BBI Contributing Editor

ORLANDO, Florida The American Academy of Family Physicians (AAFP; Leawood, Kansas) is the largest organization that promotes the interests of doctors in family practices. Its annual scientific assembly here last fall ran concurrently with the annual conference for WONCA, the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or World Organization of Family Doctors for short.

Family practitioners represent 12% of all U.S. physicians in private practice providing direct care. They see well over 210 million patients each year, 76 million more than are seen by any other single specialty. Family practitioners operate in a variety of settings: 18% are solo practitioners, 8% operate with one partner in two-physician practices, 43% are in group practices where all physicians are specialized in family practice, 22% are in group practices that have doctors specializing in other disciplines, the most common of which are ob/gyn, pediatrics and internal medicine. Attendance at the combined conference was 20,654, so this is a large gathering. Of these about 5,798 were physicians. While this is a large physician group, it is a small fraction of the AAFP's nearly 95,000 physician members.

There were three themes at this year's conference: First, keeping family practitioners current on medical developments, specifically genomics and managing the patient with multiple diseases. Second, helping the family practitioner learn how to make their practices successful businesses, so those practices will survive. A typical three-doctor practice is a business with $1 million in annual revenues, but one that generally does not have a chief financial officer or professional business administrator. Most physicians do not even have a formal business plan, something that the academy encourages. A practice needs expertise in five areas to optimize its business: medicine, accounting, billing, coding claims and information technology. The third focus of the conference was helping practices to achieve this last expertise, to successfully adopt an electronic health record (EHR) and integrate them with their computer practice management (CPM) system, which the association is strongly pushing. The key was how to "go paperless without going broke."

This is an excellent conference for EHR vendors to talk directly with physician prospects, which is not the case at many other medical information technology conferences we cover. There were 4,621 exhibitor personnel, providing almost a one-on-one match to available physicians attending.

Information technology expertise in group practices is a key issue, according to a Medical Strategic Planning (Lincroft, New Jersey) survey of physician group practices. It found that less than half of all group practices and less than 20% of family practices have a person on staff with the skills of a system administrator. This means that the practice is very dependent on support from outside sources or has a steep learning curve to ride in successfully selecting and implementing EHR systems. Nonetheless, about 12% of AAFP members already have adopted some level of EHR, which is two to three times the percentage found in other specialties in the U.S.

We talked with a number of physicians who had been early adopters of EHR, automating their practices anywhere from three to 10 years ago, who said they were happy with the benefits provided and were now running nearly paperless offices. In many cases they had taken on the role of technical support for their office systems. While this is admirable and practical, it is not a metaphor that can be widely replicated. Most doctors are interested in practicing medicine, not computer science, particularly in multi-physician specialties. Moreover, we found the knowledge level of average family physicians attending this conference to be painfully basic, judging from the presentations we monitored. However, the AAFP is providing excellent support through education and vendor demonstrations that, coupled with the pay-as-you-go approach to financing these systems offered by the mid-sized to larger vendors, is one reason for the higher-than-average adoption of these systems in the family practice specialty. Moreover, the AAFP is working with interested vendors, albeit the larger ones, to encourage implementation of basic connectivity between stakeholders in family practice, such as doctors, patients, labs, pharmacies and hospitals. One way the association is doing this is through its Intelligent Medical Practice (IMP) program.

The IMP concept was focused at this meeting on electronic communications initiatives among the association's Partners for Practice participating EHR vendors. The goal of the "Intelligent Medical Practice, The Future of the Health Record is NOW" project is to have EHR products achieve a core level of electronic communication with patients, referring physicians, laboratories, pharmacies, hospitals and electronic billing in HIPAA-compliant formats all of which will reduce paper, streamline the writing, processing and refilling of drug scripts and reduce medical errors.

AAFP's IMP initiative sets the stage for compliance with Centers for Medicare & Medicaid Services (Baltimore) requirements that all prescriptions be produced electronically by 2008, according to Jeffery Hopeland, MD, medical director of Medical Center (Elizabethton, Tennessee). Published reports place the cost of drug reactions, interactions and prescribing errors at more than $77 billion a year. eRx, when fully implemented, is projected to cut this by almost one-third. In some EHR systems, drug prescriptions, once entered, can be sent directly to the patient's pharmacy in two mouse clicks. Perhaps even more important is electronic billing in HIPAA-compliant formats. Physicians submit bills through claims clearinghouses or sometimes directly to payers. There are various claims clearinghouses, from the granddaddy NEIC to the innovative newcomers such as Electronic Network Systems (ENS; Colorado Springs, Colorado). Of these clearinghouses, the newcomers were spoken of more favorably by EHR vendors than the older clearinghouses. More than one EHR vendor had nothing but good things to say about ENS, which directs billing to more than 1,200 payers through one on-line, electronic interface. The claims can be sent directly over the Internet, simplifying the billing process by eliminating a couple of steps, and their status can be checked the same way. EHR vendors who are not yet aligned with clearinghouse providers definitely will want to talk to ENS.

