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By Michael Amedeo, MD
Advanzed Health Care, PLC
Arlington, Va.
Primary care physician participation is critical for the success of this national effort. Whether or not the majority will play is my major concern.
As part of a two-physician internal medicine practice, Advanzed Health Care, I represent the vast majority of physicians confronted with the stimulus challenge. Approximately 70% of the nation's 230,000 physician practices are 1-2 doctor practices.
Each of these practices must spend approximately $40,000 for an EHR system, with none of the economies of scale – or IT staff – of larger practices. That's a significant expense given the typical physician's $140,000 take-home pay. Surveys consistently show that the No. 1 barrier to EHR adoption is money. While the government plans to provide financial incentives on the back-end tied to meaningful use, there is nothing to ease the burden up-front.
E-prescribing is by Far the Biggest Benefit
Unlike most small practices, I'm an IT champion. The driver for my purchase of an EHR system eight years ago was patient safety. From my perspective, e-prescribing is by far the biggest benefit. Medication errors in the outpatient setting occur much more frequently than in the inpatient setting.
For example, recently I couldn't figure out why a patient's thyroid levels were so high. She brought in a bag of pills with three different names on three different bottles, each containing the same drug. She was taking one of each. E-prescribing doesn't do much good if the doctor doesn't know all the medications the patient is on. But a good e-prescribing system can download all of her prescriptions. That means safer medicine.
If skeptics need assurance that the investment is worthwhile in terms of patient safety, quality, efficiency and revenue, they need look no further than my practice. Since implementing our EHR system in 2001, we have increased the use of preventive care treatments for chronically ill patients, boosted productivity and raised annual revenue by $40,000 each — without additional support staff.
 The number of coronary heart disease patients on lipid-lowering
prescriptions has increased from 58% to 95%
The number of hypertensive patients with well-controlled blood
pressure has increased from 45% to 84%
The number of diabetes patients undergoing the
microalbumin/creatinine test to evaluate kidney function has
increased from 4% to 85%
We can access our patients' outpatient chart from the hospital electronically, which makes rounding easier. We offer patients access to portions of their chart as well as the ability to communicate with the office via a secure portal. Initially my partner hesitated, thinking we would be inundated with e-mails. We settled on charging $75 a year, hoping to sign up people who would be serious about managing their own or a relative's health online. A steady 10% of our patients participate, all responsibly. Through the portal, we can share information and reminders about medication and preventive care.
If I Had a Request, It Would Be That Standards Be Defined Quickly
Though I'm a huge supporter of more IT in healthcare, I'm not blind to the many hurdles still ahead of us. To achieve true interoperability, we need to develop a common language. My consulting neurologist uses the same EHR system that I use, so when I send him a file, it populates the patient's record. That's not the case with other colleagues.
The bigger stumbling block, however, is privacy. A few years ago, I was on the American College of Physicians Medical Informatics Subcommittee. Early on, it became clear that as a nation we would never get to a unique patient identifier. If we could, all the problems with master patient indexes would disappear. This is an area where we greatly need to reach consensus for the benefit of all healthcare stakeholders.
Regarding certification, there are many systems out there in productive use that aren't CCHIT-certified. Assuming CCHIT will remain the certifying body, are we going to force those practices to uninstall those systems and make new investments? Until these and other questions are decided, you won't see broad adoption.
If I had one request of the government, it would be to define standards quickly. Then hopefully we'll start seeing more small practices take the leap and achieve the benefits that my patients, my partner and I have enjoyed these many years.
Michael Amedeo, MD, is part of a two-physician internal medicine practice in Arlington, Va. He has advocated for the adoption of HIT since 1994 and has maintained a paperless office since 2001. He is currently president of the medical staff of Virginia Hospital Center and is a former member of the American College of Physicians Medical Informatics Subcommittee. Dr. Amedeo regularly speaks about technology issues to industry groups and associations.
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American Medical Informatics Association (AMIA)
"The potentially transformative power of EHRs rests with the increased availability of data that we can assess in order to enhance clinical and preventive care, knowledge building, and evidence creation. The motivation lies with what the technology can and must do for the nation's health and healthcare — not with the technology itself."
Read the full comments submitted by AMIA to the National Committee on Vital and Health Statistics.
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