Enhancing the enterprise: EMRs offer big gains for healthcare organizations of all sizes
Richard R. Rogoski
From a mental health center that sees more than 25,000 patients a year to a three-doctor practice with no more than 6,000 charts, electronic medical records (EMRs) are supercharging efficiencies, capping costs and personalizing the doctor/patient relationship. Plus, the growing acceptance of EMRs also is spawning new uses, like the ability to gauge staff performance through enhanced reporting.
Still, the No. 1 driver in the adoption of EMRs is clinicians’ ability to access and update patients’ charts, including test results, at the point of care, in an office or from home.
For Bruce Blakeslee, director of information services at University Behavioral Healthcare (UBHC) in Piscataway, N.J., the move from paper charts to an EMR was a strategic one. “We decided to go with an EMR to unify the organization, to easily share information on patients, on points of emergency care, and then also to support business practices,” he says.
A division of the University of Medicine and Dentistry of New Jersey, UBHC has 27 off-site locations and a staff of 800 who perform up to 700.000 individual services per year. It also is one of the few mental health service providers in the country that is profitable, a fact Blakeslee attributes in part to the institution’s adoption of an EMR.
At Onmi Medical ,Group, a subsidiary of St. John’s Health System Inc. in Tulsa, Okla., implementing an EMR was inevitable, says Tim Young, M.D., Omni’s president. “St. John’s Health System supported us looking into an EMR,” he recalls. “They probably foresaw they would eventually have to deploy an EMR in the hospital and thought it was a good way to get early experience, through us.”
Affiliated with a 571-bed hospital, Omni Medical Group has 18 offices employing 73 physicians and seven physician extenders.
For Denise Tonner, M.D., a partner in Vero Beach, FL-based Diabetes and Endocrine Associates of the Treasure Coast, the decision to purchase an EMR for this three-doctor practice was made based on potential cost savings and as a step into the future. “We have lots of $30 to $40 procedures and we had 3.5 full-time billing clerks,” she says. “All three of us had been on the board of directors [of a now-defunct multispecialty clinic] and knew how expensive transcription was. We said electronic medical records was the way of the future.” However, none had any experience using an EMR, and the one Tonner’s practice bought originally is not the same one her practice uses today. To save money, Tonner’s practice hired a local consultant who steered it to a template-based EMR and then to a separate practice management solution. “Because of the nature of our practice, we deliver a lot of office-based E&M services and have a lot of tiny charges. But the system he got us was designed for practices with large, bundled-billing amounts,” she says. “It was very user-unfriendly and the staff hated it, saying it took 15 steps for what should be a five-step process.
“We did like the EMR we were using,” Tonner continues. “It had automated coding and billing built in. The problem was, the minute we started to customize it, we lost the coding and billing functionality. We also had remote access so we could took at charts at home, and we wanted to keep this function,” she says.
There were also a number of hardware problems. It was almost impossible to create needed interfaces, Tonner says. “The situation came to a head after a year. We were hiring more and still falling farther behind in accounts. We knew we needed a new system and decided on an integrated system where every module talks to another.” Because the first system they bought had no technical support, they now wanted a Windows-based system from a vendor that would provide a sophisticated support system, preferably with remote capabilities for troubleshooting.
“We wanted appointment scheduling, billing, practice management and an EMR. We looked at a number of systems and decided on WebMD’s OmniChart and Intergy.” Tonner says her practice began automating appointments and billing through Intergy in 2002 and began using OmniChart in early 2003. For a while, the practice ran parallel systems, waiting for April through August–its off-season–to fully convert to the new, integrated system. Then, when the old system crashed badly one night, the practice decided to go entirely on the new system.
Rigorous Selection Process
Choosing a workable EMR was not as complicated for Omni Medical Group, although Young’s organization did learn some valuable lessons about the selection process.
The search began six years ago, he says, as a typical vendor-selection process. “We looked at a lot of demos and paid for a six-month pilot with a company for its, EMR product. But it didn’t work favorably, so we went back to the drawing board and designed a more rigorous selection process,” he says. “We required all vendors to take us to a practice location where does were using their EMR systems, were paperless and could claim that they were at least as productive as before the EMR, if not more productive.”
