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PODCAST: Path to EMR implementation remains a bumpy one


The electronic medical record (EMR) has become a fact of life for many dermatologists while others are hesitant to change the way they have practiced and have resisted switching to this form of record keeping. Daniel Siegel, M.D., discusses the ramifications of EMR adoption and outlines the path toward adoption of this technology.


The electronic medical record (EMR) has become a fact of life for many dermatologists while others are hesitant to change the way they have practiced and have resisted switching to this form of record keeping. Daniel Siegel, M.D., discusses the ramifications of EMR adoption and outlines the path toward adoption of this technology.

Dr. Siegel, clinical professor of dermatology, SUNY Downstate, and part-time private practitioner at Long Island Skin Cancer, was president of the American Academy of Dermatology in 2012.

Norman Levine, M.D.: I would like to discuss the promise and realities of the adoption of an electronic medical record. Everybody thought this was going to be the answer to many problems and obviously it hasn’t quite worked out that way. What is the current state of EMR usage among dermatologists?

Daniel Siegel, M.D.: I think somewhere between 20 percent and 40 percent are using electronic medical records. I think the term “use” is one you have to define in that some people are fully electronic where they never touch a pen anymore in their office with the rare exception of prescribing a controlled substance prescription.

On the other hand, I think even those of us who have been digital for a long time, will still pick up a pen and spend too much time at the keyboard dealing with some of the glitches within an EMR. The desire is there, but the technological perfection still has a way to go.


Next: Will it be possible in 5 years to practice without an EMR?


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Dr. Levine: Will it be possible in five years to practice without an electronic medical record?

Dr. Siegel: That’s more of a legal than a technological question. The state of Massachusetts recently passed a law that if a physician is not a meaningful user of a certified electronic medical record, they will not be able to maintain their license, which would force a lot of doctors out of practice in Massachusetts. But I think that it will be very possible to practice. I mean, good medicine has been practiced in this country for more than a century with paper charts, and in many ways paper charts are still excellent. I think it really is legislative and legal.

Dr. Levine: Could you describe some of the advantages of adopting an electronic medical record?

Dr. Siegel: The obvious advantage from the doctor’s side is that you give up having to store charts. If you have a small office and a busy practice, then you can open up a lot of space in your office by taking old charts, digitizing them, and being electronic going forward. You can open up rooms that can be revenue-productive. That’s a major advantage. The ability to access your records from anywhere using the cell phone or home computer; I think is a wonderful thing. Both of those are big benefits. The ability of patients to have information sent to other doctors fairly rapidly is also a major benefit. Those are really the biggies to be honest. Unfortunately, each of those has downsides, too. Patients can expect you to be “plugged in” 24/7 and therefore always accessible. After all, why should a doctor have a life?


Next: Does adoption save the doctor’s time?


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Dr. Levine: Does adoption of an electronic medical record save the doctor’s time?

Dr. Siegel: It depends on where you put the emphasis. The actual process of adoption is usually somewhat uncomfortable, if not downright painful. Most electronic medical records do not function in the same intuitive way that we have used paper or templates or drawings for many years. There are products out there that focus on the dermatologist that are graphic and let you annotate and draw.

Unfortunately, the majority of programs, especially those used in big institutions such as VAs (Veterans Affairs) or other major hospital centers, tend to be purely text-based, and instead of being able to draw a face or sketch out a body and put marks where things are, you have to get used to typing. Even if you are templating things, you still have to get used to typing and describing locations in great detail.

The process of “going digital” can be very time-consuming. For some people, it’s a process that takes two or three EMRs until they find the one that really works for them. So it’s generally not a pleasant process.


Next: Describe meaningful use incentives associated with EMR adoption


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Dr. Levine: Could you describe the meaningful use incentives associated with adoption of an electronic medical record?

Dr. Siegel: Sure. I always like to say, meaningful use is neither meaningful nor useful. When the process started, if one became an early adopter, one could be paid $44,000 by the federal government spread over a period of about four years. I think that if you start this year you are down to about a $23,500 bonus. [1]

We were meaningful users the first year the process came out in my practice, and that meant doing things that we hadn’t done before. Specifically, because we took vital signs including blood pressure, pulse and respiratory rate on patients on the day of surgery for anything beyond biopsy, we had to do those vital signs on greater than 50 percent of all patients above 2 years of age in the practice. So we wound up taking a lot of pulses and blood pressures that were unnecessary.

