Surgery News - May 2008 - (Page 6)

S U R G E R Y NEWS • M AY 2 0 0 8 THE THE E 20/20 / 0/20 B Y M A RY E L L E N S C H N E I D E R V SION O SIO SION IO Experts Share Strategies for Adopting Electronic Medical Records That adaptation can take months and slow down the practice in the meantime, said Dr. M. Michael Shabot, system chief medical officer at Memorial Hermann Healthcare System in Houston. His recommendation to surgeons is to trim the office schedule by about half for the first few weeks when implementing a system. “It’s literally money out of your pocket,” said Dr. Shabot, an ACS Fellow. But one way to manage costs is to partner with a local hospital or health system. In 2006, officials in the Health and Human Services Department issued regulations creating new safe harbors in the Stark physician self-referral law and the federal antikickback statute. Under the regulations, certain health care organizations, such as hospitals, can subsidize a substantial portion of the cost of EMR software, information technology, and training services for private physicians without running afoul of the law. Physicians who enter into these arrangements are required to pay 15% of the donor’s cost of the EMR technology and services. “This made it a lot more feasible,” said Dr. Shabot. In the past, very few solo and small practices could afford to make an investment in an EMR with a price tag ranging from $50,000 to $100,000, Dr. Shabot said. The combination of the safe harbors, new laws requiring e-prescribing, and the demands of pay-for-performance programs will drive adoption strongly, he said. For example, Memorial Hermann Health Network Providers, the largest independent physician organization in Texas, recently began offering a heavily discounted EMR to affiliated physicians. Under the arrangement, each physician pays a monthly fee of $325 for software and support services, said Scott Fenn, CEO of the Memorial Hermann Health Network Providers. Currently 29 physicians are using the system and more than 100 others are preparing to implement it, he said. While the regulations prescribe limits for the collaboration, most of the details are left to hospitals and physicians to work out on their own, so the arrangements often vary, said David Merritt, project director for health information technology at the Center for Health Transformation in Washington. One potential drawback of such collaborations, however, is that some hospitals might push out their own EMRs, which can differ significantly from technology designed for the ambulatory setting, he added. Officials at the Centers for Medicare and Medicaid Services recently announced a pilot project that offers smalland medium-size physician practices in a dozen health markets a chance to receive Medicare incentive payments for using certified electronic medical records. Financial incentives will be awarded to up to 1,200 practices that use certified EMRs to meet certain quality measures. Physicians who participate in the demonstration would also be eligible to receive bonus payments based on the number of EMR functionalities physicians incorporate into their practices. Over the course of the 5-year project, individual physicians can earn up to $58,000, and practices, up to $290,000. Contemplating the return on investment is essential because of the high cost of implementation, said Dr. David Krusch, chief medical information officer for the University of Rochester (N.Y.), who studied the return on investment for implementing an ambulatory EMR in an academic medical center. In his study of five ambulatory offices, Dr. Krusch and his colleagues found that the university was able to recoup the cost of the EMR system within 16 months, with the bulk of the savings coming from a reduction in chart pulls. When choosing an EMR, surgeons in small practices might be able to lower costs by outsourcing the software and hardware and by having the system hosted elsewhere, said Dr. Krusch, an ACS Fellow. Adopting an application service provider model that is hosted off-site means that the vendor provides the updates and services the hardware, he said. Else vier Global Medical Ne ws nly about 12% of physicians have adopted comprehensive electronic medical records, according to a 2007 report from the Center for Studying Health System Change. Among surgeons, just 9% have adopted a comprehensive EMR that allows access to guidelines, patient notes, prescription writing, and data/image exchange. To better understand what surgeons are considering when it comes to choosing and implementing EMRs, officials at the American College of Surgeons (ACS) plan to survey their members this summer. They want to learn whether practices are using electronic records and if so, how sophisticated they are. They are also seeking to find out about interoperability between office and hospital sites. When choosing an electronic medical record, surgeons need not focus on getting a lot of surgery-specific bells and whistles. The key is to find a system that has clinical decision support and can connect to other systems, said Dr. Don Detmer, an ACS Fellow who is president and