EMR success stories: Practices that are thriving after the changeover

Physicians who have seen an electronic medical records system pay for itself within a year share how they, and their systems, made it happen.

By — Posted May 5, 2008

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Like many physicians today, when James Morrow, MD, of North Fulton Family Medicine in Cumming, Ga., decided in 1998 to implement an electronic medical record, he heard the horror stories associated with EMR adoption.

But the four-physician practice, feeling financially drained by transcription costs running $9,000 per month, plunged ahead with a $200,000 investment. Ten years later, it has no regrets.

"People say we were early adopters, and I guess that's true," Dr. Morrow said. "But at the time we were just trying to survive."

The theme of survival is common among practices that decided the gamble of implementing an EMR was less frightening than continuing in their current situations.

Sometimes the gamble fails: Partners are resistant to using the system; employees aren't well-trained in it; the system itself fails to meet a practice's needs. This can result in a junked EMR and a lost investment.

But sometimes the gamble succeeds. Here, four physicians tell how they decided -- despite well-documented evidence of everything that could go wrong -- that an EMR was right for them, and how they succeeded in getting a return of their financial investment within the first year of operation.

Saving her practice
Solo family practice in Texas
8 months to recoup costs

In 2006, after five years in a shared family practice that serves mostly indigent, Medicaid and Medicare patients, Alicia V. Valdez, MD, of the South San Antonio Family Practice found herself facing life as a solo physician.

She was already drowning in a heavy patient load, and her outgoing partner was passing on several hundred more patients. Dr. Valdez hoped an EMR could make her day more efficient. But she also knew if her EMR experiment failed, it would mean the end of her practice.

Dr. Valdez took out a small business loan, invested in a $56,000 EMR and hoped for the best.

Eight months later, she broke even. A few months after that, she reduced her workweek to four days, while her monthly income continued to increase.

Because the EMR allowed her to update patient records at the time of the visit, she no longer needed to schedule several hours of charting at the end of each day. The EMR also helped her document more patient encounters, which resulted in more accurate coding and higher reimbursement levels.

Without an EMR, the highest Dr. Valdez was able to code was a level three. Even though she was asking family history, required for a level-four visit, she didn't have the time to document it. "If you don't document it, it didn't happen. You did not write it down because you didn't have the time, and when you serve the type of patients like I do, you have to see all of those patients in one day in order to pay your overhead and stay afloat."

On Dr. Valdez's EMR, which includes a handheld device she carries into the exam room, family history can be documented by simply pointing and clicking preexisting fields in a built-in template as she talks to the patient.

"When I said I needed an EMR to save my practice, that's what I meant; I can't stay here until midnight writing those notes on 40 patients. If I have 40 patients ... then that's going to take a lot of time. You can't write and see patients at the same time, but you can point and click," Dr. Valdez said.

The EMR also made billing as simple as uploading the patient encounter information into the billing system, which then electronically transports it to a clearinghouse. This meant Dr. Valdez was able to bring billing back in-house, saving her $35,000 a year.

She also saw additional revenue from overturning denials she previously didn't have the time or resources to appeal.

One major victory was a battle she won to have more than 900 denials from one insurer overturned. Without the EMR, she said, she would have been unable to provide auditors with the information needed to make her case.

Dr. Valdez estimates she lost $200,000 the previous year in denials that could have been appealed successfully.

She believes the level of success a practice finds with an EMR depends on the system it chooses and the degree of commitment from everyone in the office.

Before settling on a system, Dr. Valdez and her staff spent an entire day at an EMR road show where every staff member was expected to evaluate the different systems, report what they learned, and rank their top three choices. One system was listed in nearly everyone's top three. Dr. Valdez said it was important for each employee to feel he or she had a part in the decision to ensure commitment to making it work.

The other key selling point, she said, was the vendor's offer to conduct pre-installation training. By the time the system went live, it felt like everyone had been using the system for months, Dr. Valdez said. "It was a very smooth transition."

In addition to the successes she had hoped her EMR would bring, there were several other benefits. Dr. Valdez hadn't realized how much money she threw away in lost inventory because she wasn't able to order based on demand. Now when she's ready to order vaccines, for example, she can generate reports of how many vaccines she used the previous year and use that number to plan for the coming year.

She's also able to give more vaccines and boost other preventive care by generating reports of patients who are due for tests or shots, an efficiency that also improves patient care.

"That's how you provide good medical care. You call them in for mammograms; you are due for blood pressure check; we sent you to a specialist and we know if you didn't go. All these types of things we couldn't do before," Dr. Valdez said.

Checking on drug interactions
2-physician internal medicine practice in Virginia
9 months to recoup costs

Ralph Amedeo, MD, an internist with Advanced Health Care, a two-physician internal medicine practice in Arlington, Va., said when he decided to invest in an EMR, his goal was to improve patient care. The financial benefits were an unexpected bonus.

Dr. Amedeo had grown frustrated with drug interactions. The paper-based system he had for checking possible interactions was cumbersome, and required too much time to look up information. Soon after going live with his EMR system, he found that the time he saved doing research and documentation enabled him to take on more patients.

