By W. Rodriguez, PhD [Extracted from: Carstens, D.S., Rodriguez, W. and Wood, M.B. (2014) ‘Task and error analysis balancing benefits over business of electronic medical records’, Int. J. Electronic Healthcare, Vol. 7, No. 4, pp.331–348. The paper was co-authored with Drs. Carstens (FIT) and Wood (Mayo Clinic).]
Background: Amazingly, healthcare spending represents 18% of the U.S. gross domestic product (GDP), and is projected to be 20% by 2020 (Seiden 2012)! And while Information technology (IT) is widely used in everyday life, it is estimated that only 8% of the 5000 hospitals and 17% of the 800,000 physicians in the U.S. use an EMR (Electronic Medical Record) system (Goldman, 2009). Based on a national survey of physicians in 2008, only 4% had a fully functioning EMR and only 13% had a basic system (Mallon, 2009). It is curious that healthcare information technology systems haven’t seen enthusiastic and widespread adoption in an industry, that is, as information and data intensive as healthcare.
Reason: Physicians and hospital administrators simple do not have the time to analyze and implement EMRs in practice. Further, healthcare systems may appear complex and not easily understood at first glance (Mehrjerdi 2013).
Fortunately, Medical Scribes can serve as the link between physicians and this seemingly complex EMR software technology. Medical Scribes can help physicians during the EMR implementation (transition) and beyond.
A study performed by Chircu, Gogan, Boss and Baxter (2013) suggest that during transition times, 40 percent of medication errors, 20 percent of which cause harm, occur from staff miscommunication. Well-trained Medical Scribes can assist physicians reduced medical errors by communicating effectively and recording the physician directions and allowing them to focus on the patient rather than on the technology.
Decrease medical errors: Despite the above challenges, research suggests the importance of accurate and timely patient information to ensure proper care from a quality and safety perspective (Broekhuis & van Donk 2011). Studies provide data that Computerized Physician Order Entry (CPOE) which is another aspect of EMRs enhances patient safety by decreasing medical errors (Krohn 2003). CPOE eliminates illegible orders and most notably the names of drugs, dosages, dosing units, and administration frequency and routes. When associated with decision support function (DSS), alerts for allergies, drug interactions or inappropriate dosing occur in real-time. CPOE with DSS can provide alerts for duplicate tests or inappropriate tests based on a patient’s diagnosis or portfolio of existing test results. Brigham and Women’s Hospital in Boston implementation of a CPOE led to an 81% decline in medical errors, mainly related to decreasing adverse drug events and duplication (Krohn 2003). New York’s Montefiore Medical Center had a 50% decrease in prescribing errors and a 60% improvement in delays between prescription writing and medication administration. Clinical Documentation is another key module of an EMR as it can be designed to permit access to authorized providers involved in the patient’s care useful as a tool for integrating care between multiple different physicians, nurses, therapists and others to include record sharing.
Reduce Cost and Duplication: Cost barriers remain a hurdle associated with EMRs although HIS (Health Information Systems) will decrease global healthcare costs through minimizing duplication, enhancing appropriate test and therapy selection, improving care continuity, integration of services and decreasing avoidable medical errors and accidents (Schmitt et al. 2002; Poon et al. 2004). The difficulty is that patients and payers receive benefits yet the providers of care (doctors and hospitals) are responsible for costs making the “business case” for HIS challenging. Established ROI methodology specifically for IT has been difficult to apply to HIT because of difficulty labeling the benefits with financial metrics but reports suggest EMR improves revenues and reduces costs (Cresswell 2004; Menachemi et al. 2006; Mildon et al. 2001). David Brailer, former National Coordinator for HIT in the Bush administration suggested that a computerized health record system could save $200-300 Billion/year across the U.S. healthcare sector (Goldman, 2009). Hillestad, et al. (2005) by extrapolating the impact of IT from other industries estimated potential national savings of $81 Billion/year by full implementation of an HIT.
Wang, et al. (2003) studied a primary care physician practice that reported an annual financial benefit over a five year period of $86,500 per physician due to cost savings from decreased drug costs and x-ray utilization. Barlow, et al. (2004) reported over five years a cost savings of $140,000/physician due to decreased costs related to transcription, paper chart management and reimbursement recovery. Schmitt, et al. (2002) estimated that the installation and support costs over seven years were $19 Million without quantifying the temporary decrease in physician productivity. By year three, the financial saving exceeded the cost to date, and by year seven, there was an annual savings of $7.5 Million/year related to decreased time processing orders, decreased drug costs and costs due to adverse drug events, transcription costs, chart management costs and increased charge recapture.
California Health care Foundation studied the economic benefit of a fully deployed EMR, and reported a payback period of 2.5 years and thereafter an average gain of $23,000/year/physician despite a decline in productivity initially (Goodman, 2009). Kaushal, et al. (2006) suggested in a hospital setting that ten years of spending $11.8 Million resulted in a savings of $28.5 Million for a net 10 year benefit of $16.7 Million due to drug cost savings, nursing time and the avoidance of adverse drug events. Poon, et al. (2004) reported a net operating benefit by seven years following implementation. Kuperman and Gibson (2002) reviewed reports on the value of CPOE and concluded that it reduces costs but ROI analysis is challenging because baseline costs of key processes are difficult to calculate and several benefits cannot be measured financially. Frisse (2006) suggests that financial ROI analysis of CPOE is inappropriate because “the ROI is measured in safer and more effective medical care.”
Improve Quality of Care: Carroll (2004) suggests that the EMR financial return to a doctor’s practice is lacking. Hamilton (2008) suggests that although EMRs save money it doesn’t go to those that pay for it. Clear recognition of the disconnect between those incurring the cost and those reaping the benefits will be a major step for the widespread adoption of HIT in this country. Moreover, presidential leaders promote a “carrot and stick” approach to finance HIT. The “carrot” is the “HIT for Economic and Clinical Health (HITECH) Act” described by Centers for Medicare & Medicaid Services (2013) and the Congressional Budget Office (2013) which provides a $44,000/physician over a 5 year period for Medicare as an incentive for practices to implement and meet meaningful use standards. The “stick” is that physicians who don’t transition to using an EMR system will see Medicare payments reduced after 2015. Taner, Sezen & Atwat (2012) conducted research where the hospital organization successfully from a financial standpoint implemented technology due to optimizing efficiency through process and workflow improvements. Therefore, process improvement research may help an organization realize savings despite the expenses related to technology such as the EMR as it is essential to understand the operational impact electronic records as hospitals invest in information technology to lower costs and to improve quality of care (Mitchell, S. & Yaylacicegi, U. 2012).
Conclusion: Although EMR implementation is challenging, Medical Scribes can be instrumental in supporting physicians during the transition and beyond.