Pediatrics Face Unique Set of EMR Challenges

My recent blog about Sandhills Pediatrics and its successful implementation of an EMR prompted, fortunately, a very intriguing comment from Chip Hart, a Director of Sales and Marketing at Physicians’ Computer Company who also maintains the blog “Confessions of a Pediatric Practice Consultant: True Stories from the land of Pediatric Practice Management.” He wrote: “I’ll spare everyone the diatribe about how ARRA deals with pediatricians and how only about 1/2 of them qualify, as I write to make one quick statement.” There’s a story there, I thought to myself. So, being an avid observer of pediatric EMR news and views, I reached out to him to gauge his thoughts on where healthcare IT solutions fit in the world of pediatricians.

What sort of challenges are you seeing pediatric practices facing when it comes to implementing EMR systems?
“On one hand, most of the challenges they face are hardly unique to pediatrics: resistance to change, practice differences, the lack of time and resources to be trained and configured properly, poor support, etc.

“Specific to pediatrics, there are two major issues.  First, children are not simply small adults and EMRs, as a rule, are written for adult medicine. There are many pediatric-specific features and functionality that a pediatric practice needs that simply aren’t met by your large, generic system. Simply claiming “pediatric templates” isn’t enough.

“Second, although every specialty complains about the hit that EMRs take on their productivity, pediatricians are obviously in the worst shape. Their volume is the highest and their payment is the lowest. Just adding a minute to each encounter means an extra 30 minutes of charting a day … and I hear stories, daily, of practices adding another 1 to 2 hours! Pediatricians can’t afford to see 5-percent fewer patients. Radiologists can. And pediatricians really like to eat dinner with their families.

“One second-tier issue is that less than 50 percent of all pediatric practices don’t qualify for ARRA and the regional extension centers (RECs), as a rule, don’t understand the Medicaid rules well.  Thus, we have clients and potential clients calling us to ask how they can get money they’ll never get, or to tell us some crazy thing a REC person told them.”

Are there different sets of challenges for those that are private practices versus those that are hospital/healthcare system affiliated?
“Unquestionably – the big one being that hospital/health system pediatricians simply won’t have a choice or even a voice in the process. Yes, I’ve worked with some who appear to be at the table, but in the end … you get what they hand you. Right now, Epic is pushing everyone out but that pendulum will swing back.

Also, those employed physicians don’t have to consider the impact on their productivity in the same way. I’ve met too many peds offices whose docs didn’t take home checks for a few months after implementation – that’s not right.”

Why do you think practices like Sandhills “get it” in terms of moving forward with HIT implementations, and just being forward thinkers in general?
“If I could answer that question, I’d only be working with those practices! Every successful practice I know is successful in a different way for different reasons, but there is one common trait I see in many of them: They run their practices like the businesses they are. Keep the docs in the exam rooms, where they can generate revenue, and hire professionals to actually run the business. Just because it says “MD” after your name doesn’t mean you’re the best-qualified person to run your office. Would Dirk Nowitski or Lebron James make good coaches? I doubt it.

“In the case of Sandhills, they have some excellent, excellent staff who bring some non-healthcare experience to the table. Although I’ve seen it fail, having some management that comes from outside the healthcare system to ask and answer some tough questions pays off for a lot of practices.

“We’ve enjoyed working with them.  I should also add that they, like the other ‘heads up’ clients I know, realize that we’re on the same team. That helps tremendously.”

How long have you offered the PCC EMR? What sort of up tick in implementations have you seen since ARRA/HITECH came about?
“Our PM has had pediatric clinical features (immunization tracking, registry interfaces, well visit recall, etc.) for almost 30 years, but the official EMR itself was released about 2 years ago.

“When ARRA was first announced, we received a lot of calls, all along the lines of, “Where do I get my free money?”  It was very frustrating to explain that it would be state dependent (about a quarter of them still can’t get it) and half of our clients will never qualify due to the Medicaid requirements.

