by Jennifer Bever, MS, FACHE*
Medical practices are increasingly adopting electronic medical record (EMR) systems to help manage documentation and clinical work flow. With literally thousands of vendors and system offerings and considering the investment required for an EMR system, carefully planning for an EMR system is critical. Too often, practices transition to EMRs without an internal assessment and are then disappointed with the post-implementation results of their new system. This article outlines key questions practices should consider before purchasing a system to pave the way for optimal results.
Whether or not President Bush’s call for the majority of Americans to have computerized medical records within the decade is realized, there is no denying that electronic medical records (EMRs) are gaining momentum.
Between public advocacy and safety groups such as Leapfrog, the Institute of Medicine’s ongoing reports concerning medical errors, and continuing discussions of pay for performance based on “quality” measures, multiple groups are interested in better collection and analysis of medical-related data. While Medicare’s physician pay-for-performance plan is currently voluntary, multiple commercial insurers in a variety of metropolitan areas have already rolled out performance plans that require data collection of clinical indicators. As such efforts continue, EMRs will be increasingly important in capturing and reporting such data and realizing potential additional reimbursement.
To date, various studies suggest just 20% to 25% of physician practices have adopted an EMR system, and of those who have, the majority are mid-sized or larger groups—eight or more physicians. But beyond the perception that EMRs may become a government mandate or a necessary tool for participating in insurance incentive plans, many physicians recognize that there are benefits to adopting this technology. One surgeon recently described the EMR as the vehicle that “...unchained me from my desk and allowed me to get re-energized about practicing medicine. Suddenly I was home for dinner, on time, every night.” Who doesn’t think that sounds good?
Commonly recognized benefits of EMR implementation include:
- Reduction in costs associated with paper charts: files, dividers, stickers, etc.;
- Reductions in transcription resources—some practices eliminate it completely while others retain limited support for “stat” letters, disability summaries, or legal cases;
- Reconfiguration of space previously allocated to medical records in-house storage (One practice was able to add an extra exam room, a revenue-producing event.);
- Eventual reduction or elimination of off-site storage and retrieval costs;
- Elimination of staff time spent pulling, refilling, and searching for charts (In most cases, staff is redirected to other related duties such as scanning and archiving.);
- Potential reduction in medical records staff, depending on the size of the practice (It is important to note that many small to mid-sized practices realize no reduction in staff size as a result of EMR implementation despite claims by vendor sales forces.);
- Reduction in time spent confirming prescription order accuracy—either by clinical staff or physicians themselves;
- Remote access to records for satellite offices and for physician ease during evening/weekend call; and
- Efficiencies in certain specialties relative to storage, retrieval, and access when converting to digital radiology.
The number of practices evaluating EMR systems continues to increase and, seemingly with it, a proportionate number of dissatisfied users. This, of course, begs the question—how do you know if your practice is ready to convert to an EMR system? EMR systems often represent a $50,000 to $100,000 or higher investment, depending on group size, so the decision to implement must not be taken lightly.
How do you know if your practice is poised for successful EMR utilization? The following questions can help you determine the amount of angst that might accompany a move to EMR.
ARE ALL PHYSICIANS COMMITTED TO THE MOVE TO EMRs?
Quite simply, if the answer to this question is “no,” then the whole discussion should cease. People often discuss the importance of having a “physician champion” who is enthusiastic about the EMR, and that is important. But realistically, all physicians have to at least be on board and willing to participate. For example, the surgeon who is 61 years old and planning on retiring at 63 is rightfully skeptical about his ability to garner a return on investment (ROI). Studies repeatedly indicate ROI is achieved by the majority of practices within two to three years, but that is little comfort to those looking forward to a retirement party—sooner rather than later.
How do you know if your practice is poised for successful EMR utilization?
The monetary aspects are really only part of the story; the bigger issue is undoubtedly the concern about “old dogs learning new tricks.” Actually, it is clear that learning the new trick is quite possible, many surgeons after all, continue to learn and perform new procedures and techniques throughout their career, but does one want to go through the effort? And an EMR system, particularly for a more senior physician who only occasionally e-mails grandchildren, is a Herculean effort.
