RESEARCH
The Impact of Electronic Medical Record Implementation on the Outpatient Volumes of a Midsize Academic Center Karishma G. Reddy, BS, and Jack C. Yu, MD, DMD, MS Ed Background: Despite the proposed clinical advantages of electronic medical records (EMRs), many questions remain regarding how EMRs may limit the number of patients a provider can see on a day-to-day basis. In this study, we measured the impact of EMR implementation on outpatient volumes in the setting of a midsize academic medical center (AMC) in the southeast. Methods: The AMC outpatient visit volumes of two 12-month periods, one before and one after the EMR implementation, were collected. The mean monthly outpatient visits before and after EMR implementation were compared using the 2-tailed Student t test without assumption for equal variance. We also normalized the total annual visits to the number of full-time equivalent physicians. Power calculation was performed to measure type II error whenever P value was greater than 0.05. Results: There was an 8.37% increase in total outpatient visits after EMR implementation, with the monthly number of patients seen increasing from a mean (SD) of 25,763.75 (1673.96) to 27,919.92 (2229.07) (P = 0.018). However, this increase disappears when normalized to full-time equivalent. After conducting multiple subunit analyses of a multiphysician primary care clinic (Family Medicine), specialty clinic (Plastic Surgery), and single-physician specialty clinic (Pediatric Plastic Surgery), we also did not find a statistically significant difference in outpatient clinic volumes after EMR implementation. Conclusions: Despite the burdensome time requirements many physicians subjectively attribute to EMRs, this study shows that the EMR has not really caused a statistically significant decrease in outpatient volumes in the setting of a midsize AMC. Key Words: electronic medical records, implementation, outpatient volumes, health information technology, academic medical center (Ann Plast Surg 2014;73: 330Y332)
T
he implementation of electronic medical records (EMRs) into the US health care system has been long and arduous. Although EMR implementation promises many benefits including better coordination of care between providers and improved patient safety, many physicians were reluctant to make the change from paper charts to EMRs.1 With a number of unknowns including the impacts on patient-physician interactions and substantial upfront financial cost, physicians had endless reasons to hesitate in the EMR transition.2 To encourage the use of health information technology by health care providers, the Congress passed the Health Information Technology for Economic and Clinical Health Act as a part of the American Recovery and Reinvestment Act of 2009. With the hopes of improving the quality and efficiency of health care, the Congress provided physicians with significant financial incentives to adopt and practice meaningful Received April 1, 2014, and accepted for publication, after revision, June 6, 2014. From the Division of Plastic Surgery, Medical College of Georgia, Georgia Regents University, Augusta, GA. Conflicts of interest and sources of funding: None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article. No funding sources were provided for this study. The authors have no financial conflicts to disclose. Reprints: Karishma G. Reddy, BS, 1828 Hampton Ave, Augusta, GA 30904. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0330 DOI: 10.1097/SAP.0000000000000314
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use of EMRs.3 Through the Medicare and Medicaid electronic health record Incentive Programs, providers who implement and demonstrate meaningful use of EMR technology can be eligible to receive payments of up to $44,000 through Medicare and $63,750 through Medicaid during the ensuing 4 to 6 years. Furthermore, providers who choose to not implement EMRs will begin to face penalties via reductions in reimbursements for their services starting 2015.4 Considering the financial implications of this legislation, it is obvious why there has been a dramatic increase in the number of hospitals implementing EMRs. From 2008 to 2013, the percentage of eligible hospitals that were able to demonstrate meaningful use of EMRs has jumped from a feeble 8% to 80%, according to the most recent data provided by the Department of Health and Human Services.5 As EMR implementation continues to become a staple of health care in the United States, it is increasingly important to understand the actual effects EMRs will have upon providers and health care institutions. Various clinical studies have demonstrated the beneficial changes EMRs bring to health care, including greater observance of protocol-based care, superior clinical monitoring and surveillance, as well as fewer medication errors.6 However, there are negative consequences to EMRs as well, including an alteration in the interactions between physicians and patients as well as a perceived decrease in time efficiency.7 Although many studies have investigated the expected positive and negative consequences of EMRs on patient care, there is still much to be discovered regarding the effects EMRs have on the patient volumes of a medical center. Although past studies demonstrated that EMRs did not independently affect patient flow, these studies were focused only on certain departments and were not ref lective of the hospital clinical volumes as a whole.8 In addition, many of the past studies investigating the impacts of EMRs