To demonstrate the progress vendors are making in achieving the eRx goal, the AAFP set up a multi-station demonstration of this concept in the exhibit area. A press preview of this section of the exhibit floor was hosted by Dr. David Kibbe, AAFP's director for the Center for Health Information Technology, and Dr. Steven Waldren. Hewlett Packard (Palo Alto, California), Welch Allyn (Skaneateles Falls, New York), PMSI (Seattle), SureScripts (Alexandria, Virginia), MedPlexus (Santa Clara, California), NextGen Healthcare Information Systems (Horsham, Pennsylvania), Siemens Medical Solutions (Malvern, Pennsylvania), A4 Health Systems (Cary, North Carolina) and GE Healthcare (Waukesha, Wisconsin), demonstrated various communications among patients and healthcare providers, labs and pharmacies, underscoring the message that electronic communication is here today at least for some EHR vendors and some applications. It is clear that none of these vendors yet support all of the electronic applications that were demonstrated in this section of the exhibits. However, Kibbe indicated that more vendors were bringing more applications on line all the time, so that within a year each of the participating vendors will be supporting all of the applications.

The IMP demonstration started with a PMSI-developed kiosk application, where patients in the physician's waiting room can sign in and enter the reason for their visit, and then respond to a computer-guided list of complaints and symptoms which were then part of the problem list on the EHR. This is more productive than having them read magazines while they wait to be seen. The patient-entered data is then directly transmitted and becomes a part of the doctor's PMSI electronic patient record. The demonstration continued with direct input of patient vital signs input, from Welch Allyn monitors and office devices attached to a patient, many of which have now been given the ability to transmit their data electronically to EHR systems. These range from full 12-lead ECGs to simpler vital signs like blood pressure, pulse oximetry and other vitals that also were directly integrated, in this case into a NextGen EHR system. Assuming that the patient had some blood drawn and sent to participating national labs, the results could be returned electronically. This was demonstrated by a linkage using a Siemens network, a MedPlexus EHR to receive the data from a Laboratory Corporation of America (LabCorp; Burlington, North Carolina) or Quest Diagnostics (Teterboro, New Jersey) lab. The data also can be hosted on the web so that patients can access their own values through a secure email system. With products such as A4 Health Systems' Patient Web Portal, even the patient can see his/her own lab results, as soon as they are available to the doctor.

Another problem in physician offices is writing and renewal of patient prescriptions. This was automated in the demonstration by SureScripts, whose system works with more than 75% of all national pharmacies. This can eliminate up to 150 calls per day in even a small practice from patients or pharmacists seeking refill approvals and frees up office staff to be available for patient care activities. With the volume of prescriptions to be filled thought to have been in excess of 4 billion in 2004, this is an important advance. Unfortunately, only 50,000 physicians have systems that can transmit prescriptions today, yet about 70 EHR or CPM vendors offer this as a feature of their systems. Next, there was a demonstration of the ASTM's CCR (continuity of care record) standard, which enables a summary of one medical encounter to be sent from one provider to another or carried in an electronic format by the patient themselves. This is an XML-tagged document that can be displayed and read by any physician with a web browser or by the patient themselves. Unfortunately, many EHR vendors do not use the ASTM CCR standard as their internal data structure; rather they have other data formats for storing data and only generate the CCR structure when it needs to be exported or parse it when it needs to be imported. Most of these interactions, whether between physician and patient or physician and physician, were using CapMed's (Newtown, Pennsylvania) Kryptiq secure e-mail hub and infrastructure.

Family doctors are struggling to get their arms around the EHRs, and in some cases even practice management systems related to billing. According to a Medical Strategic Planning survey conducted last year, many physicians are afraid of the EHR, something that has not been emphasized enough as a major roadblock to more widespread adoption. Their fears are in many cases justified. The average practice is not staffed or ready to install and manage an office-wide computer network, complete with servers, wired and wireless workstations configured to be HIPAA-compliant, nor are doctors generally sophisticated computer mechanics, able to manage complex networks that would be required in their offices. Add in security threats from inside and outside of the practice, and one can easily conclude that doctor's fears about EHR adoption are indeed well-founded.