Certainly, EMRs today are flexible, and physicians can opt to utilize them to varying degrees within the same practice. However, those varying protocols mean staff must learn and manage different techniques and habits for different physicians, which tends to reduce the operational efficiency one had hoped to gain from moving to an EMR system. Having a few physicians do a trial run before the entire group goes live makes sense, but ideally the entire physician group should agree to use a core set of EMR features. Which features are deemed “required” is up to the group, but should be defined ahead of time. Will Dr. Senior be allowed to opt out of the point and click templates and continue to have his secretary transcribe notes and now paste them into the EMR? Perhaps Dr. Senior has a medical assistant help with data entry and has the option to use voice recognition with access to staff who can proofread the resulting note instead.
Bottom line, not all physicians have to be excited about the transition, but if the practice is serious about this purchase, all physicians need to commit to a baseline of utilization to make the investment worthwhile for the group.
IS THE MANAGER EXPERIENCED AND SKILLED AT GUIDING LONG-TERM PROJECTS TO COMPLETION?
Managers often describe an EMR implementation as similar in size, scope, and hassle factor to construction of a new office. If your manager is new with unproven project management skills or has many great traits but long-term management of details isn’t one of them, the practice will need to provide additional support and create a system whereby project updates occur weekly to ensure things don’t fall behind or get overlooked. Typically, this expense is not considered when evaluating the cost of an EMR system.
Support may be a part-time staff member to help alleviate some of the manager’s day-to-day tasks—new employee orientation and paperwork, payroll, accounts payable, etc. More likely, though, the additional support would be an outside advisor or consultant with experience in EMR system selection and implementation. Such a person can prompt thought on common roadblocks before they become a problem. For some, a software organizational program such as Microsoft Project will keep the large to-do list in order and on time.
WOULD YOU DESCRIBE STAFF AS TECHNOLOGICALLY SAVVY?
During a recent consultation, the group bemoaned the fact that the transition to an EMR system had been difficult, and at the end of the day, there were several features not utilized to their fullest extent. The physicians were disappointed that after spending a considerable amount of money to make work “easier” for staff, the staff seemed grumpy, and things actually took longer. What was fascinating is that no one recognized what an enormous change the staff managed in going from a DOS-based billing system and no Internet or EMRs to a new, fully integrated Windows-based billing and EMR system. In short, staff had to learn to use a mouse; abandon “function” keys; and comprehend the difference between double click, right click, and left click. Tasks took longer because staff members were still getting up to speed with basic computing and keyboarding skills; system shortcuts constituted “brain overload.”
HOW GOOD OF AN INVESTMENT CAN THE SYSTEM POSSIBLY BE IF STAFF MEMBERS CANNOT OR DO NOT UTILIZE IT?
This practice would have benefited from a phased training approach starting with basic Windows skills, then moving to billing system training and implementation, with EMR training and implementation last. Follow-up training by a vendor representative, on site (note an extra fee applied), approximately three months after system implementation was recommended to allow staff members to feel comfortable with and optimally utilize the system. Even with an extra training fee, ensuring staff productivity is critical for reaching ROI goals—how good of an investment can the system possibly be if staff members cannot or do not utilize it?
ARE JOB DUTIES CLEARLY DEFINED FOR EACH POSITION?
Often, practice disorganization is the result of staff not having clear direction on exactly who is responsible for what. As a result, everyone assumes someone else is responsible, and things slip through the cracks. While that may sound too simplistic considering practices are often million dollar ventures, it is consistently true.
Practices that already discuss and arrive at uniform operational protocols are much more prepared for EMR implementation.
Take phone messaging, for example. When a patient calls with a question, what is supposed to happen? The receptionist team often sites busy phones and a discomfort answering “clinical” questions. The clinical team, in turn, complains that the majority of the calls they return are not clinical in nature and could have been handled by someone else if a few simple questions had been asked. So who is responsible for handling patient questions? Can we define it, or do we continue engaging patients in a game of phone tag and message ping pong?
