Electronic Health Records

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How Changes in Primary Care Delivery Impact EHR Selection

EHR selection in a post-fee-for-service world will likely lead potential EHR end-users to prefer certain EHR technology and functionalities to others.

By Kyle Murphy, PhD

- The EHR selection process is about choosing the right tool for the right purpose. If EHR technology is to support care delivery, then its functionalities must be well suited to the clinical workflows of its end-users. This is hardly a reality given the vocal reaction to the notion of one-size-fits-all in the context of EHR adoption.

Dr. Dan Weeden talks EHR selection for direct primary care

Heretofore, the rejection of a one-size-fits-all EHR technology stems from the experiences of non-primary care physicians for whom popular EHR products are not geared. But the transition from fee-for-service to value-based care adds another wrinkle to the national dialogue.

For the past year, Daniel S. Weeden, MD, and his colleagues have embarked on a new primary care endeavor, breaking out on their own to set up a direct primary care service in northwest Arkansas.

Similar to value-based care, direct primary care is an alternative to fee-for-service, most notably in preventing the utilization of more costly hospital services. While the outcome is not value per se, it certainly stands at odds with the traditional model of reactive, service-based care.

Throughout his career as a primary care and pediatric physician, Weeden has served as both an employee and employer and with it an array of experiences with EHR technology.

READ MORE: Judy Faulkner: Epic Will Offer New Cost-Effective EHR Options

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READ MORE: US Coast Guard Searching for Commercial EHR to Replace Epic

In this one-on-one interview with one of the founders of the Direct Care Clinic of Northwest Arkansas, Weeden provides insight into his EHR journey and the motivations behind choosing the right EHR technology for his practice.

EHRIntelligence.com: How does direct primary care compare to traditional care models?

Dan Weeden: It's 180-degrees different. The basis of it is pretty simple. It is based on a premise that primary care is not the costly part of medicine. If you look at the big picture, primary care is routine, scheduled, fairly predictable. It doesn't need to be insured. We don't insure changing the oil in our cars. You really need to insure the catastrophic or more major stuff like at the hospital that's totally unpredictable. You spend three days in the hospital and it can be $30,000-$40,000. That's our starting premise.

With affordable care, everything is going to a high-deductible plan because of cost. People who are fairly healthy are realizing that if they have a $3,000 deductible and go to a regular fee-for-service, they are going to be paying deductible all year. Their insurance isn't going to cover anything. For us, we charge a flat monthly fee. Fifteen percent of our folks have no insurance. A direct primary care office fee is $50-$60 a month per person. It is very affordable.

The big difference, too, is that my practice at Mercy was fee-for-service and for every doctor in our building we had four employees. So the overhead is 70- to 75-percent. Our setup is that we have gone from every doctor having four employees to for two physicians we have one nurse. Actually this week we just hired a part-time receptionist. Before that there were just three of us. Overhead is about 30 percent.

EHRI: Describe your experience using EHR technology throughout your career?

DW: I'm an old enough guy that is was a necessary evil. We weren't really excited about it. Mercy built a new hospital and when we went live with the hospital, we converted to electronic medical record. We used Epic. As far as an electronic medical record, I have the most experience with the Epic EHR.

I am somewhat biased because our medical record experience right now is so much different because our practice is so much different. Coming from the Epic EHR, it was fee-for-service driven; had lots of stop signs; had a lot of hard stops. We didn't like those because it meant we had to click another button and do different things just to sign the chart. But Epic is a very broad, robust medical record. That was the experience we had with that.

One thing tied to my experience with electronic medical records is meaningful use. From my standpoint as a primary care doctor, I totally understand how they came up with the meaningful use idea. But the problem is that when you bring in the government and meaningful use and use a useful tool like an electronic medical record, all the sudden the record starts driving the care. The frustration with doctors and electronic medical records is — the electronic medical record isn't working for them; it's like they are working for the electronic medical record.

I don't think that's peculiar to Epic. That's the way all the metrics of meaningful use have been pushed out. There's nothing wrong with any one metric, but cram it in to a ten-minute appointment — that you've got to cover all the bases and then click a button at the end because they say you have to click it.

EHRI: How did EHR technology factor in to starting a direct primary care practice?

DW: You have to realize that this direct primary care is so, so different without doing insurance. We're physicians, not business people. We were learning on the fly. We went with a medical record called Atlas.md that was built by guys who are doing a very similar practice that had actually helped us. We had gone up to Wichita to meet with them. There are three family practice guys. They had a software guy write their own medical record. And it had its definite benefits in that it was reliable, but after using it for three to four months we came to the conclusion that it was geared much more toward family medicine. It didn't have any pediatric component. For lack of a better term, the whole chart was lumped in to a huge pile. My contention is that doctors don't think that way. We're much more problem focused.

My experience now is dramatically different. We started the practice in January of the last year. We actually used Kareo which was free. Essentially, we were thinking we didn't need much in terms of a medical record, just the bare bones because we weren't going to do any billing. But we found that for several reasons this wasn't reliable. We couldn't get it to work. They would be down. We could never reach anybody. Even though it was free, it was costing us.

EHRI: What ultimately drove you to the EHR selection of Amazing Charts and InLight EHR?

DW: We were definitely going to use electronic even though we don't have to. In our practice, you could do paper. Nothing says we have to do electronic. When you have to do ICD-10 billing, you have to have a computerized record. It would just be terrible without it. We do some coding if we want to get a MR scan you have to have the diagnosis code. It is nice to have that.

We have been a testing site for Amazing Charts and given them feedback and helped build it. It has been a fun process to be able to say, "This works, but this doesn't work. This is how it's working." We're 80-percent, maybe 90-percent to where we want to be. There are a few things in the accounting part that hasn't fully jived yet. This next upgrade in April or May should fix some of that stuff. We have been very pleased in that they are very, very accessible. I can email or pick up the phone and talk to somebody — granted, we have been involved in the planning and creating phase of it.



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