Despite potential to boost reimbursements, EHRs remain a challenge for primary care docs

As healthcare providers--in particular, those from primary care practices--continue to implement and work with electronic health records, some are seeing an improvement in reimbursements, according to Michael Howley, Ph.D., a certified physician assistant and associate clinical professor in the department of marketing at Drexel University.

One of the biggest keys, according to Howley, who last summer co-authored research on the financial implications of EHRs published in the Journal of the American Medical Informatics Association, was improved billing of ancillary procedures.

"All of these little things that you do at your doctor's office even though you tend not to think about like drawing blood, getting a vaccination, maybe having a medical test done in the office and they were billing a lot more of these procedures in the primary care practices," Howley told FierceEMR.

In an exclusive interview, Howley discussed the surprises behind the study's findings and the impacts--both positive and negative--that EHRs continue to have on healthcare providers.

FierceEMR: Why did you decide to conduct a study on EHRs and reimbursement?

Howley: We were hearing these reports [on difficulties with EHRs] and looking at the research. There's a lot of interesting research on the implementation of EHRs, but they're looking at things like the effect on quality and people were trying to look at financial metrics such as how much did providers save on paper costs. We thought it would be a useful contribution to look at the actual financial transactions of these practices and compare what was going on before and after implementation of an EHR.

FierceEMRWhat results and trends did you and your colleagues find? What was most surprising?

Howley: The thing that hit us immediately was that these practices were seeing fewer patients after they put in an EHR. They trended downward for two years. So that was the major impact, that this was a real struggle for them.

They install these EHRs, productivity starts to decline a little before they put them in and then they implement the EHR and boom--for two quarters, productivity goes down--and it recovers a little bit the next quarter and then continues to drop. That was the most impactful thing. Then looking at other financial impacts, it was more of a subtle story, but it was apparent that revenues and reimbursements were trending upward.

It came as a puzzle. How can this be that they're seeing fewer patients but their reimbursements are going up? What we found was the only practices where reimbursement was going up were the primary care practices; we found they were all coming from ancillary procedures. These are small dollar value items, so we're not talking about $1,000 procedures here. The EHR seemed to stimulate the billing and reimbursement of these ancillary procedures.

We then asked, 'why is that happening,' but that's where we hit a wall. Is the EHR reminding the providers to, say, give a vaccination or check a urinalysis for a diabetic patient? Is the EHR reminding the providers to conduct the test? Or is there something about the EHR that they're just capturing better the need for such tests? Maybe they're better able to document that they're doing these tests and bill them. That was beyond our data; we could not tease that out.

It's an interesting commentary on technology, that it's the small things that matter. These technologies have leverage where they impact a lot of different areas.

FierceEMRAs providers become more familiar with EHRs, how will that impact reimbursement?

Howley: Eventually, the providers will become more familiar with using these technologies and the productivity will recover. I'm not sure how long it's going to take. I've seen commentaries where people in the industry have made the point that this is a different approach to documentation so we need to change how we document using the medical record. That's going to take a lot of time, and might even take a generation of physicians coming through the system.

FierceEMR: What are your thoughts on the broad impact of EHRs on providers?

Howley: Within the provider community, the electronic health record has been very controversial. There are clearly potential benefits to using EHRs: the availability of data that's not constrained by geographic area; the potential for improved care and quality of care is there. But for most providers, converting to EHRs is a big pain in the neck. It's a very, very difficult challenge.

Providers are not able to see as many patients after they put in an EHR, and they have to spend hours in the evening catching up on documentation because they are so far behind on seeing patients during the day. They complain that the systems are clunky, the software interface doesn't align with their clinical algorithms and about how they think about clinical problems in their heads.

FierceEMR: And about the Meaningful Use program?

Howley: It pushes people to get more involved who perhaps wouldn't otherwise venture into these areas. The early adopters are jumping into this system; they're going to grab it, and work with it and try to make it work better. But Meaningful Use also brings the laggards into the picture, the late adopters, and those are the types of organizations that will struggle.  

FierceEMRHow can providers better use EHRs and other technology to improve reimbursement?

Howley: I have seen a lot of organizations using their EHR in ways that improve the quality of their care, improve the value of their care and improve their reimbursements. You can be looking into your data to identify what kind of services you can provide. For instance, if you're watching the trends in your practice, you can find that the number of diabetics is going up and say 'we need to offer these services for diabetics, we need to buy these new capabilities.'

Editor's Note: This interview has been condensed for clarity and content.