Are Podiatrists Really Using EMR?

By Brian McCurdy, Senior Editor

Given the potential benefits of quicker reimbursement and improved productivity, and the need to ensure HIPAA compliance, you would think electronic medical records (EMR) would be in place in the majority of physician practices. How many doctors are actually using the EMR Systems in the office? Not many, according to a recently published survey in the New England Journal of Medicine (NEJM). Over the last two years, researchers surveyed 2,758 physicians including various types of physicians who provide direct patient care. The authors of the NEJM article note that 4 percent of those surveyed have an extensive and fully functioning EMR system while 13 percent said they have a basic EMR system. Those who were more likely to use EMR included primary care physicians, younger practitioners, doctors in large groups or hospitals, and those in the western United States. Those who do use EMR told the researchers that they have high levels of satisfaction with their systems. Electronic medical record users also noted that EMR had positive effects on the quality of clinical decisions, communication with other providers and patients, prescription refills, timely access to medical records and avoiding medication errors, according to the survey. So why is there an overall reluctance to incorporate EMR? The present U.S. health system is “21st century medicine held together by 19th century paperwork,” says Caroline Fife, MD, quoting Tommy Thompson, the former Secretary of Health and Human Services. She notes that although the U.S. spends twice as much on healthcare per capita as Sweden, the Netherlands and the United Kingdom, those three nations have better overall health incomes. She attributes this to their modernized management of health information. In particular, more than 90 percent of Scandinavian doctors use EMR, according to Dr. Fife, an Associate Professor in the Department of Anesthesiology at University of Texas Health Science Center in Houston. In addition to EMR’s benefits of fewer redundant tests and procedures, and fewer treatment errors, Dr. Fife notes that EMR can increase patient volume as well as reduce practice overhead. She also notes that with EMR, podiatrists can have clinical practice guidelines at their fingertips at the point of care, which reduces delays in decision making. Bruce Werber, DPM, notes additional advantages of EMR. Dr. Werber, a Past President of the American College of Foot And Ankle Surgeons, cites improved documentation for protection against audits, better coding to enhance reimbursement and improved workflow. He also notes a potential decrease in office costs if electronic systems are correctly implemented and doctors and their staff are willing to “change old habits.” Dr. Fife notes further cost benefits. She says it has been estimated that widespread adoption of the technology can save an estimated $81 billion a year in the U.S. A Closer Look At The Hurdles To Incorporating EMR Of those 83 percent who reported not using EMR, 16 percent said they had purchased but not yet implemented a system, according to the survey. Authors of the NEJM article also say 26 percent of those surveyed intended on purchasing electronic systems in the next two years. Dr. Fife counters that a survey by the Health Information Management Systems Society found that 53 percent of surveyed practices are about to implement EMR. Financial considerations had the greatest effect on the decision not to implement EMR, according to the NEJM survey. Other barriers to implementation include not finding a system to meet one’s needs, uncertainty about the return on investment and concern about obsolescence. Dr. Werber concurs that cost is a hurdle for DPMs who want to implement EMR, particularly the cost of hardware and software. He suggests Web-based solutions are “the way to go” as they permit low-cost entry into systems and allow migration of collected data into other systems as technology changes. “It is incredible that physicians must bear the financial burden for these systems when the biggest beneficiaries are the insurance companies and government,” says Dr. Werber, who is in private practice in Mesa, Az., and serves as the Director of Clinical Education at Midwestern University in Glendale, Az. “Why are (insurance companies and government) not being urged to contribute to the cost and development of a system that can be integrated and facilitate the exchange of data in a safe and secure manner?” Dr. Fife notes that potential legislation currently under consideration in Congress would designate $4 billion to help physicians install EMR systems. Implementing an EMR system without a plan can be detrimental as this could reduce office production by 30 percent, according to Dr. Werber. He notes there are also risks of failure if a practice buys the wrong system. To minimize the risk of a bad decision, he says one should include staff in the decision making process, and go to other practices of your type and size to see a system in place and functioning. Dr. Werber warns that some people buy systems without thinking about how the systems will work in their practice. An additional barrier can be when physicians are unclear on whether they have an EMR system, notes Dr. Fife. She says EMR systems should