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Take steps to be informed, prepared before switching to electronic medical records in your practice
If you have a large, tech-friendly office, implementing electronic medical records can be a worthwhile initiative.
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I have attended several meetings in the past few months with leaders of other large physician groups, and one of the hottest topics right now is how to implement electronic medical records in a medical practice. While the selection and implementation of an electronic medical records system is crucial, I think it is more important for administrators and physicians to be well-prepared and well-informed in advance of the selection process.
Do you need EMR?
I love technology, and I tend to surround myself with like-minded people, but not every practice is cut out for electronic medical records (EMR). Practices that have only a few doctors, decentralized standalone locations with few shared patients, limited after-hours patient encounters, and a shortage of tech-friendly staff and doctors should not convert to EMR. In these situations, efficiency gains from EMR are much less than in large multiple-location practices supported by a central office, and it is difficult to argue that the short-term costs and mental anguish are worth it.
For practices that do not fall into this category, implementing EMR should be a strong consideration. In our practice, doctors frequently move among four metro locations, but our patient accounts and call-center functions are based at our main office to increase staff efficiency. Under this arrangement, charts are constantly in motion from one office to another, requiring employees to route dozens of charts each day and spend hours searching for charts that have disappeared. With EMR, this paper chase is eliminated; any patient’s record is available at any computer screen.
We have found these other benefits of an EMR system.
After-hours access. Our doctors are able to access our EMR system through the Internet, allowing them to review and update patient records for patients they speak with or see after hours.
Documentation. Payers and attorneys argue that work not documented is work that did not occur, and an EMR system allows your practice to more quickly memorialize the work that a doctor has performed.
Coding. While this feature is not yet in place in our office, EMR systems can recommend a CPT code for an office visit based on the work performed utilizing the strict logic used by third-party payers.
Queries. Ever run across a unique diagnosis and struggle to remember a patient you saw years ago with a similar problem? Most EMR systems will allow you to query by dozens of unique data fields.
Surgery scheduling. Surgery scheduling at our sister-company ASC is simplified when a chart is available at any time, regardless of where or when the patient received a recommendation for surgery.
Outcomes measurement. With consistent documentation guidelines, most EMR systems can create queries that quickly collect and analyze surgical outcomes.
Not all roses
There are costs associated with implementing EMR, just as with any other major initiative. While the EMR module may be a low-cost add-on when your practice purchases a practice management system, you will have additional costs that go beyond the software purchase. You will need to have computers in every patient encounter room, and doctors will need access to computers in their offices and at the nurses’ station. You will have extra costs associated with these computers, such as anti-virus software, Microsoft licensing fees and perhaps additional licensing fees from the software vendor.
If you are more than a one-doctor shop, you probably already have a server system in place, and adding EMR may or may not require you to purchase a more expensive server with faster response times and larger storage capacity. You will also incur costs to run computer cabling from the server room to each of the patient encounter rooms.
The implementation will increase your costs in the short term, but effective implementation can begin to reduce costs after that point. Our office found that it costs about $1 in supply and labor costs to create a paper chart and probably at least that much to handle it throughout the year. In prior years, the increasing number of paper charts caused us to build two additional storage rooms at our headquarters and rent two storage units, when that space and money could have been better utilized elsewhere.
Think before you leap
If your doctors and managers agree that your practice is ready for an EMR system, consider the following points before making your software selection.
- Only consider an integrated practice management and EMR system sold by one company. Implementation is difficult enough without having to worry who is to blame when the two components do not work together.
- Limit your choices to software packages appropriate for the current and future size of your practice. Vendors who could not support multiple doctors, multiple locations and Internet access were immediately cut from our list.
- Only consider a graphical user interface system – think Windows, not DOS – that can support image viewing, scanning and all the functions you are used to seeing on a new computer. If the system does not provide for scanning of documents, you will have to keep your paper-based filing system for test results, correspondence and any externally-generated documents.
- The software must be adaptable to your practice’s needs. We were a longtime Alcon Ivy user, and nothing was more frustrating than having Alcon say, “That’s a good idea, and we’ll consider that when we design our annual software update.” Your practice is not identical to mine, and we each need to be able to add fields and screens that suit our needs.