on clinical volumes used self-reported, subjective data gathered from physician surveys regarding how they felt EMRs had affected their own practices.9,10 No study to date has objectively evaluated how the patient volumes of outpatient clinics have changed after the implementation of EMRs at a midsize academic institution. Although cost-benefit studies of the past predicted that EMRs could result in positive financial returns, it is now possible to more directly measure these effects because of the increased availability of retrospective data from institutions now using EMRs.11 By better understanding patient volumes before and after EMR implementation, other institutions can stand to gain more knowledge of the financial impacts of EMRs and perhaps also devise better strategies to facilitate a more efficient transition. Although the immediate financial incentives are strong, there remains a need for a better understanding of the long-term constraints EMRs may pose on the amount of patients seen at an institution. Even with the incentive payments offered to providers, can EMR implementations offset the negative impacts due to their implementation? Has the EMR system essentially limited the number of patients a provider can see on a day-to-day basis? The answers to these questions illustrate important implications for those who have already made the transition and may also aid undecided institutions in determining whether to implement EMRs. In contrast to the evaluations of EMRs that are based upon subjective experiences and opinions of physicians, we hope to provide a more quantitative assessment of how EMR implementation has affected the number of patients a physician can see. More specifically, the objective of this study was Annals of Plastic Surgery
&
Volume 73, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Number 3, September 2014
to document the impact of EMRs on the outpatient visit volumes of a midsized academic medical center (AMC) using multiple different clinical settings.
MATERIALS AND METHODS There are 80 specialty clinics with approximately 370,000 outpatient visits occurring annually in our AMC. On June 28, 2011, after 6 months of intensive preparations, all outpatient clinics transitioned overnight to EMRs (Powerchart by Cerner Corporation, Kansas City, Mo). With institutional review board approval (Pro00001647), 2 data sets were collected. The pre-EMR data set was selected for a 12-month period from July 2009 to June 2010. All outpatient visits were extracted. For the post-EMR data set, a similar 12-month period from July 2011 to June 2012 was selected, controlling for seasonal variations in outpatient volume. The monthly mean of outpatient visits for each outpatient clinic was calculated and totaled. The mean total outpatient visits per month before and after EMR implementation were compared using the 2-tailed Student t test without assumption for equal variance. To better understand how EMR implementation had impacted individual clinics, we again used the 2-tailed Student t test to conduct multiple subunit analyses of various outpatient clinics including Family Medicine (as multiphysician primary clinic), Plastic Surgery (as multiphysician specialty clinic), and Pediatric Plastic Surgery (as singlephysician specialty clinic). The total number of full-time equivalent (FTE) physicians for the 2 periods was also calculated, and the total annual visits were normalized to give per FTE per year outpatient volumes. The significance level was set at 0.05, and power analysis was done whenever the P value was greater than 0.05 to measure type II error.
RESULTS A total of 644,204 patient visits from more than 80 specialty clinics at our AMC were analyzed in this study. There was an 8.37% increase from 309,165 patient visits before EMR implementation to 335,039 patient visits after EMR implementation, with the monthly number of patients seen increasing from a mean (SD) of 25,763.75 (1673.96) to 27,919.92 (2229.07) (P = 0.018, 2-tailed t test). However, when normalized to per physician per month, the difference disappeared (Fig. 1). Multiple subunit analyses were also conducted to compare the outpatient volumes before and after EMR implementation. Within the multiphysician primary care clinic of Family Medicine, we failed to demonstrate a statistically significant difference in outpatient volumes after EMR implementation: the monthly mean (SD) number of patient visits was 3270.5 (268.83) before EMRs and 3148.5 (197.25) after EMRs (P = 0.24, type II error 9 20%).
FIGURE 1. The pre-EMR and post-EMR outpatient volume per physician per month. * 2014 Lippincott Williams & Wilkins
Impact of EMR Implementation on Outpatient Volumes
Similarly, within the multiphysician specialty clinic of Plastic Surgery, we also did not find a statistically or clinically significant difference in outpatient clinic volumes after EMR implementation with the monthly mean (SD) number of patient visits of 355.83 (27.94) before EMRs and 352.5 (39.8) after EMRs (P = 0.82, type II error 9 20%). The monthly mean (SD) number of patient visits of a single-physician clinic in Pediatric Plastic Surgery was also not statistically significantly different: 91.67 (15.78) visits before EMRs and 97.25 (16.79) visits after EMRs (P = 0.43, type II error 9 20%). There were 339 FTEs in the pre-EMR period and 367 FTEs in the post-EMR period. When normalized to FTE, outpatient volume per FTE per year was 989.57 before EMRs and 987.30 after EMRs, a difference of only 0.23% (P 9 0.05 and type II error 9 20%).
