Guest Post: Physician comments on meaningful use, the impacts of recent healthcare reform legislation and EMR adoption

By Brad Dodge on October 4th, 2010

Ted Wojno, MD is director of Oculoplastic and Orbital Surgery at the Emory Clinic. In the following entry, he weighs in on how healthcare reform is impacting the physician. 1. What impact have recent healthcare reform initiatives, such as the HITECH act, had on your organization?In keeping with the HITECH Act, Emory Healthcare (Atlanta, Ga.) has adopted an electronic medical record (EMR) and has begun phasing it in over the last year.  As with any major change in a large organization, the conversion has been painful.  From my personal perspective, the losses have outweighed the gains to date. 

  • We adopted a "one size fits all" approach.  The EMR system we purchased from Cerner is more of a hospital-based system and more amenable to use by a physician who spends 30-60 minutes with each individual patient such as an internist.  It is not user-friendly to a physician like myself who sees 25+ patients on a Tuesday morning and 50+ patients all day Wednesday and spends the rest of the time in surgery.  The use of the EMR adds one to two minutes to each visit.  This is not significant for someone who spends 30 minutes on a patient encounter but adds one to two extra hours to my day greatly decreasing my efficiency and making my patients wait longer.  The extra time is taken up by the painfully slow "mouse clicking" between pages in the EMR representing previous visits, labs, MRI's, etc.  Normally this would take only a few seconds in reviewing a paper chart.  Also, one needs to continually keep logging in from patient to patient.
  •  In ophthalmology, we draw pictures in the patient chart.  Our EMR does not have this capability so we continue to use paper in the office visit and then have a clerical person scan the visit into the computer.  This has of course, turned out to be very expensive.
  • In an effort to speed up the patient flow, the technician now photocopies the last encounter for each patient (office visit, surgery, etc.) and places it in the room for the doctor to see.  This too, has greatly increased our expenses and is a poor use of technician time.
  • Prescription writing takes longer on the computer than it does by hand.

In short, since high volume physicians = high profitability, anything that decreases physician productivity will decrease profits (and physician satisfaction).

2.  How is your organization moving towards meeting meaningful use criteria? What future impact do you feel the new initiatives will bring?We are currently "reporting clinical quality measures and public health data" on all Medicare patients.  The physician asks if the patient is a smoker and if so offers referral for smoking intervention and then documents this in the record in a check box.  We must also check a box that documents that we used the EMR. At this point we do not "submit orders" in the Emory Clinic electronically but almost all orders are done electronically at Emory University Hospital.  Again, orders submitted by the physician in the EMR take much longer than writing them out by hand.  This has been a source of great dissatisfaction for many of us.3.  What is your outlook on the future of healthcare technology?Clearly the electronic medical record is here to stay.  To date there have been woefully few (if any) good studies that have shown that the EMR has improved physician productivity, decreased overall costs, and decreased medical errors despite glowing reports by the companies that make the software.  Personally, I have erroneously entered more improper medication orders over the last year than in my entire career.  This is simply because it is easier to "point and click" wrong than to accidentally write the incorrect dose for a medication.  I have had several instances where even the drug that showed up on the order was completely different from what I "clicked" on.  Fortunately, all of these errors were picked up by nursing or pharmacy staff.  Often, it has been impossible to understand how the error happened.  It is my impression from speaking with other physicians and nursing staff that medication errors have increased overall.  We would all like to believe that this represents a "learning curve" with the new technology but only time will tell.On the positive side, it is easier to obtain a complete record of the patient's history by opening the EMR when I need it.  It has been easier to view radiologic studies on my patients since I can pull them up on the computer and no longer need to walk over to the radiology department.  Again however, for some inexplicable reason, it now takes longer to get some reports logged into the computer and visible on the EMR than it did to receive a paper copy of the report.Patients now come to the office with their radiologic studies on a CD instead of a folder of films.  It takes longer to "load up" the CD than it did to leaf through the standard type "xray".  Additionally, there appears to be an unlimited number of software programs in use so the physician must often "learn" how to access the information on the CD.  This is frequently very time consuming and frustrating in the middle of a busy office day.4.  Are your patients able to communicate with you via email, and how do you see electronic doctor-patient communications evolving in the future?I do not encourage most of my patients to email me but continue to ask them to call me. It takes much longer to type a response to patient's questions than to speak the answer over the phone. Often a typed answer from me generates more questions from the patient and we end up with multiple back and forth emails that could have been solved by a very short phone call.On the positive side, the occasional patient who lives far away can email a picture of "the problem" to me that is better than a verbal description. This is a very small subset of patients. Clearly some of my patients use email to substitute for an office visit (multiple page letters).  If this becomes more routine then we feel that we should be able to render a charge for the time spent responding to them.My overall feeling at this point in time is that the electronic health record has decreased the time that our ancillary staff spends on issues that used to involve paper and increased the time that the physician spends on those same issues. Since time spent by secretarial and clerical staff is relatively low cost compared to the physician's time it is so far a money losing proposition. Given the large number of software programs (I use four different programs that have nothing in common at the various hospitals I work at) uniformity would be helpful. For physicians to enthusiastically adopt the technology it must save time and not waste time. That has not yet happened. Big business has done a much better job of selling the government on the technology than providing the physician with something that really works.  All this will of course be meaningless even if the technology does not improve. This is simply because the current generation of physicians in training will never know anything but the EMR and will have nothing to compare it to. They will accept it as "the norm". Ted Wojno, MD is director of Oculoplastic and Orbital Surgery at the Emory Clinic and holds an endowed chair in the department of Ophthalmology at the Emory University School of Medicine.  He has written over 80 papers and book chapters in the field of ophthalmology and given over 100 lectures at local, national and international meetings.