Are you among the many American physicians who have resisted jumping onto the electronic wagon? Are you dreading the day you will be forced to transition to electronic patient files? You are not alone, but this day may come sooner than you expect. IMWR looked into some of the reasons that may compel you to begin to consider implementing e-health in your practice.

The introduction of electronic technology into primary care is still a subject of debate. Many physicians object to the high costs involved, the time needed for implementation, security issues, and the lack of appropriate reimbursement for this demanding effort. Others argue that the benefits of e-health technology override these objections, and that resistance to this technology is dooming US healthcare to the dark ages.

A 2006 international survey sponsored by the Commonwealth Fund, which included more than 6000 physicians, showed that US primary care physicians lack the electronic tools or support to provide the best care to their patients. Only 28% of primary care physicians in the United States use electronic medical records (EMRs), surprisingly trailing behind countries such as the Netherlands, New Zealand, and the United Kingdom (Figure).

Electronic Patient Charts
Richard Hays, MD, a family practice physician in Palm Beach, Fla, is among the growing numbers of American physicians who are embracing e-health technology and are touting its benefits. Dr Hays tells IMWR he uses SRS Software's Freedom Chart Manager program, which received the first honors award at the national conference Towards the Electronic Patient Record in 2006.

The Freedom Chart Manager is one example of patient chart software that combines work flow tools—such as messaging, electronic prescriptions, referral order management, integrated transcription services, and customized flow sheets—with a document management engine that eliminates the need for paper charts without compromising patient privacy and safety.

Dr Hays decided to use this specific software for his practice 3 years ago, after a "chain reaction of events" that involved problems with storing thousands of active and inactive patient files.

To avoid having to store and retrieve around 6000 inactive patient files, Dr Hays decided to scan them onto CDs, but he was then faced with finding a way to store his 5000 active files. He started looking into different electronic options. "One of the things that a lot of my colleagues had been doing was converting to electronic health records that did not allow them to do anything with their old files. So, as long as they had old files, they still had files and a computer. That just didn't seem to make a whole lot of sense. And the other idea that sort of dovetailed into this was that we could do a better job managing our documents—we were constantly chasing charts around."

The SRS software offered a way of getting rid of paper patient charts. "Having had this recent experience with scanning everything, the SRS Freedom Chart really appealed to us, because it allowed us to scan in all those 5000 charts right into our system. Once we got to that point, we didn't have any more paper charts."

Although the entire process took approximately 6 months, the time to install the program and get up to speed took only 20 minutes.

Dr Hays acknowledges that the start-up costs of implementation can be prohibitive for many physicians. "This was not cheap; this was $30,000, and for a primary care physician that's a pretty big chunk of change." But even with this high price tag, he says, the system "basically pays for itself. Right now our costs are mostly maintenance, which is fairly modest. It has provided me the opportunity to work from home on charts." Also, whereas before his practice had to archive all charts "because we used to get overloaded," now things are there in perpetuity, he adds.

Because of the initial cost of this particular program, Dr Hays stresses the importance of looking carefully into the different applications available and the companies that provide them. "There are so many different products out there," he points out. You want to make sure the system you choose is the right one for your office. "It's a lot of work, and if you put it in and then you throw it away, it can leave a real bad taste in your mouth. You don't want to get in with a company that's going to disappear on you."

The SRS software program, and potentially others, allows you to:
• Get rid of all paper charts and use only digital charts
• Use a tablet computer when you see patients and access patient information as needed
• Access all patient information at home
• Access all the information on any office workstation, allowing you to move from chart to chart with ease
• Create an unlimited number of tabs within each chart, using subsections and adding information as needed
• Improve accuracy, minimize errors
• Provide accurate information quickly to other physicians treating the patient
• Save time.

Using electronic charts can save you time, he says. "When you realize that you weren't doing a lot of this stuff before, and now you're doing other things that you should have been doing" you begin to appreciate the benefits of this program.

