How to examine post-launch EHR productivity

Before you implement an electronic health record (EHR) system, it’s important to analyze and document your practice’s procedures. To get the most out of your system once it is in place, you’ll want to examine your staff’s performance and analyze key metrics. The insights you gain will help you ensure that practice productivity continues to increase and stabilize.

Here, Robert Rowley, MD, Shahid Shah, and Rosemarie Nelson-three healthcare industry experts in the areas of health information technology implementation, EHR development for primary care, and practice management-share their knowledge in easy-to-follow steps that you can apply immediately to ensure the health and longevity of your practice post-EHR implementation.

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Predicting the EHR pay-off

By Robert Rowley, MD,
Health information technology consultant

An electronic health record (EHR) system, which replaces the use of paper charts in your medical practice, affects everything that touches a patient’s chart. In other words, it affects just about everything.

How can you tell whether it is worth it? How can you measure the effect on productivity, overhead, and general quality of life brought about by EHR adoption? By having some useful measurement tools.

The best way to assess the effect of an EHR is to look at three domains:

• the effect on productivity,

• the effect on overhead, and

• the effect on quality of life.

For the purposes of this discussion, we will include the effect on quality of care under the heading of productivity.

Productivity

In a practice that relies on fee-for-service income as the mainstay of its compensation, the effect of an EHR on productivity can be measured in several ways:

• Raw volume. For ambulatory practices, look at an average of how many visits per day occurred before EHR implementation (use a 1-month survey to calculate average visits per day). Then count the average visits per day 30 days after implementation, 3 months after implementation, 6 months after implementation, and 1 year after implementation. Doing so should provide a sense of dip in productivity (which is common and can last weeks to months).

• Intensity of service. Look at the total receipts deposited for a 1-month interval (or total billings, although actual deposits probably are a better measure) and divide by the total number of visits for that month. The result is the average dollars received per visit. Compare this number before and after EHR implementation (30 days, 3 months, 6 months, and 1 year).

If part of your compensation comes from achieving clinical quality measure (CQM) goals (some practices, especially primary care practices, can have as much as 25% of their income come from performance-based compensation), then the measures can be either simple, or more sophisticated:

• Look at the performance-based income (perhaps weighted by total patient volume, in case that varies) in global gross dollars before and at intervals after EHR adoption.

• If the EHR is able to measure specific CQM achievement (or if there are other CQM measurement tools outside the EHR), then use those reports to see whether quality measures are improving, deteriorating, or remaining flat after EHR implementation compared with before implementation.

Overhead

Many reports in the literature conclude that the biggest monetary advantage from EHR implementation is not so much from increasing revenues but from reducing overhead. It is important to measure these savings, because they may offset the cost of implementing and maintaining the EHR in the first place. Calculate the overall overhead before the EHR, including:

• number of employees (full-time equivalents, or FTEs) needed; multiply each by their salary rates for a monthly employee cost;

• outside services needed (such as transcription, billing, answering service);

• variable costs (costs that depend on volume), such as office and medical supplies; and

• fixed costs (such as rent, insurance premiums, etc.).

After the EHR is implemented, the number of FTEs may change. This potential is especially true in larger clinics, and the reduction mainly occurs in the form of medical records personnel. In smaller practices, these FTEs may be re-assigned to other duties newly needed as a result of the EHR (such as scanning outside documents into the EHR). Calculate the post-EHR overhead, including:

• the number of FTEs; calculate monthly cost;

• cost of installing and maintaining the EHR, including direct software costs, equipment needed, servers, and local network needed if using a locally installed system (not needed if using a Web-based system);

• outside services needed (these services may change significantly, especially if a transcription service had been used); and

• variable and fixed costs, as before.

Measure the overhead at various intervals after EHR implementation and at 1 month, 3 months, 6 months, and 12 months.

Quality of life

Quality-of-life effects of EHR use are more difficult to quantify. Healthcare professionals spend much time and effort maintaining their documentation, that is, completing their charts. This task is an uncompensated burden that is simply part of life for a practicing physician. Hours spent “catching up on charts” after the practice is closed is a familiar part of a clinician’s life.

