The Electronic Medical Record in DermatologyElectronic Medical Record in Dermatology

The electronic medical record (EMR) is the in-office component of a broader interconnected electronic health record (EHR). The perfect EHR offers the potential of providing an overall picture of a patient's health by linking to hospital records, laboratories, and physicians. Treatments prescribed by other physicians would be available at all times, and redundant laboratory studies and potentially harmful drug interactions could be avoided.

President George W. Bush stressed the importance of a nationwide EHR system early in his second term of office,¹ and it is a central component of President Barack Obama's sweeping health care reform package.² The Obama administration believes its health care policies will improve the quality and reduce the cost of health care, stimulate employment in the high-tech sector of our economy, and reduce federal spending by providing the basis for an efficient and effective health care system. The health information technology (HIT) component (the HITECH Act) of the American Recovery and Reinvestment Act of 2009 appropriated $19 billion to stimulate the use of EMRs.³ The Act provides $2 billion to the Department of Health and Human Services (DHHS) and another $17 billion to defray costs of health care providers who adopt an EMR system.

Government financial support is required if a fully functional, interconnected EHR is to become a reality. A 2003 report by the Center for Information Technology Leadership notes that while physician practices shoulder most of the cost for EHR implementation, they accrue just 11.6% of the benefits.⁴ Therefore, the federal government devised a program of positive and negative incentives. Medicaid and Medicare providers are eligible for up to $64 000 and $44 000 in incentives, respectively, over 5 years. If physicians fail to implement an EMR system by 2015, they will be penalized through lower Medicare reimbursement levels with reductions of 1% in 2015, 2% in 2016, and 3% in 2017 (Table).⁵ After this time, the secretary of the DHHS will determine if further payment reductions are needed to stimulate the use of EMRs.

To qualify for EMR incentive payments from the federal government, physicians must demonstrate “meaningful use” of an approved EMR program designed to advance health care quality, efficiency, and patient safety.⁶ The proposed rules regarding the EHR Incentive Program for the Medicare and Medicaid Programs of the DHSS are 33 559 words long. These initial proposed rules also describe the certification process. “Meaningful use” requires Internet connectivity and is a moving target with 3 phases. Physicians must demonstrate increasing EMR functionality over a period of years.

Stage 1 criteria (2011) focus on

electronically capturing health information in a coded format, using this information to track key clinical conditions and communicating that information for care coordinating purposes, consistent with Medicaid and Medicare law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.^{7 (p2016)}

Specific objectives (metrics) will be devised. Demonstrating “meaningful use” will require the physician to meet a certain number or percentage of objectives.

Stage 2 criteria (2013) expand on the stage 1 criteria and

encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood, microbiologic, and pathologic tests and other such data needed to diagnose and treat disease).^{7 (p2016)}

Other areas include medication management, support for patients' access to health information, transitions in care, quality measurement and research and bidirectional communication with public health agencies.⁶

Stage 3 criteria (2015)

promote improvements in quality, safety, and efficiency, focusing on decision support for national high-priority conditions, patient access to self-management tools, access to comprehensive patient data, and improving population health.^{6 - 7 (p2016)}

The proposed rules also detail a 2-phase EHR certification system. Currently, there is no government-backed organization with the authority to certify EHR systems or vendors. The first phase (temporary certification) will authorize organizations to test systems. The second phase will introduce a permanent process administered by an outside agency to accredit certifying bodies.⁸ Certification Commission for Health Information Technology (CCHIT) Certified programs are certified by an independent group that inspects the integrated functionality, interoperability, and security of EHR systems using criteria developed by expert work groups.⁷ They hope to gain government certification status but have not yet received it. The combination of complexity and vagueness in the government's “meaningful use” standards is exasperating, to say the least, and represents just one of the complex issues affecting a dermatologist's decision to implement an EMR system.

