American Academy of Neurology Forms Workgroup to Evaluate EHRs for Neurologists

The push for Electronic Health Records (EHRs) has suddenly reached the tipping point. Although it is estimated that only 10% of physicians currently use an EHR, forces calling for universal use of and EHR are mounting. Healthcare costs are one driving force. Healthcare costs have risen to 16% of the GNP and continue to grow faster than GNP. Both government payors (Medicare and Medicaid) and private payor (large and small businesses) are alarmed by the growth of healthcare costs. EHRs are seen as a tool that will help rein in rising healthcare costs.

A second factor has been medical errors. Although the true numbers of medical errors is unknown, the Institute of Medicine and other organizations including the Leapfrog Group have called for universal use of EHRs to prevent medical errors and improve the quality of healthcare.

A third factor has been the role of EHRs in improving practice efficiency. Physicians in general, and neurologists in particular, are looking at EHRs as a way of improving practice efficiency by speeding the flow of information, streamlining the office of workflow of scheduling, communicating, prescribing, and billing. Installing an EHR is an expensive proposition, estimated at $20,000 to $35,000 per physician over a 3 year period. The jury is still out as to whether EHRs will offer neurologists a positive return on investment (ROI) on this major investment.

A fourth factor is the need for neurologist to use EHRs to generate the necessary data for P4P and quality reporting programs.

What Does the Future Hold?

Although it is always hazardous to predict the future, neurologists need to be aware of emerging trends in health information technology that are likely to affect the way we practice.

1. Pay For Performance (P4P) is emerging a strategy used by both government and private payors as a way to improve quality and reduce costs. In the future, physicians may get paid based on quality data aggregated from their EHRs.
2. Quality Reporting is gaining momentum. Government payors (Medicare and Medicaid) are likely to require that quality data be reported and this quality data will likely be plugged into programs that direct patients to high quality providers. Quality data may be derived directly from EHRs and feed into P4P programs (see above).
3. EHRs will become universal. Although the timeline is uncertain, it clear that government payors as well as many large employers are committed to universsal implementation of EHRs as a means of increasing healthcare quality and containing costs.
4. ePrescribing (eRx) is gaining traction. Surescripts (www.surescripts.com) (a pharmacy-owned data network) allows two-way real-time communication between pharmacies and physician offices. Increasingly prescriptions will become an electronic transaction.
5. Decision Support (the use of evidence—based medicine to create embedded rules that guide medical decision making) will become an essential part of patient care.
6. NHIN. Providers will be able to exchange health care data through The National Health Information Network (NHIN).
7. Standards. Standards for health information exchange and transmission such as HL7, SNOMED, CCR, and CDA will dominate patient data exchange between healthcare providers.

Who Will Pay for It?

EHRs are likely to cost $25,000 to $35,000 per physician over a 3-year period.

• HHS? Current signals are that the government will not fund the purchase of EHRs by physicians.
• Physicians? To date, physicians have borne the brunt of the expense of purchase of EHRs.
• Hospitals or Insurers? Relaxation of the Stark and Anti-Kickback rules by HHS may make it possible for Hospitals and Insurers to underwrite up to 85% of the cost of EHRs or eRx. The verdict is not in yet. Watch this trend carefully.

The American Academy of Neurology (AAN) EHR Workgroup Between August 2005 and August 2006, the Electronic Health Records Workgroup met regularly through Conference Calls and Webex Conferences to evaluate the current Electronic Health Record market in order to provide advice and direction to AAN members. The target audience for the EHR Workgroup was smaller ambulatory-based neurology practices with 1 to 10 physicians. Specifically, the EHR Workgroup did not look at EHR products designed for inpatient (hospital-based practices) and did not look at products designed for larger multispeciality group practices with 50 or more physicians. The workgroup was led by Orly Avitzur MD MBA and staffed by Amanda Becker of the AAN. The workgroup was assisted by Mark Anderson of the AC Group.

The Work Product The final work product identifies 7 vendors who sell EHRs. Based on an extensive review of the products by the EHR Workgroup, these vendor products have been selected as appropriate for implementation in smaller neurology practices. The workgroup offered no definitive ranking among these 7 vendors. They differ in price, features, ease of use, and “look and feel”. Neurology practices considering the purchase may wish to look at these 7 vendors closely.

1. eClinicalWorks (www.eclinicalworks.com)
2. e-MDs( www.e-mds.com)
3. Greenway Medical (www.greenwaymedical.com)
4. Medical Communication Systems (MCS) (www.medcomsys.com)
5. Misys (www.misyshealthcare.com)
6. NextGen Healthcare Information Systems, Inc. (www.nextgen.com)
7. Practice Partner (www.pmsi.com)

The complete report is available for download at www.aan.com/professionals/patient/ehr.cfm. All vendors are certified ambulatory EMR products by the CCHIT (Certification Commission on Health Information Technology).