One approach to quantifying this task would be to create a log consisting of two columns, hours and location. Each row represents a specific day. For a trial period of time (I would recommend 1 week), write down, for each day (including weekends), the hours spent completing charts after the office is closed, and where those hours were spent. Typically, in a paper-based environment, those hours were spent at the office, because you do not want to take home incomplete charts. In a post-EHR environment, those hours may be spent in part in the office and in part at home (where the EHR can be logged into remotely and the charts completed).

It might even make sense to include a third column in the log: time arrived home. That way, you can see whether you are, in fact, getting home earlier after an EHR is installed.

Conclusions

It is important to quantify the effect of an EHR on your practice. Review the effect on productivity, on overhead, and on quality of life at intervals after EHR implementation: 1 month, 3 months, 6 months, and 1 year.

Armed with your own data, you can realistically assess your EHR and answer the question, “Is it worth it?” with facts, not just gut-based conjecture.

Anatomy of a successful EHR adoption

By Rosemarie Nelson, MS

Principal consultant, MGMA Healthcare Consulting Group

How do you measure success? Some would suggest that we must determine the return on investment before we sign a vendor contract for an EHR acquisition. That task may be overwhelming considering that we don’t often understand the costs of our current operations.

Greg Spencer, MD, chief medical officer of Crystal Run Healthcare, a group practice in New York with about 200 physicians, says, “Paper costs money, too, but that feels more like a ‘normal’ expense.”

And therein lies the dilemma: What is the new normal? 

Let’s look at the story the data tell us.

Looking at the table “Orthopedic surgery, median per FTE physician, 2010 report” (numbers rounded), at first glance, we might point our fingers at the higher head count for orthopedic surgery practices using an EHR. Look further, however, and the EHR practices produce more relative value units (RVUs) and generate a higher percentage of medical revenue after operating costs than practices in the paper environment or those that are operating in a hybrid setting. 

The table “Multispecialty, not hospital-owned, median per FTE physician, 2010 report” addresses the question: Do multispecialty practices using an EHR with more support staff per FTE physician use their staff more effectively as represented by more RVUs per FTE physician? The increased production would support a higher percentage of medical revenue after operating cost, and that includes the cost of the additional support staff.

The table “Multispecialty by years EHR in practice, median per FTE physician, 2010 report” points to experienced EHR practices realizing the most significant benefits in the form of a higher percentage of medical revenue after operating costs and increased production as measured by total RVUs. The efficiencies of the EHR allow us to see more patients and provide more services, a win-win situation for the patient and the practice.

The table “Family practice, median per FTE physician, 2010 report” (again, numbers rounded) depicts family practice data that raise the question of staffing to support the provider. Do practices enter into the EHR implementation without appropriate staff to support the transition and adversely affect production?

It would appear that billing and collections operations are significantly enhanced with the use of the EHR in family practice. It is clear that a hybrid approach increases cost without supporting a better bottom line. The take-away says, “If you’re going to do it, do it all the way.”

In the table “Surgical specialty, median per FTE physician, 2010 report,” it is not surprising to find a mixed message. The EHR can improve the coding and charge capture (more RVUs) for surgical specialties, but it may be more difficult to transition the physician from a dictation model to a point-and-click-template for documentation (more support staff to scribe).

The table “Pediatrics, median per FTE physician, 2010 report” shows that practices using EHRs see similar trends as the family practice groups-fewer support staff and lower production (as measured in physician work RVUs) than those practices using paper records. EHR pediatric practices, however, produce a higher percentage of medical revenue after operating costs (lower staff head count may be a factor) and

collect it very effectively (as do the family practice EHR adopters).

Can the data help us more effectively define a successful EHR adoption? They certainly provide direction. Know your pre-EHR data points.

A 12-provider family practice group in Newport Beach, California, on implementing its EHR experienced:

• 15% average higher fee-for-service collections per visit through automated charge capture and integrated coding compliance features;

• 50% reduction in office supply expenses by eliminating chart materials, charge tickets and other preprinted forms; and

• 10% reduction in labor cost ($100,000) in first year after implementation.

Be patient with your implementation. It takes time to fully integrate a new tool into the nursing and provider workflow. The EHR will deliver a better bottom line, but not without a strong, ongoing effort at integrating the technology tool into the clinical operations.

