Tuesday, March 7, 2017

The Practice Impact of Electronic Health Record System Implementation Within a Large Multispecialty Ophthalmic Practice

Many physicians tell anecdotal stories how implementing EHR impacts revenues and markedly decreases efficiency in day to day clinical operations.  Few standardized studies have been published however.

This original publication from JAMA discusses the impact of an EHR implementation at the Cole Eye Institute.  Some of the findings are in stark contrast to anecdotal stories.  There are several caveats. 1. Cole Eye Institute is a large single specialty Ophthalmology practice.  2.  They have a considerable depth in IT managment.  EHR for ophthalmology has many specific imaging requirements which necessitate interoperability with diagnostic equipment.

The study was published in 2015 in JAMA

Importance  Given the lack of previous reports examining the impact of electronic health record (EHR) system migration in ophthalmology, a study evaluating the practice and economic effect of implementing an EHR into an ophthalmic practice is warranted.
Objective  To examine the clinical and economic impact of EHR system implementation into a large multispecialty ophthalmic practice.
Special factors:
The customization process began July 1, 2011, and was completed March 31, 2012. During this time, 7 full-time employees worked exclusively on adding content and features within the system.  (few practices can afford or implement this activity)  No EHR has the ability to 'plug and play' off the shelf.  All require some customization and hands on training of staff.  This time is not reflected in the overall outcome of time and revenue effect.
The pre-EHR period (defined as April 4, 2011, to March 30, 2012) and post-EHR period (defined as April 2, 2012, to April 5, 2013) were compared. The primary end points evaluated were total revenue, total visit volume, revenue per visit, and the frequency of diagnostic tests and procedures performed with year-to-date comparisons. In addition, costs of the implementation and reimbursement from meaningful use reporting for the EHR implementation were included in the evaluation.
Meaningful Use
The Health Information and Technology for Economic and Clinical Health Act  HITECH . (http://www.cbo.gov/publication/20452) allows hospitals and physicians an opportunity to receive authorized incentive payments through Medicare and Medicaid, provided they adopt EHR in a way that improves care delivery, also known as the meaningful use of EHR. These incentives are tied to the achievements in patient care with EHR adoption.10
Implementation Costs
The budget for EHR implementation during the project period was made up of capital purchases and personnel-based costs. Capital costs included an image management system, legacy medical device upgrades, and license fees for the EHR system. The actual amount spent was $424 880 in 2011 and $1 146 984 in 2012 for a total of $1 571 864 (eTable 2 in the Supplement). The total personnel and ongoing costs of the EHR system in 2011 were $1 160 694, and the total operating costs were $1 514 334 (eTable 3 in the Supplement). These costs consisted of full-time employee salaries plus fringe benefits.
There was a net loss of approximately $ 400,000.  
The EHR incentive payments (stage 1 and stage 2) toward eligible physicians with implementation of EHR are presented in eTable 1 in the Supplement. Estimation of payments based on the total number of clinicians and participation was performed for future years. In 2011, there were 1 participating physician and 24 nonparticipating physicians, which yielded a reported total of $18 000 of stage 1 EHR incentive payment. From 2012 to 2016, it is projected that there will be continuous participation of 23 of the 25 physicians within the Cole Eye Institute, who will receive a combination of stage 1 and 2 meaningful use incentives. The practice forecasts receiving $983 103 of meaningful use incentives by 2016.  This meant there is a 5 year period of negative cash flow to purchase and maintain the new electronic health record.  Despite the HITECH incentive program, the practice was required to subsidize the EHR for several years.  The forecast for increase incentive was not documented since the JAMA article appeared in 2015, and the study period was only for 2011. Given the vicissitude of CMS calculations and the likely possibility that not all MDs satisfied the eligibiity requirements for full incentiviation.
During and before the implementation there were significant changes in coding with more emphasis on E/M coding from Ophthalmology CPT codes. In additioin several new diagnostic tests became preferred practice patterns adding to the quantity of billing.
More charges may have been captured after EHR was implemented in transitioning from paper records.  The providers also may have taken more care in billing due to anecdotal stories about revenue reductions.
Some bias is present due to the limited reporting period for two weeks of training. In my experience the learning curve is much longer, sometimes taking up to six months.
Buried somewhere and missing in standard deviations and tables is the angst of the process and the additional late night completion of the EHR record.
No mention of figures were detailed as to any improvement in quality of care or improvement in surgical/medical outcomes.
Not withstanding that criticism of the report, it is a good beginning, however readers should not necessarily expect the same results.
A later study may provide evidence of the accuracy of the projection for the Cole Eye Institute.

My thanks to the Cole Eye Institute for releasing proprietary information to benefit all physicians, and thanks to JAMA for publishing these important facts.

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