Sometimes when we think about EMR, I think we forget about the subtle nuances of paper charts that make them so undesirable. Check out this story which I got in response to my post called “Think About the Problems with Paper Charting.” It’s a a good illustration of some of the more simple things we often forget about:
I was recently visiting a relative at a major teaching hospital in the Midwest. While in the hall I noticed that they had charts in binders stored in boxes affixed to the wall. Just as I was wondering why such a prestigious institution relied on paper charts a nurse went to re-insert a chart into its box. She was in a hurry and missed, the chart dropped to the floor and binder opened and paper went all over the hall. What was even more surreal was the nurse did not at fist notice her mistake and was at leas 6 feet away before she noticed it and fixed her error.
Sometimes it’s not what you get from an EMR, but what you don’t get that matters.
I think that this also happens when the head hits the platter at 7200 rpm.
Yo’, Doc, your EMR is basically FREE!
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Assume for this back-of-the-envelope example a primary care solo practice (I know it can be more complex; that’s why God made spreadsheets).
– You see 25 pts a day, 5 days per week, 48 weeks per year.
– 6,000 charts touched per year, then.
-Assume your average annual per-chart handling time per year (pulling, schlepping, manipulating/updating/re-filing) is 5 minutes (on AVERAGE. Yes, some will be much less, others much more, e.g., beyond the visits, inbound Rx refill requests, payor info requests, auditors, referral requests, etc)
-3 Well, then, 6,000 x 5 = 30,000 minutes, or 500 FTE hrs.
– Further assume a realistic blended fully G&A multiplied actual aggregated labor cost of $40/hr for touching those charts.
– Do the math: 500 FTE hrs x $40/hr = $20,000. This is what you are paying now for the paper.
– Buy, say, eClinicalWorks ($10k license, plus all the hardware, training, and support).
Free. Even with the transient learning curve productivity drain. Even recognizing that not 100% of the schlep process disappears – but, say 90% of it truly does.
Think about it. And think about the myriad quality of care benefits of fingertip access to all that individual and aggregate data (including better E&M coding and charge capture). Forget all this Meaningful Use incentive blather and REC hubbub. That’s just potential icing on the cake.
Graham,
That’s why you have multiple backups. Not sure how you backup a paper chart;-)
Bobby,
Don’t try to use numbers and reason. It’s all about the stimulus money now. lol
On a serious note, yes Bobby, the numbers you have derived at least gives a number to talk about. And, yes, its quantified. I believe, more than anything else, its about structured data that can be used for various analytics.
Backups needs to be addressed and its something thats very common practice without any exhorbitant costs.
Anthony Subbiah
@John… Recognize your tongue in cheek … but unfortunately for too many periphery folks the focus on EHR implementation has been about getting some money in exchange for some to be still determined stuff that’s supposed to be meaningful to somebody somewhere sometime but probably not to the practitioner who is footing the bill up front.
So I will paraphrase one more time as John Lynn said … EHR choice and deployment must meet the business and clinical needs of the practice. Taxpayer incentive for MU is a bonus.
@Bobby…
Defining the total resources theoretically freed up by EHR implementation across all practice functions is important… but not an end itself. Efficiency does not advance the state of medicine.
Here’s perhaps an alternative path. First… work with the practice to define “What To Change To” that improves practice capacity, clinical quality, and top line. Then… demonstrate how an effective EHR deployment contributes to making the improved processes and outcomes in the To Be model possible. Last… identify the resources made available through EHR deployment across the practice that can be assigned to the new and improved functions making the “What To Change To” possible. This puts EHR sourcing and deployment squarely in the practice’s path to where it is and where it wants to go.
From a practice perspective implementing an EHR to theoretically save 500FTE hours across the entire practice but without defining where to reassign those FTEs … does not advance the state of medicine. It is difficult for an EHR developer or REC to know where the practice (customer) is … and where it needs to go based on the practice’s priorities and its patient population… but without that step in the improvement process then it looks to the practice that all they are doing is implementing an application to save paper.
@Anthony… To your comment: “more than anything else, it’s about structured data that can be used for various analytics”. I thought it was all about improving the effectiveness and efficiency of the delivery of health care services? If it’s all about analytics … then NIH needs to fund and deploy the nation’s EHR system.
On the subject of “backups” to protect critical data. One chart falls… only one chart (patient) is affected. One server crashes … ALL the charts and other data records are affected for ALL patients. I believe a practice’s EHR as a component of the practice’s ERP (in deference to John’s vision) is a critical system.
In aeronautics design critical systems have primary services, secondary services, and emergency services each with full or limited functionality based on the resources available under specified conditions to remain fully or partially operational in the event of a failure of the primary services.
John you may have a feel for this too: Are there standards and protocols in health records application and data storage system design similar to those in aeronautics design? What analytics are generally available on the local system? Is the data mirrored to secondary storage or are analytic processes run in background on the active system?
@Don B –
Thanks for your comments. Of course it’s not “an end in itself.” Where did I state or imply that? All I was doing was addressing the perceived EHR “cost barrier.” It all come down to dollars per chart per year, etc, no matter how you do your recordkeeping. The net marginal differential too frequently gets lost in this debate.
See some of my workflow graphics:
http://www.bgladd.com/ElementsOfWorkflow.jpg
http://www.bgladd.com/ElementsOfWorkflowPg2.jpg
http://www.bgladd.com/Flow101.jpg
The focus of our adoption support work is precisely the realignment/redeployment of clinic resources for improvement across the board.
See also my blog post at
http://regionalextensioncenter.blogspot.com/
I know just a bit about what “the ends” are.
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“On the subject of “backups” to protect critical data. One chart falls… only one chart (patient) is affected. One server crashes … ALL the charts and other data records are affected for ALL patients.”
During implementation project management, this is rather routinely known as “disaster mitigation and recovery planning 101,” and is a core consideration. C’mon.
Don B,
Check out the keynote by Sully at this last HIMSS for the best aeronautical perspective. It’s a pretty interesting comparison.
Great post. The value of adopting EMR’s will definitely be realized soon. 2011 should be a great year!