Wading into EMR: Going electronic, one step at a time

You don't have to put your practice through an extreme tech makeover. Experts offer some suggestions for testing the waters with incremental changes.

By Tyler Chin — Posted Nov. 13, 2006

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Four years ago, Partners in Internal Medicine considered buying an electronic medical records system. The eight-doctor practice was having trouble finding paper charts and had run out of storage space.

But its doctors weren't ready to adopt the technology, much less swallow the $250,000 they were told an EMR would cost. So the group opted for a document imaging system, not only to address the immediate problems, but also to position itself for an eventual EMR. It was a fraction of the price.

"We called it a phase-one approach to achieving some operational efficiency, and reducing some of our overhead and expenses by transitioning to an electronic health record in this manner," said Debra Roberts, administrator of the Ann Arbor, Mich., group practice. "What is even nicer was that I didn't have to change my doctors' behavior. The only adjustment my doctors had to make was that they had to get used to looking at the record on the computer versus having a paper chart, but they still take notes on what we call a physician check list and they still dictate."

Given that EMRs have a reputation for being costly and disruptive to work flow, many doctors are avoiding them. But clinical automation doesn't have to be all or nothing, observers say.

Doctors can take baby steps -- with document imaging, electronic prescribing, portable electronic drug references and clinical messaging systems -- and gradually work toward an EMR, observers say. These stand-alone systems are cheaper and easier to use, and they help both doctors and staff prepare for an EMR. In some cases, the components can be linked together and integrated with an EMR, consultants said.

Doctors "should absolutely phase in and take a stepping-stone approach so they can acquire some level of comfort with technology and let their nursing staff feel comfortable using computers, keyboards and a mouse," said Rosemarie Nelson, a health care technology consultant at the Medical Group Management Assn. Even the early adopters of EMRs generally had prior experience with technology, such as office billing systems, personal computers or even EMR exposure during residency.

Start at the beginning

Document imaging systems, which allow practices to scan and file paper documents electronically, are a common first step.

"It does all kinds of wonderful things, because the information is now sort of electronic, so they can quickly and easily pull it back up," said John Jessop, a health care technology consultant in New Hampshire. "It gets rid of the paper shuffle. It can reduce their medical record staff so there's a quick return on investment that way. It also can get physicians used to using the computer to look up information."

Not everyone thinks document imaging is a step in the right direction. "It's a worthless application," said Margret Amatayakul, president of Margret\A Consulting LLC, a Schaumburg, Ill.-based health care technology consulting firm. "I honestly believe that scanning all the documents that you get today is doing nothing for you except for providing slightly better access to information. Unless you have an enormous clinic ... and are seeing the same patients at multiple different sites, document imaging, in my view, is a baby step that is not worth taking because it's quite expensive to undertake."

Partners in Internal Medicine, however, said it wasn't a misstep for them.

Scanning paper lets the practice move toward a paperless environment with a minimal impact on physicians, Roberts said. The only change in the doctors' work routines are to view patient information on computers while seeing patients in the exam rooms, Roberts said.

They document findings on a paper-based encounter form with a checklist, and staff members enter it into the computer. Physicians also dictate notes on digital recordings that are securely transmitted to a transcription service then uploaded into the appropriate charts, stored in the document imaging system.

The practice also scans each document it receives, then shreds the original. The system has enabled the group to expedite filing and access information more quickly. "We improved the turnaround for patient inquiries, which increased patient and staff satisfaction," Roberts said.

The system, which cost $65,000, has saved the practice "a ton of money," Roberts said. For example, it enabled the group to reduce medical records staff from five full-time-equivalent employees to 1.5 FTEs.

Eyeing the big step

The practice hopes to implement an EMR in 2008, but the timing ultimately will be decided by the physicians.

"The most difficult challenge of moving to an electronic health record, at least for our practice, is having physicians adjust to real-time point-of-care data capture in the exam room," Roberts said. "They don't want to be slowed down, they don't want the number of visits to decrease because they are using an EHR, and they are not convinced that they can maintain the [productivity] levels they are seeing today by moving to an EHR."

Still, the group eventually will make the transition. While the document-management system has been useful, it lacks the true database EMRs have, "so therefore you don't really have a lot of reporting that you can do from it," without labor-intensive and time-consuming effort, Roberts said. "With pay-for-performance kind of being placed upon us, or mandated, we're going to need the reporting."

