How to measure ROI and practice impact of EHR

Learn to test your software’s capabilities.

By Rishi P. Singh, MD

Like it or not, EHR systems are slated to become commonplace in ophthalmology over the next few years regardless of practice setting, geographic location or subspecialty focus. The implementation of EHR into the medical setting is a topic of debate as it pertains to efficiency, quality of care and its economic impact. The transition to EHR from paper charting can theoretically reduce long-term costs and improve efficiency.¹ Items such as pre-populated fields, one click ordering of diagnostics and procedures and a shared medical record amongst practitioners can potentially increase the productivity of the physicians.

The reality is that studies have instead demonstrated higher costs associated with the transition to EHR systems.^2,3 In these cases, hospital monetary savings that were expected with EHR implementation were offset by the expense of purchasing, training and maintaining the new medical record system.³ These start-up costs are often a reason for reluctance in adopting EHR.

This article will explore the many methods of evaluating the return on investment of EHR and the different metrics by which you can determine just how well your practice is doing.

STREAMLINED PAPERWORK

Minimizing documentation times

EHR start-up costs per physician have been estimated at $10,329 per provider and few studies have evaluated the costs of implementation in the outpatient setting.⁴ So, for these investments, how are practices going to be able to recoup their costs? We have found a variety of methods by which our practice has seen a return on the initial investment. The visibility of the EHR charts allows for the auditing for appropriateness of billing, compliance and documentation by multiple people on our staff. Leveraging EHR tools, such as the ability to receive their most recently filled prescriptions through Surescripts, allows us to populate the medications lists of even new patients quickly. Utilizing sections, such as the medical and surgical history and allergies populated by other practioners at Cleveland Clinic, helped by bringing in historical items into the chart rapidly and minimized documentation times significantly.

Capturing charges

The EHR system has made capturing charges a much more streamlined process. When all Cole Eye Institute billing was done via paper tickets, some diagnostic tests did not get billed if the ticket was misplaced or the interpretation was absent. Now, we are easily capturing 15% more charges as a result of the new system.

In addition, most of the bills to the insurance agencies are processed within two to three days whereas, prior to EHR, we averaged approximately one week before sending out claims.

Audits

The electronic chart has also been useful in cases when CMS or JCAHO audits our facility and is incredibly helpful when an insurance provider is asking for documentation support for prior authorizations. A few clicks and the entire record can be printed and submitted to an insurance carrier for review.

These tasks required many hours in the past by our billing team and now can be handled efficiently increasing our turnaround of appeals for denied claims.

CLINICAL EFFICIANCY

Reduce redundant tests

The availability of the chart and the imaging tests through a universal PACS system also has allowed for a decrease in redundant testing. For example, an OCT performed by a referring physician from our satellite office is visible within the entire Cleveland Clinic system. The specialist can review the image and even analyze on the original raw data files. This saves our group on the labor cost associated with the photographers performing additional tests and improves the throughput in the clinic by not “bottlenecking” any of the diagnostic areas.

This is of special importance since carriers are now limiting a certain number of diagnostic tests to be performed on a patient each year.

Transcription costs

Our use of transcription systems has declined steadily to only a handful of dictations per month. Transcription costs can be incredibly burdensome to a practice with some practices spending as much as $10,000 a month on outside services with quick turnarounds.

In our EHR build, we included an enhanced communication manager capable inserting elements from the eye exam into the letter and the capability of faxing directly from the system.

The Health Information Technology for Economic and Clinical Health (HITECH) $27 billion grant might help offset some of these implementation fees. Our practice was able to attest for Stage 1 for most of our physicians and is in the process now of attesting for Stage 2. Our practice forecasts receiving $983,103 of meaningful use incentives by 2016. This does not come without significant teaching, enhancements, and costs needed to get to Stage 2 meaningful use metrics.

TRACKING THE METRICS

Year-to-date numbers

To determine the success of your EHR roll out, you can rely on the obvious or the not-so-obvious methods. Visit volumes, RVU production and revenue per month are the obvious metrics, but its important to make year-to-date comparisons as these metrics can vary based on the location of the practice.

We strategically rolled out our EHR system in March, 2011, which is historically a lower volume period for our group. This reduced the financial impact of a reduced clinic volume during the roll-out period. When we evaluated our transition a year later, year-to-date comparisons (March 2012 versus March 2011) showed no significant differences in revenue, visit volume and RVU production. However, looking at individual specialties in ophthalmology (retina, cornea, plastics), we saw some significant increases and decreases.

This allowed our practice to go back and perform optimization programs on those specialties that were struggling

Revenue/volume ratio

Another comparison to evaluate is the revenue/volume ratio for the practice. A higher ratio might indicate an increased recouping of procedural and diagnostic fees by the visibility of the record or conversely a rise in testing or procedures that are ordered because of the ease of the system.

Former HHS Secretary Kathleen Sebelius and Attorney General Eric Holder authored a warning to those hospitals that use EHR to “game the system” to their advantage, for instance, when facilities “clone” medical records to inflate what providers are paid. The revenue/volume ratio may be an important indication of whether this is occurring in the practice following implementation. Our analysis showed there was not a statistically significant difference in the ratio a year after implementation.

Measuring productivity

The changes in diagnostic and procedural volumes can also be watched as a measure of productivity after the transition. While some procedures showed increases in the number of tests orders (eg, Optical coherence tomography scans, CPT 92134), the majority showed no significant difference. These changes in coding volumes cannot be attributed solely to EHR implementation, as physician availability and changes in medical indications for drugs and procedures within the observed year may also be a significant factor.

Quality of care

There are a variety of metrics when determining how your practice is doing with the EHR transition. However, none of these measurements necessarily indicate a change in the quality of patient care or allow us to comment on physician productivity with implementation of EHR.

The stability of patient volume observed in our practice does not accurately document physician efficiency nor does it provide a valued observation of improvement in quality of care with implementation of EHR. We hope that further studies will demonstrate ways at which we can add these metrics to the full evaluation. OM

References

About the Author
	Rishi P. Singh is a staff physician at the Cleveland Clinic, and assistant professor at Case Western Reserve University Disclosure: Dr. Singh has no relevant relationships to disclose.