The ROI of EMR Explained

Some of the toughest obstacles to EMR are the “Physician Doubters.”  These people say, “My charts are going to be on a computer.  So what?  All I know for sure is that it will take longer for me to finish my charts every day and we will have another component in fixed overhead.  Why this is a good idea?” 
The concerns are valid.  When my practice chose to get EMR 6 years ago we made a decision of faith and vision, not from an ROI analysis.  But for most practices, faith and vision are not good enough.  We need a return on investment (ROI) rationale that justifies EMR adoption to the Doubters.  The IT experts talk in vague terms about workflow and re-designing your practice to take advantage of EMR, but these arguments are not concrete or specific enough.  Yet after 5 years of EMR no one in our group has ever suggested that our EMR investment was unwise.  I am convinced the ROI argument exists.  My next few posts will attempt to make the case.
Let’s start with an unusual example.  Your car needs new tires.  You live in a beautiful rural area but there is only one car shop, staffed by a single mechanic.  He is glad to put on new tires but the job will take all day.
Why so long?  How many steps does it take to put on new tires?
1.     Remove the first wheel from the car
2.     Take the old tire off the wheel
3.     Put the new tire on
4.     Balance the wheel
5.     Put the wheel back on
6.     Repeat the above with other 3 wheels, one at a time.
Any interruptions such as other cars needing work, a phone call, emergency, etc. will make the job take longer because these events interrupt the work on your car.  Our solo auto mechanic must operate by sequential processing – defined as one operation at a time.
Now consider the other extreme.  You are an Indy racecar driver going 180 miles per hour around the track.  You need new tires fast.  You pull into the pits and the pit crew changes all 4 tires at the same time.  You also get mechanical adjustments, a full tank of gas, and the windshield cleaned.  A pit stop that takes more than 8 seconds is considered a failure.   This is parallel processing – defined as multiple operations taking place simultaneously.  Thanks to parallel processing the Indy pit crew can do in 6 1/2 seconds what takes the solo mechanic all day.
Now go to the doctor’s office.  The physician sees a patient with a suspicious nodule in his thyroid gland that needs surgery.  How many steps does it take to get that patient to the operating room?
1.     Create a chart note that supports the need for surgery
2.     Schedule the operation with the surgical facility
3.     Preoperative labs, imaging, EKG
4.     Specialist clearance (i.e., cardiology)
5.     Precertification with insurance
6.     Generate and complete documents
a.     Surgical consent
b.     History and Physical
c.      Preop and Postop orders
7.     Communication with the referring physician
8.     Handle the unexpected – patient calls with questions, abnormal lab values, scheduling conflicts, etc
How does the paper chart office handle these tasks?  In all but the smallest practices these tasks are each handled by different individuals.  Every step requires access to the paper chart, which can only be in one place at a time.  The chart won’t be available to anyone for at least 24 hours until the transcription comes back and is filed.  The paper chart office must therefore accept the slowness and inefficiency of sequential processing.  Workflow is defined by stacks of paper charts – stacks waiting for transcription, stacks waiting for labs, waiting for scheduling, etc.  And if the patient scheduled for surgery calls with a question…what stack is the chart in?  Will the chart find its way back to the right stack after the phone call is handled?  Everyone competes with each other for access to the chart.  Not only is the process slow and inefficient, it carries a high risk of workflow failure.
How is the same process handled in a doctor’s office that has EMR?  With the power of parallel processing:
1.     The chart note, including the diagnosis codes, is immediately available to support preoperative workflow. 
2.     The chart note is paperless faxed to the referring physician the same day, sometimes before the patient leaves the office.
3.     The staff is immediately notified of the new workflow via the EMR system
4.     Consent, H & P, and orders are all generated with a single button click
5.     All workflows are performed simultaneously, greatly improving speed and efficiency and reducing the risk of a workflow failure.
With parallel processing there are no stacks of charts and no competition among staff for access to the chart.  Copying and faxing charts within the practice is eliminated.  The chart is everywhere, all at once.  Any phone call regarding a patient is easily handled without having to search for a paper chart and without the risk of killing a workflow because the chart was not put back in the right stack.
So where is the ROI?  The same work gets done with fewer people, fewer resources and less space.  These initial benefits happen without having to “re-engineer the practice” or change anything else about how things get done.  After electronic documenting becomes second nature it will be time to employ the concepts of remote access, computerized provider order entry, workflow design / automation and  “e-patient” functions like secure e-mail and patient portals to really get things cooking.  I will cover those in detail in a future post.
Thanks again for reading and for your thoughtful comments.  The response so far has been very strong, far better than I had hoped.

About the author

Dr. Michael Koriwchak

Dr. Michael Koriwchak

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery.
After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations.
Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia.
With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.


  • Hi Mike. It's great to see a physicians take on the ROI of EMR's. In other businesses, technology is leveraged to increase efficiency and to lower costs and electronic health records solutions should be no different. There has to be a clear ROI that doesn't include stimulus for widespread adoption. Your blog post doesn't quantify financially the exact savings but it's not hard understand the benefits for the patient and the practice.


  • Thanks for the thoughtful post. I'm a doc looking hard at ROI and it's great to hear the ROI from an actual MD, and not a vendor or consultant!

    But I don't think you really answered your own question… "So where is the ROI? The same work gets done with fewer people, fewer resources, and less space."

    So, specifically, how much cost did your practice eliminate?

    Fewer people: did you fire anyone, cut their hours, or avoid the expense of a budgeted new hire?
    Fewer resources: what resources did you eliminate and how much did they cost?
    Less space: how much did you save on your lease? or did you avoid building out new space?

    Thank you!

  • Good metaphor. Very concrete and sticky. In my humble opinion, the problem with the EMR story isn’t the theory. The problem lies with the execution. Imagine the Indy Car’s success when the air pumps driving the torque wrench take 8 minutes to boot up and every time the pit crew complains about it, they get ignored until they ‘write up a job ticket’ and submit it to the air pump provider, who prides himself on a 24 hour response time. Or, when the same pit crew tells the torque wrench manufacturing person of a problem, they get labeled as “resistant to change” and ignored, and later offered a “Meaningful Use” cash incentive to use the wrench that didn’t work well. Just my opinion, but EMR has been deployed by a few software centric companies, with a software oriented agenda (e.g. big market share, huge embedded customer base, impossibly high barriers for customer to leave –imagine replacing Cerner?, etc). The end customers, are being forced to use something that just doesn’t deliver on its promises, and is told if they don’t like it they can go pound sand.

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