Who can afford this??

Replies to This Discussion

Permalink Reply by Mary J Wilkinson on October 8, 2009 at 5:41pm

So IF the stimulus comes, this will offset the cost.
After listening to the same breakout session, I went home and looked at the costs of our system.
Even if the stimulus offsets the install, there is an ongoing maintenance cost for upgrades, etc.
My sense was the physicians who presented at the breakout session were from groups who required the robust systems that can support both radiation oncology and medical oncology .
Smaller groups may have other less expensive options:
1. Web based subscription EHR.
2. A less expensive generic product that is geared to primary physicians that can be customized, adding on an oncology chemo program -- such as intellidose or smart ID works.

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Permalink Reply by Robert S. Miller, MD on October 8, 2009 at 11:56pm

It's not new information to anyone reading this that small and even moderate-sized medical oncology practices are highly endangered species. So it will be very tough for the smaller non-diversified practices to have the adequate capital at their disposal to pony up anything near 100K. We saw many good products this week although IMHO virtually all had some gaping holes. While personally I am an evangelist and think that all practices need to make the dive sooner rather than later and that we simply must do away with unsafe and inefficient tools like paper records, practices are in such a tough spot since at some level the decision will be to put all of the eggs in one vendors' basket. I think we will get there some day, but think how much easier this would be if the EHR landscape were mature and defined by standards and products created by some type of authoritative clinical and technical source, not by dozens of companies whose primary goal is sales. While I do respect our vendor colleagues and believe they are trying to do the right thing most of the time, I continue to harbor this fantasy that open source really will work, and that we could devote our energies not to picking the winner but in making the "winner" product that we already were using (because it is a standard tool and accessible to everyone) better, more effective, safer, etc. Ah, I must still be dozing on the flight back home...

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Permalink Reply by Jonathan B Blitzer on October 9, 2009 at 3:19pm

I suspect that 110k is the "all up" cost, including software and hardware acquisition, employee training, etc. There are of course ongoing costs associated with EMR, but the most important is loss of productivity. At the most recent EMR presentation we attended, the PROPONENTS of adoption said that most MD's experienced a loss of productivity of 20-30%, and that many of these MDs NEVER made it up. Think of it...20% cut in productivity cannot EVER be recompensed by a temporary increase in Medicare reimbursement that may never appear.
The fault is in the EMRs themselves, which are balky and complicated, and result in robotic, repetitive notes devoid of human input and completely opaque as to what's really going on in the exam room. That's just fine with the designers, since what the EMR is REALLY for is to justify billing, coding, and reimbursement.
I expect this technology will continuously improve, as anyone who has owned an automobile, cellphone, or personal computer can attest. But right now early adopters will be punished for their foresight by productivity penalties no one cares to pay for.

Robert S. Miller, MD said:

It's not new information to anyone reading this that small and even moderate-sized medical oncology practices are highly endangered species. So it will be very tough for the smaller non-diversified practices to have the adequate capital at their disposal to pony up anything near 100K. We saw many good products this week although IMHO virtually all had some gaping holes. While personally I am an evangelist and think that all practices need to make the dive sooner rather than later and that we simply must do away with unsafe and inefficient tools like paper records, practices are in such a tough spot since at some level the decision will be to put all of the eggs in one vendors' basket. I think we will get there some day, but think how much easier this would be if the EHR landscape were mature and defined by standards and products created by some type of authoritative clinical and technical source, not by dozens of companies whose primary goal is sales. While I do respect our vendor colleagues and believe they are trying to do the right thing most of the time, I continue to harbor this fantasy that open source really will work, and that we could devote our energies not to picking the winner but in making the "winner" product that we already were using (because it is a standard tool and accessible to everyone) better, more effective, safer, etc. Ah, I must still be dozing on the flight back home...

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Permalink Reply by John Cox on October 9, 2009 at 5:07pm

Jonathan.....I agree that the large number of over 100K is an ‘all up’ cost…. Though I don’t know if the presenters factored in the lost ‘opportunity’ cost you outline. I know that with our implementation our practice suffered a significant hit… we had to slow down for greater than a month until the practice acclimatized to the new world of EHR. Though two years later we have recovered, and now can see routine practice loads… you never get the time back. I do think that many overlook the ‘cost’ of lost opportunity in their calculation of the impact of this decision. I agree with you that the cause of this is in large part the clunkiness of the EHR products…. Even the best of them. The other cause is the lack of standards that would help you and me shift from one environment to another ala getting into an automobile……..

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Permalink Reply by John Cox on October 9, 2009 at 5:08pm

Bob your reflection on a ‘mature’ and standard driven market is so true. Look at the cell phone market 10 years ago cf. to today… And even more so in Europe where (it is my understanding) the standards have made the availability of phones that can switch between providers more easily than here due to standards……

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Permalink Reply by Jonathan B Blitzer on October 14, 2009 at 12:21pm

Another question that should be asked is whether $44,000 is sufficient payment for the right of the government to dip its straw into your data pool, mine the data, punish or reward you for its quality, etc. It is likely that what we are seeing is the nose of the camel in the tent of private practice. One could argue that this was why the AMA opposed Medicare in the '40's and onward. I am not a reactionary, small government type, and I support a role for the government in reforming, and paying for, healthcare. But the latest round of reimbursement games leads me to suspect that whatever Medicare gives, in subsidy for EHR adoption, it will take away in payment cuts or just plain irritation, doing nothing to catch or punish real offenders, and saddling the rest of us with what used to be called paperwork (mousework?)...

John Cox said:

Jonathan.....I agree that the large number of over 100K is an ‘all up’ cost…. Though I don’t know if the presenters factored in the lost ‘opportunity’ cost you outline. I know that with our implementation our practice suffered a significant hit… we had to slow down for greater than a month until the practice acclimatized to the new world of EHR. Though two years later we have recovered, and now can see routine practice loads… you never get the time back. I do think that many overlook the ‘cost’ of lost opportunity in their calculation of the impact of this decision. I agree with you that the cause of this is in large part the clunkiness of the EHR products…. Even the best of them. The other cause is the lack of standards that would help you and me shift from one environment to another ala getting into an automobile……..

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Permalink Reply by Douglas Blayney, M.D. on October 15, 2009 at 6:45am

In recent news....

Our infusion center, which does about 45,000 infusion visits per year, was just approved to implement a vendor EMR, (about which I have commented on the inpatient hospital elsewhere here and here) which includes CPOE (computerized physician order entry), eMAR (electronic medical administration record) for the infusion nurses and pharmacists, and a nursing flow sheet (which allows our infusion nurses, to document in real-time, the medications administered). As the project was pitched to our hospital managment as a safety enhancement measure (we track chemotherapy errors and "near misses" pretty closely, though there is admittedly reporting bias) we were specifically prohibited from including physician documentation tools in our project. (There are however, likely to be some workflow and efficiency enhancements, in addition to the safety enhancements.)

In regards to the expense per physician, we have about 160 medical school faculty physicians, who have between one and five half day sessions per week in the outpatient clinic. As nearly as we can tell, this represents ~ 35 physician FTE (assuming an oncologist FTE has six half day sessions). The total projected budget -- including software acquistion, training of our nurses and pharacists, configuration, and a small amount of time for physician "gatekeepers" to approve the order sets as they are translated from our paper-based standard orders to computer orders. We already have the hardware, so the hardware acquisition cost is minimal.

So a back of the envelope calculation comes in the ball park calculation, comes to $88,571 per physician, as an "all in" direct and indirect cost. Gulp.

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