The EMR provides an excellent vehicle to more efficiently record and route messages from patients—but the question still remains, who is responsible for answering which kinds of questions? The EMR does not define that for you. If you haven’t reviewed and updated job descriptions, now is the time.
DO THE PHYSICIANS ALREADY FOLLOW UNIFORM OPERATIONAL PROTOCOLS FOR COMMON TASKS?
As discussed above, varied levels of physician involvement with the EMR generally result in reduced efficiency. Practices that already discuss and arrive at uniform operational protocols are much more prepared for EMR implementation. If you haven’t reviewed the various protocols in place for your practice of multiple physicians, take a quick poll before you get serious about reviewing and purchasing an EMR system. Many physicians are surprised to learn the variation among their partners.
DOES THE PRACTICE REGULARLY CONDUCT ALL STAFF AND/OR DEPARTMENT MEETINGS?
Regular communication will be critical in the EMR implementation phase. Practices that regularly meet every other week or monthly are well positioned to continue this trend and discuss pending changes as a result of new system implementation. If your practice does not meet regularly, start now.
Often practices require coaching to have effective meetings. Basics such as preparing agendas, distributing notes afterwards to ensure follow-up and to inform those who could not be present, and adhering to start and end times are sometimes foreign concepts. Setting the right tone now, while things aren’t stressed by implementation, is also a critical step—the edict that staff can “bring up a problem . . . as long as they also bring at least two solutions” is often popular.
DO PYSICIANS CURRENTLY MAKE USE OF MACROS, AND IS SCANNING ALREADY IN PLACE?
Common examples of macros include minor procedure notes for supply applications or injections where surgeons simply fill in patient-specific details such as side, site, drug utilized, etc. Physicians who routinely use macros typically have an easier transition to documentation templates in EMR systems as they are used to moving quickly through and selecting out specific items of information.
The time-intensive nature of scanning and archiving is consistently a surprise.
Similarly, practices that already utilize scanning for various patient forms and/or explanation of benefit storage and retrieval in the billing department are well positioned. Stand-alone document scanning solutions are available and offer an intermediate step on the way to EMR implementation. Practices using scanning understand that it is time consuming and that accurate archival of documents is critical. Scanning a document doesn’t help if you can never remember which folder it “lives” in!
An EMR is a tool; it will not automatically “fix” what isn’t working in your practice.
Conversations with practices that initiate scanning with, as opposed to before, EMR implementation reveal that the time-intensive nature of scanning and archiving is consistently a surprise. In larger practices, it is very common to have a full-time employee who does nothing but scan and archive paper documents into the EMR system (which by the way explains why so many practices do not see a dramatic drop in medical records personnel).
IS THE PRACTICE CURRENTLY FUNCTIONING WELL, AND IS REIMBURSEMENT VIEWED AS OPTIMAL?
At the end of the day, an EMR is a tool; it will not automatically “fix” what isn’t working in your practice. Many a practice has fallen into the trap of believing an EMR will be the ultimate panacea... and then been disappointed. Fixing operational issues before EMR implementation is key to a smooth transition and optimal ROI.
If the answer to four or more of these questions is “no,” the practice would be well serviced to take a step back and conduct a more thorough self assessment. Often, this has the added benefit of defining the features and benefits needed from a new system such as an EMR system. Understanding the features needed in the practice provides the platform for a more educated vendor comparison and selection process and also helps ensure system success.
Additional articles from The Journal of Medical Practice Management:
Reprinted with permission from The Journal of Medical Practice Management, Copyright Greenbranch Publishing, (800) 933-3711, www.mpmnetwork.com.
*Formerly Consultant, KarenZupko & Associates; Currently Director of Education, Sg2, 5250 Old Orchard Road, Skokie, IL 60077; phone: 847-779-5594; fax: 847-470-9009; e-mail: jbever@sg2.com. Copyright © 2007 by Greenbranch Publishing LLC.