The following article is written by Eric J. Stenson, director of enterprise applications for Surgical Notes. The views expressed are those of the author and are not endorsed by Surgical Notes.
It is well understood that ambulatory surgery centers are not included in the HITECH stimulus funding. Some ASC management companies have attempted to justify EMR in the ASC setting through creative interpretations related to physician use requirements — yet, ASCs often misunderstand the clinical basis for EMR implementation. Computerized charting does not serve the needs of ASCs and will likely impede, rather than help, clinical workflows.
In the hospital setting, the healthcare community is trying to address clinical issues related to cost containment and the standardization of care. The EMR offers a way to standardize care through predefined order sets and improve patient safety metrics by barcode-based validation of drugs before administering to the patient. Health systems are then able to collect dozens of quality measures over a large population, allowing for the birth of the accountable care organization.
1. Significant basis of clinical risk. In contrast with a general office visit, the risk and result of system failure during surgery is considerable. The patient is sedated, cut open and surgery is being performed. A workstation with EMR being used in surgery will have a direct and an indirect impact on care — the loss of critical patient data can create dangerous situations, particularly when compounded with a resulting shift of focus from the patient to the technical glitch. In mission critical situations, for example administering anesthesia, waiting two or three minutes for a computer to restart and having a significant patient distraction could prove fatal. These risks should not be understated and often prove so significant that paper charting in the OR is still commonplace in numerous "full EMR" hospitals.
2. CPOE contradicts the tenets of ASC practice. A cornerstone of EMR systems is computerized physician order entry (CPOE). The principal of CPOE is that it will improve medicine by standardizing physician orders for given medical conditions, based upon standards set by a governing physician body for the healthcare system. ASCs seldom dictate (and unlike hospitals largely lack the authority to mandate) to their physicians how to practice medicine and order sets are largely already standardized by the physician for a given procedure. Unlike standalone provider EMR adoptions (where a physician gets to determine his own orders), getting multiple physicians and physician groups to agree on order sets for the entire ASC would be highly challenging, if not impossible.
3. EMR is a guaranteed productivity loss. According to Jeffrey Belden, MD, of the HIMSS Usability Taskforce, documenting patient exams in an EMR takes 10 times as long as documenting by dictation. A study by the Medical Group Management Association found that 67 percent of physicians surveyed believed there would be a decrease in physician productivity in meeting meaningful use under HITECH, with many physicians estimating productivity loss between 20-40 percent due to increased time performing clerical tasks associated with data entry. The physician and clinical staff productivity loss associate with EMR systems is becoming such an acute issue in medicine, that many facilities — such as the University of Texas Medical Center — have started employing full-time scribes to document physician work in EMR systems.
4. Physician satisfaction will go down. Driving business to an outpatient surgery facility requires the facility to maintain positive relationships with its referring providers. Implementing an EMR system and changing clinical workflows is nearly guaranteed to reduce physician satisfaction. A study conducted by the Department of Medicine at the University of Pittsburgh found negative post-implementation physician scores in time required to enter orders, time required for documentation, rapport established with patients, patient privacy, physician autonomy, patient satisfaction and overall quality of healthcare provided. The study concludes "Prior to the implementation, most physicians' optimism about EMR is without any basis in reality… [at] the 6-month post-implementation point, our results strongly demonstrate that physicians are disenchanted with EMR."
5. Your center does not face hospital challenges that are addressed with EMR. Hospitals can leverage benefits of EMR systems to capture revenue leaks and better coordinate care across providers. In the inpatient setting, a patient may be seen by numerous physicians and nursing staff on different rotations, residents, attending physicians and consulting physicians. The EMR can contribute to the continuity of care. In the ASC environment, the patient is treated by a predetermined surgeon that regularly performs the procedure and is familiar with the patient. Coding is done from the operative report. The need to share knowledge between rotating providers and collect large amounts of structured data electronically is less compelling.
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