HIStalk Practice Interviews R. Michael Kroeger

R. Michael Kroeger, MD, FACS is a urologist with The Urology Center PC of Omaha, NE.

Give me some background on your practice.

We’ve been expanding, so I always have to stop and think. We’ve got 12 urologists and one physician assistant. We have one main office, but we have a total of five offices here in this area; and then about four or five outreach locations in western Iowa. We’ve got our own ASC. We’ve got two Medicare-approved operating rooms; an ambulatory surgery center. Within the last year and a half, we got our own CT scanner. We’ve got a bone density machine; conventional x-ray. Our specialty is urology.

What kind of software are you using?

We’ve had a practice management system since we started. This practice was actually created in about 1989, and I think we were both on manual practice management systems at that time. We started out with a company called MEDS that was in Dallas.

After about eight or nine years, in 1994, we switched to IDX for practice management. Then we got a network for the doctors to use for kind of interoffice communication and scheduling. This was the late ‘90s. We were using Palm Pilots and that sort of thing, so it was nice to be able to synchronize up with the scheduling system that we used in the office.

Actually, our vendor that set up the network encouraged us to use Lotus Notes. I know it’s a very powerful program — maybe a little more than we needed. We’ve still got Lotus Notes. We use it mainly just for the e-mail function and are kind of wondering a bit if we should switch to Outlook for compatibility reasons and so forth.

As far as clinical things, there’s nothing we really had that could be considered a clinical application until we got the EMR. Urodynamics has some software involved, but that’s really just single modality there.

It wasn’t until we got the EMR that we had any clinical IT applications. That’s one of the things that we’ve been able to do with this particular application. I don’t know if it would be the same for others, but we’ve been able to create a lot of documentation tools for the ASC that we just created from scratch, basically. They weren’t off-the-shelf kind of applications, and that’s been quite helpful. It allowed us to do most all of our documentation in the EMR. We do some general anesthesia in the ASC and that’s still completely on paper, but pretty much everything else is EMR.

Tell me about the EMR. Which one you’re using and how long? How did you decide on it?

Well we started talking about it in the early 2000s, about 2001 or so. I’ve been interested in it a long time and I saw a demo actually, by Mark Leavitt. That’s the name of the guy that’s now the head of CCHIT. He had a company called MedicaLogic at the time. I went to a VHA meeting and he gave a demo of MedicaLogic and I kind of got fired up about it. This was probably in the mid ‘90s.

We actively started talking about it in 2001. Every year, we’d have long-range planning and next year was going to be the year. It wasn’t quite ready yet … that sort of thing.

We finally, about three years or so ago, got into more of a formal selection process. There was a speaker at our national meeting from The Coker Group who gave a talk and kind of led us to believe that he had had a special interest in urology, and we ultimately engaged him to help us in kind of doing a little hand-holding, I guess, to kind of get us over the hurdle.

Again, we talked about it for many years and really hadn’t taken any action. Then we set up an RFP. I’ve got a hospital job in medical informatics and so I’ve been to HIMSS and that sort of thing, so I had a chance to visit a lot of vender groups. I kind of had an idea of what was out there. They helped us get a short list of vendors.

The hospital that I referred to is a Cerner place. We looked at what Cerner had on the outpatient side. I think I was sort of OK with it. I’m well aware of the limitations of Cerner. I think Laura, our practice administrator, had some real skepticism about some of the scheduling things and so forth. So we kind of scratched that from our list pretty early. At one point we were down to eClinicalWorks and A4, which had just been purchased by Allscripts.

I kind of liked eClinicalWorks; she kind of liked A4. Then I was reading a discussion board, EMR Update, and somehow I ran across Bond Clinician. Somebody had mentioned that they thought it was particularly good for surgical practices. We got a demo from them and thought it maybe was a good …. kind of met in the middle.

It’s a Web-based program. It’s got kind of a different kind of a cool look to it and very customizable and so forth, and so we ended up going with it. We knew it was a small company. I guess I never would have guessed, when we started out, we would have ended up with something like that. I thought we would have ended up with maybe a larger vendor. And now we are with a larger vendor, so it all kind of works out.