In addition, we inquired with people about smoking cessation counseling, vaccination history, and the like - things that were not really necessary to our practice. When a patient would ask why, we would just tell them that if we wanted the government to pay us, we had to do this.

None of the meaningful use criteria really help the patient per se nor help the dermatologist, but it is something the government put into play to encouraging doctors to go digital.

One way you can look at is, “Wow! The government is willing to give me $44,000 for doing some extra work.” On the other hand, if you look at the time it takes to have your staff do most of those things, and then you break it down to 48 weeks a year, eight hours a day, and five days a week: What it amounted to in the beginning was you were getting an extra $20 a day. Toward the end, it’s like you’re essentially throwing away $20 a day. So it’s not really a great program.


Next: Nearing retirement - adopt or not?


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Dr. Levine: If a physician is nearing retirement, perhaps two to four years from now, would you advise him to adopt an electronic medical record or just forget about it?

Dr. Siegel: I would say do not adopt if you have a junior person coming in to buy or take over the practice. I would say, let that person make the decision.

The investment can vary. It’s almost like a car: You can buy something or lease it and you have maintenance costs - you can get into a fairly large expense. So if you’ve got a defined timeline of two to three to four years, I think getting out of the practice would not involve getting an EMR to start. If you have a longer timeline, you probably will need to do it, and it can be made cost effective.

Now I know I have sounded somewhat negative on this. I am a techie, I co-wrote my first EMR to generate most documentation, referral letters, and bills back in 1986. So I have been electronic for a long time. I am concerned. The EMR process for us began with the president’s State of Union speech in 2004 when George W. Bush said, “By 2014, all Americans should have electronic medical records to avoid dangerous medical mistakes.” This was probably influenced somewhat by his cousin, Jonathan Bush, the president of Athena Healthcare.

There was a marvelous article in New York Times last February on how the big EMR vendors were not doing all that well economically and realized that they needed to find a way to make some money and get more people to engage with EMRs[2], so they got a mandate and they convinced both sides of the aisle to support this concept, but the technology unfortunately has traveled behind the legislative mandate.

If you look at the amount of money that is spent on developing video games every year, it dwarfs the amount of money that’s spent on development of electronic medical record technology. So when you take a look at EMR use, it has not met the mandate.

For example, at the VA hospital, I work with an EMR that is essentially a word processor that lacks a search function. I contrast that with my own days of training in Dallas in the 1980s when a patient who was being seen for mild plaque psoriasis on the elbows and knees could have five years of records summed up on one page with a brief note, such as “psoriasis follow-up, refill VA tar-steroid mix #2” while the patient with anticardiolipin antibody syndrome might have a four-page handwritten note. With the former patient, you could simply scan the chart and you knew what was going on, you knew it was a quick visit. With the latter you knew you should read the note, somebody took the time to write it.

Now when I go on rounds with residents to see patients in the hospital, everybody has a six-page note, regardless of whether they’ve got a single toenail onychomycosis or mycosis fungoides with a secondary solid malignancy somewhere. And they all read alike, and there are a few sentences of meat and the rest is gristle. So the way the EMR is being used, for the most part, has not met the mandate.

The VA system takes it one step further, in that their compliance people go around encouraging the residents to write detailed copious notes, because in the VA system, the local VA administrative unit does not get paid unless they have a level three or higher visit. So if something is an appropriately low-level, follow-up visit, there still is copious documentation that one must wade through to figure out what’s going on and why the patient might be there.

Nothing stresses me more than walking into a room with a resident who has asked me to see a patient with him, and seeing the resident immediately sit down and start typing away. There is no eye contact with the patient, only an occasional glance.

So in some ways, Medicine has changed for the worse because of the electronic record.


Next: What features do I assess?


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Dr. Levine: If one decides to go down the route of adopting an electronic medical record, what specific features should one look for?

