A New Way to Efficiency

Improving Your Practice With an EMR

By Susanna Donato
Susan Donato is a writer for Physicians Practice

Technology changes so quickly that it can feel like a race to keep up with the latest. When it comes to major decisions like selecting an electronic medical record (EMR), however, slow and steady wins the race. Careful planning and introspection as a practice will help you make the right EMR investment.

Ready to join the EMR ranks?
As with any endurance test, evaluating EMR options should begin with some basic training. An EMR is a computerized patient chart that allows patient data to be sorted, shared and rapidly updated. Many EMRs include components such as electronic prescribing. You will still need a practice management system and claims submitting tools, either separate from or integrated into the EMR.

While it sometimes seems everyone is going electronic, EMRs are still an elite breed; it is estimated that the range is only 3 percent (source: Gartner Group) to 17 percent (source: Harris Interactive) of primary care practices that are using EMRs. But, computerizing medical charts becomes more attractive particularly as HIPAA (Health Insurance Portability and Accountability Act) rules go into effect because most programs include automated security measures.

"I would say there is an impossibility in being HIPAA compliant without EMRs," said William Jackson Epperson, M.D., M.B.A., of Inlet Medical Associates in Murrells Inlet, S.C. Besides working with an EMR in his own practice, Epperson often speaks to physician groups about EMRs. "An EMR requires passwords for access to patient files. Every time someone accesses an EMR, it leaves a signature behind so you can tell who's been there. There is no way in a practice to functionally lock up paper records, as HIPAA requires, and practices will have a very difficult time not violating HIPAA — sometimes without even knowing it. The EMR allows practices to meet HIPAA compliance in many ways, even those you might not be aware of."

In addition to automating some compliance measures, using an EMR can provide excellent returns in terms of saving time and money. But be aware that implementing one is not without its challenges.

What works for you?
Before you delve into the many EMR products available, look closely at how your practice works and what processes you want to change. The EMR should support your practice style to make the practice more efficient and to better document your patient care.

"The number-one qualification is an EMR that's comfortable for you," said Richard Byrd, practice manager for Lakeview Family Health Care in Lake Havasu City, Ariz. "You can spend a heck of a lot of money and not get something that's user-friendly. Why is one system higher priced than another? I really can't explain it."

Market researcher Vinson J. Hudson, president of Jewson Enterprises, advised approaching the search for an EMR with a touch of skepticism. "At base, an EMR is a business investment to improve how you do business," Hudson said. "Don't believe everything the vendor says — they're trying to sell you a solution. You've got to see if it fits you and the workflow you're trying to automate. It's not like buying toothpaste, where you just look at the shelf and pick one."

The most important part of the process is to define your needs. Do you want to cut time spent searching for charts? Reduce errors? Improve coding? Eliminate pharmacy callbacks? Speed communication with labs? Support HIPAA compliance? Make records accessible simultaneously to multiple staff? An EMR can help you do any of these things, but you need to prioritize your objectives.

Finally, before you go EMR shopping, make sure the physicians in your practice are ready to make the leap to technology.

"There has to be a desire to use a computer," said Thomas Bat, M.D., of North Fulton Family Medicine, near Atlanta. "Some doctors want to be organized, want to use a computer, but without using a computer. They have to overcome their fear of the clerical and become willing to touch the mouse."

Do your homework
Before you start researching EMRs, understand you are committing to a process. Selecting an EMR can take six months to a year or longer. Adopting any program will temporarily affect your billing, staffing, work hours, practice management system, infrastructure and even storage.

Every team needs a coach. To stay on track, put someone in charge of the whole EMR project — both driving the selection process and taking the technological lead.

Hundreds of EMR vendors are competing for physicians' business. To learn what they offer, see reviews on industry Web sites, such as the American Academy of Family Physicians' vendor survey (www.aafp.org/fpm/20010100/45elec.html) or the site Kirk Voelker, M.D., developed to let physicians compare EMR systems (www.elmr-electronic-medical-records-emr.com/). Or, ask the opinion of other physicians you respect — perhaps those with a practice similar to yours.