- Advertising brochures often represent possibilities, not reality. After purchasing a software system, one of my peers began listing the features on the vendor’s brochure that she wanted to implement; complete implementation took over a year because the vendor had not actually designed all of the features.
Once you have narrowed your vendor list to three to five finalists, make site visits to comparably sized practices to see the software in action. Do not rely solely on vendor presentations at your office; it is pretty difficult for the salesperson to screw up a presentation on how the software works at the make-believe practice living on his laptop. We host about six practices a year for this purpose, and this is the best way to find out if the software works as advertised and how to implement the system. You should also try to make those site visits without the vendor representative, so the hosts will have more freedom to speak their minds.
When you select the winning vendor, be sure to negotiate not only the purchase price but also the monthly support fee and what is included as standard support. Once you have completed negotiations, the vendor will provide you with a boilerplate contract to sign, but run it by an intellectual property attorney before signing it. Be sure to include provisions about how much you will pay for upgrades and updates (I still don’t understand the distinction), how they will reward you for hosting site visits for other practices and how quickly they will respond when you have a crisis or just a simple question.
Implementation
Even if you have selected the software vendor best suited for your practice, the implementation process will still be difficult. You will have to coordinate wiring installation, new server installations, employee training sessions and the transfer of data from the old system to the new system. To avoid making the implementation worse, make good decisions beforehand.
One of the worst implementation decisions we made was to transfer demographic data without the patients’ corresponding insurance information because we felt that too many patients had outdated insurance information. In retrospect, at the most 10% of our patient population had bad insurance data, but we forced our front desk staff to input insurance data for 100% of the patients we saw after implementation. They already had a difficult learning curve moving from a DOS-based system to a Windows-based system, and we made it even worse.
One of the best decisions we made was to convert all of our old medical record files into read-only text files that were attached to patient files in the new system. Although the old records could not be broken down into individual data fields that could be queried, they were still accessible with a few mouse clicks. If you are planning on upgrading your EMR system, make sure your purchase agreement covers the transfer of old information.
Since most practices wisely purchase a practice management and EMR system at the same time, be sure that you continue to use your old billing system until the new billing system has been successfully tested with most of your insurance companies. We skipped this step, and our cash flow took a dive for almost 6 months until we finally were transmitting to every insurance company. You may also want to delay your EMR implementation date until about 6 months after the practice management implementation to allow your management staff to devote appropriate attention to each system and to maintain their sanity.
Once you have implemented EMR, do everything in your power to stop using a paper chart system. While most of our new patients over the past 5 years have been entered into the EMR system, we still were creating paper charts for patients with tests and correspondence, and we hardly made a dent in converting established patient charts. Under these parallel systems, we incurred the high costs of both systems without enjoying the full efficiencies of an EMR-only system. We finally began scanning in tests, correspondence and previous charts earlier this year, and I expect our EMR-only patient percentage to reach 80% within 2 years.
Even after implementation, it is important to continue training your staff on the new system. Your smartest staff will develop shortcuts that maximize efficiency, and the best doctor-tech teams will develop templates and verbal cues that will allow for well-documented records without intrusive exam room dialogues.
Proceed with caution
I believe that adding EMR to a large medical practice helps in many key areas, including front office efficiency, outcomes measurement, coding and even optical sales. Like many high-impact projects, the implementation requires good planning, diligent oversight and strong doctor support to be successful. If you do your homework and select the best software for your practice needs, the sky is the limit.
For Your Information:
- Jay P. Slagle, CPA, MHSA, CHE, is the administrator of Midwest Eye Care, a 10-MD, 3-OD eye care practice based in Omaha, Neb. MEC has four full-service metropolitan locations, 20 outreach clinics in rural communities and a two-room ambulatory surgery center. Mr. Slagle can be reached at 4353 Dodge St., Omaha, NE 68131; 402-552-2806; fax: 402-552-2367; e-mail: jslagle@midwesteyecare.com.