Small and mid-size physician practices can eradicate EMR challenges with homework and planning.
By Richard R. Rogoski, Contributing Editor
The Bush Administration is pushing for their adoption. Hospitals are rolling them out in greater numbers. More large physician practices and independent practice associations have become adopters.
But what about small and mid-sized physician practices? Aside from cost concerns, what are the challenges and obstacles they face in considering electronic medical records (EMRs) and electronic health records (EHRs) for daily use? Solo and small independent practices dominate the U.S. landscape. For EMRs to become SOP, they must be affordable, installable and usable by the majority of U.S. physician offices.
“I realized that to document properly would take an EMR,” says Michael Dotti, M.D., owner of North Country Family Practice in Grapevine, Texas. “An EMR would enable us to keep better track of data. We could treat patients better because information would not fall between the cracks.”
Similar gains in efficiencies have been reported by Les Wilson, M.D., who, with his doctor-wife Vicki, own and operate Wilson Family Medicine in Tallahassee, Fla. “We are more thoroughly documenting patient encounters and documenting at the point of care while we are in the room with them,” he says. “We have been surprised at how much more efficient we are with internal communications among staff, nurses and providers.”
Debbie Eddlestone, chief operating officer of Stern Cardiovascular Center in Germantown, Tenn., says her practice began implementing an EMR module by module.
By interfacing the lab results module with an existing laboratory information system, physicians soon discovered that the information they wanted was just a point-and-click away. “We entered lab results for patients into the system, and when doctors wanted them, they realized how quickly they could get the results they wanted,” she says.
Still, the decision to purchase an EMR was not made overnight. In fact, all three practices carefully weighed their options and wrestled with questions related to implementation, tech support and maintenance.
Weighing the Options
For Drs. Les and Vicki Wilson, being able to purchase an EMR was a dream come true after years of being a dream deferred. Until October 2002, both were manning an outpatient clinic and were employees of Tallahassee Regional Hospital. They had already considered purchasing an EMR for the clinic, so when they later established their own private practice, they saw it as a perfect opportunity.
The Wilsons narrowed the field to four vendors. The HealthMatics EMR from Cary, N.C.-based A4 Health Systems consistently emerged the frontrunner, largely because it could easily be interfaced with the Wilson’s existing practice management (PM) system. But then, support for the PM became an issue from the vendor involved. Wilson Family Medicine is a small practice consisting of two physicians, one nurse practitioner, two nurses, an office manager, an operations manager, three receptionists and 6,000 active patients; getting the necessary technical support from a large vendor isn’t always easy.
Rather than interface the new EMR with the old PM system, the Wilsons secured a bank loan, opted for single-source status and purchased both the HealthMatics EMR and the Ntierprise Practice Management system from A4 Health. “When you choose an EMR, you buy into a relationship that’s long-term,” Les Wilson says.
Since installing the new PM system in July 2004 and the EMR in October 2004, the practice has had few technical glitches. Admittedly, being computer literate has helped. “If we’re at home on the VPN and it gets disconnected, I now know how to get into the server and re-establish the connection,” Les Wilson says.
Critical Choice Factors
Having someone on staff with a basic knowledge of computer hardware and software is invaluable for smaller practices, says Dwight Rector, practice administrator at North Country Family Practice.
“We looked at several vendors’ products, but we didn’t want the ‘do or die, flip a switch and everybody’s on’ kind of application.”
—Debbie Eddlestone
Stern Cardiovascular Center
Both Rector and Dotti were already familiar with the computer-based patient record system (CPR) and the practice management system developed by Misys Healthcare Systems in Raleigh, N.C. When it came to purchasing an EMR for the practice, Misys got the nod. Yet, Rector says vendor support is only part of the equation. “Practice administrators need some computer fluency and to be amenable to EMRs. Misys has great support, but a small practice can’t rely strictly on vendor support. You must have someone in the office who is in charge of implementation, and you have to learn to troubleshoot.”
Running a practice with three physicians and three nurse practitioners who see more than 130 patients a day, Dotti had been contemplating buying an EMR for five years before he finally made the purchase. With a number of vendors offering similar products, he wanted to be sure that the vendor he chose would still be in business after another five years.
