With all the talk about electronic medical records (EMR) and hundreds of products flooding the market, why aren't more physicians adopting the technology? The Institute of Medicine's 1991 watershed report on computer-based patient records1 spurred widespread excitement and inspired many information technology (IT) companies to invest in the development of new health care products. Accounts vary greatly about how many EMR packages are on the market today, but it's somewhere between 200 and 800. Yet only an estimated 5% to 10% of neurologists are operating full-blown EMR systems, according to Orly Avitzur, MD, MBA, a neurologist in private practice in Tarrytown, NY, and EMR advocate. A standardized electronic health information exchange could save the country $78 billion a year in health care costs, according to proponents writing in Health Affairs.2 The report assessed the value that electronic health care information exchange and compatibility among hospitals, medical group practices, independent laboratories, radiology centers, pharmacies, payers, public health departments, and others would bring to today's system. Judging from recent activity, however, a growing number of physicians are paying closer attention to EMR application. The Physicians' Electronic Health Record Coalition (PEHRC) was formed in July 2004 to educate its members and to be part of the national dialogue on standards. Twenty organizations are members of the PEHRC, including the American Academy of Neurology (AAN). Together, members represent a half-million physicians. Another organization, the National Alliance for Primary Care Informatics, also was formed last year. According to American Medical News, several other physician and nonprofit industry groups are banding together to ensure that their unique needs are met as EMR standards are developed.3 TERMINOLOGY: EMR OR EHR? Although the terms are often used interchangeably, EMR in this article refers to an electronic record that is integrated with hospital, clinic, and practice records and is owned by the provider. Electronic health record (EHR) refers to an electronic record that a patient owns and shares with health care providers. EHR is often used as a generic term by the industry, and it encompasses all electronic patient care systems, including EMR. According to the Medical Records Institute, Boston, the vision for EHR systems was born some 40 years ago. C. Peter Waegemann, CEO of the institute, said in a column published in Health Management Technology in May 2004: "At the time, health informatics experts thought that the obvious benefits of the EHR would lead to adoption within a few years, but in reality, little happened. . . . Now, EHR systems are again at the top of the list for many organizations. This time, all signs indicate that we will make considerable progress."4 That is more likely to happen with the backing of the nation's CEO. President George W. Bush is requesting $125 million for further development of health information technology in his 2006 budget. He also is advancing creation of an Office of the National Coordinator for Health IT, to which he proposes reallocating $50 million for other health care IT solutions in the 2005 budget. Spending in the proposed budget is targeted at improving patient safety through EMR, developing technology for small community and rural hospitals/health care systems, and developing uniform health IT and standards. BARRIERS TO ADOPTING EMR Randolph W. Evans, MD, a neurologist in solo practice in Houston and president of the Texas Neurological Society, has the same reservations about implementing an EMR system that he had 2 years ago, and he plans to continue to hold out a while longer before investing in an EMR system. Evans believes broad adoption will come when "some huge impediments" are addressed. Some of those impediments are the lack of universal standards, an absence of adaptations for the unique needs of neurologists, and the lack of a guarantee that there will be ongoing software support. Without uniform standards, one should invest in an EMR package that is open-source-that is, its source code is available to the general public for use or modification from its original design free of charge. If it is not open-source, reliable long-range support for maintenance and upgrades will be needed. "Who is going to support your system and back up your data at a remote site if the company is bought out or goes out of business?" asked Evans. Evans thinks there may be universal standards within 1 to 2 years. With potential new federally mandated standards, however, additional costs could come for those who have already invested in a system, trained their staff, and adjusted to a new workflow. What if the national standards are different from the standards of the system that you invested in? Evans recalls the Health Insurance Portability and Accountability Act (HIPAA) compliance requirement, which mandated electronic transactions and code sets standards. Many physicians had to purchase new computers and software to make their offices HIPAA-compliant by the October 2003 deadline. Another impediment for Evans has been the need to scan in thousands of records, which he estimates could take his office 6 months. He believes "it makes sense that it should be implemented" once barriers are removed. One benefit that he sees is reduced reliance on storage for patient records. In Texas, physicians are required to keep patient records for 7 years. With his patient load increasing by 2000 new patients a year, Evans said he only has room to keep the current records and 3 previous years of charts in the office. Evans says it now costs him about $2500 annually to securely store and retrieve as needed the old records through a contract with a vendor. Prices for implementing an EMR system can range from a few hundred dollars a month for a Web-based system offering basic components to $200,000 or more a month for a customized local secure system. For Evans, it's not so much the cost as the compatibility and longevity of the systems that are now available. Then there's the simple fact that some physicians prefer holding a paper chart to reading a chart on a computer screen. "Even though I am on a computer all day long, there's still some convenience with using a paper chart," he said. PIONEERING NEUROLOGIST'S