CEO of the American Medical Informatics Association and a member of the ACS surgical informatics committee. Then, keep in mind that the practice workflow will have to change to accommodate the EMR, he said. O COMMENTA RY: Increasing Fellowship Training in General Surgery general surgery is threatened by loss of young surgeons ready to fill of The future offrom practice. Declining the ranksthe those retiring numbers of adequate surgical coverage. General surgery was cited as one of the major undersupplied services (www.aha.org/aha/content/2002/7pdf/EdoCristudents are seeking general surgery residencies, and sisSlides.pdf ). Residents opting to pursue surgical speincreasing numbers of general surgery residents are cialties are less likely to participate in general surgery lost to attrition into other medical fields during train- call or to provide emergency general surgery services once they become practicing attendings. ing (Arch. Surg. 2002;137:259-67; Curr. This may be caused, in part, by feeling unSurg. 2005;62:128-31; Am. J. Surg. 2007; comfortable managing surgical emergen194:751-6; Surg. Clin. North Am. 2007; cies outside of their area of expertise (Col87:811-23). Even among the remaining orectal Dis. 2006;8:273-7; J. Am. Coll. Surg. number entering and completing the 52007;205:704-11). year clinical program, there is still no guarWhat can be done to address this loomantee that they will choose to practice ing shortage? The answer may lie in novgeneral surgery. el surgical specialties focused on providing A growing number of general surgery broad-based and emergent care for the residents are choosing surgical fellowships rather than careers as general surgeons BY TED A. JAMES, M.D. general surgery patient. However, in order to attract and retain residents, these new (SURGERY NEWS, January 2008, p. 1). The phenomenon of “progressive specialization” through specialties will have to ensure career satisfaction, flexfellowships—notably in thoracic, plastic, and vascular ibility, and competitive reimbursement under surgery—has been observed in more than 70% of gen- Medicare’s Resource-Based Relative Value Scale. In 2002, an ad hoc committee formed at the Amereral surgery graduates ( J. Am. Coll. Surg. 2005;201:925-32). In fact, according to a survey of 40 ican Association for the Surgery of Trauma developed U.S. general surgery residency programs, only 15% of a framework for an acute care surgery specialty to adgeneral surgery residents intended to pursue careers dress the needs of emergency surgical patients and also offer an attractive, sustainable career and lifestyle in general surgery (Curr. Surg. 2005;62:429-35). These reports illustrate a trend many of us have ob- (Am. J. Surg. 2005;190:212-7). The implementation of served in training programs for years. The predicted such services at the University of California–San Franshortage already is affecting many parts of the coun- cisco Medical Center has had very favorable results in try (Ann. Surg. 2007;246:541-5). A survey of emer- terms of physician satisfaction and remuneration, gency department directors found that 75% had in- and improved patient care ( J. Am. Coll. Surg. 2007;205:704-11). Similarly, an emergency general surgery service established at the University of Pennsylvania, Philadelphia, improved the satisfaction of trauma surgeons and provided a practical model for emergency general surgery coverage ( J. Am. Coll. Surg. 2004;199:96-101). Integrating dedicated time off and allowing opportunities to pursue academic endeavors contributed to the success of these models. Training in rural surgery may also help to address the general surgery supply and demand problem. About 25% of Americans live in a rural area and rely on their local general surgeon for a wide range of care. Residency programs with training in rural surgery may help produce a stable supply of surgeons who maintain a broad-based general surgery practice ( J. Am. Coll. Surg. 2007;204:416-21; Am. Surg. 2007;73:148-51). The impending disappearance of the general surgeon is a national health care emergency. Simply mandating that all surgeons take general surgery call would force some “specialty surgeons” to practice under circumstances in which they felt unsuited to provide the highest quality of care. The solution is to create a cadre of surgeons whose dedicated service to acute care surgery and rural general practice is supported, facilitated, and rewarded. General surgery residents must be given incentives in order to perceive the value of pursuing these career paths. DR. JAMES is assistant professor of surgery and surgery clerkship director at the University of Vermont, Burlington. http://www.aha.org/aha/content/2002/7pdf/EdoCrisisSlides.pdf http://www.aha.org/aha/content/2002/7pdf/EdoCrisisSlides.pdf

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Surgery News - May 2008 Contents New Lung Approach Speeds Extubation Innovative GI Procedures May Improve Diabetes Quality Programs Differ on Risk Data Crystal Ball Medical Modeling Ventricular Valve Taking Stock

Surgery News - May 2008

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