The other challenge is the vast number of EHR products available. The AAFP has 60 EHR vendors it communicates with, of which 10 are Partners for Practice companies. These are mostly the larger companies. This is unfortunate, as the larger companies offer the more expensive solutions, some of which are not based on the most current and flexible software foundations. They also have higher-than-average ongoing support costs, often totaling 18% of original system cost per year. To some extent the middle tier of vendors have missed an opportunity with AAFP, which is open to working with all, as those vendors offer the lower-cost solutions that are hosted on more modern platforms, which would be a better value to family practices. These are companies with 50 or more employees who have achieved installed bases of 300 or more sites, some of which were exhibitors at the conference.

Medical Strategic Planning, in conjunction with Andrew & Associates, tracks 75 of the more than 170 vendors of systems in the market. There is much concern about the potential survival of the smallest ones, but there is equal concern that the largest ones aren't always offering the most advanced software platforms or a current infrastructure for future expansion. Such companies also are the higher-priced vendors, and adopting any EHR is a major financial undertaking for the smaller practices. Some vendors are addressing the financial issues by pricing their systems using physician licenses, a charge per physician user/month. This allows the true cost to be amortized over a period of 60 months lessening the front-end sticker shock and financing risks for smaller practices.

One of the things we observed at the AAFP conference, both in hallway and meeting room chatter and on the exhibit floors, was one physician asking another about which system to purchase. While such referrals are common, they are not necessarily the best way of selecting a system. Many of those giving advice were early adopters of EHR systems. The systems they selected were not always the best currently available products nor necessarily the easiest to use and implement. Early adopters by necessity overcame the technical challenges of managing and troubleshooting their systems, something that those looking to adopt now may not be willing to do. They also were willing to get into their systems and develop templates for specific diseases and complaints, while physicians looking to purchase now may expect to have a library of such templates already developed for them. System architectures also were different enough five years ago from what's available today, to "date" such system recommendations.

Early adopters were willing to settle for less support than doctors currently in the market. When asked who provided the technical support for his office system, one AAFP physician speaker answered, "I do." This is not a solution that most doctors are willing to accept, as they are in business to care for patients, not trouble-prone computers, networks and file servers. The more mobile the system design, the more it uses wireless networking, the more fiddling will be required from time to time. A more universal solution is for the practice to outsource the installation, troubleshooting and support of their systems to others, but the question is to whom?

Family practices often select more than just one supplier to ship all the boxes they will require, making it more difficult to bundle support with one vendor who can come in, open the boxes and hook up all of this technology and transform it into a working system with the EHR and CPM software installed. They also are in need of local technical support to come by every two to three weeks to manage all software updates, system backups, configuration changes and do maintenance, as well as someone to call who is close by to provide emergency service when something goes wrong. This is what many of the smaller value-added retailers (VARs) that represented companies such as Medical Manager and others did, before these companies were purchased by larger suppliers like WebMD (Elmwood Park, New Jersey), which discontinued their relationship with such VARs (presumably to reduce sales/support costs) in favor of direct representation. As a result, there is substantial discontent among licensees of Medical Manager and other widely installed practice management systems, which is creating an opportunity for smaller CPM and integrated CPM/EHR vendors to replace this installed base.

Some of the EHR and CPM vendors have begun to do some of this. Indeed, while many EHR and CPM vendors exhibited at the AAFP meeing, about a dozen stood out from the others. Some of them had partnered with AAFP in its Partners for Practice program, but not all. Those whose implementations stood out at the conference included A4 Health Systems, PMSI, iMedica (Mountain View, California), AcerMed (Irvine, California), JMJ Technologies (Marietta, Georgia), eClinicalWorks (San Jose, California), MedcomSoft (Toronto, Ontario) and a few others. Most of these companies have achieved some of the connectivity required for true Intelligent Medical Practices and are working to expand connectivity in future software releases. Most, for example, provide at least direct drug orders by fax server, but not all provide direct electronic ordering using SureScripts to pharmacies.