So you’ve been up and running now for about how long?

About a year and a half.

Has it been pretty well adopted by all of your physicians?

Well, it’s been adopted by all the physicians. The “pretty well” I don’t know. I think as well as could be expected. There clearly are things that frustrate people. I think most of them are more just the whole dealing with change and so forth, not so much this particular product. 

I think we’ve been fortunate since it still is, in a sense, kind of a small company mentality in terms of the people that are working on this particular product. Even though it’s now under the Eclipsys umbrella, we’ve been able to get a lot of our issues addressed pretty rapidly by the Peak Practice staff, and so we’ve been real happy with that.

How are you and your partners actually putting the information into the system? Are you dictating? PCs?

We’ve created several templates for different clinical issues, although in actual practice, I think most of us use primarily generic templates. We’ve got generic mail and generic e-mail templates. I would guess that over half of the notes are done using those templates.

For certain visits — follow-ups, cancer patients and so forth — you’re always kind of looking for the same set of information on each visit. We’ve been able to use some specified notes for that. Doing the HPI in a structured, clicking template kind of mode is not very satisfying, I think, for most of us, and so most of us do dictation using Dragon or typing.

Some of the guys’ keyboarding skills are really quite, quite, good. So HPI, in Plan, we do a lot of pre-text, either Dragon or keyboard. Everything else we’re able to do mainly with the template, like for the physical exam. That, of course, plays well into the coding aspect.

One of the things that we wanted to do was to be able to improve our coding accuracy. I think we underestimated how much work it would be just to get the thing going. Now we’re kind of circling back and trying to add some of these extra features that we wanted in the first place, like the coding aspect.

But I’m certainly not saying that people don’t complain about it, but I think people like it. They like the access. Since it’s a Web application, if you’re at home, it’s literally just like being in the office. You can access it from the hospital and that’s been so very powerful. So, they like to use it to look up information, but as is always the case, they don’t like putting information in.

Do you have PCs in every exam room?

No, we don’t. We’ve got wireless, convertible laptop/tablets, and that works pretty well. I think there’s some thought that it would be nice to have a PC in every room with a larger screen; particularly when we want to show patients x-ray images and that sort of thing, and we’ve talked about that.

I think sometimes the architecture of your building dictates how successful that is. How large your exam rooms are and whether you’re able to put them in in such a way that you don’t have to turn your back to the patient and so forth, so we’re certainly toying with that idea. But for now, we’ve got something that works and that hasn’t really been a pressing issue for us. But I think eventually, as we get more connectivity to PACs systems and images and so forth, we’ll probably want to have PCs in the room.

Has the passage of the ARRA legislation changed your focus at all in terms of technology adoption?

Well, I think so. Again, we have started on this pathway well ahead of any inkling that that was going to happen. I think it maybe has changed the timetable and maybe helped us focus on making sure that we do those elements that are going to be needed to get the money. I mean, if we’re going to do this and there’s money to be gotten, we might as well make our timetable fit the schedule that will allow us to get that stimulus money.

Sounds like you’re pretty well connected with your medical informatics role and HIMSS. What’s your impression — why do you think EMR adoption still remains pretty low?

I think the main issue’s cost. I think for a lot of people it’s very hard to justify the cost. It’s hard to show that there’s truly any return on investment; and then resistance to change in general, and the fact that it probably is going to slow you down, at least for a period of time. 

Ultimately, I think probably the best you can hope for is going to be time-neutral. I think to argue that you’re actually going to save time with an EMR; maybe some people can do that, but I don’t think that’s a realistic goal, at least at the current level of the technology.

What’s next for your practice in terms of technology adoptions? Do you have any additional plans? Or just tweaking what you have?

