Hospitals' Unstoppable EHRs May Slow Their EDs

April 2010

Hospitals that rush to purchase new systems often see ED productivity fall, liability risk rise.

By Mary Ellen Schneider
Elsevier Global Medical News

LAS VEGAS -- Electronic health records often are touted as a way to save time and improve quality--but in the emergency department, the technology so far has led to losses in physician productivity and a greater risk for liability, one expert warned.

Those losses won't stop hospitals from implementing electronic health records (EHR), however, so emergency physicians need to get involved in the process to mitigate some of those problems, explained Dr. Michael Frank, J.D., general counsel and director of risk management at Emergency Medicine Physicians of Canton, Ohio.

The typical ED business model requires that physicians see 2.3-2.6 patients per hour, Dr. Frank said. But with the implementation of EHR systems, some ED groups have seen their productivity drop immediately to 1.5 patients per hour--and only rise back up to about 2 patients per hour once staff learn the new system, said Dr. Frank.

Dr. Frank said he has seen EDs work for 6 months to implement an EHR system, only to have the hospital remove the system because physician productivity and patient satisfaction both decline.

EHR systems also have the potential to increase liability, Dr. Frank said at a meeting on reimbursement sponsored by the American College of Emergency Physicians.

For example, at one hospital that had implemented an EHR, the nurses stopped having patients sign the discharge instructions because the forms would have to be scanned and then incorporated into the EHR. Instead, the nurses noted in the record that the patients had received the instructions. But that type of notation is a far less powerful legal defense than having the document signed by the patient, Dr. Frank said.

EHRs also could present a unique legal risk in the records' metadata. Unlike a paper record, an EHR leaves an electronic audit trail showing the time when a document was opened and edited, and by whom. It also shows what was deleted or edited. If used in court, that could force physicians to defend not just their final product, but the entire evaluation process, Dr. Frank said.

Even with those potential problems, emergency physicians should expect to see more and more hospitals moving aggressively to implement EHR systems in the next few years, Dr. Frank said. The reason is simple: As a result of financial incentives passed in the American Recovery and Reinvestment Act of 2009, hospitals are eligible for billions of dollars in Medicare and Medicaid incentives for the successful implementation of EHRs.

The Recovery Act includes $19 billion in incentive payments for hospitals and physicians. Because of the way the incentives are structured, individual hospitals could qualify for millions of dollars in payments. "This is what the hospitals are paying attention to," Dr. Frank said. "You really can't blame them. This is a huge amount of money, and they're not about to ignore this."

The other factor driving hospitals toward EHR systems so quickly is that the incentives phase in over time, with more money going to hospitals that implement earlier. Incentives aren't the only thing set to phase in; by 2015, penalties will be levied against hospitals that haven't implemented an approved EHR system.

What hospitals are missing in their rush to purchase systems are the actual costs of lost physician productivity and of potentially increased liability, Dr. Frank said.

Rather than simply complaining about the prospect of an EHR implementation, emergency physicians need to get involved, Dr. Frank said.

Emergency physicians should work with the hospital on the selection of a system and the requirements for the vendor. The ED group also can negotiate with the hospital to share the savings they may realize from an EHR implementation.

For example, having an EHR usually means the hospital can drop its transcription services. The ED group may be able to get a share of the transcription savings to offset its own losses from lower physician productivity. Similarly, ED groups might be able to get hospitals to agree to share some of the Recovery Act incentives they receive, Dr. Frank said.
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