The great hope is that EMRs will improve medical office efficiency just as medical practice management systems have revolutionized billing and collections. An EMR system may decrease overall practice operating costs in the primary care setting. Reported changes in operating expense range from $330 000 in net savings to net losses of $2300.⁹ The choice of system and effective implementation strategies may explain this wide range of gains and losses.⁹ On the one hand, a study in ambulatory offices of an academic medical center showed decreased costs of long-term management and upkeep with an EMR system compared with paper-based and transcription-dependent practices.¹⁰ On the other hand, the dermatology group, among the 5 practices studied, incurred significant losses when they went from hand-written paper to transcribed notes without implementing a more cost-effective templated, real-time documentation system used by the other offices.¹⁰

There is a significant potential to increase efficiency through document management within a dermatology office practice. Computer servers store large volumes of information in a very small space, opening up file areas that can be converted to other productive uses. In addition, employees dedicated to the preparation, filing, upkeep, and management of medical charts can be eliminated or retasked. One study showed a 79% reduction in “chart pulls” after 6 months and 96% after the first 2 years of EMR implementation.¹⁰ An internal review of the Department of Ambulatory Care and Prevention at Brigham and Women's Hospital estimated a savings of $5 for each chart pull that was eliminated.⁹ In addition, the potential for catastrophic loss of medical records is diminished when electronic information is backed up off-site. These financial savings are diminished by the cost of information technology support. It is possible to purchase inexpensive systems with unstructured data entry (scanning) to accomplish these goals by archiving written records or typed records without an EMR system. Such records, however, cannot be easily searched and do not permit seamless data entry or graphing of laboratory data.

The efficiencies of EMRs are most important at the interface of the physician and patient in the examining room, since the physician's time is the most valuable resource of the dermatology practice. Efficiency in accessing and charting information should decrease the length of time required for a patient visit. In practice, however, the evidence is mixed. In one study, the time required for seeing a new dermatology patient in consultation was significantly greater using EMR (19.15 minutes) compared with 15.70 minutes with paper-based encounters. However, EMRs proved to be superior when follow-up visits were timed (9.7 minutes vs 10.3 minutes).¹¹ A study in specialty care practices demonstrated no significant difference in the time required to see patients comparing EMR vs traditional systems.¹² Then again, many organizations have found that they can see fewer patients after an EMR system is instituted, and there is certainly a steep learning curve, during which time dermatologists should plan on patient visits taking longer.

Though no ideal system currently exists, the fully compatible EMR of the future should allow for other special efficiencies. Constantly updated information should be available for all physicians tending to the patient. Time-saving tools, such as disease-specific templates for common complaints and formatted procedure notes, should speed documentation of routine office procedures. For instance, notes prepared with electronic templates required less time for completion and review and had fewer errors than a free-form system for Mohs surgery.¹³

Among the most enticing components of the EMR is the ability to implement automatic billing and coding by integrating information from the patient history and encounter with a data bank of International Classification of Diseases, Ninth Revision (ICD-9) codes. The automatic coding may produce more accurate and appropriate billing of both routine and complex patient encounters. The University of Rochester pilot study found an increase in higher encounter codes (99214 and 99215) and a decrease in lower encounter codes (99211, 99212, and 99213) after implementation of an EMR system.¹⁰ Finally, the EMR offers medical information at a moment’s notice at any location. In the office, the dermatologist can as easily access a medical chart for a walk-in patient or for after-hours telephone calls or e-mail questions.

Interestingly, a systematic review of all studies on the cost and benefits of EMRs concludes that there is insufficient evidence on the effects of EMRs on quality, efficiency, and costs to determine the financial effects of adoption.¹⁴ A more recent study suggests that benefits in administration and data acquisition are clear, but additional studies are required to assess potential benefits in efficiency in the community.¹⁵

Electronic medical records have been recommended by government organizations such as the DHSS,¹⁶ the Agency for Health Research and Quality,¹⁷ and the Institute of Medicine. Findings from a national survey of outpatient physicians in 2008 showed that most liked their EMRs and believe that EMRs improve overall quality of care.¹⁸ It is difficult to generalize this data, however, since only 4% of physicians surveyed had a fully functional EMR system, and these early technology adopters are certainly not a representative sample.