We’re not really looking into any other software products in particular. There are lots of things that this product has available that we would like to get back to. Actually, one of the things that we bought this for was it had a surgery scheduling. They call it Surgery Planner. Then when we tried to actually use the Surgery Planner, it really didn’t fit our workflows for a variety of reasons. So we’re hoping that we can kind of circle back with the Peak Practice people and get a project going to make a better surgery scheduling planner.

We’d like to do the patient portal, which is available. We’ve already got access to that. A patient kiosk that gives us access to the instant medical history. They call it IntelliHistory, and we’ve just had difficulty. We’ve tried with a couple of conditions getting that to work and we’ve just had some issues there. Are you familiar with Allen Wenner and Instant Medical History?

No, I’m not.

IMH is just a tool that you can basically put the patient in front of a computer and they’ll take a history. You have to tee it up and say, this is about blood in the urine or this is about chest pain or whatever; and it’ll ask them questions; it’s not just a flat fill-in-the-blank kind of thing. It branches. So if you say, “Yes, I get up at night to urinate,” it’ll ask you a bunch of questions that apply to that, and it will take that and it will actually fill in your history of present illness for you. I think for some patients, that could be a great time-saver.

Wenner argues that actually, you can do a better history by using a tool like that. People might be more inclined to answer honestly through a machine than they would sitting face-to-face with a person about, maybe, some delicate issues. And so I think it’s a great concept. Again, it addresses that data entry issue. You can actually get the patient to enter the data directly for you. But it, again, we’ve had some challenges getting that to work.

Another thing, in our state, the statewide RHIO, which is called NeHII, Nebraska Health Information Initiative — we’re participating in that as one of the pilot sites for that. We are hoping to be able to actually get an interface to Peak Practice so we can selectively pull in data so we don’t have to look it up on the NeHII system and enter it into our system.

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News 12/8/09

From Seeker of Truths: “Re: ARRA funding. All the EHR vendors I’m talking to lately tell me that practices can get their money right now. I’ve heard it so much that I’m beginning to doubt what I know to be true! Am I the only one?” I suppose I shouldn’t be surprised to hear that some vendors may be saying ARRA money is available today. Technically the government is handing out some money, though none of it has yet flowed to providers for their meaningful use of a certified EMR. Perhaps someone needs to remind those vendors that we’re still waiting on the final definitions for meaningful use and certified EMR.

The AMA expresses concern that easily accessible patient records could lead to a decline in care as doctors avoid the sickest patients to improve quality performance scores. I thought the AMA was suppose to advocate for physicians, not diss them. But, I agree that unintended consequences could occur as we rely more on EMRs to measure quality care improvement. I prefer to be optimistic that most doctors will remain more concerned with providing quality care than performance ratings.

Desert Cardiology (AZ) selects Medfusion for its patient-to-provider online communications solutions. Desert Cardiology is a six-location, 10-provider practice.

Hayes Management Consulting announces that more than 50,000 providers are now using its MDaudit Professional compliance audit software. They also just introduce a hospital version of the product.

Healthpac Computer Systems contracts with Alpha II to resell Alpha II’s ClaimStaker claims scrubber software to Healthpac’s office-based physician clients.

Shares in athenahealth hit a two-year high Friday afternoon after the company stated expectations of annual revenue growth (30%) and profits (40%) through 2014.

Cielo MedSolutions partners with DrFirst to provide e-prescribing functionality for practices using Cielo’s Clinic clinical quality management system. Dr. First’s Rcopia solution will be fully integrated into the Cielo Clinic application.

The Bureau of Labor Statistics says the healthcare sector added 28,500 jobs in October, including 4,800 jobs in physician offices and 10,000 in hospitals. A separate survey finds that 95% of the hospital CEOs claim they have a shortage of physicians, with a vacancy rate of 11%. In other words, more than one in 10 physician job openings are unfilled.

Related problem: if 40 million people suddenly get health insurance, rural areas don’t have nearly enough primary care doctors to see them. The reason is obvious: the doctors go into specialties and geographic areas where the pay is better.

The California Nurses Association, the MA Nurses Association, and some members of the United American Nurses combine to form National Nurses United. The new entity represents over 100,000 nurses.