Dr. Siegel: The feature to me that’s probably most critical to a dermatologist is something that is graphic and visual. Because if I have to sit down and write a novella or a book on every patient, that gets real dull real fast. Admittedly, one can hire a scribe who does that for you, though in some states such as California, some insurance companies want the doctor to do the documentation, which is simply a way of delaying throughput.

Ideally something visual and graphic that lets you point and tap is the way to go. Also look for something that is user-friendly and something that would save these steps as you go. We have a lot of redundancy when we document.

Even if you are going back to a simple SOAP note and you are describing something that you think is a basal cell cancer on the nose and your impression is basal cell and your plan is to do a biopsy, and then you document the biopsy - wouldn’t it be nice if you could start out with a point where you’re visually looking at something, where you’re making a diagnosis and then let everything feed through from there automatically? After all, the benefit of the electronic record is to automate, and some programs have gone ahead and done that, but a great majority have not done that yet.


Next: Cloud vs. Server

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Dr. Levine: Could you compare and contrast the various ways that these programs are administered, the cloud based versus the server-based?

Dr. Siegel: Early on in the days of EMR, pretty much everything was server-based. A server is a fairly powerful computer in your office that acts as the traffic controller for all the other computers that talk to it. So with that server, you’ve got a closet that tends to be a very warm room with its own air-conditioning system and the software runs on that server and each computer - be it a tablet or a laptop or desktop - talks to it continuously. That means everything is local. So if you have a fire or someone breaks into your office and that server is damaged or stolen, everything is lost.

In the days when we used the server model, we happened to be into belts, suspenders and duct tape: We had what was called a RAID (Redundant Array of Inexpensive Disks). This included multiple duplicated hard drives so that if one disk failed, the system would send a message saying “disk number one has died, please replace,” and the system wouldn’t be disrupted. One arguably could say that’s the belt part.

The suspender part included an appliance that, everyday at 7 p.m., would back up the entire server. If the server died or crashed, we could boot that appliance to run what’s called a virtualized environment that allowed us have everything back up and running. It would take about an hour to boot it up, it would be a little bit slower, but it would be there. But of course that didn’t address the issue of theft or fire.

So, additionally we had continuous cloud backup. This went back to about 2005. If something died, we’d have backup. As part of that backup service, we could have a disk FedEx-ed to us overnight that would have the last backup. So if there was fire in middle of the day, we risked losing a half of a day’s worth of work. But we could have data there the next day; and additionally we would do once-a-week hard-copy backups that would go home on alternating days with one of the partners, so we would, at most, be a week off.

With the cloud having come along, it’s made things a lot easier. You don’t have to invest in a server. Not investing in a server means not paying someone to maintain it, occasionally balance, tune it and tweak it, and then upgrade it as the software got too big for the server.

The cloud makes things easy. Because essentially you run the program and you get an interface that may look like a Web page or may not look like a Web page but functions like a Web page, and everything is done by transferring data back and forth. The advantage obviously was a lot less setup. The disadvantage is if you have no Internet connection, you are offline and you can’t do anything.

Also, if there is a problem with the cloud host, then you can’t get your data. For those of us who are somewhat paranoid, a model where you have a cloud server but also back things up locally, such as your demographics file and all closed notes, is important.

But again, if you are in a place like New York City, Chicago, Boston or Los Angeles where you’ve got good redundancy; where you might have a fiber optic line as your primary and cable as your backup or vice versa; or if you are rural where you might have a cable and then you have a satellite dish as a backup, you are probably OK as long as your provider is not in any sort of trouble.

Again, nothing is perfect. One concern with the cloud is that if there is some big attack - and we talk of electromagnetic pulse or thermonuclear attacks - but more likely in today’s era it would be a terrorist attack where someone is taking down communication systems, then you might have some problems.


Next: Logistics, cost, training


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Dr. Levine: What are the logistics of the implementation in terms of cost, training and impact on one’s practice; what does one face when he is about to start this kind of system?

Dr. Siegel: The first thing is to find the system you want. Then you negotiate with the vendor about when you are going to do the install, because the small vendors usually don’t have enough employees to do an install the next day. You have to come down to a possible time because there’s usually some training beforehand.