Once you have a few vendors in mind that can meet your practice's needs, compare their costs and service. Try to do an "apples-to-apples" comparison, rather than just looking at vendors' marketing materials.

Share your must-have list with each vendor. Find out specifically whether their product meets your needs. If not, move on — there's likely a product out there that will do what you need. Learn how the vendor handles training and support. Finally, contact the vendor's references and ask those practices how the EMR works — and what hasn’t worked.

"Ask what problems the practice encountered with their implementation," Hudson advised. Epperson suggested taking the questioning even one step further: "Ask if they'll get a commission if you buy the product," he said.

Seek references in your same practice area because the way coding templates are set up makes a huge difference in an EMR’s effectiveness. You'll want a template that makes sense for you — and the ability to personalize templates by practice or even by individual user.

For example, "our pediatricians wanted to add 'fussy baby' as a chief complaint," said Pamela Coyle-Toerner, president and chief operating officer of Cincinnati-based Queen City Physicians, Ltd. "We did have to figure it out, but the system has the ability to expand terms and knowledge very easily."

Costs and savings
The initial expenditure for an EMR can range from $20,000 to $150,000 for practices from one to 10 physicians, according to Hudson. For a practice of 100 physicians or more, the tab could approach $1 million. As with many major purchases, costs spike in the first year, then drop to basic maintenance fees thereafter.

The cost includes purchasing software and hardware — desktop computers, servers, printers and the handhelds many physicians use to directly input data or write prescriptions — and installing necessary network systems and wiring. Your cash outlay will depend on how many sites, physicians and nonclinical users you have and the types of interfaces you need.

Some costs continue once you've bought the software. Smooth management of your clinical records will rely on your vendor’s customer support, which includes training, software maintenance and product enhancements, as well as technical assistance to resolve problems. Most vendors charge support fees averaging about 20 percent of the software price annually, Hudson reported. Check into additional fees for services, such as electronic prescribing.

The start-up process has a ripple effect on productivity, which in turn can temporarily affect finances. Most practices slow down for at least a few weeks, and some for a few months, while they adjust. For instance, taking existing charts completely electronic would require scanning all your paper charts — a daunting task. More commonly, practices gradually scan or key in only necessary history — such as a mammogram’s date and result, but not all the documentation. Using this method, within about 18 months, you won’t use your old paper charts at all.

"From the moment our first practice went electronic, each physician made the decision about what went in the electronic record. Historical records [each physician] thought critical to [the patient's] care would go in; other things stay on the shelf," recalled Epperson.

"With us, it was very difficult on some physicians," Epperson added. "They got to where even putting a period on a sentence made them irritable. It took us about six weeks to be proficient, and four months to be very good at it."

However, even in the short term, some cost centers will go down, offsetting some expenses related to the EMR purchase. You might slash dictation and transcription, stop adding to your records storage bills and save hours playing lost-and-found with charts.

"Our biggest win has been the opportunity to bill appropriately for care," said Coyle-Toerner, who oversees 38 providers at seven sites. "Physicians were shy and actually left money on the table because they didn't bill appropriately. Now they're certain, and they aren't bashful because they know the documentation is there to support it."

Long-term improvements
The whole EMR process might sound intimidating, but the payoff can be phenomenal. Epperson reported that his four-physician practice’s income jumped by $200,000 a year — $150,000 reaped from eliminating undercoding, plus $50,000 annual savings in dictation costs. "Our greatly improved medical records management leads to greatly improved quality of care with less risk of patient management errors," Epperson said. "We now believe that we code to an accuracy level reaching 100 percent all of the time."

And with experience comes a shorter learning curve. Bat's North Fulton Family Medicine just recently brought a new physician on board. "[On] his second day of seeing patients, he [saw] eight patients and [completed] charts," Bat said. "The learning curve can be spoken of in a matter of hours. We have found it to be very rewarding — and in the end, it hopefully makes us better doctors."