meet HIPAA requirements and they should capture and present all patient information required to support coding. CDC: Nearly 8 Percent Of Americans Have Diabetes By Brian McCurdy, Senior Editor The rate of diabetes continues to rise with nearly 3 million new cases of the disease estimated in the last two years, according to recently released statistics from the Centers for Disease Control and Prevention (CDC). In 2007, 23.6 million people (7.8 percent) in America had diabetes, according to the CDC. The report notes that this includes 5.7 million people who are undiagnosed. In addition, the CDC notes that more than 60 percent of non-traumatic lower extremity amputations occur in patients with diabetes. The total medical cost of diabetes in 2007 in the U.S. was $174 billion, which included $116 billion in direct medical costs. What Can Stem The Tide Of Rising Diabetes Rates? Why does diabetes prevalence continue to rise? John Steinberg, DPM, attributes the increase to environmental factors such as diet, exercise habits and limited access to healthcare. “We know this is going to keep spiraling because people are getting fatter and eating more processed food,” says Dr. Steinberg, an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. “It has so much to do with what we are doing and how we are eating.” Public healthcare initiatives may be the key to stemming the tide of diabetes, notes Dr. Steinberg. He says there should be a multidisciplinary focus and notes that specialists such as nutritionists, dieticians and certified diabetes educators can make “a huge difference.” Dr. Steinberg points to the Texas Diabetes Institute, an outpatient center in San Antonio. He notes the program teaches patients with diabetes how to cook their favorite foods, which may be unhealthy, in a more healthy way. Since high fructose corn syrup can have adverse effects, he suggests the rule of thumb of shopping only supermarket perimeters where items such as meats, produce and dairy are kept. Dr. Steinberg says one should avoid the store’s inner aisles, which usually hold processed foods. “I think people know what they need to do but feel it is too much of a sacrifice,” says Dr. Steinberg. Study Abstract Examines Link Between Anti-TNF Drugs And MRSA By Brian McCurdy, Senior Editor Do tumor necrosis factor (TNF) inhibitors have a cause and effect relationship with methicillin resistant Staphylococcus aureus (MRSA) infections? An abstract recently presented at the European League Against Rheumatism conference suggests such a relationship. The abstract authors advocate discontinuing the use of TNF inhibitors among those with MRSA. Researchers identified 450 patients who underwent anti-TNF treatment between August 2003 and July 2006. The study notes that 15 patients developed MRSA. They subsequently had to stop taking TNF inhibitors and start on IV antibiotics. The authors say 12 patients were hospitalized. The patients’ concomitant immunosuppressive treatment included prednisone and methotrexate. Ten patients also developed methicillin sensitive Staph aureus (MSSA), according to the study. Researchers noted that their efforts to restart TNF inhibitors after the MRSA infections were under control caused seven patients to experience recurring MRSA infection. However, after their MRSA infections were under control, two patients were able to resume anti-TNF therapy while six other patients required different types of therapy. The authors conclude that they would not continue using TNF inhibitors in patients with MRSA or MSSA infections, and would not start therapy in patients who are MRSA carriers. Loan Lam, DPM, says that the FDA expressed concerns as early as 2001 about patients on TNF inhibitors being at higher risk for bacterial infections, namely tuberculosis. She is not sure if there is a direct connection between patients who are taking anti-TNF medications and those who contract MRSA. Dr. Lam believes that being on TNF inhibitors increases the risk of many different types of opportunistic infections and suggests that the increased prevalence of MRSA may be causing higher numbers of infections. What You Should Know About Screening And Prevention What screening methods might be effective? With the rates of MRSA rising, it would be safer to initially screen patients for being MRSA carriers and determine if they are candidates for TNF therapy, according to Dr. Lam, who is in private practice at the Comprehensive Foot and Ankle Centers in Naples and Marco Island, Fla. Dr. Lam notes that patients take TNF inhibitors for conditions such as rheumatoid arthritis or other inflammatory arthropathies. If patients have to stop taking TNF inhibitors, are there any effective substitutes for their condition? Although options for rheumatologic conditions include prednisone and methotrexate, she says those options have their own mechanisms and side effects. She also says the research is unclear whether it is TNF inhibitors alone or their combination with prednisone and methotrexate that predisposes patients to MRSA. “Just as you would do with any other drugs, I think you have to take the initial research with a grain of salt and not completely point fingers only at anti-TNF therapy, and ask if the side effects outweigh the benefits,” says Dr. Lam.

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