DISCUSSION Despite the subjective feeling of extra time requirement many physicians attribute to EMRs, this study shows that EMRs have not caused a statistically significant decrease in outpatient volumes. Furthermore, we were surprised at first to find that the overall volumes in outpatient clinics actually showed a significant increase of 8.37% (P = 0.018) after the EMR was implemented. However, after taking into consideration the increase in the number of FTEs, the outpatient volumes per year per FTE were remarkably similar before and after EMRs, with only a 0.23% difference. There is currently limited research to explain the causal relationship between EMRs and alterations in clinical volumes.12 It is understandable that the EMR provides a more centralized access to widespread clinical data, thereby allowing physicians to spend less time searching for consultation reports, laboratory results, and patient histories. The fact that health care providers are now able to quickly and simultaneously access a comprehensive picture of a patient, thus allowing more time to see more patients, should help to explain the overall expected increase in patient volumes. In addition, EMRs allow a large facility, such as the one we studied, to track valuable and extensive information on patient flows and trends. The ability to receive real-time, up-to date information on clinical volumes and efficiency allow health care providers and administrators improved ability to accurately staff their practices, detect inefficiencies, and plan how to improve them.13 For further evaluation, we compared the patient volumes before and after EMRs in several different outpatient settings to broaden the scope of our study. Regardless of whether the clinic was of specialty versus primary care or a single versus multiphysician group, the data reveal that there was simply no statistically or clinically significant loss in patient volume in every single outpatient clinic we examined. These findings support and expand past studies of individual outpatient departments in that EMR implementation does not in fact threaten the productivity of outpatient facilities.11,14,15 However, power calculation for all of the abovementioned analyses indicate A error (type II error) of greater than 20%. Thus, we cannot conclude definitively that the pre-EMR and post-EMR volumes are the same. The implications of this study are interesting and unexpected and stress the need for more quantifiable evaluations of how EMRs will affect health care providers. The fact that no single clinic experienced a statistically or clinically significant decrease in patient volume can hopefully provide some comfort to physicians who fear that EMRs will constrain them in terms of number of patients seen per day. Taking into consideration the results of this study along with the added financial benefits of meaningful use of dollars, providers now have clear reasons to consider EMR implementation if they have not already done so. For future considerations, the use of more comprehensive presentations of these findings to physicians may help to allay subjective concerns and encourage further adoption of EMRs.16 The particular EMR system used in this study was not www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
331
Annals of Plastic Surgery
Reddy and Yu
selected by the authors, and our results may not be duplicated using other EMR systems or in other institutions using the same system. It is also important to consider these results from the perspective of third-party payers and in terms of the original purpose of EMR implementation. The costs of EMR implementation are tremendous, not only for hospitals and health care providers but also for the Centers for Medicare & Medicaid Services. As of October 2013, more than $10.2 billion in payments have been made by the Centers for Medicare & Medicaid Services to eligible health care providers who are currently demonstrating meaningful use of EMRs.4 With spending of this magnitude, one should, if not must, question whether the EMR has the ability to increase efficiency and productivity in the delivery of health care to compensate for its costs. Although we showed that EMRs are not likely to constrain outpatient volumes, this may not be enough to justify the enormous resources that have gone into this program implementation, which is estimated to be between $10,000 and $30,000 per physician.17 At the national level, with approximately 880,000 physicians, this represents $17 billion in upfront cost. Without doubt, there is a need for more objective and detailed cost studies of EMRs as we continue to see its adoption grow, to fully remark on its ability to improve patient care while increasing hospital efficiency in relation to the cost of its implementation. The EMR impacts on quality as measured by the Surgical Care Improvement Project and the National Surgical Quality Improvement Program are being conducted, and we will report the results in the near future.