Electronic medical record systems could have an impact on health care quality in several areas. Medical charts are rarely lost in an electronic system, and this certainly has an impact on quality. However, no charts are available if there is an electricity outage in the absence of a back-up generator. User-friendly image management software would enhance dermatology records.¹¹ The ability to track disease progression and search image databases by patient age, sex, location of image, disease process, procedure, and date would be particularly helpful.^{19 - 22}

While this is currently the rare exception, an EMR system is maximally effective when the entire health care system shares information. Optimally, new laboratory values, radiology reports, dermatopathology reports, and consultations from other physicians are flagged for daily review and then automatically inserted into the EHR. The challenge is to seamlessly meet the needs of a variety of health care professionals in the development of compatible EMRs.^{11 ,23} Health Level 7 computer standards are the first step in allowing medical records to be imported and exported. This does not, however, represent true interoperability because each individual computer software system must be redesigned to handle arriving data. In fact, the specifications for a true interoperability system do not yet exist. Many physicians are wary of making large capital expenditures for an EMR package that may soon be obsolete because of compatibility issues.¹⁹

The effect of EMRs on the interaction between the physician and patient is of critical importance. Surveys before and after the introduction of an EMR system have shown that patients perceive no change in the interaction with the physician.^{24 - 25} Each physician, however, will need to be cognizant of the potential for patients feeling less engaged. This is particularly true when physicians are typing into the medical record with their back or side to the patient.²⁶ Laptop tablet computers may eliminate this problem.²⁷ Alternatively, computer scribes can enter information during the patient encounter, but this adds to administrative costs. It is particularly important that the physician does not allow computer-induced frustration to color his or her interaction with the patient. In addition, patients may worry about the inclusion of sensitive medical information or images that may not be perfectly secure, as judged by recent episodes where millions of credit card numbers were compromised by computer hackers.²⁸

A RAND Corporation study in 2005 concluded that implementing a nationwide EMR system could produce up to $81 billion per year in savings, while annual costs of such a system were estimated to be $17.2 billion.²⁹ Most savings would be accrued by reducing hospital lengths of stay, nurses' administrative time, drug use in hospitals, and drug and radiology use in the outpatient setting.²⁹ Interestingly, only 4% of savings are predicted from other outpatient expenses that include decreasing drug interactions, fewer adverse drug events, and better care of chronic disease.²⁹ A Congressional Budget Office report in 2008 suggests that this study of potential savings is wildly optimistic when compared with the likely savings from the introduction of this technology.³⁰ Of course, dermatologists must make decisions based on their own business plan. An EMR system for a solo private practice will cost approximately $50 000 for software and implementation and new hardware (tablet computers, workstations for the front desks, and Wi-Fi and telecommunications systems). Compatible software will cost approximately $15 000.³¹ An average annual fee per physician for maintenance of the system is approximately $8000.³¹ Government incentives may provide payments for purchase of an EMR system, but the ongoing costs must be borne by the practicing dermatologist.

The ability to access information on millions of patients through compatible EMRs has exciting implications in medical research. Identifying patients with a specific condition would allow treatment protocols to be established that can be paired with outcome measures. In the event that a medication is taken off the market, dermatologists could quickly find a list of patients taking that particular medication and inform these patients of the need to choose an alternative agent. Third-party payers (Medicare, Medicaid, or Department of Veterans Affairs) may also use information gleaned from the EMR to identify evidence-based outcomes with the potential to alter practice patterns and diminish costs.

The federal government must determine the owner of each patient's EMR, the parties responsible for security of these records, and the degree of liability of each party. Paper records are owned by the physician.³² The patient has the right of privacy as well as access to this paper medical record.³² The physician must maintain the records and may provide a copy of the record as directed by the patient's for a reasonable fee. Legal uncertainty remains as to who owns the EMR.³² With the government's requirement that EMR be shared among health care providers, new problems arise. Should the government or third-party payers have unfettered access to these records? Which health care providers are permitted access? Who holds the key to permit access to the record? Furthermore, there are security concerns with respect to breach of confidentiality when each EMR record is released and when security breaches expose multiple records. Thefts of great magnitude (1.4 million records were stolen from the University of California at Berkeley) were impossible with paper medical charts.³¹

