Why Convert to Electronic Medical Records
Bob Glorioso MD

What’s wrong with paper?

• Need to pull chart for every contact (visit, phone call, report, form, etc.)
• Documentation is either time-consuming or inadequate
• Many tasks require double/triple entry (meds, messages, problem lists)
• Waste time looking for data
• Too much writing (notes, Rxs., problem and med lists)
• Illegible entries
• Paper chart is only accessible to one person at a time
• Lost charts

Why EMR?

• Improved Efficiency
• Decreased Stress
• Improved Patient Care
• Overhead Cost Savings

Why is an EMR better than paper?

All of the features below save time, money or both and many improve care

• Accessible Data
• No lost charts
• No chart disassembly and copying
• No Filing of outside reports is (scan instead)
• Chart is organized into familiar sections (can be customized)
• All data is only a few clicks away
• Most recent data is displayed first
• Labs, vital signs, and flowsheets display trends
• Can search for keywords
• Prescription Writer
• Templates eliminate need to look up dosing or size
• Prints legible prescriptions – less errors and pharmacy callbacks
• Refill Multiple Rxs with one keystroke
• Automatic drug interaction, allergy, age, dosing, and disease state checking
• Can Fax electronically to pharmacy
• Progress Note Templates
• Design your own problem-specific or procedure-specific templates
• Expandable quicktext macros and pick lists
• Can calculate E&M codes
• Can contain embedded reminders, standards of care, history, PE, and tests to perform/order
• Can automatically insert PMH, FH, SH, Problem List, Meds, Allergies, Recent Labs into notes. No need to re-dictate or type these in.
• Eliminates or reduces transcription costs
• Note Templates – Can duplicate other commonly used forms and have the system pre-fill and print them
• Work/school notes
• Lab/Xray requests
• Forms
• Work/school physicals
• Messaging (In-office Email)
• For patient messages, refill request, referrals, and office memos
• Staff no longer “hover” outside of Exam Room to “Catch” the physician between patients
• Email message pulls up appropriate chart section of patient chart with one click
• Completed message can be recorded into patient chart
• Letter Templates
• To patient, insurance company, consultant, or referring doctor
• Automatically inserts PMH, FH, SH, Allergies, Meds, Problem List, Recent Labs, etc.
• Branching logic allows sophisticated form letters giving patient instructions automatically customized based on test results (eg. Cholesterol result letter)
• Improved Care
• Accessible Data
• Legible notes and Rxs.
• Note Templates can prompt physician to address needed care based on disease, age, or sex
• Automatic Health maintenance reminders and reports
• Allergy and Drug Interaction Checking
• Can easily do Self-Audits (eg. How many diabetics have HgbA1C >7?)
• Links in note templates take physician to disease-related articles and recommendations
• HMO site visits are easy – data is quickly accessible
• Cost Savings
• EMR software cost is typically $15,000 to $20,000 per provider and hardware cost is $10,000 per provider
• Maintenance costs run $5,000 per year for software and $2,000 for networking support and hardware
• Biggest saving is from needing less staff
• EMR: 2.0-2.5 staff/full time provider
• Paper: 4.3 staff/full time provider (source: MGMA)
• We use 2.96 staff/full time provider saving $35,000 per year
• Cost of paper chart: $3-$6/patient
• Includes chart material, chart racks, labor, and office space
• Better documentation allows higher coding
• Practice Promotion
• Search EMR and contact patients for a new procedure or service
• Office Efficiency impresses patients
• Attracting and retaining staff – With a successful EMR, staff never want to work with paper charts again

What is the downside?