“Things are starting to settle down and get organized.  Still, we are busier right now than we have ever been. We are telling potential clients they might get installed in May or June. A nice problem to have, but it’s not fun to get some excited only to explain it will be 6 months, especially when it used to be 6 weeks!”

Are any of your pediatric clients thinking of becoming involved in ACOs?
“Thinking?  Yes.  They’re all being told how if they don’t get big, they’ll be out of business, which is utter BS. The rules, as we know them now, seem to make no sense whatsoever for pediatricians. I did see a compelling presentation by Colleen Kraft at the AAP NCE last week that very much supported the ACO-esque model she employs, but I think her situation is both unique and not potentially an ACO.

“With some issues – 5010, PCMH, etc. – we take a pro-active stance. With ACOs, I’m glad to let someone else jump first.”

How will your solutions enable your customers to integrate with ACOs or coordinated care programs?
“Far too soon to tell.  In general, I can say, “Hey, we have had really good reports that have tracked patient populations for years.”  Our clients use them all the time, as it’s both good medicine and good business.  As a practical tool, I’d put our patient recall program up against anyone’s – your front desk can crank out a list of kids who need flu shots or asthma followups in seconds – but we don’t know quite what the ACOs will need.

“One thing we’ve learned, though: when a small peds office puts its data in the hands of a large entity, it’s worth double-checking the results. For more than 20 years, I’ve helped our clients fight insurance companies (which an ACO emulates) and the insurance companies never have the data right. Ever. So if a private peds office can work with us and still be in an ACO, they’ll be able to confirm the accounting.

“Here’s my prediction: As ACOs grow, the practices who participate are going to regret losing control of their data. I’m really going out on a limb there, I know.

What do you think is the greatest challenge being faced by pediatrics when it comes to keeping up with healthcare IT?
“Not getting run over by the Juggernaut.  Everyone else’s demands are put ahead of the pediatricians and the peds usually get served what everyone else is eating.  And it rarely suits them.

“I also tell them all the time: ignore the Meaningful Use money. Completely. And ignore the “deal” that you can get from your local hospital/IPA/etc. Pick the EHR that suits you the most and go with that. All the discounts or federal checks in the world won’t make up for even a 5-percent hit in your productivity or having to spend an extra 10-20 hours a month on charting or IT work. If you do like the local deal, great!  But don’t feel like you have to leap in.”

So there you have it folks. I’d be interested to hear from a pediatrician or two who has gone through or is going through some sort of HIT implementation as a follow-up to these views. Feel free to get in touch with me via the comments section below.

About the author

Jennifer Dennard

Jennifer Dennard

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

13 Comments

  • Chip’s comments are “dead on.” We searched for years to find an EHR that would not slow down productivity in our office. The physician’s time is the most important asset a pediatric practice has. Our 5 year search led us to SRS. Because it is a hybrid system physician productivity is not compromised. Our patient per doctor per day numbers have not declined an our doctors have not extended their day to see the patients. Even though pediatricians make up a small percentage of SRS EHR clients, we are treated as though we are their most important clients and they “understand” pediatrics. As Dr. Wessinger said in your first article, it is the best decision we ever made.
    Kenneth L. Fenchel,
    Practice Administrator, Sandhills Pediatrics
    Retired US Army Physicians Assistant

  • As usual, Chip is correct. I couldn’t agree more.

    We implemented an EMR 7 years ago and boy was it a difficult task. In fact, even today, we have issues with the system. Mainly because we don’t get the support we need from our vendor.

    and after 7 years, documenting is a “burden.”

    One of the reasons I think EM’s are so hard to implement is because the majority of software vendors don’t really understand the business of medicine; let alone the business of pediatrics.

    We’ve seen great improvements in design and functionality on Web, MS, Google and iOS devices, yet EMR and PM vendors are still creating product that looked cool in the 80s and as functional as it was in 1992. That has to change.