The UK’s Medical Defence Union warns doctors not to respond to “flirtatious approaches” form patients on  social networking sites like Facebook. The MDU advises members of the importance of keeping relationships with patients on a “professional footing.” Could be that the Brits remain more formal than us since I haven’t heard any official warnings on this side of the pond.

Quantros and Allscripts integrate their respective products to create a Web-based care management solution.

The latest story of greed in healthcare comes from Canopy Financial, who provides software to help manage HSAs. Canopy filed for bankruptcy protection after the FBI began looking into alleged fraudulent financial statements that were created as part of a $75 million investment scheme. Co-founder Jeremy Blackburn recently resigned as president after the allegations came to light and his assets have since been frozen. KPMG first discovered the potential fraud after realizing Canopy was claiming that its financial statements were audited by KPMG. In fact, KPMG had never been retained by Canopy to audit its financials. Perhaps one day Blackburn and Charles McCall will have a chance to be roommates.

E-mail Inga.

News 12/3/09

From Golden Creeper” “Re: MD salaries. While doing some research on physician wages, I came across this blog. Found it interesting and just thought I’d tell you.” While not really HIT related, the MD $alaries has an interesting variety of income data, including comparative figures from various parts of the country and other countries, plus suggestions for boosting income (or reduce expenses). The latest post says that physician executives with an MBA earn 11% more than those without a post-graduate degree.

The Kerlan-Jobe Orthopaedic Clinic, which serves virtually all the professional sports organizations in Southern California, agrees to pay taxpayers $3 million to settle a federal lawsuit. The Justice Department charged it with taking illegal kickbacks from HealthSouth Corporation in the form of stock option grants, donations to the Kerlan-Jobe Foundation, and loan forgiveness on equipment leases.

CCHIT certifies four new products under the newest programs announced in October. ABELMed EHR-EMR/PM, Version 11 received certification under the CCHIT 2011 Comprehensive program, while eHealth Made EASY, KIS Track, and Medios earned Preliminary ARRA 2011 certification.

Here’s the difference between the two certifications: the Comprehensive certification program “provides a more rigorous inspection of integrated EHR functionality, interoperability, and security in addition to full compliance with Federal standards.” CCHIT also includes an inspection process in the Comprehensive program that considers successful use at live sites and good usability. Additional certification announcements are pending, per CCHIT. And OK, I admit it — I’ve never heard of any practices using any of these products.

Claims clearinghouse Navicure recognizes four clients for their substantial improvements in RCM and billing using Navicure solutions. Winners of The Biggest Gainer Awards (love the name) included the 24-physician North Atlanta Primary Care, which cut its A/R days by 43% (less than 18 days) and raised its collection rate to 97.4%. The single doctor Spinella Orthopaedics Association, which has a single FTE for billing, reduced its A/R by 30% and cut its over-90-day A/R by 67%. Here’s a nice spiff: all the winners receive six months of free Navicure services.

Johnson Memorial Hospital (IN) will offer eCW to its employed physicians and use eCW’s Electronic Health eXchange to allow access for other physicians and hospitals.

Participation in quality reporting programs requires resources with measurable costs, a fact supported by a recent study in Annals of Family Medicine. A major problem is lack of interoperability among IT systems. Participation is especially difficult for small primary care practices, who often need to hire outside consultants. Physicians in smaller practices also spend more of their personal time after hours collecting the required data.

SK3 Group signs a letter of intent to acquire Medical Billing Specialists for $4.1 million from its owner, Healthcare of Today.

Maryland is spending $100,000 of taxpayer dollars to train observers to keep an eye on doctors. Specifically, the program will teach certain hospital employees how to covertly monitor the hand washing practices of healthcare workers as they leave patients’ rooms. I’m all for clean hands, but can’t figure out why it costs $100,000 to train people to observe other people washing their hands. And why Maryland is using federal ARRA dollars, because I don’t see the connection with economic stimulation. When will the insanity end?

