to medical records rush – Subsidies given for computerizing, but no reporting required when errors cause harm,” by Christopher Rowland, Boston Globe staff, July 20, 2014).


    If you missed the good news about EHRs, “… potential for efficiencies and safety benefits,” is as good as it gets. The bad news:

    Contrary to what our lawmakers were promised by HIT stakeholders, EHRs have only made patient care more dangerous than ever, and have failed to show a return on investment even for providers who accepted ARRA stimulus funds (and CMS’ subsequent claw-back audits). According to the Boston Globe article, it looks like Americans have been cheated by corporate control of politicians who continue to protect EHR developers from accountability.

    “Voluntary reporting of adverse events to private safety associations, with no public disclosure, will remain the norm, the [FDA and the OCR] said.” Rowland continues: “The industry — while supporting voluntary reporting systems — contends that mandatory reporting of injuries and death would discourage medical staff from revealing mistakes, for fear of repercussions.” Is there really any difference between evasion of repercussions and evasion of accountability?

    Meanwhile, the liabilities and expense of HIPAA compliance only become worse, even as the FBI warns Americans that EHRs are becoming increasingly vulnerable to hackers. (See: “Health Care Systems and Medical Devices at Risk for Increased Cyber Intrusions for Financial Gain,” April 8, 2014).


    On July 7, Matt Fisher, writing for HITECH Answers.net wrote, “The government is done offering guidance and letting entities off the hook without any financial harm. Now, based upon settlements and other indications, the gloves are off and any and all HIPAA Entities are fair game for the imposition of penalties. (See: “Now’s the Time: Get HIPAA Compliant,” July 7, 2014).


    Ted Kobus, partner and co-leader of the privacy and data protection team at Baker/Hosteller, tells HealthLeadersMedia.com: “Documenting and compliance are the two most important things. If you’re forced to do something that may not be exactly the way that you think the security rule requires you to do it, or you make a decision and accept a risk, the key is going to be documentation. If OCR comes in [and] they see that you’ve documented that risk, you’ve understood that risk, and you’ve responded to it in a certain way, whether it’s physical controls or administrative safeguards or some other technological safeguard, you’re going to be in a much better position.” Kobus adds, “The problem is there are so many healthcare providers that have small physicians’ offices or small surgical centers, that may not be as prepared as a sophisticated health system.” (See: “As HIPAA Breaches Accelerate, Tools Lag,” by Scott Mace, for HealthLeaders Media, July 22, 2014


    Marianne Kolbasuk McGee, writing for HealthcareInfoSecurity.com ominously points out that “Criminal prosecutions, always permitted under HIPAA, may be on the rise. In March, U.S Department of Justice indicted a former employee of an unnamed East Texas hospital, charged with wrongful disclosure of individual identifiable health information in violation of HIPAA. (See ”Former Hospital Worker Faces HIPAA Charges,” July 16, 2014).


    On the other hand, on December 6, 2013 in the ADA News, an anonymous American Dental Association author announced: “EHRs provide long-term savings, convenience,” but failed to reveal study which discovered the good news. Probably out of fear of repercussion.


    Have I mentioned that the ARRA stimulus legislation was passed as a jobs bill rather than attached to healthcare law? … Get it?

    D. Kellus Pruitt DDS


  28. Conflicting EHR Reports

    I have a Google alert set for “electronic health records.” Here are today’s headlines:

    “Hospitals Slow To Adopt Electronic Health Records,” Kaiser Health News, August 8, 2014



    “HHS Reports Wide Growth in Electronic Health Records Numbers,” Health Professionals Network, August 8, 2014


    And lastly,

    “Second Breach at Riverside Health Affects 2000 Patients,” Health Data Management, August 8, 2014


    Darrell Pruitt DDS


  29. Know any good news about EHRs?

    “HIPAA Omnibus Rule Penalties Deserve Serious Attention – Of particular concern is the issue of audited or investigated organizations having done little or nothing to become HIPAA compliant, such as failing to be able to produce policies and procedures that govern a compliance program, or not being aware of the need for compliance. ‘On this point, ignorance is not bliss,’ said Lorretta Duncan, senior medical practice consultant at liability insurer Volunteer Mutual Insurance Co., during a presentation at the MGMA Annual Convention in Las Vegas.” By Joseph Goedert for HealthDataManagement, October 28, 2014.


    “Company Claims ‘HIPAA Has No Teeth’, Will Start Notifying Affected Individuals of Security Breaches and Vulnerabilities that Have Not Been Disclosed by Organizations – Starting today [SLC Security] will start mailing out notifications directly to the affected person[s] when we don’t get a response from the organization we report. It’s not fair that companies can choose to ignore issues that they know exist and it’s really not fair that they take the stance that if they are not aware of the issue that they can just ignore it while consumers are sitting by hoping nothing happens to their identities or their bank accounts…” By Charles Shih for JDSupra Business Advisor, October 28, 2014.


    “Malpractice suits often tap electronic medical records – Issues include efforts to manipulate time stamps and contents, autofill problems and failure to enter comments when warranted, said Marianne DePaulo Plant, a partner at Goodell DeVries, who also spoke at the session.” By Judy Greenwald for Business Insurance, October 27, 2014.


    “Doctors are using digital tools that can’t talk to each other — and this hurts everyone – SAN FRANCISCO — Well, we totally blew it on that whole electronic health record thing. According to Athenahealth’s Dan Haley and Surescripts’ Seth Joseph, speaking onstage today at our HealthBeat 2014 conference, the U.S. government has set such a low bar for the technology that despite the wide adoption of electronic health records (EHRs), these new systems still can’t communicate with each other.” By Kia Kokalitcheva for Venture Beat News, October 27, 2014


    On the other hand, despite such discouraging news about EHRs outside of dentistry, American Dental Association leaders steadfastly assures dues-paying members that “EHRs provide long-term savings and convenience.” (No byline, ADA News, December 6, 2013).


    However, one should be aware that the ADA officials who anonymously make the happy claims about EHRs do not respond to consumers’ requests for data on which their incredible promises are based.

    D. Kellus Pruitt DDS


  30. Differences of Opinion

    “Electronic records putting financial squeeze on doctors.” WRAL.com, Raleigh, North Carolina.


    “EHRs provide long-term savings and convenience.” ADA News, Chicago, Illinois.


    Submitted for your consideration.

    Dr. D. Kellus Pruitt DDS


  31. HIT

    The deployment of technology is becoming more and more critical to the success of an organization. There are many options one can choose, from a basic information system to more complex applications such as CPOE systems and EMRs.

    In addition, although precise quantitative ROIs are difficult to calculate for HIS, the association of clinical to financial outcomes is becoming more clear.

    Given the current governmental direction as well as the new consumerism movement in healthcare, systems that improve quality of care and go beyond just administrative functions are becoming more critical to hospital and medical center success. With careful implementation and a little luck, a HIS can turn quality improvement into financial gain.

    Brent A. Metfessel MD


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