Limitations Because of the retrospective nature of this study, we are at risk for rival alternatives for we cannot rule out the possibility that other concomitant events may also contribute to the effects observed. A prospective multicenter study with greater control over variables such as seasonal variations, f luctuations in population, and changes in provider practices pattern would provide more definitive answers. In addition, there are many related questions regarding the full impact of EMRs that were unable to be answered by this study. Because our primary goal was to assess patient volume constraints, we did not consider or measure whether EMRs may increase the time physicians may spend after hours finishing EMR documentation. In addition, it is important to remember that EMR initiatives were created to not only increase clinical efficiency but also to improve patient care. Although this study showed that the number of patients seen per month was not affected, it is important that future studies address how the EMR has impacted the quality and safety of patient care.
CONCLUSIONS After analyzing the outpatient visit volumes of a midsize AMC, we have found that EMRs did not constrain the patient volume but instead was associated with an 8.37% overall increase in visits. However, this increase disappears when normalized to FTE. Regardless of whether a clinic was a multiphysician primary care clinic, a multiphysician specialty clinic, or a single-physician clinic, the data reveal that there was simply no statistically significant loss in patient volume in every single outpatient clinic we examined. Although this study will hopefully help to clarify general impressions of EMR implementation for apprehensive, reluctant physicians, it also demonstrates the need for further objective analysis of how the EMR is impacting health care. A better understanding of the ways in which
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EMRs can increase patient volumes is needed to further improve clinic efficiency and allow future users to get the best value for their investments. Our study, however, is limited in its applicability to smaller private practices and larger AMCs with greater than 400,000 annual visits. Further investigations are necessary to fully gauge the impact of the EMR on those clinical settings. Regardless, as the penalties for EMR implementation deadlines quickly approach, it is crucial that health care providers replace personal opinions of the past with a more objective understanding of whether EMRs will be able to increase clinical efficiency in health care in proportion to its costs. REFERENCES 1. Balfour DC 3rd, Evans S, Januska J, et al. Health information technologyV results from a roundtable discussion. J Manag Care Pharm. 2009;15(suppl A):10Y17. 2. Yan H, Gardner R, Baier R.Beyond the focus group: understanding physicians’ barriers to electronic medical records. Jt Comm J Qual Patient Saf. 2012;38: 184Y191. 3. Healthcare Information and Management Systems Society. A HIMSS guide to participating in a health information exchange. Published 2009. Available at: www.himss.org/files/HIMSSorg/content/files/HIE_GuideWhitePaper.pdf. Accessed November 2, 2013. 4. Centers for Medicare & Medicaid Services. EHR incentive programs. Published 2013. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms. Accessed November 1, 2013. 5. US Department of Health & Human Services. Doctors and hospitals’ use of health it more than doubles since 2012. Published 2013. Available at: http://www. hhs.gov/news/press/2013pres/05/20130522a.html. Accessed November 2, 2013. 6. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742Y752. 7. Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12:505Y516. 8. Mathison D, Chamberlain J. Evaluating the impact of the electronic health record on patient flow in a pediatric emergency department. Appl Clin Inform. 2011;2:39Y49. 9. Grabenbauer L, Fraser R, McClay J, et al. Adoption of electronic health records: a qualitative study of academic and private physicians and health administrators. Appl Clin Inform. 2011;2:165Y176. 10. Terry AL, Brown JB, Bestard Denomme L, et al. Perspectives on electronic medical record implementation after two years of use in primary health care practice. J Am Board Fam Med. 2012;25:522Y527. 11. Wang SJ, Middleton B, Prosser LA, et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med. 2003;114:397Y403. 12. Furukawa M. Electronic medical records and efficiency and productivity during office visits. Am J Manag Care. 2011;17:296Y303. 13. Scopelliti JA. Benefits of an early start with EMR. Healthc Inform. 2010;27:50Y57. 14. Cheriff AD, Kapur AG, Qiu M, et al. Physician productivity and the ambulatory EHR in a large academic multi-specialty physician group. Int J Med Inform. 2010;79:492Y500. 15. De Leon S, Connelly-Flores A, Mostashari F, et al. The business end of health information technology. Can a fully integrated electronic health record increase provider productivity in a large community practice? J Med Pract Manage. 2010;25:342Y349. 16. Vishwanath A, Singh SR, Winkelstein P. The impact of electronic medical record systems on outpatient workflows: a longitudinal evaluation of its workflow effects. Int J Med Inform. 2010;79:778Y791. 17. Fleming NS, Culler SD, McCorkle R, et al. The financial and nonfinancial costs of implementing electronic health records in primary care practices. Health Aff (Millwood). 2011;30:481Y489.