Physicians, Techies & Policymakers Try to Close the Primary Care IT Gap

Can health information technology really deliver on its promise of lowered healthcare costs, faster revenue return, fewer medical errors and improved communications between doctors and patients?

The answer is an emphatic yes, according to some holistically-minded physicians who’ve taken the IT plunge. While it is still a daunting task to convert an established practice from paper-based systems to electronic management, billing and record-keeping, the process is getting easier, and less expensive. In some areas, local hospitals are offering financial assistance for solo and small-group practitioners interested in digitizing their offices.

While nearly all of the nation’s hospitals and fully half of all groups with 50 or more doctors have electronic medical record (EMR) systems, fewer than 10% of all solo physicians’ offices and small clinics are EMR-enabled, according to a federal government survey of more than 2,600 physicians, published in the New England Journal of Medicine in July (DesRoches CM, et al. N Engl J Med. 2008 Jul 3; 359(1): 50–60).

According to the survey, physicians who’ve overcome the financial, logistical and time demands of installing IT systems and converting their paper records see overwhelmingly positive impact: 82% reported improvements in clinical decision-making; 86% saw reduced medication errors; and 85% said EMRs improved their ability to provide preventative care.

Health policy experts believe widespread use of EMRs is essential for improving health care at large, an idea with considerable traction in Washington, DC. Earlier this summer, Medicare announced a $150 million project offering doctors in 12 cities up to $58,000 over the next five years to implement EMR systems. The program attempts to address the some of the fiscal hurdles that deter more doctors from jumping into healthcare IT.

Some insurers and employer groups are making EMR adoption and electronic billing a non-negotiable criterion for “medical home” designation, in an effort to incentivize primary care physicians to go digital.

Hospitals Extend a Helping Hand

Local hospitals can be valuable allies for IT-hungry primary care dotors in some communities. Many hospital systems have significant and largely untapped financial resources for community-based EMR expansion. These hospitals also have purchasing muscle and tech support undreamed of in most private practices.

Under current Stark regulations, hospitals are permitted to pay up to 85% of EMR software costs for community-based physicians in their cachement areas. And since hospitals have a lot of bargaining clout with vendors, they can usually get 10%–15% off on hardware, as well.

Todd Rothenhaus, MD, chief medical information officer for Caritas Christi Healthcare Systems, a 6-hospital network in Eastern Massachusetts, urged doctors to call the business development and community outreach offices at their area hospitals. “You may be pleasantly surprised at the resources available.”

Speaking at the 4th annual World Health Care Congress, Dr. Rothenhaus said hospital systems like Caritas Christi are interested in helping local doctors overcome IT roadblocks in the hope that this will engender goodwill leading to increased patient referrals. He stressed, however, that physicians are under no binding obligation to refer to hospitals that provide IT support.

He gave the example of a two-physician, one-nurse primary care practice that, with Caritas Christi’s help, converted from paper to EMR. On their own, the doctors would have spent roughly $28,000 for hardware, $25,000 for software, $1,500 for training, $4,500 per year for software maintenance and $2,400 for a software support contract, for a total of about $61,000 in the first year.

With the hospital’s help, hardware costs came down to $25,000, the software was only $3375, the training dropped to $1200, the maintenance contract was just $810, and the support costs went down to $2160, for a final cost of just over $42,500. That’s still a lot of money, but far less than the practice would have spent on its own.

Many Happy Returns (On Investment)

The potential financial returns on EMR and digital management systems are substantial. According to Charles Parker, Vice President and Chief Technology Officer for Masspro, a healthcare performance improvement group founded by the Massachusetts Medical Society, 99% of clinics see return-on-investment in EMR within 2 years. In some cases, the ROI comes within 90 days.

Mr. Parker, who also spoke at the World Health Care Congress, said the big savings come from reduced need for transcription services, more rapid claims processing (for those who take Medicare and/or insurance) and fewer days in accounts-receivable. In EMR-enabled practices, staffers spend less time tracking down lost records or missing bits of patient information.

Grace Keenan, MD, founder and medical director of the NOVA Medical Group, a 4-site integrative health care group near Washington, DC, said she will have spent close to $900,000 on a total digital overhaul of her clinical operations, which include comprehensive primary care, naturopathic services, a medical spa facility, nutrition counseling and a fitness center. But she expects that investment to pay off, big time.

“We should see a return of $1.4 million after one year. We’re looking at major reduction in salaries for billing staff, marked reductions in paperwork, reductions in lost time, and improvements in quality of care and patient service.” She added that NOVA spends an average of more than $75,000 just on manila chart folders, and many thousands on photocopier paper and forms for printing bills. Her new system all but eliminates those costs.