The choices were limited, so Young says they visited only two such sites. But after careful consideration, they chose the Practice Partner system from Physician Micro Systems Inc. One of the reasons Omni chose this EMR was because it also uses “dot codes,” which facilitate the scanning or dictating of data into a patient’s record. “You can append a dot code to dictation and it drops it into the right place in the chart,” he says, making it easy to move current charts from paper into the EMR.
While saving money was indeed a factor in UBHC’s choice of an EMR, Blakeslee says integrating data was the major consideration in deciding on the Avatar Clinical Workstation from Creative Socio-Medics (CSM). “This EMR combines both clinical and back-office functions” he says,”When we did our due diligence in 1998, it was one of only a few that offered this capability.”
UBHC began working with CSM in 1998, Blakeslee recalls. “In November 1999, we did the first parallel test runs with the system we had in place then. We went live in July 2000. Actual electronic charting started around June 2001.”
Betsy Haines, M.D., a psychiatrist at UBHC and the project manager for electronic medical records, says that to initially define the “content” of the system, “we assembled people from all parts of the behavioral system, and built it around an integrated assessment. We call this the ‘core assessment.’ Except for emergency patients, every patient has one core assessment, and every part of the patient’s record is connected to it. That means a patient history is never lost. It essentially provides us with a longitudinal behavioral record.”
Creating a longitudinal patient record has long been one of the selling points of EMRs. But Haines says being able to access all this information is vital. “Information about every aspect of treatment is put only in one place,” she explains. “For clinicians, the system provides access to data, and that’s critical. It also gives a legible patient record, and that’s very important when you have an ongoing, longitudinal record. In building our clinical documentation, we are striving to also build a real database from which to generate reports and support research.” One of the next steps, she says, will be to create an enterprisewide data warehouse.
Omni’s Young also values having an extensive database from which to draw, saying that physicians have found that “everything is available at once.” He gives as an example a simple phone message. If it’s written on paper and Delivered to the physician’s desk, it might be a while before any action is taken. But with an EMR, “the doctor can see right away that he has a message. Maybe a patient called for a refill prescription. While he is reading the message on the screen, he can open the patient’s record and see that the patient hasn’t been in lately for an office visit. He might then prescribe a two-week supply and tell his assistant to bring the patient in for an office visit–all electronically.”
Tonner has discovered the same benefit by using the Clinical Task Manager module, which not only generates a to-do list, but also includes within the list both patient and non-patient phone calls. “It has eliminated my inbox and sticky notes all over the office,” she says. “It lets me prioritize everything throughout the day–hospital consults, calls and notes from other physicians, prescriptions, patient calls–and lets me see it all in my toolbar. If I handle a call from a patient of another physician in the practice, I can interact with the patient, advise the patient, document the interaction and flag it for the other doctor, so he can see it in his toolbar first thing the next day.”
A similar feature is available through the Avatar system, says Haines. By using an internal messaging system, “a user can select an individual clinician, type him or her a note about a patient, and This is especially valuable on weekends when a patient who is normally seen at one facility walks into UBHC’s emergency room.
“The problem was, how do you let the clinician know Monday morning that the patient was seen?” Haines asks. In the past, to get access to a chart, a security guard would have to go up to the central chart room and get a copy of the patient’s chart. Documentation of the emergency visit would then have to be sent to the patient’s regular doctor. Now, everything is done electronically. All notations made in the emergency room will be in the doctor’s computer when he gets in on Monday morning, and the ER clinician can send an alert to the doctor’s to-do list, she says.
Being able to access additional information through an EMR also is helpful. Tonner says tapping into WebMD’s database has made diagnosing easier. “You can put in ‘sore toe’ and the search engine is phenomenal. It gives you symptoms, examples, coding, etc. It uses official codes, so our documentation is always coded,” she says.
Another feature she likes is the Prescription Writer. Since updates to the drug database are sent out quarterly, Tonner and her partners know when new drugs hit the market and their available dosages.