And you can actually increase patient safety, while adhering to HIPAA requirements, according to Dr Hays. "Before, when we were doing paper charts, everything was on sticky notes. A lot of times sticky notes didn't find their way into the chart. So there was no paper trail, and you often didn't know what you gave a patient. Because of this, we do all interoffice e-mail, everything has a HIPAA trail, and you know who signed on and who signed off. It's all right there."

It Takes a "Tech-Savvy" Physician
There are many reasons why American primary care physicians are lagging behind their counterparts in some other countries, Dr Hays notes, such as the inherent problems associated with an EMR. "Many physicians are encouraged to adopt an EMR. So they go ahead and get an EMR….The learning curve is intensive for use, the up-front cost is high, and it's only as good as what you put into it. Plus, it doesn't solve their document problems or their old chart problems."

Another issue is that to successfully manage e-health technology, physicians need to be "tech-savvy," he says. "If you're not, you are going to have a hard time with the glitches that occur on an almost daily basis in the system. If you don't have the ability to do that, you're not going to want to get into it."

Another intimidating aspect of e-health technology is that it doesn't have the free and easy correctability that paper-based record keeping offers. "If you mess up on a piece of paper, you throw it out and get another piece of paper. If your whole network shuts down, you're in trouble."

For the healthcare industry as a whole to embrace e-health technology, management software that can interface seamlessly with other programs is key. Choosing the right program can be taxing. "People get dizzy just trying to figure out which one is best for them. The government talks about getting everyone together under an EMR. But what if everyone has an EMR, and there are 500 different EMRs out there?"

Admitting that the Freedom Chart Manager is not perfect, Dr Hays says that because it is portable document format (PDF)-based, it interfaces well with other systems he uses. "It allows everything that comes in to blend in with it. It kind of makes you the ‘O positive' of document managers," he observes.

Impact on Patients
Evan Steel, CEO of SRS Software, tells IMWR, "A patient's paper chart can only be in one place at one time, which impinges on the level of patient care that a physician can provide. When physicians, nurses, and staff can access charts anytime from anywhere, patient care increases, as patient issues can be dealt with instantaneously rather than waiting hours or days to get the paper chart in the hands of providers."

When asked what it will take to encourage US physicians to integrate e-health technology into their practices, Mr Steel says, "The slow EHR [electronic health record] adoption rate is due to EHR's negative impact on physician productivity and income. Software that increases patient care, while not decreasing physician incomes, is key to speeding up healthcare IT adoption. This is an industry that is smart to be cautious, because patient care is at stake."

Electronic Faxing
At the recommendation of SRS Software (www.srssoft.com), Dr Hays also implemented Faxination (www.fenestrae.com), a server that allows faxing through Microsoft Exchange and Outlook.

"Everything that comes in by fax goes right into the computer, so we no longer have pages and pages of faxes. And it got rid of a lot of our junk fax. Everything else we convert to PDF and drag and drop it into the [patient] chart," he explains.

By implementing this software, Dr Hays notes that his stack of mail has gone from 12 inches to 2 inches, and that there are only a few healthcare practices in his area that are unable, or unwilling, to fax information to him.

ONLINE EXTRA
Treating Your Patients Online
In addition, Dr Hays uses Relay Health (www.relayhealth.com), an online portal that provides secure communication for healthcare practices. This service allows him to provide online clinical services, such as e-mail correspondence with patients, sending electronic prescriptions anywhere in the country, and performing online visits to resolve patients' nonurgent healthcare needs, which are reimbursed by the patients' insurance plans.

"Patients send us an e-mail and don't have to wait around for the phone to get picked up, and we send them any file they want. And the really nice thing is that, say you're from Florida, and you go to Las Vegas, and you get sick while you're there. You can just log on and do a visit from there, and they have all the pharmacies in the country, so if you need an antibiotic prescription I can send you an e-script, and you can point it to the nearest pharmacy," Dr Hays explains.

He adds, "I've got patients, and if they can't leave work they do an online visit, and their insurance pays for it. They just log on and pay a copay. I think patients recognize that it's a symbol of keeping up. It gives them a bit of extra confidence—if you're keeping up on that, they think you're keeping up on your medicine too. You're a 21st century practice."