The 18-physician Naugatuck Valley Radiology Associates (CT) claims it’s now 100% paperless following the implementation of a MedInformatix RIS, DR Systems PACS, and Nuance PowerScribe voice recognition.

Dialog Medical expands its partnership with A.D.A.M. to include A.D.A.Ms’ QuickSheets patient education solution in its iMedConent application.

Ping Inga.

HIStalk Practice Interviews Mark Brown

Mark Brown, MD is an ophthalmologist with Vision Partners at Providence Park Hospital, with offices in Daphne and Mobile, AL and Biloxi, MS.

Give me some background on your practice.

We are a group of eight doctors, six ophthalmologists and two optometrists. We founded our practice eight years ago. A smaller core of us was on faculty at the local university and basically things were very restricted in terms of our desire to go more electronic and high-tech. And is often the case with universities, they’ve got their committees etc., and we just didn’t get to do what we wanted to do with it.

Ophthalmology in general is probably one of the more techie kind of subspecialties, and so the entire department left in 2000 — staff, doctors, clerks, everybody in the department. We basically created our own office called Vision Partners. Most of the doctors are fellowship trained and experts in their field. We built an office on a different hospital campus that was built to be paperless.

We had a kind of luxury because we decided when we were going to leave and they didn’t fire us. We had a year to plan and that was instrumental for a number of reasons. We had never done what we were about to do and we needed to choose practice management software and electronic medical records and build a building. We’d never done any of this. We were just kind of flying by the seat of our pants.

I spent the better part of nine months really looking at practice management software and medical records software. We built our building to be very much wired from a networking and computer perspective, and paperless from a perspective of no storage facility in the office at all. Every square foot we wanted to be productive, so we didn’t want to have 2,000 square feet of storage for charts. Over the past couple years, we’ve added on doctors. There were four or five of us when we started; there are eight now.

We have three offices. Our main office is in Mobile, Alabama. We’ve got an office downtown and an office in what’s considered across the bay in Eastern Shore. Basically, we rotate patients in various areas. It’s not quite as bad as New York, but patients desire to stay within two square blocks of their house and don’t want to go anywhere. That’s particularly true for the patients across the bay. Eastern Shore is the city that has been really written up in the news as a top retirement city in the United States. Those patients really look down their nose at coming over to Mobile for anything, so you have to provide services over there.

There was also an issue of how to have everything connected with charts going back and forth. That would be something we would never, never have been able to have done with paper charts. One of my biggest pet peeves at the university and why we wanted to have electronic medical records was my boss, who is now my partner, would notoriously take charts and put them in the back of his Ford Explorer, never to be seen again. I mean, the patient would come in and we have no idea why they were there. You’ve got no chart. The chart’s missing.

Then you have all of these human issues; people unable to follow the alphabet. They just can’t file charts correctly either numerically or alpha, and so the chart is misfiled. It’s there somewhere, but no one knows where it is. Or, the typical scenario is that it goes from surgery to billing to a doctor and it’s always en route from one place to another. You add into the wrinkle of, “Oh my God, it could be in a different office twenty minutes away.” It was just never going to work. We needed the digital copy.

Tell me what kind of technology are you using.

We use about four programs to do everything. I’ll tell you the history, briefly. About nine years ago when I looked for an integrated solution, an integrated practice management/medical record — the whole nine yards — didn’t exist. When one company did well on one, it didn’t do well on the other. The people that had practice management software really had crappy EMRs and I don’t think that’s changed.

I’ve lectured at the New Orleans Academy and I don’t think there’s a product, at least in ophthalmology, where you can get the best of both worlds. So we chose Medical Manager as a practice management software. At the time, they had the claim to fame of having set up a lot of practices and they had widespread customization available. I don’t particularly care for the company — Sage. There are enough freelance programmers out there that could do things if you wanted to be done.