Dr. Amedeo bought a used system from a retiring physician and used his own technical knowledge to customize it. He doesn't recommend this route for others, he said, but it worked out in the end.

The first year after implementation, Dr. Amedeo saw 400 more patients than he had the previous year and within nine months had earned back the $25,000 he spent on the EMR. Additional savings were realized over time, as he was able to reduce his staff from four employees to three.

Small things add up, too, he said. For example, the system can generate letters to certain groups of patients with a few quick clicks. When lab results come back, the results are entered into the records, and the system generates a letter to the patient that explains the results, saving him a lot of time.

The system also helps strengthen personal relationships between him and his patients.

"Who was the patient who is a marble dealer? I can tell it to search the social history and find the word marble," he said.

The key to success, he said, is a commitment from everyone in the practice. Dr. Amedeo said he was forced to dissolve a partnership with another physician who was not as invested in using the EMR as Dr. Amedeo would have liked.

"When one partner says I am not going to use it, that's when I see systems fail," he said.

Customizing -- a little
Large gastroenterology and surgery practice in North Carolina
6 months to recoup costs

Frank Chapman, chief operating officer of Asheville (N.C.) Gastroenterology Associates, said the practice is split between a surgery center that sees about 50 patients a day and a clinical office that sees about 130 patients a day, which meant a lot of money was going to transcription fees.

The two-phase EMR deployment started on the surgery side, where savings were realized immediately. Although startup costs were about $15,000 per room, the transcription fees were eliminated on day one, Chapman said. It took about six months for a positive cash flow on the clinical side, because staff first needed to scan paper files into the electronic system.

Chapman said he wanted an EMR that was customized for his specialty but not customized to the point that would require replacing the salary of a low-level transcription assistant with the higher salary of an information technology specialist. The system was specific to the gastroenterology practice and provided 90% of the customization he was looking for.

EMRs can be very specialty-specific, Chapman said. "Bad choices are cause for failure," he said, adding that physicians sometimes make the mistake of looking to local practices for EMR advice, when they should be looking at practices within the same specialty.

Unexpected benefits of the practice's EMR installation included ease in sending and receiving referral notes to and from other doctors, Chapman said. Before the EMR, the "fax machine was turning out faxes every minute of the day," and the cost of paper and copies added up. Now, everything is done via e-mail with attachments, leaving a nearly paper-less office.

Going for the cheap one
Solo family physician in Texas
1 month to recoup costs

A.R. "Buddy" Garcia, MD, a family physician in solo practice in Houston, said that when he lost one of his two physician assistants in 2002, he knew he needed help to keep up his workload of about 35 patients per day. He also was experiencing professional burnout and knew he had to make a change or stop practicing medicine. He thought an EMR could help reduce some of the administrative work that was bogging him down.

After searching systems ranging from $3,000 to $200,000, Dr. Garcia decided on a system that set him back about $13,500 for the system plus a server and two handheld tablets. Within one month, he had a return on his investment, and his net revenue had increased by 30%, Dr. Garcia said.

The biggest change in cash flow came from his ability to code more accurately.

Like many physicians, he said he commonly undercoded because he was afraid of being audited. His EMR system takes into account things such as the length of the clinical notes, the diagnosis and treatment plans, and generates a suggested code for each visit, which are generally level three and sometimes as high as level five.

"If you get audited, you have all the documentation needed to justify those codes," he said.

The ease of using the system was the selling point, he said. It's easy to learn, and there's no mistake that can't be corrected. The system made Dr. Garcia's practice so efficient that he is now seeing about 50 patients a day and still is out the door by 5:30 p.m.

Dr. Garcia said physicians shouldn't discount the relatively inexpensive systems. "They look at price and say, 'That's a cheap one,' and they don't take the time to look at the system."

Dr. Garcia was able to buy his system without a loan or lease, and it still had all the bells and whistles of the more expensive systems.

"No way I could have bought one at $50,000 or, heaven forbid, $75,000," he said. "It's the middle of the road and does everything I want it to do."

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Overcoming barriers

Physicians share tips on how they got through the pitfalls that often present when adopting electronic medical records.

High initial startup costs: The price of EMRs has dropped during the past five years. Systems are now available for a few thousand dollars, or even less for practices that have computers and an Internet connection. Small business loans are an option for funding. Experts advise using a system that doesn't require high monthly or annual maintenance and system update fees.

Lack of technical knowledge: Good systems don't have to be hard to use. Many include options and applications that are unnecessary. Get only the features you know you will use. That approach also might lower the startup costs.

Reduced productivity during implementation: Some vendors offer Web-based training in advance, so the practice knows how to operate the system the day it is installed. Physicians also suggest finding a system that mimics the existing workflow pattern. The less doctors have to change the way they practice, the smoother the implementation.

Difficulty migrating from paper: Practices have approached this in a number of ways, including hiring temporary staff to scan old paper charts, or by scanning files as patients make appointments. Whatever the game plan, an end-date should be set for the practice to go paperless, with a commitment from everyone to meet that deadline.

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