EMR not boosting productivity? It could be a mismatch between system and specialty

If it's been many months since you bought your electronic medical records system and you're still seeing fewer patients as you did before you got it, the problem might not be you -- it might be your EMR.

Specifically, it might be that the EMR you bought isn't designed or customized to work with your specialty -- a problem technology industry experts say could become more common and acute as practices rush to buy systems to gain federal financial incentives.

Researchers at the University of California at Davis studied how an EMR implementation at six primary care offices affiliated with the same academic medical center affected physician productivity levels. They found that after an initial dip in productivity during the training period -- which is normal -- internists were able to increase productivity above pre-EMR rates, while pediatricians and family physicians were never able to regain their pre-EMR productivity. Why? Because the EMR system more closely matched the work flow of the internists.

Hemant Bhargava, PhD, associate dean and professor of management and computer science at the UC Davis Graduate School of Management, said the practice he and others researched adopted an EMR system that made tasks associated with treating sick patients -- such as reviewing radiological images, notes from previous visits and charts of test data -- more efficient. But tasks associated with well visits, such as data entry, were made more cumbersome and time-consuming for physicians who were used to quickly jotting down notes with a pen and paper.

Bhargava thinks productivity could have increased for all specialists if the group had adopted different versions of the EMR system that were tailored for each specific group of physicians and the way they practice medicine. The as-yet unpublished UC Davis study was presented at an academic conference in October 2010 and released to the public in December.

Work flow becoming a problem

Andres Jimenez, MD, CEO of the Las Vegas-based consulting group ImplementHIT, said the work flow issue is one that has become more problematic as the EMR industry matures.

Five years ago, most EMR systems were specialty-specific, he said. In an effort to make the systems more attractive on an enterprise level, vendors are making the systems less specialty-specific. As a result, using them has become less natural-feeling for many physicians, he said.

The introduction of federal incentive programs, which could pay physicians up to $44,000 over five years through Medicare or up to $63,750 over six years through Medicaid, has led to many practices buying systems or taking advantage of subsidy programs that allow hospitals to donate IT systems to affiliated practices.

With deadlines approaching this year to show meaningful use, technology analysts say practices might not be taking enough care to ensure that their systems are tailored to their needs. The UC Davis researchers are warning that a one-size-fits-all approach may do more harm than good.

Their study comes just weeks after technology company CDW Healthcare published a report that found productivity in the first year after an EMR implementation could fall up to 10%, which amounts to a monetary loss of $120,000. This and other studies have predicted that the productivity loss would be temporary and eventually would increase above pre-EMR levels when the training period is complete.

To ensure that happens, experts say a comprehensive look at work flow needs to be done before implementation. After implementation, practices continually must look for opportunities to customize and fine-tune the systems to meet changing needs.

Productivity up in one study

Adam Cheriff, MD, chief medical information officer at Weill Cornell Physician Organization in New York, studied productivity levels of his multispecialty practice after implementation of an EMR. That study was published in the July 2010 International Journal of Medical Informatics.

Unlike the UC Davis study, Dr. Cheriff's study did not compare productivity levels from one specialty to the next. But it did find that, overall, productivity increased after the first several months, in large part because the practice made sure its system would meet its specific needs.

"Those groups that don't invest in trying to do some of that analysis up front before they install the system really have a lot of trouble, and they are doomed to some degree to failure or loss in productivity," Dr. Cheriff said. "But I would say despite the best analysis in trying to match system design to work flow, it is only after you become a user of a system that you truly understand how to apply the tool."

David Lagrew, MD, chief integration and accountability officer for the MemorialCare Health System in Southern California, said involving the end user -- namely, the physician -- from start to finish will get the needed results. Dr. Lagrew, who also is the medical director for informatics for the MemorialCare Physician Society, said he has seen major projects fail "when people on the informatics side say, 'This is what you need to do.' "

For small practices without an IT staff, the work flow analysis is especially important, even for those who consider themselves tech-savvy. Bhargava said he was surprised to see in his research that physicians considered to be so-called physician champions who helped pick out an EMR system did not have higher productivity than their colleagues in the same specialty.

At a basic level, a work-flow analysis should map out current processes detailing what is performed by whom using which system, or in the case of a paper-based system, which forms or paper charts are used and how long it takes to perform each task. Then the analysis should look at how those processes ideally would change with an EMR. Experts say some of those changes can be made before EMR adoption. The chosen EMR should complement the desired changes to the work flow and processes.

Dr. Jimenez, however, said physicians should realize that no system will be an exact match to every physician's work flow. They should also realize that some new work flows that are introduced by the EMR probably are there because they have proved to be efficient, he said. As systems get tweaked, physicians should be willing to make minor changes to how they do things, he said. It's important for practices and hospitals to allow ample time for physicians to learn and practice those changes, Dr. Jimenez said.

Experts stress that implementation is an ongoing process. Because health care takes place in a continually changing environment, the processes used by physicians to navigate that environment must adapt.

Bhargava says that even though adjustments might be made continually to the EMR systems and the work flows of the people who use them, once the EMR has been in place for more than 18 months, any gains -- or losses -- to productivity after that time are going to be caused by something else, not just EMR use alone.