For many physicians in small office practices, the thought of adopting electronic medical records to meet federal "meaningful use" guidelines and timelines is a daunting one at best.
"There's a whole bunch of obstacles that are making us hesitate," says Paul Speckart MD, a San Diego internist in a five-physician practice. "We're in a different spot than the large hospital-owned clinics and practices, in that all of the EMR burden falls squarely on our shoulders."
For starters, he says, doctors aren't sure the systems they buy will be "interoperable" with their hospitals or will meet certification standards. And they're not sure the government will make good on its promise to provide stimulus reimbursement.
And what if they need interoperability with several hospitals where they have staff privileges, but those hospitals are on different systems?
"We get promises that there will be bridges. But who's going to be making these bridges, and who's going to be paying for these bridges?" he asks. He says the large Scripps hospital system, where he has staff privileges, has not said it intends to provide that for independent practices.
The estimated cost, he hears, is "between $60,000 to $80,000 to start, plus the maintenance. That's a lot of money," when doctors are facing possible Medicare pay cuts of 21.5% in March.
Speckart, whose practice now has some electronic systems to exchange imaging, pharmacy, and lab reports, believes that EMR systems have great potential to improve quality of care because of their reminders and communication with hospitals.
"But you have to remember, we feel like we're at the battlefront, and people are shooting at us day and night. We're not interested in great grand performance, because we're worried the next shot will get us. You open the doors and hope you survive until the doors close at night."
Steve Waldren, director of the Center for Health Information Technology for the American Academy of Family Physicians (AAFP), agrees that many of his 95,000 member doctors are delaying implementation because of worries about buying the wrong system.
"Once the creation of CCHIT (the Certification Commission for Health Information Technology) was announced, we saw a drop in adoption in our members. There's so much uncertainty. We still don't have the regulations on how the certification process will be governed. So there's no way [a vendor] can say they have a certified product or not," he says.
Waldren expects the AAFP to send a list of concerns to the federal government to request changes in the meaningful use guidelines announced Dec. 31, within the 60-day comment period.
"We're very excited about moving to meaningful use, but we have concerns that some of the reporting burdens aren't necessary to achieve meaningful use. We want everyone to focus on the quality outcomes, and managing those instead of managing workflow in process," he says.
And then there's the concern about reimbursement, and whether physician practices will be able to install systems to get the greatest percentage of stimulus funds available at the front end.
Speckart says, "A lot of people are worried that, in fact, Washington is inoperable, and the things they say and make us adhere to are not being backed up by the support they've promised us."
And then there's the chatter from a few early adopter colleagues that the impact on them has been "economically devastating," Speckart says.
"You hear that their experience is very checkered, with stories that are much different than the ones you hear from the salespeople. Doctors say 'We're struggling with it,' or 'The system is finally coming around.' You're advised that your office can handle about half the patient load for the first month and the next month, two-thirds, but that it will be three or four months before you're able to resume full patient care."
And then there's the question of what good it will do. "The EMR people will tell you that your coding will improve, but the experience of most clinicians is that it doesn't save money; it doesn't balance out in cost."
Instead, Speckart says, "The money it will save benefits the medical management companies and insurance companies and the government."
Joseph Heyman, a solo practitioner in Amesbury, NH, and a member of the American Medical Association board of trustees, understands concerns of physicians, such as Speckart. He adopted EMR in 2001, and now reaps the benefits. For starters, he has more room in his office because he doesn't need storage space for paper charts and says he now spends more time with his patients.
But, he acknowledges, "Many physicians are worried. They don't know where to start. It's not an easy thing to switch to, especially if there's workflow interference."
Like the AAFP, the AMA intends to issue a letter to the federal government asking for changes in the guidelines and timelines for "meaningful use" compliance.
"We're concerned about how quickly people are going to be required to do some of these things. And we're concerned about measurement reporting for specialties that don't have measures," he says.
For example, Heyman says, currently the meaningful use guidelines call for compliance in stages. "But we think that there should be some percentage of success in one stage before you more onto the next stage."
And of course there are very few hospitals that are offering bridges to physician practices today, which is a goal of EMRs. "That's a major issue. They have to have a vehicle to send the information through to the hospital or to another physician.
He says the AMA is working with Compuware Covisint, a medical record platform and exchange developer, to offer basic EMR service to AMA members, with upgrades that will cost varying amounts. "The AMA is intent upon providing solutions for its members, which will make it possible for members to do this in the easiest way possible," Heyman says.
For Speckart, there is one other major concern: The loss of the precious human connection with patients.
"You'll get patients who enjoy the fact that you have access to electronic records. But then there's the patient who wants to talk with you about the really grave issues that are affecting him and his family—and there you are pounding away at the computer."