TECHNOLOGYTechnology exam: Why should you buy?Before prescribing technology for what ails your practice, diagnose the problems in your office and take the time to examine the most workable solution.By Larry Stevens, amednews correspondent. June 25, 2001. You're worried that office automation technology may be passing you by. Might be a good idea to get on board the computer bandwagon while the getting is good. Cold calls from software vendors are more frequent. Maybe this is a good time to see what they have to offer, right? Wrong, say most experts. Buying technology for its own sake or out of fear of being left behind is a big mistake. "Many physicians browse for technology products in a vacuum without reference to their specific needs. What they frequently end up with is a system that is never used, or is never successfully implemented into their practice," says health care informatics specialist Eugene R. Worth, MD, Dr. Worth helps doctors evaluate and purchase health care technology through his firm, Medical Information Technologies in Columbia, Mo. He warns against buying a system because it is the latest or has the most bells and whistles. "Technology should be in the background -- a tool, not a monument," the Columbia, Mo., anesthesiologist says. Before calling a technology vendor, physicians should consider their workflow process, budget, technology assets and skills, and, most important, the problems that need to be solved. Only then can you decide on the technology that fits best with your practice. A technology solution should be just that: a solution to an identifiable problem. Physicians who have successfully implemented technologies know before purchasing each product how it can help a specific activity of the practice. Says internist Sarah T. Corley, MD, "We paid close attention to which aspects of office jobs are expensive, not working well, are time-consuming or are hated." Dr. Corley, part of two-doctor group, Internal Medicine Associates in Arlington, Va., says she purchased an electronic medical records system only after her staff said that finding, pulling and filing charts were their biggest problems. Because no one at the office liked to print patient statements and stuff envelopes, bills were not being sent out as often as they should, hurting cash flow. So she contracted with an electronic patient statement clearinghouse. Nurses at Internal Medicine Associates also complained about the need to stay late to fill out lab requisitions. So Dr. Corley got a label printer that takes information from electronic medical records and puts it on a label that can be affixed to the lab sheets. After these problems were solved, Dr Corley turned her attention to smaller ones. Because the staff was always losing the ICD9 and CPT books, she got electronic versions. The nurses spent a lot of time searching for the correct patient assistance form for indigent patients' drug requests, so Dr. Corley scanned all the forms into the computer. The schedule was being thrown off when new patients took too much time filling out paperwork, so the forms were put on the practice's Web page to be done ahead of time. "Once you know the problem you want to solve, finding the right technology is relatively straightforward," Dr. Corley says. Similar to patient encounterDr. Worth likens the process of determining technology needs and choosing a system to a patient encounter, consisting of three parts: the history, the exam and the prescription. The history phase uncovers all the problems -- the work flow bottlenecks -- in the office. The exam phase determines the readiness for technology. This includes an evaluation of current computer infrastructure and an understanding of how comfortable people in the office, including physicians, are with technology. The prescription phase involves matching the solution to the problem. But that requires a determination of whether the people will actually use it. When treating a patient, a doctor may feel that a regimen that requires five doses a day would be optimal. But knowing the patient won't follow that regimen, the doctor may opt for an alternative. Similarly, while an electronic medical records system may be the ideal prescription for an office, a doctor who is used to dictating notes into a handheld tape recorder may resist entering data into a computer between patient encounters. As a result, the physician may end up forgetting to use the system, resulting in more confusion rather than less. Another issue, also analogous to the prescription phase of a medical encounter, is cost. Just as doctors have to consider a drug's price when prescribing, they also have to determine whether the anticipated benefits of a new technology justify its cost. "You need to have a rough idea what you're currently spending to not have technology in order to find the low-cost alternatives to do the job," says Keith Michl, MD, a solo practitioner in internal and geriatric medicine in Dorset, Vt. Dr. Michl says he's "become very skeptical about cutting-edge technology that might be expensive to implement, such as complex drug interaction software and voice recognition systems." Instead, he suggests looking at the cost -- material and labor -- of relatively mundane things such as assembling, collating, photocopying, storing, pulling and archiving charts. It's impossible to get an exact figure, but labor cost can be determined with a simple formula: total time divided by the hourly salary of people involved in the activity. Dr. Michl determined that the cost of dealing with a chart for a single encounter is as high as $5. That includes the cost of the chart, storage costs, and the value of myriad activities including pulling the chart, making chart entries, and even "the cost of staff time when they're turning the office upside down trying to find a lost chart." He ended up buying SOAPWare electronic medical record software from DOCS Inc., Springdale, Ariz., for about $750. While solo physicians such as Dr. Michl can make their own technology decisions, not all have that autonomy. But even doctors whose groups have opted not to use technology may find they can buy systems that do not impinge on others. Matthew W. Levin, MD, a family physician with Westmoreland Primary Health Centers, a division of Westmoreland Regional Hospital, in Delmont, Pa., says he configured his SOAPware software so that he's essentially generating a dictated report. Dr. Lewin says that, for now, he has decided not to involve the staff (or other doctors) in using his EMR system. He prints all generated reports at the time of care so that he is able to send paper to others but work with the electronic version himself. A final option -- one especially good for doctors who cannot agree with other members of their groups about technology -- is to use an application service provider. ASPs host applications and allow doctors to access them for a monthly fee. There are usually no licensing or setup costs, and physicians only need Web access to use the software. Internist Brian T. Keefe, MD, decided to go it alone with ASP charting system Medscape Chart Note. His seven-doctor group, Albany Internal Medicine in Albany, Ga., found itself without charting software after it left a larger group with which it was associated for a number of years. The larger group had a legacy charting system, so after the breakup Albany physicians considered buying the same system. But then they found out the cost: almost $800,000. "That price was nowhere near our ballpark," Dr. Keefe says. So members of the group went in different directions. All the doctors except for Dr. Keefe went back to the old pen-and-paper charting system. Dr. Keefe signed up for Chart Note, which costs $100 a month. The product provides a series of templates, each relating to a different kind of encounter. Because Dr. Keefe types the data himself, he eliminates the need for transcription services, which he says used to cost him about $1,500 a month. "The cost savings here was clear and easy to figure," he points out. There is no quick and easy formula for deciding on the best technology for a practice. It could take days or even weeks to ferret out the practice's problems and even longer to match them up with the right solution. "The hardest part of any technology decision is self-evaluation of what works well and what doesn't work well in a practice, and then looking in detail at what doesn't work well to figure out why it doesn't. It never helps to replace bad paper procedures with bad electronic procedures," Dr. Corley says. On the other hand, when technology is purchased because it can improve specific processes, the chances of success are greatly enhanced. ADDITIONAL INFORMATION:Matching technology with practice needsNikki Ellis, PhD, a senior research associate at the Centre for Health Services Research, University of Newcastle upon Tyne, England, outlines five steps a practice should follow to determine its technology needs.
Identification of functions (needs assessment)All staff should be asked to identify functions that they wish to achieve with the system. Identification of issuesAll staff should be asked to consider their requirements for:
Identify resourcesYou will need to identify available:
This can best be achieved through a program of system demonstrations, visits to organizations using the systems you are interested in and asking friends and colleagues about their experiences. PrioritizeAll staff, as a team, should agree on which functions are priorities (those you must have) and which functions are less important (wishes). Take stockAll specifications must contain a requirement for the system to meet national legal and medical standards for security and confidentiality as well as health insurance requirements for data recording. Copyright 2001 American Medical Association. All rights reserved.
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