One Doctor’s Electronic Health Record Story

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A physician in rural Kansas opens up about what an EHR system has meant for her practice.

Dr. Jen Brull has her rural practice in Plainville, Kan., down to something of a science.

The energetic family physician has 1,245 patients, and on its busiest days, her practice sees as many as 40 people. It’s a volume that she says would be difficult to manage without one full-time and two part-time nurses plus front office staffing shared with other community providers. There’s another critical piece of the puzzle, however, to helping her lean practice meet ambitious goals — electronic health records.

“Until you have the real data in front of you,” she says, “you just have no idea how you’re doing.”

A “Champion” for EHRs

Brull was a self-proclaimed “champion” for the EHR as early as her residency in 2001. When she finally transitioned to an EHR system in 2008, she quickly began leveraging the value of aggregate data.

Brull started generating regular reports on the health of her patients. She evaluates smoking status, weight, immunizations and other important indicators of well-being. The data gives her a snapshot of averages and trends, but she can also drill down to individual patients to see over time, for example, how much weight a person has gained or lost and be prepared to address any concerns in advance of a visit.

The data also shed light on areas of Brull’s practice that were weaker than she expected. In 2008, Brull began participating in a quality benchmarking program through the Centers for Medicare & Medicaid Services and used the data contained in patient EHRs to closely evaluate her colon cancer screening rate – it was a mere 43 percent.

“First of all I didn’t believe it, and then I was just horrified,” Brull says. “How could I be missing 60 percent of my patients?”

She aggressively tried to improve the rate and reached 93 percent after three years of identifying lapsed patients. The remaining 7 percent, she says, includes patients who refuse to undergo a colonoscopy.

During that time, Brull discovered that three of her patients had early colon cancer, the type that required no further action beyond surgery. Statistically, she says, she likely would have missed the diagnosis in one or two of those patients had the data not illustrated the larger picture of screening rates in her practice.

“It’s the most powerful thing when you start seeing real human examples of what you could have missed.”

Making a Bet on an EHR

Brull shares these anecdotes with physicians who are skeptical of adopting an EHR system; only 42 percent of U.S. physicians use one that meets federal standards, though more report using electronic records to some degree. In a survey of 3,100 office-based physicians conducted by the National Center for Health Statistics last year, three-quarters of respondents with an EHR system said it enhanced patient care.

Emotional anecdotes to this point are compelling, but many physicians, Brull says, are concerned about practical issues around cost and workflow.

Brull conducted a return-on-investment analysis. Convinced that an EHR system would yield cost-saving efficiencies, in 2005, she lobbied the physicians partnered with her practice to transition from paper to digital charts and records.

When the upfront expense became a concern for some of her partners, Brull offered to borrow the $50,000 necessary to purchase the server, hardware and workstations. Her partners spent about $10,000 on individual software packages. Today, the average cost of an EHR system is about $40,000, according to the American Academy of Family Physicians, and many doctors finance some or all of that amount.

For Brull, it was a plodding process as an early adopter, long before there were national rankings and associations that vetted vendors. She recalls compiling a list of 200 companies, narrowing them first by affordability and other important measures. After settling on three, she and her colleagues made site visits to doctor’s offices to see each EHR in action. Three years of exhaustive research later, they chose the Austin, Texas, vendor e-MDs.

Brull laughs when thinking about how difficult the process was several years ago. At the time, she says, “Our picking an EHR was like buying a car without knowing how to drive.”

But the choice has paid literal dividends: her practice’s baseline revenue has increased each year since making the transition to an EHR system in 2008.

Brull also received an $18,000 payment last year from CMS after she passed the first round of meaningful use testing; she expects to receive a second $12,000 payment.

‘Build it One Piece at a Time’

The transition to digital records was not always easy. Brull is quick to point out that no EHR system is perfect, and that they require work and creativity beyond what the vendor conveys in a sales pitch.

In the beginning, she dreaded working on an electronic chart, but eventually made a rule that she would complete it before leaving the room at the end of a patient visit. She became more thorough with each visit, slowly adding measures of wellness to review, like immunizations and smoking status. Brull is also disciplined about building her own templates.

“I learned how to capture all the information,” she says. “If you build it one piece at a time you realize you can get an awful lot done if it becomes part of the way you do things.”

Many physicians share that sentiment; 85 percent of the respondents in the NCHS survey said they were “very” or “somewhat” satisfied with their EHR system.

For Brull, the occasional frustration inherent to using software is worth the ability to look at a dashboard and see a comprehensive picture of her patient’s health.

“If you do it right,” Brull says, “the data is always there for you.”

Are you a physician? Share in the comments below how an EHR system has or hasn’t changed your practice.


Photo Courtesy Jen Brull