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Impact of Electronic Medical Record Implementation on the Outpatient Volumes of a Midsize Academic Center Karishma G. Reddy, BS, and Jack C. Yu, MD, DMD, MS Ed Background: Despite the proposed clinical advantages of electronic medical records (EMRs), many questions remain regarding how EMRs may limit the number of patients a provider can see on a day-to-day basis. In this study, we measured the impact of EMR implementation on outpatient volumes in the setting of a midsize academic medical center (AMC) in the southeast. Methods: The AMC outpatient visit volumes of two 12-month periods, one before and one after the EMR implementation, were collected. The mean monthly outpatient visits before and after EMR implementation were compared using the 2-tailed Student t test without assumption for equal variance. We also normalized the total annual visits to the number of full-time equivalent physicians. Power calculation was performed to measure type II error whenever P value was greater than 0.05. Results: There was an 8.37% increase in total outpatient visits after EMR implementation, with the monthly number of patients seen increasing from a mean (SD) of 25,763.75 (1673.96) to 27,919.92 (2229.07) (P = 0.018). However, this increase disappears when normalized to full-time equivalent. After conducting multiple subunit analyses of a multiphysician primary care clinic (Family Medicine), specialty clinic (Plastic Surgery), and single-physician specialty clinic (Pediatric Plastic Surgery), we also did not find a statistically significant difference in outpatient clinic volumes after EMR implementation. Conclusions: Despite the burdensome time requirements many physicians subjectively attribute to EMRs, this study shows that the EMR has not really caused a statistically significant decrease in outpatient volumes in the setting of a midsize AMC. Key Words: electronic medical records, implementation, outpatient volumes, health information technology, academic medical center (Ann Plast Surg 2014;73: 330Y332)
T
he implementation of electronic medical records (EMRs) into the US health care system has been long and arduous. Although EMR implementation promises many benefits including better coordination of care between providers and improved patient safety, many physicians were reluctant to make the change from paper charts to EMRs.1 With a number of unknowns including the impacts on patient-physician interactions and substantial upfront financial cost, physicians had endless reasons to hesitate in the EMR transition.2 To encourage the use of health information technology by health care providers, the Congress passed the Health Information Technology for Economic and Clinical Health Act as a part of the American Recovery and Reinvestment Act of 2009. With the hopes of improving the quality and efficiency of health care, the Congress provided physicians with significant financial incentives to adopt and practice meaningful Received April 1, 2014, and accepted for publication, after revision, June 6, 2014. From the Division of Plastic Surgery, Medical College of Georgia, Georgia Regents University, Augusta, GA. Conflicts of interest and sources of funding: None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article. No funding sources were provided for this study. The authors have no financial conflicts to disclose. Reprints: Karishma G. Reddy, BS, 1828 Hampton Ave, Augusta, GA 30904. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0330 DOI: 10.1097/SAP.0000000000000314
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use of EMRs.3 Through the Medicare and Medicaid electronic health record Incentive Programs, providers who implement and demonstrate meaningful use of EMR technology can be eligible to receive payments of up to $44,000 through Medicare and $63,750 through Medicaid during the ensuing 4 to 6 years. Furthermore, providers who choose to not implement EMRs will begin to face penalties via reductions in reimbursements for their services starting 2015.4 Considering the financial implications of this legislation, it is obvious why there has been a dramatic increase in the number of hospitals implementing EMRs. From 2008 to 2013, the percentage of eligible hospitals that were able to demonstrate meaningful use of EMRs has jumped from a feeble 8% to 80%, according to the most recent data provided by the Department of Health and Human Services.5 As EMR implementation continues to become a staple of health care in the United States, it is increasingly important to understand the actual effects EMRs will have upon providers and health care institutions. Various clinical studies have demonstrated the beneficial changes EMRs bring to health care, including greater observance of protocol-based care, superior clinical monitoring and surveillance, as well as fewer medication errors.6 However, there are negative consequences to EMRs as well, including an alteration in the interactions between physicians and patients as well as a perceived decrease in time efficiency.7 Although many studies have investigated the expected positive and negative consequences of EMRs on patient care, there is still much to be discovered regarding the effects EMRs have on the patient volumes of a medical center. Although past studies demonstrated that EMRs did not independently affect patient flow, these studies were focused only on certain departments and were not ref lective of the hospital clinical volumes as a whole.8 In addition, many of the past studies investigating the impacts of EMRs on clinical volumes