• 6-9 month transition period
• Requires data entry from paper to EMR
• Many features to set up and learn. This is very time-consuming and many offices never get beyond basic use of the EMR because they don’t invest in the setup time.
• Computer-phobic docs and staff
• You must have at least one tech-savvy staff member or hire a part-time IT specialist
• Maintenance costs
• Downtime (a lot less common than lost charts)

Predictors of a successful transition to EMR

• Slow, well-planned transistion
• Sell the advantages to docs and staff
• Need a “Champion” to lead office through the process (usually a Physician or staff member, can be vendor rep or IT person)

Evaluating EMRs

• Feature lists are least important (most vendor have all the features, but some implement them poorly)
• Demos are not “real world”
• Physicians and staff should do a site visit
• Does the system improve your biggest time-consuming tasks?
• Phone calls/Messages
• Chart pulls and lost charts
• Med refills
• Dictation is “not back yet?”
• Doing Progress Notes and consult letters?

Our Top Timesavers with EMR

• Messaging (In-office email)
• No chart pulls or sticky notes
• No staff hovering outside exam rooms waiting for providers
• Prescription writer
• All data online and accessible (no chart pulls or page flipping)
• Records requests - “Copying the chart” (Easily prints whole or part of chart to paper, disk, or fax)

Evaluating EMRs

• Beware of “vaporware” (features that are not yet implemented)
• Are the EMR tasks more or less efficient?
• Does it allow you to do tasks once and then automatically populate the other chart sections (eg. writing Rx will print Rx, update med list, and update progress automatically)?
• How much do I need to change the way I practice?
• Does the EMR support multiple data input methods?
• Dictation/Transcription
• Note Templates
• Voice Recognition
• Certain providers and visit types work better with one vs. the other
• Can the system handle multiple offices or scale to large practices?
• What is the company history and installed base of users (you want them to still be in business in 10 years)?
• How are ongoing support, upgrades, and costs handled?
• User meetings, user groups, discussion threads – often a better source of information than the vendor

Do a site visit

• Do not depend on a sales rep’s demo. They are not real-world.
• Choose a practice similar to yours
• They should have at least 2 years of experience with the system
• Request a demo from all types of users (Provider, Med Sec., Nurse)
• Get your staff together to make a list of office tasks that you do repeatedly through the day and ask the demo site to show each one (eg. writing and renewing Rx, handling phone messages, looking up lab and other test results, getting outside labs and reports into the system, writing progress notes and PEs, patient reminders, managed care referrals)
• Ask common sense questions (What do you like/dislike? What tasks are more/less time-efficient)

Transitioning to EMR

• Decide which old data to enter
• Problem list
• PMH/Surgical History
• Current Meds
• Allergies
• Training and template setup takes 1-3 months
• Note and procedure templates
• Rx. Templates
• Implement scanning of outside reports and data entry for labs
• Set start date for all new data to go into EMR: “live date” No paper gets added to paper charts after this date.
• Old data is entered by all staff (provider, nurses, and secretaries) before or at visit, but definitely before the end of the day
• Start with patients scheduled on the first “live” day
• Pull charts for 6-12 months after start date (read only, don’t add info to paper chart)
• Start using new features in steps (don’t try to implement too much, too fast)
• Use Rx. Writer and Messaging early (big time saver)
• Lab request forms, work notes, and other repetitive tasks
• Then start using Progress Note and Procedure templates (start with repetitive, predictable visits first, eg. HBP visits)
• Implement features with your most tech-savvy providers and staff first. They will pick it up easier, and tolerate the “bumps” without giving up. You can fine-tune procedures and templates with them.

EMR Links

AAFP’s Center for Health Information Technology (CHIT)

http://www.centerforhit.org/

Collection of EMR articles in Family Practice Management

http://www.aafp.org/x20091.xml#f

Selecting an EMR – Sarah Corley MD

http://drcorley.net/selectvendor_files/frame.htm

Interview with Jerome Carter, author of

Electronic Medical Records: A Guide for Clinicians and Administrators

http://www.acponline.org/journals/news/mar01/emr-tips.htm

Computing for Clinicians

http://www.computingforclinicians.com

Physician Micro Systems (Practice Partner Patient Records) – the system I use

http://www.pmsi.com