Criteria for Validation of the EHRs

EHRs were evaluated along the following dimensions:

1. EHR Functionality: Did the EHR provide the needed functionality to support a typical ambulatory neurology practice?
2. End-user Satisfaction: How satisfied are end-users in general with the EHR? Are neurology practices using the EHR satisfied?
3. Company financial viability: Is the company viable financially?
4. Client Base: How large is the base of users? Are neurologists using the EHR?
5. Technology: Does the EHR support the latest hardware and software technologies?
6. Price: What is the total cost of ownership?

Workgroup Methodology

The Workgroup was assisted by AC Consulting during the review process. The Workgroup methodology included the following steps:

1. Established critical functionality needed by neurologists in an ambulatory EHR based on a polling process
2. Ranked 75 EHR products according to needed by neurologists using the AC database
3. Selected 8 EHR products for more detailed review by the Workgroup
4. Created a sample neurology note for a documentation demonstration by each vendor during a 1-hour Webex conference.
5. Created a sample neurology note for a live documentation demonstration in front of the entire Workgroup at the 2006 AAN Annual Meeting. During the documentation challenge vendors were asked to demonstrate the problem list, the medication list, documentation of the encounter, prescribing, CPT coding, and letter generation.
6. Invited all EHR vendors to display their EHR at the Vendor Exhibits at the 2006 AAN Meeting
7. Contacted at least 2 Neurology practices using each Vendor’s EHR for a reference check

Price

An important consideration for all purchases is cost. Cost is best expressed as Total Cost of Ownership (TCO) over a 3-year period. Generally, costs are expected to be $25,000 to $35,000 per physician spread over three years. Vendors will quote software acquisition costs that include implementation and training. In general, there will be an additional annual software maintenance fee to cover software updates and troubleshooting. Network costs, workstation costs, server costs are extra

The EHR Workgroup did not establish firm prices on any EHRs. Prices always depend upon vendor-physician negotiations and discounts can often be negotiated from “list” prices. However, some EHR systems have established their pricing at the upper end of the 3-year price range per physician ($35,000) whereas other EHR systems are closer to the lower end ($25,000 per physician). Data consolidated by AC Group.

Workgroup Ratings of 7 EHR Vendors After Demonstration, Analysis of Functionality, and Reference Calls

The EHR Workgroup established several omnibus ratings of the EHRs. The AAN Omnibus Rating was a composite rating generated by the AC Group based on Functionality, Price, Perceived Value, Company Viability, Sophistication of Technology, Installed Customer Base, and End User Satisfaction. All vendors were felt to have capable products worthy of consideration and the AAN makes no attempt to distinguish between these 7 vendors.

Selection Considerations for Neurologists Looking at Purchase of an EHR

Prescribing

Electronic prescribing (eRx) is inevitable. The EHR should support eRx and be positioned to electronically transmit prescriptions across one of the standard eRx networks (Surescripts or RxHub). A two-way interface is needed so that prescriptions can be transmitted to pharmacies and pharmacies can transmit refill requests back to physician offices.

Documentation and Progress Note

For most neurologists, documentation of the visit will be the most time consuming task other than taking the history and doing the examination. Dictation is time-efficient for the neurologist but incurs costs and does not create discrete EHR data suitable for decision support or data reporting. A positive ROI is difficult to obtain if a practice selects dictation as the means of creating clinical notes. Typing is laborious and time consuming. Advanced EHRs provide editable templates that speed documentation using “pick” lists and other techniques to speed documentation and to help create discrete data. EHRs with strong documentation support and advanced features can speed documentation and help neurologists use the EHR effectively. Neurologists should look closely at documentation features in each EHR that they evaluate for adoption.

Medication Lists

Easy to maintain medication lists are critical to good care. These medication lists should be linked to the ePrescribing module and use decision support to identify dangerous drug-drug and drug-diagnosis interactions.

Navigation

The EHR should be logically organized and allow efficient and intuitive pathways for navigation. Navigation should reflect the actual workflow of the physician.

Problem Lists

An easy to maintain problem list is critical to good patient care. It should support accurate ICD-9 (or successor coding systems) that can be passed easily to the Billing Module.

Reporting Functions

Some EHRs have sophisticated reporting functions (e.g. How many patients in my practice have epilepsy and take the drug topiramate? How many patients in my practice have MS and take an interferon?). Other EHRs lack these reporting functions. With the growth of Quality Reporting and P4P, the importance of these reporting functions will grow.