e-Prescribing (e-Rx), the electronic generation of medical prescriptions, is another significant component of many EMR systems. The elimination of illegible prescriptions is certainly a laudable goal. In one study, it was shown to be cost-effective in the outpatient setting.³³ Medicare has begun awarding bonuses to physicians who adapt their offices to e-Rx. Penalties will soon follow. Physicians not using e-Rx by 2012 will see a 1% reduction in their Medicare reimbursement. Penalty rates rise to 2% in 2014 and thereafter.⁵ There are both benefits and drawbacks to e-Rx.

Medication errors are ubiquitous and are associated with an estimated 25% of ambulatory care patients.³⁴ Some of these errors lead to adverse reactions. The e-health initiative suggests that the universal adoption of e-Rx could save as much as $27 billion.³⁵ Many e-Rx programs automatically search for drug interactions, alerting the physician when they occur. e-Rx systems may also reduce errors associated inappropriate prescriptions.³⁶

e-Rx may be particularly useful in the field of dermatology. A limited spectrum of specialized medications and treatments is used in the treatment of many skin conditions. The automatic generation and storage of these prescriptions can potentially increase office efficiency, since current prescription medications appear on the computer screen and can be renewed instantaneously or adjusted. In addition, these prescriptions can be automatically faxed to the patient's pharmacy of choice, eliminating the waiting time associated with “dropping off” prescriptions.³³ Of course, all medications and dosages, whether dermatologic or not, must be entered into the system and updated each visit. In addition, all errors will not be eliminated. Point and click systems can cause errors in generating prescriptions that have similar initial letters or slight variations in dosage. For dermatologists without an EMR system, stand-alone e-Rx systems, such as AllScripts (AllScripts-Misys Healthcare Solutions Inc, Chicago, Illinois) are available. They may have up-front costs and yearly subscription costs, though a free version is available.³³

There are a number of unintended consequences that can occur when physicians adopt an EMR system. Older physicians, many of whom cannot even type, may retire early when confronted with nonuse penalties. Since half of dermatologists are older than 50 years, this exacerbates the dermatology work-force crisis.^{37 - 38}

Another problem is associated with EMRs that use “pull-down” menus to generate a review of systems and negative physical findings automatically. The physician need only enter positive findings. This efficient charting of routine visits can quickly produce 20 pages of information that represent a “bullet-proof” medical chart for coding purposes. Unfortunately, these medical records are so cumbersome that it is difficult to find the diagnosis and treatment plan needed to render subsequent care efficiently. Other physicians may simply copy and paste visit notes with minor changes, leading to dull repetitive notes devoid of relevant information. This practice curbs creative clinical thinking and produces information overload.²⁶ Ultimately, the best medical record is one that is manageable and enhances the potential of providing high-quality care.

Another potential consequence of EMR is the enhanced ability of the federal government and other third-party payers including insurance companies to perform real-time audits of dermatology practices to manage the delivery of medical care. This could be helpful in some circumstances, but it represents a significant intrusion into the physician-patient relationship if it focuses on rationing care to save money.

Perhaps the most cumbersome unintended consequence will occur after the EHR is mature. Each patient may have a massive EHR with information from many physicians, laboratories, and pathology laboratories. It may be nearly impossible to find the time required to collate and summarize data for each new patient from an overwhelming amount of medical information. Reimbursement will need to be dramatically increased to cover the time required for digital medical chart review. Unified problem lists, allergy lists, medication lists, and summaries are helpful but still must be confirmed and updated.

Each dermatologist must carefully consider all of the costs, benefits, and consequences involved in the introduction of EMRs as they relate to their specific practice. The system chosen should be compatible with health information technology systems used by nearby hospitals, laboratories, physician groups, and contracted insurance companies. Most importantly, dermatology practices that accept, or anticipate accepting, Medicare or Medicaid must consider implementing an EMR system while the government is offering incentives and before they impose penalties. Of course, this decision is currently complicated by the incomprehensible “meaningful use” proposals.