Eddlestone says her decision to purchase the TouchWorks electronic health record by Chicago-based Allscripts Healthcare Solutions was driven by three factors: flexibility, functionality and support. Of the three, flexibility became the deciding factor. “We can implement one module at a time, one physician at a time. We looked at several vendors’ products, but we didn’t want the ‘do or die, flip a switch and everybody’s on’ kind of application,” she says.
Also, because the practice’s 16 physicians, ranging in age from 32 to 78 years, have their own unique way of examining patients, “The EMR had to be flexible enough to accommodate their little quirks.”
Interestingly, return on investment was not an important factor. “We started looking for an EMR in 2001 and for a new practice management system at the same time,” Eddlestone says. “We realized we were going to spend money for the EMR, but its capture would not be as immediate as from the practice management system.” She adds that compliance was an additional driver that overshadowed concern about the initial investment.
Standard Bearers of Adoption
Eddlestone was fortunate to have three physicians who were instrumental in getting the EMR up and running: Thomas Stern, 78, turned out to be the one doctor on staff who consistently pushed for an EMR. As new modules have been added, Stern has essentially become the practice’s “beta tester.” Then there’s Stacy Smith. “She came to our clinic from another clinic and had no paper charts here,” Eddlestone says. “She was very interested in technology and was very good at communicating with other physicians, so we made her the physician advocate.”
Affiliated with the Baptist Hospital System, Stern Cardiovascular Center also was able to draw upon the advancements being undertaken on the hospital side. “Dr. Steven Gubin, a cardiologist on our staff, was very instrumental in helping Baptist Hospital set up their electronic system,” Eddlestone says. As a result, some physicians at Stern Cardiovascular had grown accustomed to working with an EMR and electronic signing through the hospital’s system.
Having this kind of provider support early on is crucial to the successful roll out of an EMR, says Les Wilson. “The physicians really need to be the standard bearers of adoption.”
Winning Strategies
By adopting a modular strategy, Eddlestone says Stern Cardiovascular could install only those modules that the ancillary staff could learn first and that would not directly impact the way physicians did their jobs. “We wanted to do as many modules as possible behind the scenes without involving physicians. We started training our ancillary staff, and once they were trained, the doctors came on without having to be pushed,” Eddlestone says.
Helping the adoption process was the fact that scanning of patient information began early on, so older patient data was already in the system for physicians to access.
Implementation began in June 2002 with the roll out of TouchWorks Dictate, which provides the functionality of a handheld digital recorder, but also incorporates features like patient list information and dictation templates. This module was interfaced with the Crescendo dictation system already in place; this “allows physicians to dictate the same way they always did, so it was seamless if they wanted it to be,” Eddlestone says.
Installing the note module, however, was more challenging. Although it provides Web-based physician tools that support clinical note creation, inbound transcription, structured data entry, clinical correspondence and real-time access to clinical documents, some docs were initially slow to adopt.
“When you choose an EMR, you buy into a relationship that’s long-term.”
—Les Wilson, M.D.
Vicki Wilson, M.D.
Wilson Family Medicine
Each of the practice’s 39 exam rooms have PCs. None of the physicians wanted to use tablets because they considered them too slow, but a few gravitated to PDAs. If there was something specific that the PDA-packing doctors wanted to find, they would pull it up on a desktop, Eddlestone says. But when it came to entering their own notes, Eddlestone admits, “Some doctors wanted to point-and-click to enter information. Others wanted to be able to continue dictating. We were able to give physicians an option without having to force anyone to dramatically change his or her workflow.”
Eddlestone says Stern Cardiovascular also installed the TouchWorks Rx+ module, an e-prescribing tool featuring drug interaction, allergy checking and plan-specific formularies, and is currently installing the order and charge modules.
Tweak Before Launch
North Country Family Practice began its installation in December 2000 and was finally up and running in July 2001, says Rector. “We had initially planned to go live in January 2001, but as we implemented, we learned about things we wanted to tweak on the system that we thought would be useful for the doctors.”
Grouping lab tests under specific diagnostic codes, for example, was possible because the Misys system is customizable, allowing new templates to be written or parts of existing templates to be combined. “We had a lab test worksheet that we had been using and created groupings,” Rector explains. “Now you just click on it and it shows only the lab tests you want to see.”