Knowledge-Based Features

Knowledge-based features include decision support, practice guidelines, disease management, patient education, formulary management and other sophisticated knowledge-based features based on evidence-based medicine. Currently, most EHRs have only rudimentary capabilities. However, knowledge-based features will grow in importance over the next 10 years as P4P gains hold. Neurologists will want to look for EHR vendors with a vision of adding knowledge management to their EHR.

Importation of Documents and Lab Data

EHRs vary in their ability to import lab data (e.g. anticonvulsant levels from outside reference labs) and documents (radiology reports, physician letters). In some practices importation of lab data, radiology results, and outside documents may be critical.

Billing

Although some EHR products are entirely stand-alone, integration with practice management (billing and scheduling) is desirable for most practices. Information can move seamlessly from the EHR to the billing module. Patient demographics can be shared between billing, scheduling, and the EHR. Advanced EHRs have automated CPT coding wizards, which generate appropriate CPT codes based on the level of documentation. Billing diagnoses on the patient’s problem list can be passed as ICD-9 codes to the billing modules. The CPT coding wizard should support the single-exam CPT coding methodology used by neurologists.

Scheduling

Most buyers will want and EHR that offers integrated scheduling. By integrating the scheduler with the EHR, the neurologist will be presented with a “pick” list of patients scheduled to be seen that day. This “pick” list enhances patient flow and speeds work flow.

Workflow

Every practice has a rhythm and flow. The EHR should enhance that workflow by integrating the functions of scheduling patients, logging them in, getting vital signs, documenting the visit, prescribing medications, ordering tests, educating patients, giving discharge appointments, CPT coding, ICD-9 coding, maintenance of drug lists, maintenance of problem lists, billing patients, communicating with other physicians, and issuing return appointments. Buyers of EHRs need to determine how well each EHR will support and enhance their workflow.

Communicating and Messaging

EHRs need to support both internal messaging (physician to clerical, clerical to physician) as well as external communication including physician-to-physician correspondence.

“Look and Feel”

Look and Feel varies considerably by vendor. Look and Feel may be important in determing how pleasurable and easy the EHR is to use. Since Look and Feel may be highly personal, the EHR Workgroup did not rate EHRs on this important dimension. Potential buyers are encouraged to spend time with each EHR they are contemplating to buy and assure themselves that they like the “Look and Feel” of the system.

Stark Law Changes

HHS has recently relaxed anti-kickback and Stark Law regulations that prohibited hospital and insurance companies from subsidizing the purchase of HIT (EHRs and eRx) by physicians. Relaxation of these rules may mean that physicians may have opportunities to have up to 85% of the purchase cost to be subsidized by an insurance or hospital partner. Physicians contemplating purchase of an EHR need to watch these changes closely.

Installation and Training

The installation and training process is critical to the success of new EHR implementations. Before contracting with a vendor, neurologists need to understand fully how the vendor will implement, train, and maintain the software. Some companies use onsite trainers and technical support staff whereas other use remote access methodologies over the Internet or a mix of the two,

Vendor Financial Viability

Determination of the financial viability of the vendor is a critical part of the selection process. Unfortunately, detailed company financial information is difficult to obtain. Two good surrogate markers for financial viability are years in business and number of customers (active sites). Some of the vendors have a large installed base than others. Some of the vendors are more likely to sell to small practices . Although the CCHIT certification process is just beginning, EHR vendors unable to either obtain or afford EHR certification may pose long-term risks for viability.

Other Evaluations of EHRs

A number of organizations provide evaluations of EHRs:

• CCHIT. CCHIT (Certification Commission on Health Information Technology) is a government-funded commission with paid jurors that evaluate EHRs according to a published test script (www.cchit.org). Currently, only ambulatory EHRs have been evaluated in the first round of CCHIT. CCHIT certification is not specialty-specific and provides a minimum standard of EHR functionality and data interoperability. All of the 7 products evaluated by the EHR workgroup are certified by CCHIT.
• TEPR. he annual TEPR Awards (Toward and Electronic Patient Record) are awarded at the annual meeting of the Medical Records Institute (an independent organization promoting electronic health records) based on a judged live electronic demonstration of the EHR (www.medrecinst.com). 3 of the 7 vendors won awards for ambulatory EHR at the May 22, 2006 meeting.
• KLAS. KLAS Online (www.healthcomputing.com) is a privately held company that collects end-user and institutional evaluations of health information technology. Evaluations are dependent on end-user feedback. KLAS ratings can be used as a gauge of end-user satisfaction. KLAS does no independent testing of EHRs such as done by CCHIT or TEPR.