In most cases, the EMR is not simply a medical record, but you have what’s called the front-end, which is the appointment making and the demographic capture, and the back-end, which is the billing. If those three components aren’t part of one company, you have to schedule them all. Then you have to get the appropriate hardware to make sure things work.

Those converting directly from paper may find it easier than those who already have hardware in terms of what will work and what will not work. Some may find the system they bought three years ago is potentially obsolete in terms of hardware, and they may have to start from scratch - so there is the timing of all of that.

Then, there is the question of which way one is going to move forward: Will one close the office on Friday on paper and then open up Monday morning digitally, or will one close on paper on Friday and then, over the weekend, scan in the charts for the patients that will be seen on Monday, and start going digital on those and maybe take a few extra patients, or just start working backward digitizing things from the previous few weeks?

Who will be doing the digitizing? Will you do it in-house? Will you hire a third party service, the EMR vendor, someone the vendor recommends or someone your colleagues recommend who can digitize all records. Will you change your schedules so that you cut your workload by about 75 percent until you get up and running? Or will you plan on doubling or tripling the length of your day?

So there are many different ways that one can do it and again it depends on the program. With some programs, people claim they have only a two- or three-week period of adaptation; for others, it can take people months to get used to using them to the point they are comfortable and functioning, and they never really get back their pre-digital efficiency again, because they are spending too much time typing and documenting and meeting regulatory requirements.

Dr. Levine: How much is this going to cost a small private practice that chooses to go down this route?

Dr. Siegel: It depends on the model. If you go with a cloud-based vendor, you could be looking at spending a few hundred to a few thousand dollars per month per provider. On the other hand, if you decide to buy something, you could be looking at anywhere between $100,000 to $200,000 upfront. Either one of them can have ongoing maintenance costs. Usually the cloud maintenance costs are a bit higher per month; the server-based costs tend to be lower per month.

For some vendors, transitioning to a new coding system is just a routine part of the upgrade; for others, there is going to be significant cost. So there are many different variations.

When one buys a piece of software for home use like Microsoft Office or downloads Adobe Reader or iTunes, most of us click through the licensing agreement and don’t read it. I think if for the first and only time in one’s life one is ever going to read a licensing agreement - and potentially have the lawyer take a look at it, too - that should be done when you get an electronic medical record. It’s much like a leasing agreement for office or home purchase. These can be messy and complex and will have terminology that most of us as doctors have never thought about before. Hence, buyer beware.


Next: Where can I find helpful resources?


Listen to or read more Takeaways in our series




Dr. Levine: Lastly, are there academy resources to help those who are interested in adopting a medical record?

Dr. Siegel: Absolutely, the academy has the EMR (HIT) Health Information Technology kit.[3]

This has been shepherded in a loving fashion by Rachna Chaudhari and William Brady, who are AAD staff. They along with a small cadre of people, including Mark Kaufman, M.D., have been working on keeping this up-to-date with all the rules and all of the advice that one could want. The resources are product agnostic.

The academy has not stepped behind a particular product, but there are enough sessions that one can go to at the annual meeting and also spend time with vendor’s exhibit booths that one can quickly make up their mind as to whether something seems to work for them, is intuitive, whether or not it’s something that they want to get into. The academy does have a lot of resources.

Disclosures: Dr. Siegel is an adviser to and has options in Modernizing Medicine.



[1] CMS EHR Incentives Programs: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html

[2] A Digital Shift on Health Data Swells Profits in an Industry: http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html?_r=0

[3] AAD’s Health Information Technology Kit: http://www.aad.org/members/practice-and-advocacy-resource-center/practice-arrangements-and-operations/hit-and-ehr/ehr-adoption-and-hit-kit


Like this discussion? Jump directly to a topic:

What is the current state of EMR usage among dermatologists?

Will it be possible in 5 years to practice without an EMR?

Does adoption save the doctor’s time?

Describe meaningful use incentives associated with EMR adoption

Nearing retirement - adopt or not?

What features do I assess?

Cloud vs. Server

Logistics, cost, training

Where can I find helpful resources?


And, listen to or read more Takeaways in our series


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