A few workflow issues, especially pertaining to the use of paper in the office—including patients’ charts—also had to be addressed. Essentially, physicians were allowed to use the charts for only three visits per each existing patient. During the first visit, the patient’s past history was entered into the EMR, as were medication lists and consulting notes. “At first, I wanted to scan in the entire chart, but that would have been impractical,” says Rector. Instead, the providers determined which pages they wanted scanned into the system.
“We gave them three chances. During those first three visits, we had the paper chart there for viewing only by clinicians. After three visits, we stopped pulling charts altogether and the clinicians relied on the system,” he adds.
While such drastic measures were not necessary at Wilson Family Medicine, its relatively small staff is still transitioning from a paper-based practice to one that, in time, should be all electronic. “We are still using encounter forms to track patients and to bill, because we have not yet interfaced with billing,” says Vicki Wilson. “We also still use some paper forms to order lab tests.”
Paperless Providers
While the Wilsons admit they are in a period of transition, they have already begun to realize many of the benefits inherent in an EMR. For example, Les Wilson says that by being able to customize about 30 templates of the most commonly seen medical problems of patients, he has been able to create a series of “short lists.” These enable him to click on a list, then click on a specific problem instead of having to do a time-consuming search of all problems or all patients.
In addition, by using wireless tablet PCs in any one of their eight exam rooms, the clinical staff can be examining one patient and still be able to respond to an urgent message about another patient, since information on every patient can quickly be accessed from the central database.
Similar benefits have been reported by North Country Family Practice, which has 13 wireless laptops being used in 14 exam rooms. As an example, Dotti cites a young mother who brings in one child with a medical problem but whose other child—sitting in the waiting room—has the sniffles. If possible, she would like the doctor to look at that child, too. No longer having to pull paper charts, the physician can just pull up the second child’s chart on his laptop. “In a moment, we’ve done a second visit,” Dotti says.
Problems arising from billing or questions from patients or payers also can be handled more efficiently now. “The billing staff has access to the EMR so they can pull up notes right at their desktop and resolve any billing issues or answer any questions,” he says.
Eddlestone says the EMR that Stern Cardiovascular Center installed has made billing more efficient and compliant, resulting in savings of approximately $260,000 thus far. Although some physicians still find it hard to deal in a totally paperless environment, Eddlestone says new providers who come into the practice go paperless from the moment they walk through the door.
Money Metrics
Paper charts take up valuable space in a small practice. While the EMR at North Country Family Practice resides on an in-house server in a locked room, there is off-site tape backup, according to Dotti. In the beginning of 2004, all paper charts were sent off-site for storage, and the practice became 100 percent paperless. With the old charts gone, the storage space that once housed them was quickly converted into another exam room and space for additional storage.
Besides gaining space and efficiency, the cost savings have been “unbelievable,” says Rector. In seven months, beginning in February 2002, the practice was able to reduce its staff by six, saving about $200,000 a year. Plus, the practice originally had five transcriptionists who were no longer needed after implementing the EMR. “That saved us $60,000 and that took place on day one,” says Dotti.
The Wilsons, too, have gained a firmer financial footing. Les Wilson says the practice now saves between $2,500 and $3,000 per month because it no longer needs transcriptionist services. Increased productivity garnered through efficiency gains has helped the practice increase its patient list by 60 patients a month, Les Wilson says, and that translates to revenue. “We have increased our charges by $4,000 to $5,000 per month,” he adds.
“We’re also seeing less staff overtime, says Vicki Wilson, “because they don’t have to stay late to call in prescriptions.” But the Wilsons are not the only ones benefiting from their new EMR. Not only does the practice serve as a teaching facility for third-year medical students completing their clinical rotations at Florida State University’s College of Medicine, but also, both physicians are on the clinical faculty. When third-year students were introduced to the Wilson’s EMR as part of their clinical documentation requirement, “they picked up the use of this system within three days,” Vicki Wilson says.
An EMR can benefit any size practice, but its ultimate success depends on how that practice is run. “One of the things I tell people is that if you have a disorganized office and you install an EMR, you’ll have a disorganized office with an EMR,” says Dotti. But clearly, the opposite is true, too.
For information about the HealthMatics EMR from
A4 Health Systems,
www.rsleads.com/505ht-203
For more information about TouchWorks from Allscripts,
www.rsleads.com/505ht-204
For more information about the Misys Computerized Patient Record,
www.rsleads.com/505ht-205
Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol.com
© 2005 Nelson Publishing, Inc |