The Congressional Budget Office 2008 report suggests that physicians in small practices might gain little from implementation of EMR because their practices are too small to benefit from the efficiencies they create.³⁰ Expensive EMRs with the most comprehensive feature list are not appropriate for most small or solo practices. Newly opened dermatology practices and those in the planning stages are better positioned to implement an EMR system because they have more time to customize systems to fit their needs. Furthermore, younger physicians who are exposed to EMRs in their residencies may more easily adapt to electronic systems.

Mature dermatology practices should consider appointing an EMR advocate (physician or office manager) to explore costs, benefits, barriers, and risks associated with an EMR system. The advocate would implement the program and foster staff EMR education. Several vendors should be interviewed, and EMR continuing medical education programs can be excellent sources of information. Dermatologists who do not see Medicare or Medicaid patients are best advised to wait until specific parameters for a fully compatible national EMR system are released. This is particularly true of cosmetic or “cash-only” practices. Dermatologists who anticipate retirement within 5 to 10 years may choose to avoid implementing an EMR system.

Multidisciplinary practices and academic practices should consider implementing an EMR system. With greater numbers of physicians using EMRs, individual costs are lessened and more overall income may be obtained from government incentives. Choosing a system that will satisfy the wants and needs of many physicians may be more difficult and will require a longer period of planning. This is particularly important for teaching programs because most graduating residents should be exposed to this technology. Academic centers are also well positioned to perform the research needed to elucidate the costs, risks, and benefits of this technology as it affects medicine in general and dermatology more specifically.

Correspondence: Robert T. Brodell, MD, Dermatology Section, Northeastern Ohio Universities College of Medicine, 2660 E Market St, Warren, OH 44483 (rtb@neoucom.edu).

Accepted for Publication: June 2, 2010.

Author Contributions: Drs Brodell, Grosshandler, and Tulbert had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Grosshandler, Tulbert, Bhatia, and Brodell. Acquisition of data: Grosshandler, Tulbert, and Kaufmann. Analysis and interpretation of data: Grosshandler, Tulbert, Kaufmann, and Brodell. Drafting of the manuscript: Grosshandler, Tulbert, and Kaufmann. Critical revision of the manuscript for important intellectual content: Grosshandler, Tulbert, Kaufmann, Bhatia, and Brodell. Administrative, technical, and material support: Grosshandler, Tulbert, Kaufmann, and Brodell. Study supervision: Bhatia and Brodell.

Financial Disclosure: Dr Bhatia is the cofounder of derm.md and The Derm Education Foundation that has developed MARS, a desktop application used to log Mohs surgical information. Dr Kaufmann is on the medical advisory board of an electronic medical record company, Modernizing Medicine Inc. Dr Kaufmann is co-chair of the Dermatology Work Group of the Certification Commission for Health Information Technology (CCHIT). Dr Brodell does not have an electronic medical record in his office. Drs Bhatia and Kaufmann use an electronic medical record. Dr Brodell has been on the speaker's bureaus for Allergan, Janssen, Roerig-Pfizer, Sandoz/Novartis, Westwood-Squibb, Galderma, 3M/Graceway Pharmaceuticals, Upjohn, American Osteopathic Association, Connetics Corporation, GlaxoSmithKline, Dermik/BenzaClin, Genentech/Raptiva, CollagGenex Pharmaceuticals, Novartis Pharmaceuticals Corporation, Pedinol Pharmacal Inc, Stiefel, Sanofi-Aventis, and Medicis and has served as a consultant, as an investigator, or on the advisory board for Janssen, Galderma Laboratories LP, Sirius Laboratories, Medicis, Connetics, Genentech Inc, MDsConnect.net, and Dow Pharmaceuticals Sciences. Dr Bhatia has been on the speaker's bureaus and/or has served as a consultant and clinical trainer for Johnson & Johnson, OrthoDermatologics, Galderma, Ranbaxy, Suneva, Medicis, Sanofi-Aventis, Cutera, Candela, Lasering USA, and Bioform/Merz.