used self-reported, subjective data gathered from physician surveys regarding how they felt EMRs had affected their own practices.9,10 No study to date has objectively evaluated how the patient volumes of outpatient clinics have changed after the implementation of EMRs at a midsize academic institution. Although cost-benefit studies of the past predicted that EMRs could result in positive financial returns, it is now possible to more directly measure these effects because of the increased availability of retrospective data from institutions now using EMRs.11 By better understanding patient volumes before and after EMR implementation, other institutions can stand to gain more knowledge of the financial impacts of EMRs and perhaps also devise better strategies to facilitate a more efficient transition. Although the immediate financial incentives are strong, there remains a need for a better understanding of the long-term constraints EMRs may pose on the amount of patients seen at an institution. Even with the incentive payments offered to providers, can EMR implementations offset the negative impacts due to their implementation? Has the EMR system essentially limited the number of patients a provider can see on a day-to-day basis? The answers to these questions illustrate important implications for those who have already made the transition and may also aid undecided institutions in determining whether to implement EMRs. In contrast to the evaluations of EMRs that are based upon subjective experiences and opinions of physicians, we hope to provide a more quantitative assessment of how EMR implementation has affected the number of patients a physician can see. More specifically, the objective of this study was Annals of Plastic Surgery
&
Volume 73, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 73, Number 3, September 2014
to document the impact of EMRs on the outpatient visit volumes of a midsized academic medical center (AMC) using multiple different clinical settings.
MATERIALS AND METHODS There are 80 specialty clinics with approximately 370,000 outpatient visits occurring annually in our AMC. On June 28, 2011, after 6 months of intensive preparations, all outpatient clinics transitioned overnight to EMRs (Powerchart by Cerner Corporation, Kansas City, Mo). With institutional review board approval (Pro00001647), 2 data sets were collected. The pre-EMR data set was selected for a 12-month period from July 2009 to June 2010. All outpatient visits were extracted. For the post-EMR data set, a similar 12-month period from July 2011 to June 2012 was selected, controlling for seasonal variations in outpatient volume. The monthly mean of outpatient visits for each outpatient clinic was calculated and totaled. The mean total outpatient visits per month before and after EMR implementation were compared using the 2-tailed Student t test without assumption for equal variance. To better understand how EMR implementation had impacted individual clinics, we again used the 2-tailed Student t test to conduct multiple subunit analyses of various outpatient clinics including Family Medicine (as multiphysician primary clinic), Plastic Surgery (as multiphysician specialty clinic), and Pediatric Plastic Surgery (as singlephysician specialty clinic). The total number of full-time equivalent (FTE) physicians for the 2 periods was also calculated, and the total annual visits were normalized to give per FTE per year outpatient volumes. The significance level was set at 0.05, and power analysis was done whenever the P value was greater than 0.05 to measure type II error.
RESULTS A total of 644,204 patient visits from more than 80 specialty clinics at our AMC were analyzed in this study. There was an 8.37% increase from 309,165 patient visits before EMR implementation to 335,039 patient visits after EMR implementation, with the monthly number of patients seen increasing from a mean (SD) of 25,763.75 (1673.96) to 27,919.92 (2229.07) (P = 0.018, 2-tailed t test). However, when normalized to per physician per month, the difference disappeared (Fig. 1). Multiple subunit analyses were also conducted to compare the outpatient volumes before and after EMR implementation. Within the multiphysician primary care clinic of Family Medicine, we failed to demonstrate a statistically significant difference in outpatient volumes after EMR implementation: the monthly mean (SD) number of patient visits was 3270.5 (268.83) before EMRs and 3148.5 (197.25) after EMRs (P = 0.24, type II error 9 20%).
FIGURE 1. The pre-EMR and post-EMR outpatient volume per physician per month. * 2014 Lippincott Williams & Wilkins
Impact of EMR Implementation on Outpatient Volumes
Similarly, within the multiphysician specialty clinic of Plastic Surgery, we also did not find a statistically or clinically significant difference in outpatient clinic volumes after EMR implementation with the monthly mean (SD) number of patient visits of 355.83 (27.94) before EMRs and 352.5 (39.8) after EMRs (P = 0.82, type II error 9 20%). The monthly mean (SD) number of patient visits of a single-physician clinic in Pediatric Plastic Surgery was also not statistically significantly different: 91.67 (15.78) visits before EMRs and 97.25 (16.79) visits after EMRs (P = 0.43, type II error 9 20%). There were 339 FTEs in the pre-EMR period and 367 FTEs in the post-EMR period. When normalized to FTE, outpatient volume per FTE per year was 989.57 before EMRs and 987.30 after EMRs, a difference of only 0.23% (P 9 0.05 and type II error 9 20%).
