AAOS Bulletin - October, 2006

EMRs bring your office into the 21st century

They’re essential tools for securing your future income

By Stephen P. Makk, MD, MBA, and Marty Krawczyk

This is the first in a series of articles on electronic medical records (EMRs) in orthopaedic practices. Future articles will feature orthopaedic surgeons who are converting or have made the transition to an EMR office and will cover topics such as assessing your current workflow, developing a plan and timetable, selecting products and implementing an EMR system.

It is easy to see the impact computers have had on orthopaedic research and training. Simulators enable orthopaedic surgeons to perfect techniques before encountering patients in the operating room (OR). In the OR, computers monitor the patient and allow the surgeon to perform microscopic surgery.

At the practice level, computers help streamline the appointment process and increase efficiency of the billing and collection processes. The Internet enables orthopaedists to establish Web sites that promote their practices and provide patient education on prevention and treatment options.

Lagging behind
Unfortunately, optimal use of computer technology in health care—particularly at the physician practice level—still lags behind other industries. For example, in the financial services sector, stock transactions, fund transfers between accounts and bill payments can be completed in minutes, if not seconds. Compare that to the time it takes to order a lab test, find and review a patient’s lab result or locate notes on the patient’s last visit.

Illegible or misunderstood paper prescriptions result in thousands of prescription errors per year. Paper records limit the amount of information available to an on-call physician in an emergency. In short, paper is preventing the health care field from making dramatic strides in patient safety, improved outcomes and access to care.

In other industries, computers promote rapid transmission of information between designated partners, eliminate geographic boundaries and serve the provider’s and consumer’s needs for information, goods and services. Medical practices need to implement EMRs so that physicians can conduct both the medical and the business sides of their practices in a cost-efficient manner. The EMR is also an important cornerstone in shaping a patient-centered care practice.

The EMR refers to the patient medical record kept primarily by the physician. A practice may have either a “full” or “partial” EMR system. A “full EMR” system incorporates the functions of electronic ordering of prescriptions and tests, electronic reporting of test results and electronic physician notes, while a “partial EMR” system uses one or two of these functions.1

EMRs are essential in gathering data for developing a workable pay-for-performance (P4P) model. An article in the New England Journal of Medicine (July 2006) analyzed the clinical impact and increase in income of family practitioners during the first year of a P4P program in the United Kingdom. The authors report that between April 2004 and March 2005, the P4P payments increased the average gross income of family practitioners by $40,200. Higher payment levels during the 2005-2006 performance years are expected to generate increased payments to physicians.2

What’s the hold-up?
The Centers for Disease Control and Prevention (CDC) reported that nearly one in four (23.9 percent) of U.S. physicians reported using full or partial EMRs in their offices in 2005. This represents a 31 percent increase in usage since a previous CDC survey in 2001. However, only one in 10 physicians, or 9.3 percent, has a complete EMR system.1

There are three probable primary reasons for the low percentage of total conversions: cost, time commitment and fear.

EMRs cost too much
The capital expenditure to implement an EMR system is costly in the short term, ranging from $20,000 to $50,000 per physician. But this figure is certainly in line with other capital expenditures, such as replacing or acquiring new medical equipment. According to one study, the average cost to implement an EMR system is $44,000 per physician for the first year, and an average of $8,500 per physician in subsequent years.3 The study also found that the average practice recouped the initial capital expense within 2.5 years.

The cost of implementing an EMR system also needs to be balanced against the costs of continuing to do business without it. These costs include filing space, personnel costs, and the cost of inefficiency—the delays incurred while looking for misplaced, lost or not filed information.

There’s no time
A successful conversion to EMR does require a substantial time commitment by physicians and office staff. It takes time to evaluate current work processes, to research potential vendors and software, to convert current records to the new system and then to maintain the system.

But the purchase of any major piece of medical equipment requires a similar time commitment. An EMR system should not be treated any differently. When physicians recognize the importance of EMRs in establishing a patient-centered care practice, the time commitment needed to select an appropriate system is viewed as necessary.

But what if…?
The third reason physicians may delay converting to an EMR system is fear, usually expressed as “But what if…?” What if the software costs more than expected? What if it does not work properly? What if the new system is difficult to learn? What if the conversion disrupts service to patients and others?

Most physicians know of at least one practice that either struggled or failed in its attempt to convert to EMR technology. A healthy (not immobilizing) dose of fear is actually good; it will trigger a strong desire to learn as much as possible about EMRs in advance so that your conversion will be successful.

AAOS Resources
The AAOS Practice Management Committee recognizes the complexity of converting to an EMR system. In the coming months, members of the committee will examine EMRs from a practice standpoint and address related issues such as privacy and government regulations. Be sure to check the Practice Management section of the AAOS Web site for practical tips on making the conversion.

To share your experience with converting to either a full or partial EMR system, contact Stephen Makk, MD, MBA, chair of the Practice Management Committee, at smakk@lbjs.net or Marty Krawczyk, coordinator of the practice management group, at krawczyk@aaos.org .

Stephen P. Makk, MD, MBA is chair of the AAOS Practice Management Committee. He can be reached at (502) 897-6579 or smakk@lbjs.net

Marty Krawczyk is coordinator of the practice management group. She can be reached at (847) 384-4337 or krawczyk@aaos.org


  1. Centers for Disease Control and Prevention Media Advisory: “More Physicians Using Electrical Medical Records,” July 21, 2005. Accessed online
  2. Doran T, Fullwood C, Gravelle H, et al. Pay for Performance Programs in Family Practices in the United Kingdom. N Engl J Med 355:375-84, July 27, 2006.
  3. Study: EHRs may benefit small practices financially, but only modest gains in quality seen. Healthcare Financial Management, Oct. 2005.

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