A4 Health Systems provides an automatic backup service, in which a PUSH of the last hour's data from each practice is made to a Level 1 secure data center over a secure web link. Thus, in addition to whatever data is backed up in the practice itself, there is an offsite archive that is current to within 1 hour, which is maintained offsite. A4 goes further, however, and provides a web-based access and thin client platform for a practice to access their data in the event of a failure within the practices. As long as they have a working computer and Internet connection, they can access their patient data over the net using a web browser. This could be important in the event of a hard disk failure, in order to keep going until the end of the day when they have time to stop and get the hardware replaced, or in the event of some other unanticipated failure. The company is a growing and successful vendor, poised to capitalize on the accelerating adoption of EHR that is now occurring.

iMedica is another private vendor that is poised for growth. This supplier is rapidly growing, profitable, reportedly has no long-term debt and is offering a system that ranks well in EHR shootouts like those conducted each year at the Toward an Electronic Patient Record conference.

eClinicalWorks, an AAFP Partners for Practice company that claims an installed base of 700 sites, offers electronic labs, but only fax server for pharmacy scripts in its current release, but was working to integrate SureScripts in its next release. It offers competitive electronic transmission to various clearinghouses for claims as well as direct billing in some states. eClinicalWorks' system embedded the Multum drug interactions database from Cerner (Kansas City, Missouri). The company reports it is debt-free and profitable, with 80 employees and robust sales. It said it feels what separates it in the market is its care about its customers. The system is a client-server model, using HPPT+XML with Java on the server. Its latest version 6 software was shown at the conference.

One of the newer EHRs seen at the AAFP meeting was SpringChart EMR, from Spring Medical Systems (Spring, Texas), a small company (20 employees) that started in 2000. The company has developed a product for family practices that is being sold for it by NDCHealth (Atlanta). It runs on a Mac, Windows or Linux platform and offers eRx thru partner NDC and electronic lab transmissions through partners Quest and LabCorp (plus three or four regional labs). The company claims orders from 100 sites, although it was unclear if these were all live yet. Spring Medical has used an object-oriented database as a back-end repository rather than embedding Medcin or SnoMed, saying that most family physicians do see the benefit of such back-ends. The system uses a user-modifiable, template-driven approach to charting.

MedcomSoft has the first EHR we have seen that has not only integrated with Medicomp's Medcin ontology, but built an entire EHR and CPM around it. The motif of the EHR is a bottom-tabbed notebook, with tabs labeled Today (for MD status), Encounters, etc. The system accommodates three classes of encounters an office visit, a telephone consult/visit and a worker's compensation encounter. Based on the type, the system narrows and customizes the other elements of the EHR to eliminate unneeded tabs and questions, focusing the user on only what needs to be charted. The system also supports care protocols or disease encounter forms when charting, which could be user-modified to some extent. They could also be blank or pre-populated (for charting by exception) on a case-by-case basis, as determined for each clinical encounter. When protocols were used, it was possible to select more than one protocol, so that patients with complex presentation, such as congestive heart failure and diabetes, could be charted. Some other systems we saw allowed only one protocol to be selected at a time, making documentation of a complex patient, a two-step process.

The system readily accepted scanned data, as well as images of the patient, their insurance cards and various radiology and pathology test results. It has a bullet counter for E/M code calculations and helps the physician recognize where there may be under coding for billing purposes. As the review of systems (ROS) or history of present illness (HPI) is worked through, the ICD-9 and CPT codes are collected and displayed. The system referenced the NDC drug database for interactions and offered electronic results integration into the chart from LabCorp and Quest labs. Electronic billing via ENS, Thin and Proxymed was supported in the most current release, but was not able to be demonstrated at the AAFP conference. The system reportedly is installed at 200 sites. Because the data is all structured in Medcin, this system offered one of the most powerful retrospective data mining and retrieval capabilities we have seen, without incurring a lot of additional time on the front end inputting the data.

Aside from the vast array of practice management products Quinton Cardiology Systems' (Bothell, Washington) Burdick (Deerfield, Wisconsin) division was showing its automated external defibrillators (AEDs) and 12-lead ECG products. Its newest AED is the Cardiovive DM, a new automatic AED that has an optional manual mode. This rounds out the family of three Cardiovive AEDs, which range in price from $1,995 to around $3,995. These products work with both adult and pediatric patients. The DM does a daily self-test, a daily low energy test shock and a daily check of the impedance of the electrodes. This later feature is important, as some AEDs in public access locations go so long between uses that they can have dried-out electrodes, limiting the quality of electrical contact (low impedance) with the patient. The Cardiovive defibrillators claim to use an impedance-adjusted, high-energy biphasic waveform to adjust the dose (shock) delivered based on the quality of the electrical contact with the patient.

Overall, there were many vendors at AAFP showing therapies and technologies that will allow family practitioners to handle a wider variety of patients, do fewer referrals and increase the revenues to their practices. As these physicians are the first line of defense for most patients and a group that has been disproportionately disadvantaged by many of the changes in the U.S. healthcare system, the benefits of this conference should increase in future years as more doctors decide to take a hard look at how their practices could be re-engineered to improve efficiency and quality of care for the future.

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