Pay for Performance
Accuracy is a mainstay of EMRs, and these three organizations capitalize on it in different ways.
Tonner says she likes how a chart will not close if there are any deficiencies in documentation. “You might think you’re providing a Level 4 follow-up, but if all you document in the system is activities and services of a Level 3, the system will stop you and give you prompts on other items that would be necessary for a Level 4–items you should have documented. You’ll know before you seal the encounter if it meets payment criteria for a Level 4 patient encounter.”
Both Young and Blakeslee are taking accurate reporting to a new level. “We are beginning to use the EMR as a quality improvement tool,” Young says. “Through its reporting function, we can look at asthma measures or diabetes measures, and give physicians feedback on what they’re doing and how their performances match one another.”
He explains that three clinical areas were chosen–asthma, diabetes and heart failure–and that each one has been assigned certain standard quality measures. In diagnosing and treating diabetes, for example, all physicians should order the same blood test. By being able to search the database for which tests were ordered and by whom, it’s easier to track the level of care patients are receiving.
A similar monitoring process is under way at UBHC, says Blakeslee. “The desire of our president is to make sure we provide the services we are capable of providing. By using chart reviews, it’s easy to see which clinicians are working up to capacity.”
All this ties into the billing process, Blakeslee explains. “On the fiscal side, we can closely monitor work that’s done by clinical staff. We don’t bill a service until all work is completed electronically. From a clinical standpoint, all documentation must be done to make something billable, and the EMR enables this comprehensive type of documentation. We also include treatment plans, assessments and evaluations. Charges are not billed until the work is in place.”
Because the organization’s goal is 100 percent compliance on documentation, UBHC has established monetary incentives for clinician productivity. Haines says that until documentation is complete, clinicians are not eligible for the bonuses. Coincidentally, staff productivity during the past five years has just about tripled, according to Blakeslee.
Training for Utilization
Of the three organizations, the easiest launch seems to have been accomplished by Omni Medical Group. In part, that’s because the group devised an incremental strategy and rollout that extended from January 2001 to March 2003. Assuming a moderate level of resistance, the practice began the rollout with the physician offices that wanted the EMR, graduating to offices that were less enthusiastic.
“We installed our ‘guinea pig’ office and took four months to do it. The next office took us two months. Then, we did one office installation per month,” says Young. He describes a process whereby IT people would go out to each office, assess IT equipment and requirements, get the office cabled and send the docs to training. When that office was ready to go live, its schedule would be cut back to half of normal.
“We had an IT person with each doc every day for the first week. For the second week, we had one IT person with two docs.” By the third week, one IT person was handling the entire office, and by week four, the office ran the EMR with no outside assistance.
Training the staff at UBHC became a major challenge, recalls Haines. “We trained 500 people in six weeks, and we also had to train the trainers,” she says. This had to be done without closing down any part of the facility.
Resistance from the staff, however, was minimal, due mainly to the commitment of UBHC’s president, Christopher Kosseff. “He made it very clear that use of the EMR was part of their jobs,” Haines says.
For Tonner’s office, also, the challenges were minimal. “All it takes is practice to use an EMR effectively. Actually, it’s not hard going from paper to an EMR; it’s harder going from one EMR to another, as we did. With the WebMD system, there is less free-texting, more point-and-click and dropdown menus. I type fast, but not every doctor does, so point-and-click is a definite advantage.”
Although none of these organizations is 100 percent paperless, each is approaching that goal. In fact, Tonner says, “We have eliminated so many charts that we use the chart rack area as an office for a new lab director we are hiring. We are adding to staff without needing additional office space.”
These three organizations also have found that their patients are satisfied with the results. “They can see what I’m putting into their charts, and I can review it with them,” says Tonner. “They like getting copies of their lab results instantly or knowing they were sent to other docs instantly.”
Some patients even wondered why it took so long for practices to adopt an EMR. “When we first wired all the exam rooms and deployed the EMR, the reaction of some of our patients was, ‘Welcome to the 21st century,'” Young says.
Richard R. Rogoski is a free-lance writer and contributing editor to HMT Contact him at firstname.lastname@example.org.
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