    @PediatricInc

  • I echo Chips comments. As an early adopter (paperless since 2004), I ended up getting involved in many HIT initiatives both in my state of PA and for the AAP. While some consider me no longer vendor neutral (I am the part time medical director of a pediatric-specific EHR in my “free” time), pediatricians need a loud voice in the HIT conversation and most of my colleagues have felt I’m “up to the challenge.” Pediatricians are the Rodney Dangerfield’s of medicine….we just get no respect. Unless we speak up and demand attention and make folks understand that the beginning of any medical record STARTS WITH THE PEDIATRIC MEDICAL RECORD! If this isn’t done well with a good foundation that makes sense to pediatric care, it’s like building a 30 story building without paying attention to the first 10 floors. We don’t have the big money, we don’t have the big lobbyists, but we matter. We DESERVE a pediatric EHR that makes sense for our needs. If you can find the EHR that works for your pediatric practice, it can improve the quality of your care and your business. The problem for most pediatricians is that they don’t know what they don’t know and they don’t know what to ask.

  • Thanks for your comments. I’m glad that Jennifer could play some small part in making the pediatric voice heard. There’s little doubt that many (probably even most) EHR vendors haven’t focused on peds.

    The idea of a patient’s health record starting with their pediatrician is interesting. I’ll have to think more about that and how that could be leveraged for good if it was done right.

  • Thanks everyone for sharing your comments. I knew Chip’s comments would spark a conversation, and it has definitely given me food for thought regarding how to take this conversation further. I reviewed a pediatric PHR – MotherKnows.com – a few months ago over at HealthcareITNews.com, which seems like it could evolve into what John and Sue have commented about. As a parent tasked with keeping up with this PHR, my main hurdle has been time and, honestly, lack of interest, which I think many other adults might also encounter- whether that be a PHR for themselves of their child. The only way I see folks being really into keeping up with their PHR if it is housed in a space where they already spend most of their day anyway, or perhaps incentivized in some way. Yes, John, I’m talking about Facebook. I know you laughed off the possibility of Facebook becoming involved in EMRs, but I don’t see it as such a stretch to think that some developer in the very near future won’t create some sort of Facebook-integrated PHR.

  • Just a follow up comment from yesterday. We have been with PCC just a short time. From first contact through implementation and training, PCC has been outstanding. The PCC product and staff that work at PCC have been a dream to work with. It is products like PCC and SRS that help make practices successful. I echo what Chip said in that we are partners. Their close relationship with our practice helps make us successful. I am just sad we did not learn about PCC years ago. Thanks Chip.

  • What do people think would be the impact of an HHS “model pediatric EHR format?” Something that pediatricians and vendors could use to benchmark EHR products against, as a standard for what a pediatric EHR should do. Helpful? Not? Thoughts?

  • Jess,
    How much value has the EHR Certification from HHS provided. I guess I see what your describing as similar and not a great place for government to help.

  • I think Chip’s comments here and the previous article he commented on underscore the glaring need for standardization of EMRs. Not only pediatricians, but really doctors in general have little voice in guiding development of EMRs, because once we choose we are locked in. Just look at some of the things Sandhills was “excited” about (this is not to harsh on their EMR, this is universal). We can input immunizations and it can… wait for it… print it out! We can input height and weight and it can… graph it! This takes the processing power of a Commodore 64. Our standards are way too low.

  • At the risk of sounding extinct, I wonder if some of the abbreviations such as ACO could be defined in a margin. At age 59, and employed, not private, I am trying to get on board but not understanding ARRA, ACO etc is as frustrating as not being able to SEE THE SCREEN, even with bifocals.

  • Thanks! i am going to paste the list to the wall. It has been 6 monyhs and there is still a minimum of three extra hours of charting per day for no additional income. (being salaried). Life and enjoying medicine as we knew it is over

  • I went to PA School with Ken Fenchel. He was definitely not on top of our class, in fact he was much further down. That said, I wouldn’t put any faith in what he has to say. He was lackluster then and I can’t imagine he improved his credibility to any notable degree. His comments here are just jargon without substance, which is what he did in class.

    The expression caveat emptor applies here, IMHO

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