EMR SYSTEM Joel S. Perlmutter, MD, head of the Movement Disorders Section at Washington University in St Louis, has been using EMR for more than a decade. Perlmutter started the Movement Disorders Section 20 years ago, which has grown to include 9 doctors and 20 other staff members. He also created the office's EMR system, making it one of the technology's earliest adopters. He started writing the program in DOS 15 years ago. When the Windows 3.1 operating system became available 12 years ago, he hired an outside consultant to help him. The programmer developed a more easily usable graphic interface, and Perlmutter continued to design new modules to broaden the usefulness of the program. All physicians in the Movement Disorders Section use the system, which has 12,800 patients in its database. "Our database is now used by neurologists treating epilepsy, neuro AIDS, and general neurology," says Perlmutter. Neurologists who treat patients with sleep disorders and multiple sclerosis plan to start using it in the future. The system has been customized for neurologists and is being adapted for use at other institutions. Massachusetts General Hospital, the University of Toronto, and the University of Edmonton are using Perlmutter's system, with more institutions scheduled to come on board soon. Washington University made a technology transfer agreement with Medsys Technologies (www.medsystechnologies.com) that now sells licenses for the program and provides customization and support services. Perlmutter said he developed the system to make his job easier. It writes prescriptions, schedules, and generates narrative reports. The system tracks patient allergies and has the capability to pull up related drugs and standard rating scales for stroke, movement disorders, epilepsy, mental status, and essential tremor. The system eliminates handwriting errors, and there are "zero lost charts," said Perlmutter. An added benefit is that physicians can access the database remotely through a secure server. Access can be made through a desktop system or a wireless laptop. A notepad-type interface is available, and a handheld interface is in development. Although he is seated at the computer during office visits and types in notes, Perlmutter said the EMR system doesn't impede the physician-patient relationship. He can access a patient's complete record at the touch of a button. The EMR system has reduced overhead by 30% to 40% in Perlmutter's office. It also frees up time to see more patients. "It allows for better care-it's cutting-edge medicine." When HIPAA came along, he found it was far easier to implement since he already had an automated system. Perlmutter said EMR systems offer "a huge advantage for research." Brad A. Racette, MD, a colleague of Perlmutter, used the database of 1600 Parkinson disease (PD) patients to examine the correlation between welding and PD. Racette's studies based on that research have been published in Neurology and Movement Disorders. Regarding one study,5 Perlmutter said: "We had noted that some PD patients had welding exposure. So Racette went to the database and quickly identified 15 such patients. He was then able to quickly pull 100 consecutive PD patients without welding exposure to compare their characteristics. Finally, once we found that the only difference between the 2 groups was the younger age of onset in the welding-exposed group, Racette was able to pull another 100 PD patients matched for age of onset. This type of work took only a few days rather than the many weeks of paper-chart searching." Another, more recent study6 relied on the database in a new way. "Racette and his team evaluated more than 2000 people in Alabama, including a video session of each. He then took DVD recordings of patient videos, sent them to a variety of movement disorders experts around the country, and they rated them, remotely logging onto a secured interface for our database system," explained Perlmutter. "In this way, we have now used the database for a multicenter-type study. This substantially streamlined data management for this study. All of our patient-oriented research studies are made much easier with the EMR [system]. We can identify potential research subjects much more easily, substantially facilitating subject recruitment. This applies to nearly all of the patient-oriented studies that we are currently doing." THE TASK OF DATA ENTRY Perlmutter acknowledged that some neurologists are averse to the amount of keyboarding that is required to maintain an EMR system. Usually, the physician enters all of the data during the patient visit, and the system is generally a point-and-click affair that includes template editors, all of which cut down on the amount of typing required. Perlmutter said physicians who don't enjoy typing have the option of using voice recognition software, such as Dragon NaturallySpeaking and IBM's ViaVoice. Support staff can be greatly affected by the move from paper to electronic record keeping. "The office needs to have some level of comfort with computers and software," said Perlmutter. Otherwise, tasks can be outsourced. The "ramp-up" time necessary for loading data, training, and testing can be significant, lasting 3 to 4 weeks, says Perlmutter. Converting to EMR requires significant changes in the office workflow. Positions will change. For example, secretaries no longer take dictation, but they will spend more time entering data on new patients and confirming updated medications on follow-up patients. In larger institutions that employ IT staff, the technology typically leads to a push for a comprehensive "systemwide solution" because it's easier for the IT staff to manage. "Unfortunately, that doesn't drill down to the level we need as physicians," noted Perlmutter. He advises neurologists who are considering an EMR system to study what's available, talk with people who have experience using it, and "have a clear understanding of how it will affect your work flow." BUILD INCREMENTALLY Avitzur, the Tarrytown, NY, neurologist, is passionate about EMR and about EHR-the even more ambitious health integration system that incorporates patient interaction with health records and resources. She started using health care IT in her practice after enrolling in business school in 1999. She quickly realized when working on her MBA that