Sixteen physicians in solo to small group practices are participating in a government-funded pilot program to learn the problems and best practices in deploying an electronic medical records system.
The family physicians who volunteered for the program organized by the American Academy of Family Physicians are in practices of one, two, three, four and six physicians scattered across six states.
"They're all up and running with the application now," said David Kibbe, M.D., information technology guru for AAFP, and are working in what Kibbe called "the sandbox phase," the period in which the doctors are playing around with and learning the system.
The first "go live" documenting patient encounters with the system hooked up in real time via the Internet to a remote database is expected soon.
The six-month pilot, funded by a $100,000 grant from the CMS, looks to find ways to best deploy the computerized systems in what experts say will be the toughest EMR market to penetrate, small group practices.
The pilot involves an Internet-accessible electronic medical record system developed by MedPlexus, a privately held healthcare IT vendor from Santa Clara, Calif.; database and connectivity services by Siemens Medical Solutions, Malvern, Pa.; and hardware by Hewlett-Packard, Palo Alto, Calif.
The CMS initially approached the AAFP about starting the pilot project, which was announced last July, and planning commenced last fall, Kibbe said. When then-CMS Administrator Tom Scully left in December, the project slowed, but MedPlexus, Siemens and HP volunteered to go forward with the program without CMS's money, he said.
Thus, the project was well underway when CMS said Friday it was providing the funds, said Kibbe, director of the AAFP's Center for Health Information Technology. "The announcement of the grant coming forward was a very pleasant surprise."
Current CMS Administrator Mark McClellan, M.D., in a prepared statement, said, "This grant will help support technological changes to enable family practice doctors to participate fully in a more modern and efficient healthcare system. Our support of the AAFP initiative is an important part of the Department of Health and Human Services' broader program to promote the use of information technology to update our healthcare system and organize it around the best interests of patient care."
According to the American Medical Association, citing 2001 survey data, the latest available, about one-third of physicians involved in direct care of patients in non-federal, non-institutional settings are in solo practice, 11.2% are in two-physician practices and 8.5% are in three-physician groups.
Little solid data exists for EMR penetration rates in these small office settings, but experts, including Kibbe, say it's probably well below 10%.
Financial barriers to EMR adoption at this level are even more acute than in larger groups, according to published reports by the AAFP and the Center for Information Technology Leadership, Wellesley, Mass. Also, lack of access to training and technical support have been cited as hurdles particularly high for small groups to overcome.
One oft-mentioned solution to these problems has been the application service provider model of delivery. With an ASP, the software and data reside with the vendor and both are piped to the user on demand via an Internet connection, providing, in theory, lower software costs and affordable technical support through economies of scale.
Despite the hoopla several years ago about the advent of ASPs, their promise is as yet unrealized in the small-practice EMR market. It is a problem the pilot hopes to address, and Kibbe is optimistic it might.
"I feel a lot more comfortable about the solution we've crafted that involves very large companies with a great deal of skill and engineering experience," Kibbe said. "A lot of the problem of ASPs in the past has been very small companies without the size or experience to run a first-class business application. You can't say that about Siemens or HP.
"I think scale is very important, this whole idea of being able to take a product and a set of services and scale it from a small number of practices to a very large number of practices," he said. "The product improves as more and more people use it, but the cost per user decreases, which will be a key strategy in this market."
Kibbe did not disclose the names of the participating physicians, but said they were drawn from a pool of more than 60 volunteers. The idea was to obtain a cross-section of family practices of small to medium size from diverse geographical areas. For example, one is a solo practitioner from suburban Pittsburgh starting a practice for the first time; another is a group in a "very rural" area of North Carolina, Kibbe said. While several physicians had previous experience with an EMR system during their residencies or with other groups, none of the physicians were using an EMR at the time they were selected, Kibbe said.
"The main thing we're looking for is, what are the costs associated with the implementation of the EHR in the practice?" he said. "It's not just the costs for the software and the hardware, which are free for six months, it's the costs for training and the effort that these practices have gone through.
"We're also interested in what are the factors of success, what makes it more or less successful, more or less stress-free, and what are the subjective components in the transition from paper to electronic medical record."
The study also hopes to identify ASP-specific issues -- whether performance is acceptable, if there are difficulties in connecting with other IT sources such as labs, pharmacies and hospitals, and how the system works with secure messages.
From an IT vendor's perspective, providing on-site training at the small-group level is expensive and problematic.
In the pilot, "all of the training has been done telephonically and via (the) Web," Kibbe said. "That cuts down on the cost of the training and it also helps to create a culture whereby the practices are working together.
"The physicians and nurses have been working (across practices) on templates, so that they now have a common library of templates, for otitis media and some chronic illness patients with multiple diagnoses. Those templates are the keys to speed. (Also) we want to use those network capabilities to speed up implementation."
Physicians won't be the only beneficiaries from the pilot, Kibbe said.
"We would hope that some of the learning from this pilot project will be valuable to any vendor who wants to pay attention," Kibbe said. "It will give them some heads-up as to what works and what doesn't."
Siemens Medical Solutions is a big name in healthcare IT data storage. Its Malvern data center serves about 1,000 customers, mostly hospitals, and boasts a track record stretching back nearly 30 years, thanks to its 2000 purchase of Shared Medical Systems, according to spokesperson Molly Grasso.
The applications running out of the data center include its Invision and Soarian clinical IT systems.
What the IT giant hadn't done -- until the pilot-- is run an ASP-based clinical system for a small physician practice, according to Mickey McGlynn, director of ambulatory connection at Siemens. McGlynn stopped short of saying whether Siemens sees opportunity in participating in that market long-term with an ASP.
"We're looking at the whole process to learn from it," she said. "I certainly think it's an important market and we'll continue to look at it and make our decision (whether) to move forward."
So far, so good, even though connections to the Siemens database are being made by pilot physicians via the Internet through DSL and cable modems.
"We don't have any performance problems to report," McGlynn said. "We're very happy with how things are progressing. We're hoping to get the physicians up and running live with patients in a couple of weeks."