Overcoming Mistrust

Cost and the difficulty of converting records are not the only reason physicians have been slow to embrace health care IT. “Doctors have been treated very badly by the insurance and government systems, and many view EMRs as a noose laid by insurance companies and the Fed. There is a lot of distrust,” says Louis Cornacchia, MD, a neurosurgeon in Garden City, NY, who is also the founder of Doctations, one of a handful of EMR/IT companies developed by and for physicians (

Dr. Cornacchia told Holistic Primary Care that many existing EMR systems were designed by IT specialists in conjunction with actuarial people who do not really understand patient care and have more interest in facilitating insurance transactions than in restoring doctor-patient communications. “One of the big problems has been that EMR vendors and EMR advocates tend to see physicians as part of the problem in health care. There’s a lot of animosity in that relationship.”

He and several physician friends founded Doctations in 2005, with the goal of developing a health IT system that truly serves doctors and patients, and utilizes the internet’s inherent interconnectivity to re-build the physician-patient relationship. Over the past 3 years, they’ve spent $3.5 million of their own money to develop the Doctations system, a comprehensive electronic practice management suite including EMR, e-prescribing, visit scheduling, and patient education components. The Doctations system is linked with a patient-friendly system called iMedicalHome.

Doctations is currently being beta-tested by 30 physicians in 9 different specialties. Dr. Cornacchia is planning for a full national roll-out in 2009. “The idea is to grow it organically. If you try to do it any other way, you run the risk of damaging physicians and patients. You cannot force it on people.”

Billing Builds the Bridge

If relatively few primary care doctors have EMRs, a far greater number have at least some sort of electronic billing system. David Rosenblum, chief executive officer of Medical Transcription and Billing Company (MTBC), believes that electronic billing is the bridge that will enable more doctors to fully digitize their practices.

To this end, his company—a leader in billing, collections, and health information management, has built a full scale EMR software system that is available at no additional cost to physicians using the company’s billing and collections services.

MTBC ( was founded in the late 1990s, by Mahmud Haq, a former American Express executive whose wife is a physician. After watching his wife wrangle with insurers and the complexities of coding, Mr. Haq decided to take on the challenge of developing systems to help doctors reduce their hassle-factor and increase their fee collections.

The company provides billing collection services at very low cost to doctors, charging just 4% where most collections companies charge between 10%–12%. MTBC is also the first to introduce software-enabling doctors’ offices to interface with the Real Time Adjudication systems established by several major insurers.

“The carriers created these Real Time Adjudication mechanisms, that can provide immediate adjudication of a claim and much faster payment. But nobody was using them because they were very difficult to use,” said Mr. Rosenblum. “It has taken us months to develop a system that automates this and makes RTA accessible to practicing physicians.”

Keeping the ‘Puter in Its Place

Health IT holds great promise to improve care and streamline the business of medicine. But it can also intrude and interfere with day-to-day practice if it is not designed and implemented properly.

Elson Haas, MD, founder of the Preventive Medicine Center of Marin, a comprehensive holistic center, said that he has mixed feelings about digital technology in the clinic. He recently spent between $30,000 and $40,000 for a new electronic billing system, a necessity since his clinic does take insurance. But he has stopped short of embracing EMRs.

“Aside from the fact that it is daunting to even think about digitizing our thousands of patient records, I’m also concerned about the intrusion of electronics into the patient encounter. If we have to enter patient information into a computer, then we have to divide our attention even more than with written charts. We’ll end up looking at the screen more than the patient,” Dr. Haas said in an interview. “There’s that element of digital detatchment. We all have so many electronics around us all the time. I’m not sure I want it in my exam rooms.”

Dr. Haas acknowledged that EMRs have tremendous value in terms of ensuring that medical information is portable, easily updated, and accessible to patients and other doctors, a set of goals he strongly supports—even with a paper-based system. “For every test that I do, one copy of the results goes directly to the patient for them to keep in their files. We want to minimize redundant testing, and we encourage patients to keep all their health information.”

If you do bring an EMR system into your exam rooms, make sure you practice until you are skilled in using it. You do not want to waste valuable patient time searching for drop-down menus, retyping info you neglected to save, or fumbling around on your keypad with a befuddled look on your face. Patients’ expectations of competence extend to your use of your computer. Make sure your IT will facilitate, not hinder your work with patients.

The February 2008 edition of Physicians Practice contained an excellent article called, “Making EMRs Work in the Exam Room,” that offers many tips for easing EMRs into your daily practice.

Among them: Set up the computer so your patients can see the screen, thus engaging them in the process; Try to maintain a sightline with the patient and minimize the amount of time you look away; Explain to patients how they will benefit from your new EMR system (reduced medical errors, information portability, fewer redundant tests, etc.); Make maximal use of your system’s ability to generate patient-friendly information for handouts and visit summaries.

Patients—especially younger ones—like to see that their physicians are on top of current technology, but not if the gadgets become an obstruction to communication. You need to make up for any digital disengagement by extremely attentive listening when you are engaged with the patient.

The pros and cons of EMRs in holistic practice is among the topics to be explored at Holistic Primary Care’s upcoming “Heal Thy Practice: Transforming Primary Care” conference at the Westin La Paloma, Tucson, AZ on Oct. 31–Nov. 2. Drs. Grace Keenan and Elson Haas, interviewed for this article, are among the faculty.


Subscribe to Holistic Primary Care