she needed to "beef up" her IT competency and that getting up to speed on new technology offerings would make her practice more efficient. Avitzur presents workshops on setting up electronic offices for other neurologists, publishes frequently about EMR topics in neurology-related publications, and serves on an AAN task force on EMR created by the AAN's president, Sandra Olson, MD. Avitzur points to the American Association of Family Physicians (AAFP) as an organization that has created tools for members with similar requirements. The AAFP "has become very advanced in the use of digital tools," explained Avitzur. General practice physicians have found it easier to customize EMR systems by using drop-down menus and click-through formats, she added. "Neurologists tend to be technology proponents. Everyone agrees there are a lot of wastes in health care," says Avitzur, and she adds that waste, along with medical errors, are some of the best reasons for neurologists to consider using an EMR system. EMR technology also has great potential to improve efficiency, productivity and billing accuracy. It maximizes the sharing of knowledge between clinics and hospitals. Hospitals are adopting EMR systems in greater numbers, and neurologists will benefit from having compatible systems. Avitzur hopes there will soon be more incentives for small practices to adopt EMR technology. While it might appear to make sense for the average neurology group with 1 to 3 members to share technology tools with the group practice down the street, privacy concerns rule that out, she said. Many of the products are still too experimental and expensive for smaller group practices. In addition, because small practices don't have IT departments, they lack the capability to maintain their own servers and may be limited to using Web-based EMR packages for now. Avitzur is a big fan of incremental adoption. She recommends that neurologists consider the costs and the learning curve involved. "Ask yourself and your staff: What are the top 3 problems I want to solve?" She suggests starting with an electronic prescribing solution and adding more features when you're ready to expand. More vendors are adapting their offerings to an incremental approach, says Avitzur. Another incremental step is adding voice recognition software. To make their products more useful, IT companies need to tailor their EMR systems to the neurology office, Avitzur explained. IT companies must incorporate specialty terminology, and the EMR systems must have the ability to create comprehensive reports. Click-through and drop-down menus appear clumsy in the detailed narrative reports that neurologists must share with referring physicians, says Avitzur. "We need products that allow for free text entry so the results don't look truncated." KEYS TO PLANNING AND MANAGEMENT Making the commitment to migrate to a paperless practice is a major investment and carries some risk. Hiring a project manager skilled in implementing health care technology is one option available to physicians. The project manager will be responsible for bringing vendor and user teams together. He or she also can help practice owners with pre-implementation planning decisions regarding hardware requirements and tasks. The project manager creates implementation timelines and plans for the training of end users. He also knows when to bring in applications support specialists. "A rule of thumb is that 30% to 40% of an EMR implementation is spent on project planning," said Brian Doby, CCP, PMP, a senior project manager in St Paul and president of Project Management Institute Healthcare, a special interest group for project managers working in health care technology fields. "It is far cheaper for the physician practices and institutions to hire a project manager so that business can continue as normal. Every minute the physician takes to address a business issue, it decreases their revenue exponentially," said Doby. In writing about the evolution of electronic health care records, Edward H. Shortliffe, MD, PhD,7 summarized the current reality. "Health care provides some of the most complex organizational structures in society, and it is simplistic to assume that off-the-shelf products will be smoothly introduced into a new institution without major analysis, redesign, and cooperative joint development efforts." References 1. Dick R, Steen E, eds. The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: Institute of Medicine, National Academy Press; 1991 (revised 1997). 2. Walter J, Pan E, Johnson D, et al. The value of health care information exchange and interoperability. Health Affairs. January 19, 2005. Available at: http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.10/DC1. Accessed February 23, 2005. 3. Chin T. Services pop up to help doctors pick EMR system. American Medical News. 2004;47:42. Available at: http://www.ama-assn.org/amednews/ 2004/11/08/bisc1108.htm. Accessed February 23, 2005. 4. Waegemann CP. The year of the EHR? Health Management Technology. 2004;25:5. Available at: http://www.healthmgttech.com (search Archives for May 2004). Accessed February 23, 2005. 5. Racette BA, McGee-Minnich L, Moerlein SM, et al. Welding-related parkinsonism: clinical features, treatment and pathophysiology. Neurology. 2001; 56:8-13. 6. Racette BA, Tabbal SD, Jennings D, et al. Prevalence of parkinsonism and relationship to exposure in a large sample of Alabama welders. Neurology. 2005;64:230-235. 7. Shortliffe EH. The evolution of electronic medical records. Acad Med. 1999; 74:414-419. Kathy Stone is a freelance writer in St Paul. --- Resources for More Information: Electronic Medical Records www.elmr-electronic-medical-records-emr.com/index.htm Physician-maintained site provides a downloadable 8-page primer on electronic medical records, cost comparisons, and reference links. Healthcare Information and Management Systems Society www.himss.org/ASP/index.asp Klas Enterprises http://healthcomputing.com/ Independently measures vendor performance for the benefit of consultants, investors, vendors, and health care provider partners. Medical Records Institute www.medrecinst.com/index.asp The Medical Records Institute's mission is to promote and enhance the journey toward electronic health records, e-health, mobile health, and related applications of information technologies.