DISCUSSION Despite the subjective feeling of extra time requirement many physicians attribute to EMRs, this study shows that EMRs have not caused a statistically significant decrease in outpatient volumes. Furthermore, we were surprised at first to find that the overall volumes in outpatient clinics actually showed a significant increase of 8.37% (P = 0.018) after the EMR was implemented. However, after taking into consideration the increase in the number of FTEs, the outpatient volumes per year per FTE were remarkably similar before and after EMRs, with only a 0.23% difference. There is currently limited research to explain the causal relationship between EMRs and alterations in clinical volumes.12 It is understandable that the EMR provides a more centralized access to widespread clinical data, thereby allowing physicians to spend less time searching for consultation reports, laboratory results, and patient histories. The fact that health care providers are now able to quickly and simultaneously access a comprehensive picture of a patient, thus allowing more time to see more patients, should help to explain the overall expected increase in patient volumes. In addition, EMRs allow a large facility, such as the one we studied, to track valuable and extensive information on patient flows and trends. The ability to receive real-time, up-to date information on clinical volumes and efficiency allow health care providers and administrators improved ability to accurately staff their practices, detect inefficiencies, and plan how to improve them.13 For further evaluation, we compared the patient volumes before and after EMRs in several different outpatient settings to broaden the scope of our study. Regardless of whether the clinic was of specialty versus primary care or a single versus multiphysician group, the data reveal that there was simply no statistically or clinically significant loss in patient volume in every single outpatient clinic we examined. These findings support and expand past studies of individual outpatient departments in that EMR implementation does not in fact threaten the productivity of outpatient facilities.11,14,15 However, power calculation for all of the abovementioned analyses indicate A error (type II error) of greater than 20%. Thus, we cannot conclude definitively that the pre-EMR and post-EMR volumes are the same. The implications of this study are interesting and unexpected and stress the need for more quantifiable evaluations of how EMRs will affect health care providers. The fact that no single clinic experienced a statistically or clinically significant decrease in patient volume can hopefully provide some comfort to physicians who fear that EMRs will constrain them in terms of number of patients seen per day. Taking into consideration the results of this study along with the added financial benefits of meaningful use of dollars, providers now have clear reasons to consider EMR implementation if they have not already done so. For future considerations, the use of more comprehensive presentations of these findings to physicians may help to allay subjective concerns and encourage further adoption of EMRs.16 The particular EMR system used in this study was not www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
331
Annals of Plastic Surgery
Reddy and Yu
selected by the authors, and our results may not be duplicated using other EMR systems or in other institutions using the same system. It is also important to consider these results from the perspective of third-party payers and in terms of the original purpose of EMR implementation. The costs of EMR implementation are tremendous, not only for hospitals and health care providers but also for the Centers for Medicare & Medicaid Services. As of October 2013, more than $10.2 billion in payments have been made by the Centers for Medicare & Medicaid Services to eligible health care providers who are currently demonstrating meaningful use of EMRs.4 With spending of this magnitude, one should, if not must, question whether the EMR has the ability to increase efficiency and productivity in the delivery of health care to compensate for its costs. Although we showed that EMRs are not likely to constrain outpatient volumes, this may not be enough to justify the enormous resources that have gone into this program implementation, which is estimated to be between $10,000 and $30,000 per physician.17 At the national level, with approximately 880,000 physicians, this represents $17 billion in upfront cost. Without doubt, there is a need for more objective and detailed cost studies of EMRs as we continue to see its adoption grow, to fully remark on its ability to improve patient care while increasing hospital efficiency in relation to the cost of its implementation. The EMR impacts on quality as measured by the Surgical Care Improvement Project and the National Surgical Quality Improvement Program are being conducted, and we will report the results in the near future.