We deployed Medical Manager on a Windows-based system and then we chose SRS medical records. We tied them together with a custom interface so that when a chart would be created in Medical Manager, they would appear in the medical records software automatically and all the demographics would come over on the schedule, the insurance, all of the details. That was important because one of the things we wanted to get with an EMR was not re-inventing the wheel every time with rewriting the patient’s Social Security number and insurance number on every form when we book a surgery or on a consent form or whatever. Those are what they describe as ‘mergeable.’ They come over, and then if you create a Word document, you can have those numbers drop into it automatically.

Two years ago, we stopped liking the clearinghouse Medical Manager had and we went to a product called Practice Insight, which enables us to track our claims and divvy up tasks based on rejected claims in a very systematic way that we never could do with Medical Manager. We initially went with a coding software that was part of Medical Manager, where you filled in the circle like you do on a standardized test.

Then two years ago we moved to a product called White Plume, which interfaces beautifully with SRS. We click the tab, the form comes up electronically, we tick off the buttons that we want. We can add the modifiers, we can see the patient’s insurance right there. We can do really sophisticated things with macros, so we can bundle an ICD-9 and a CPT code all at once. Our office exam rooms all have a computer and we can leverage the system very well. We do all the billing in the room and keep track of what needs to be done, without wasting paper for that matter, or losing charts.

Does White Plume interface with everything? Is it just for the charge ticket or is there a clinical component to it as well?

It’s an electronic charge ticket. When an appointment gets made in Medical Manager, it goes off two different ways. You get a charge ticket created in White Plume and you get an appointment created in SRS. So as soon as I walk into the patient’s room, I’ve got my schedule up on SRS of the patients I’m seeing today and I can sort it by name or by time or whatever I want. Then I launch the bill ticket just by clicking on one of the tabs in SRS. Each of the doctors has their own superbill and it’s seamless for the doctor.

I think that’s the whole thing — I wanted a system that wasn’t going to slow anyone down. Dr. Rich, the guy who was my boss and my partner, he’s at a real high volume. So when I was looking at these systems, he had a low tolerance for anything that was going cause him to see two less patients a day; that was inadequate. As for both the SRS and for the White Plume, it had to be at least as efficient as paper, if not more. So both of those systems had that criteria for us.

You mentioned difficulty finding an EHR that would work well with ophthalmology. What is it about SRS that worked better than some of the other ones out there?

I think the wish would be that you could have a system that doesn’t slow you down. Except that all of the systems out there slow you down. You look at the patient and you say, “Okay, you have a diagnosis of a corneal abrasion.” So I’m going to take my piece of paper through SRS or a paper chart, and I’m going to go to my exam form and I’m going to go to my form and mark corneal abrasion. That takes a microsecond, whereas so many other systems there are these drop-downs where you kind of have to go to the right section of the exam, then you choose anterior segment; and it’s in a series.

It’s a philosophy thing, of grouping or splitting, and so for it to work, you’ve got to split. So you choose anterior segment — that’s the front part of the eye — and then you choose cornea. There are four million things that could be wrong with a cornea and you’ve got to choose whichever one best fits. It’s all about clicks today and it’s one of my biggest gripes when I call up vendors and I say I don’t have any problem with your software — you missed the boat here when they do something that requires five clicks that could be done in one. I went through this with White Plume, asking why do I have to click ‘close’ and ‘save and close’? Why can’t I just click one button to save it all? And they’re like, ‘Well, every click matters.’

I’m under constant fire from the insurance companies for my reimbursements. Blue Cross just announced a 20% fee cut. I can’t make up 20% in my volume and it turns out that my employees don’t want a 20% pay cut. I’m not sure why.

And neither do you.

Yeah, and neither do I, and that’s a problem. It’s a huge problem because every click and everything that slows me down is not good. So I think the other thing about [our selection of SRS] is the reality that paper exists. I mean, let’s not deny this. The fact is, charts are going to come over from other offices that are paper. I looked at one of the companies, a very large company, that had an EMR and a practice management component together and I said, ‘Well, here’s this fax. Put it into your system.’ You know there’s like nine steps? They had to scan it, they had to name it, they had to put it in its place. On a day-to-day basis, there are just too many faxes to deal with that. It would just never be realistic. All of the medical clearance that we get from other medical offices are all paper. Hospitals all work with paper.