How to tell whether your implementation was successful

By Shahid Shah

Founder and chief executive officer,
Netspective Commmunications LLC

Many initial implementations of EHRs cause at least minor or in some cases major productivity declines, and most cause physicians to be able to see fewer patients after the install than they could before the installation. That sounds counter-intuitive, especially because technology always is supposed to make things faster and easier. The “old” technology of paper records is infinitely flexible, however, and allows variations in workflow, procedures, training, and other conveniences that computer software still can’t manage.

So, reviewing productivity carefully after an EHR installation is key to ensuring no loss of clinical effectiveness and that problems in billing and receivables don’t linger.

Measuring success

In the post-2009 era of “meaningful use” (MU), it seems everyone is thinking that if you meet MU requirements and get your incentive check, you’ve achieved EHR success. Because incentive payments currently are paid based on the honor system and you won’t be tested for compliance, you should be wary of thinking of success in MU terms.

If MU payments don’t determine success, what does? Most practices that started their implementations without pre-install metrics in place and expectations set appropriately find that they don’t know when they’re done. Consider putting some productivity metrics in place before you implement your EHR and then measure the same ones afterwards. For example:

• how long it takes to pull up a patient chart;

• where you can pull up a patient chart (in office only, from home, via mobile phone/tablet);

• how long it takes to update common data elements in a chart (medications, problems, etc.),

• how long an appointment takes to schedule;

• how many patients are seen on a daily basis;

• how much data are being captured per patient visit;

• how long the patient check-in and check-out processes take;

• how much time is spent on non-essential phone calls (better handled by EHR messaging);

• how much time a physician spends on non-clinical activities,

• how much paper is completely eliminated versus simply moved to archives;

• how many faxes are sent and received; and

• many other metrics that are specific to your practice.

Chart access

Keep a close eye on chart access time. You will want to know how patient charts are indexed, found, and stored on paper compared with your EHR. The time from knowing a patient ID or name to getting into his or her chart should be less than 10 to 15 seconds (based on typing speed).

Once you have identified some simple workflow metrics, focus on questions related to disruption-generating tasks:

• How long will it take to install hardware such as computers, printers, and scanners? With a good information technology team, it shouldn’t take more than a day or two to install an entire network. Otherwise, productivity will be affected.

• How long will it take to install and maintain interfaces with other systems, such as practice management systems, external lab systems, and electronic prescribing? Can the EHR be used while interfaces are being built, or will the system be down during interfacing? If it takes longer than 30 days to do interfacing, be concerned.

• How long will it take to train a physician-user versus a clinician assistant versus the administrator and other staff? If it takes longer than an hour to train a physician, be wary. Training for clinician assistants and administrators should take fewer than 4 hours. The more automated (online) and on-demand (use outside business hours) the training is, the better.

• Are there any expected revenue disruptions? Many EHR implementations end up reducing patient volumes and throughput or cause documentation and coding errors that reduce billing effectiveness.

Computer literacy

Disruption can occur when basic computer literacy is lacking. Just as you wouldn’t buy a car for someone without driving skills, don’t bother implementing an EHR unless each user who will be involved has at least these minimum skills that you can measure before and after an implementation:

• Turn a computer, printer, and monitor on and off, and know how to reboot each.

• Type on a keyboard (at least 40 words per minute) and easily use a mouse.

• Identify and use a Macintosh or PC to control windows, dialog boxes, desktop icons, task bars, start menus, the basic file system, and standard buttons.

• Launch and use multiple simultaneous programs, especially a Web browser and word-processing software.

• Highlight, format, cut, copy, and paste text.

• Open and save files, and be able to choose a printer to print the files.

Measuring quality

Once you’ve looked at the key disruption generators, start to consider data quality and the system effects of an EHR. Look for the following specific benefits after installation, and try to quantify them:

• increase in staff productivity;

• increase of practice revenue and profit;

• reduction in costs outright or controlled cost increases;

• improved clinical decision-making;

• enhanced documentation;

• improved patient care; and

• reduced medical errors.

If you don’t like the metrics you’re receiving, be willing to disengage from your vendor and get your money back. It seems like silly advice, but if you don’t have metrics and your vendors know that you’re scared of change, then you won’t have any power. If you know what you want and you have measures to prove your requirements, then tell the vendor that unless it meets your needs, you’re going to toss the vendor.

That way, you’re always in the driver’s seat. Otherwise, you’re in the back seat as a terrified passenger.