Limitations Because of the retrospective nature of this study, we are at risk for rival alternatives for we cannot rule out the possibility that other concomitant events may also contribute to the effects observed. A prospective multicenter study with greater control over variables such as seasonal variations, f luctuations in population, and changes in provider practices pattern would provide more definitive answers. In addition, there are many related questions regarding the full impact of EMRs that were unable to be answered by this study. Because our primary goal was to assess patient volume constraints, we did not consider or measure whether EMRs may increase the time physicians may spend after hours finishing EMR documentation. In addition, it is important to remember that EMR initiatives were created to not only increase clinical efficiency but also to improve patient care. Although this study showed that the number of patients seen per month was not affected, it is important that future studies address how the EMR has impacted the quality and safety of patient care.
CONCLUSIONS After analyzing the outpatient visit volumes of a midsize AMC, we have found that EMRs did not constrain the patient volume but instead was associated with an 8.37% overall increase in visits. However, this increase disappears when normalized to FTE. Regardless of whether a clinic was a multiphysician primary care clinic, a multiphysician specialty clinic, or a single-physician clinic, the data reveal that there was simply no statistically significant loss in patient volume in every single outpatient clinic we examined. Although this study will hopefully help to clarify general impressions of EMR implementation for apprehensive, reluctant physicians, it also demonstrates the need for further objective analysis of how the EMR is impacting health care. A better understanding of the ways in which
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EMRs can increase patient volumes is needed to further improve clinic efficiency and allow future users to get the best value for their investments. Our study, however, is limited in its applicability to smaller private practices and larger AMCs with greater than 400,000 annual visits. Further investigations are necessary to fully gauge the impact of the EMR on those clinical settings. Regardless, as the penalties for EMR implementation deadlines quickly approach, it is crucial that health care providers replace personal opinions of the past with a more objective understanding of whether EMRs will be able to increase clinical efficiency in health care in proportion to its costs. REFERENCES 1. Balfour DC 3rd, Evans S, Januska J, et al. Health information technologyV results from a roundtable discussion. J Manag Care Pharm. 2009;15(suppl A):10Y17. 2. Yan H, Gardner R, Baier R.Beyond the focus group: understanding physicians’ barriers to electronic medical records. Jt Comm J Qual Patient Saf. 2012;38: 184Y191. 3. Healthcare Information and Management Systems Society. A HIMSS guide to participating in a health information exchange. Published 2009. Available at: www.himss.org/files/HIMSSorg/content/files/HIE_GuideWhitePaper.pdf. Accessed November 2, 2013. 4. Centers for Medicare & Medicaid Services. EHR incentive programs. Published 2013. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms. Accessed November 1, 2013. 5. US Department of Health & Human Services. Doctors and hospitals’ use of health it more than doubles since 2012. Published 2013. Available at: http://www. hhs.gov/news/press/2013pres/05/20130522a.html. Accessed November 2, 2013. 6. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742Y752. 7. Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12:505Y516. 8. Mathison D, Chamberlain J. Evaluating the impact of the electronic health record on patient flow in a pediatric emergency department. Appl Clin Inform. 2011;2:39Y49. 9. Grabenbauer L, Fraser R, McClay J, et al. Adoption of electronic health records: a qualitative study of academic and private physicians and health administrators. Appl Clin Inform. 2011;2:165Y176. 10. Terry AL, Brown JB, Bestard Denomme L, et al. Perspectives on electronic medical record implementation after two years of use in primary health care practice. J Am Board Fam Med. 2012;25:522Y527. 11. Wang SJ, Middleton B, Prosser LA, et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med. 2003;114:397Y403. 12. Furukawa M. Electronic medical records and efficiency and productivity during office visits. Am J Manag Care. 2011;17:296Y303. 13. Scopelliti JA. Benefits of an early start with EMR. Healthc Inform. 2010;27:50Y57. 14. Cheriff AD, Kapur AG, Qiu M, et al. Physician productivity and the ambulatory EHR in a large academic multi-specialty physician group. Int J Med Inform. 2010;79:492Y500. 15. De Leon S, Connelly-Flores A, Mostashari F, et al. The business end of health information technology. Can a fully integrated electronic health record increase provider productivity in a large community practice? J Med Pract Manage. 2010;25:342Y349. 16. Vishwanath A, Singh SR, Winkelstein P. The impact of electronic medical record systems on outpatient workflows: a longitudinal evaluation of its workflow effects. Int J Med Inform. 2010;79:778Y791. 17. Fleming NS, Culler SD, McCorkle R, et al. The financial and nonfinancial costs of implementing electronic health records in primary care practices. Health Aff (Millwood). 2011;30:481Y489.
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