You know I’m not saying in ten years or fifteen years it might not be different. I guess we’ll have to wait and see, but I’d say for a long period of time, the standard is going to be an 8½ x 11 sheet of paper. So many of these other practice management software had no way to really bridge the gap between paper and digitized, but what every one of us liked about SRS was that it didn’t require us to change what we do. We still could write on paper and we’d have the PDFs, my built-in system. I don’t have to worry about the company going out of business. Everything’s a PDF. There’s nothing proprietary about it.

And, it’s intuitive. The first training session we had, I took a group of 20 people from the university. Generally, university employees are like government employees, you know? They’re just not the most motivated people. These people, they didn’t have computers at the University. I sat them down and they had never used a mouse, aside from people that had a computer at home. I mean, people were looking at me like, what was I thinking? It was a thirty-minute training session. I still haven’t read the manual on SRS. I’m sure there are other features that I could be using that I’m not. The reality is that we can hire new staff and say this is what it is and they can just kind of look at it and figure it out. It’s just intuitive, and that’s not the case for most software.

Has the passage of the ARRA legislation changed your focus at all in terms of your technology adoption and usage?

Well, it annoys me. I don’t remember signing up to be a government employee when I went to medical school. I’m very cynical about the whole premise that it’s going to save money. I see money being spent, but I don’t see money being saved. I think that capitalism should take over. It reminds me of when the HIPAA rule came out two or three years ago. We’re like, ‘Oh, I’ve got to have this piece of paper that I have my staff or my patients sign that I’m not going to share your information.” Well, I don’t know, the people in Washington decided that was important and so then I had to implement it.

I had to pay for those papers to be created and printed and passed out. I think that the first time that a doctor’s office sells their patient information, I bet that patient doesn’t go back to them. I just think well, I don’t get reimbursed to do that. It just seems like a common sense kind of thing, or common courtesy, or free market would take care of itself. So when you go and impose this, “This is how we want you to document your medical records.” Well, who is that saving money? Because it’s not that I’m going to get more money from Blue Cross or Medicare. I might get a less of a penalty, but it doesn’t translate into making my office better. It just serves their need of that’s what they want to do.

But let’s say we all did that. How does it really save anyone any money having everything — I mean, we’ve spent how many billions of dollars doing it now? Ten years later, everyone’s got an EMR. Has it saved the system money? I mean, I’m not really convinced that it has. With the exception, perhaps, of redundancy of ordering tests that have already been ordered. There are lots of other ways to deal with that. They could just put a penalty on you to say, you know what? If you order a test that another doctor ordered and you’ve repeated it because you were too lazy to look up the result, then you know, you get fined. That would prevent people from ordering tests that aren’t necessary or have already been ordered.

I think the government has a really bad track record of following through on the payments. I think the physician practice in this scenario is kind of being forced to take on a liability or a risk without really any guarantee of payment. I don’t think people that I’ve talked to have gotten their PQRI payments. The reason we went with an EMR was: a) to save money, and a) to be more productive. The ones that are qualifying to meet those criterion are going to slow me down, and so I’m not excited about it because if I have a lost productivity of seeing a couple patients less a day, it’s not worth it.

So you are saying you may not change anything and just forego the incentives?

That’s exactly what I’m saying, and I’m mad about it because I have an EMR and I have a system that I believe meets the realistic criterion. I don’t think that the people that are coming up with the criterion are in practice. Patients can easily get a copy of their medical record; it’s portable; I can have multiple copies of it. It’s a huge step up from the paper record, and yet it doesn’t change the way Mark Brown wants to be an eye doctor.