The group is satisfied that the system has improved its operations and will ease the transition to a full-blown EMR "because we are going to be used to working on a computer, we're going to be used to typing, we're going to be used to pointing and clicking and maneuvering through the electronic chart," Roberts said.

Automating paper

If even the price of document imaging systems seems too high, a lower-cost alternative involves putting office notes online. A personal computer with a word processing program can be used to create and access key patient data electronically, Nelson said. While storage on a network server would be ideal, practices without computer networks can store notes on a PC.

"It's kind of the poor man's version of document management," Nelson said. "What I'm talking about is doctors actually having their transcriptionist save every patient's file separately, and that way you have an electronic document for each patient's office visit, and maybe a folder for each doctor."

Having the note available electronically will help practices handle telephone calls more efficiently and save them the cost of pulling charts, which ranges from $5 to $12, she said.

Another lower-cost alternative is a fax server, selling for less than $1,000, Nelson said. With a fax server, practices can arrange to get every piece of clinical correspondence electronically. Medical records staff then can organize those faxes into a comprehensive, up-to-date chart.

These electronic documents later could be imported into an EMR. "They won't start with a blank chart anymore. That's going to make it far more enticing for any physician to use the EMR system if they actually have valuable information at their fingertips," Nelson said.

Computerizing prescriptions

Another interim step is electronic prescribing, with systems that range from a few hundred dollars to $5,000.

"I think it's probably the most useful baby step," because it requires doctors to use and enter data on computers, Jessop said. Electronic prescribing also exposes doctors to the types of decision support and alerts most EMRs offer, so "the transition won't be that big of a leap."

Electronic prescribing systems also offer doctors access to health plan formularies and help doctors build electronic problem and medication lists, Jessop said. These can be exported into an EMR, if the practice's contract with the electronic prescribing vendor covers data conversion.

Two other baby steps are a personal digital assistant loaded with a drug information database and messaging systems to communicate with referring physicians and clinical partners through secure Web portals, Amatayakul said. "It's just one small step, but it gets them started thinking, 'The computer is good for me. It has valuable information for me.' "

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Inching toward the goal

If you aren't ready to leap to an electronic medical records system, there are alternatives. You may -- or may not -- be able eventually to incorporate stand-alone components into a full system. (Costs shown do not include monthly maintenance and service fees.)

Step Included with an EMR? Start-up cost
Document imaging software Yes 25% to 50% of the cost of an EMR
Electronic prescribing software Yes $400-$5,000
Personal digital assistant for accessing drug database Yes Free-$500
Web portals for clinical messaging No $1,000-$5,000

Sources: John Jessop; Rosemarie Nelson; Margaret Amatayakul; Andrew Murphy, MD; Partners in Internal Medicine

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Looking for an EMR

What if you want to move to an electronic medical record system but can't afford it?

One alternative is to assemble a group of practices. That's what Andrew Murphy, MD, an immunologist at a two-doctor group in West Chester, Pa., is working on. "The cost is ridiculously expensive," he said, adding he decided against an EMR in 2005 after vendors quoted him a $30,000 to $50,000 first-year start-up cost per physician. Now he's approaching other immunologists and allergists in his community to join together to buy an EMR, sharing the cost and hopefully getting a better deal.

"If you're only a one- or two-man practice, I don't think the companies are real interested in adjusting things quite as much as they would" for large groups, Dr. Murphy said. "If you have a larger group purchasing it together that may be a way of trying to (a) get what you want and (b) make it a little more cost effective."

Some health care attorneys said Dr. Murphy's approach is similar to what large health care organizations, including regional health information organizations and independent physician associations, are doing to make EMRs more affordable for members. If doctors aren't members of an IPA or a RHIO, then "from a practical perspective they need to form an entity to sign a contract allowing them to purchase the [software] licenses," said Diana J.P. McKenzie, a health care lawyer at Neal, Gerber & Eisenberg LLP, Chicago. They also need some agreement about how to distribute the licenses, she said.

Consortium members also might need to address other issues, including privacy and security of data, said Adele Waller, a health care technology lawyer in Chicago. So it might be cheaper and easier for doctors to lease Internet-based software from a vendor.

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