And by the way, patients, I don’t think, really care for the idea of my spending my consultative time staring at the computer ticking off boxes rather than making eye contact with a patient where I can do with a clipboard and a piece of paper. You can’t talk into the screen and have the patients hear you, and not to mention it’s rude. So now I’m looking at the patient and having a conversation, but normally I could be filling out a form at the same time, but now I’ve got to turn and document things after. Well, I guess I could hire a scribe to enter all that. That’s going to just be a drain of another salary per doctor. There are all these things that you could do to justify it, but the practice keeps absorbing the expenses. It’s not like I get reimbursed any more money. The rules that are imposed by the government only decrease our productivity.

You said one of your initial goals was to save money. Has that occurred?

Absolutely. We fired two people. I don’t want to get rid of every human being. I want to support the local economy, but we got rid of people that prepared the charts every day. What a ridiculous job. Day in and day out you go and you look for the chart and you put a blank piece of paper in, form the chart for the exam, sort and organize the chart. That was an entire salary at university.

The other is the charge entry. It’s all automated — it’s ready to go out the door. I think the biggest thing is the sanity factor. What we all like is the fact that the chart can be open. What typically happens in a practice is Mrs. Smith calls in with a complaint, the technician answers the phone, and now they’ve got to get the chart. Think about how much time that takes. They’ve got to find the chart and then they’ve got to review it. Then they’ve got to go pass the chart to the doctor and they’ve got to review it. Whereas with the SRS here, they could pull up the chart, they can either buzz me in my office or they can send me a message attached to the chart and I can just look at it. And, the chart can be open in two places at the same time. That can’t happen in a paper system.

As you know, overall EMR adoption is still pretty low. Why do you think that is the case? Why are so many of your colleagues still so resistant?

Initially, it is the upfront expense. Then you look at the past year and ask what the government is going to do. They are uncertain if these standards are really set. Are the standards going to change? What if I buy a system that’s not upgradeable? This isn’t done as a rebate system from what I understand, so I think potentially you’re talking about not getting the money that you want or think you’re going to get. I think that you’ve got an economy that’s not good and you’re asking the doctors to put up the money to do it. It’s one thing if you were already moving or built an office, but if you were going to outfit an entire office, it’s expensive. And, it’s a tremendous loss of production while you’re going through that transition.

If you look at the EMRs that are out there [versus SRS] and you say, ‘Well, OK, we have 100,000 charts.’ [For us, the transition was 100% transparent to the doctors.] We hired a bunch of college kids to start scanning the files and we did it for months. But, what does the average office do? How long does it take to roll into a new system and what do you do with all the old records in that time? You have no access to the old data, and so you’ve got a paper chart that you’re reviewing, and then you’re starting a new system. [With a CCHIT, we would be basically doubling our work as we reviewed patient’s notes on paper and then started their CCHIT chart.] I can tell you that during that first two years I bet our production [would have] dropped 30-40%  [compared to our old paper system] because we [would have been] basically doubling our work. No one’s going to want to do that.

The other issue is so many of these systems really are complicated and require an IT person. You get to have an EMR, then you get to hire someone at a $50,000 a year salary to babysit the computers because Windows needs updates and the network goes down. All of those things are reasons why people didn’t sign up for EMR.

Any other general impressions on the industry you’d like to share?

I think in general, SRS seems to be more unique in understanding what doctors do. Medical Manager is up to version 10 or so, so they’ve had enough years of feedback to be told. Other companies that we’ve dealt with, we say, well this is what we want to do, and they’re like, “Well, oh, we hadn’t thought of that” or “the programmer didn’t design it that way”.  I can’t speak to other products, but it’s the same thing over and over again with the companies and the programmers. There’s a disconnect between how the practice of medicine is performed. For some reason, it is not present in SRS. They seem more responsive and more in-tune.

I think the other companies that I’ve worked with, White Plume and Practice Insight, are responsive to my suggestions, which is good because of course, I always like my suggestions. But I’m often amazed by products, asking, “What were you thinking when you designed it that way?” I kind of hit my head against a wall sometimes. It’s just an example of someone who actually is designing from a computer perspective, and not from an IT perspective. I don’t know if it’s a matter of the industry needing more practicing physicians on their consultative boards and things like that.

You can look at me as the “doctor not for the $44,000.”