Know your EMR needs (Towards the Electronic Patient Record conference)

With more vendors entering the industry, experts say, physicians can be choosy about their technology. But first identify your key choices.

By Pamela Lewis Dolan — Posted July 14, 2008

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When Cleveland internist James Saul, MD, implemented an electronic medical record in 2004, he was simply looking for a system that would integrate with his practice management software.

He didn't consider how an EMR might change his work flow, for better or worse, or how it could generate revenue.

Luckily, Dr. Saul said, his implementation was successful. But he regrets not thinking ahead, as there are features he wishes he had but that his vendor doesn't offer.

Many physicians have had buyers' remorse over systems. Fear of such remorse is often listed as a major factor in doctors not buying health information technology.

At the recent Towards the Electronic Patient Record conference, technology vendors and other stakeholders discussed how to combat these fears and expand the use of health IT.

As has often been said, physicians need to analyze their practice work flow and how technology will affect it so they may become wiser buyers.

"Unless you know what you want, you will get what you deserve, which may not be what you need," said Bernd Wollschlaeger, MD, a physician consultant for the EHR Now! project of the Florida Academy of Family Physicians. The project is offering free EMRs to physicians through a contract with the Medicare Quality Improvement Organization for Florida.

Vendors also acknowledged that they needed to make changes to make the decision easier for physicians.

Jack Callahan, vice president of corporate development for West Des Moines, Iowa-based MediNotes Corp., said his company has been forced to change many times in its 11-year existence, both in terms of the systems themselves and in how the company sells them.

"We've had to adapt to everything," he said, adding that not only are doctors more educated now in terms of what they want, but they also are demanding systems that meet certain criteria for interoperability or certifications such as that from the Certification Commission for Healthcare Information Technology.

Lessons learned

It shouldn't be news by now that a practice will experience changes to its work flow once it goes electronic. While most vendors and consultants agree this fact has too often been ignored or underestimated, many doctors are now getting the message as they learn from others' mistakes.

"I think those who are skilled in implementation have known work flow is important but there's now a critical mass of experienced peer physicians who can stand up and say, 'They told me, and I didn't listen,' " said Carol Slone, RN, a regional manager for the Weymouth, Mass.-based consultancy firm Beacon Partners.

Kevin Spencer, MD, a family physician with the South Austin (Texas) Family Practice, learned the hard way that figuring out what you need and want has to be done before implementation.

Dr. Spencer is in the market for his third EMR. His first EMR project was scrapped after he folded his solo practice into another group. Implementation of the EMR that his newly formed group purchased went downhill because, Dr. Spencer said, the group didn't get the vendor support necessary to help with the work flow issues that he now knows should have been addressed prior to adoption. "We learned the hard way to do the work ahead of time."

Deresa Claybrook, with the Moore, Okla.-based consultancy firm Positive Resources, said practices often can't foresee the ways technology can change the way they do things. For example, at one practice she worked with, a billing clerk did not understand that workers' comp forms would no longer have to be faxed, but could be sent electronically. These are the types of system features that practices need to be aware of when they are analyzing work flow changes prior to implementation, she said.

Beyond automation

But adopting an EMR shouldn't just be about automating what is happening in the paper world. Practices should also think about potential EMR advantages, such as finding new sources of revenue or ways to meet patient demands for services such as e-prescriptions and e-mail contact.

Dr. Saul said when he implemented his system four years ago, little was said about e-prescribing. When he recently decided he wanted e-prescribing, he had to implement it as a stand-alone system because his EMR vendor doesn't offer an integrated option.

Barbara Cox, senior principal for the Noblis Center for Health Innovation in Hunting Valley, Ohio, agrees that physicians need to think about services their patients might later demand, such as online scheduling, use of a personal health record, and e-mail consultations. Finding a system that either includes those things or can allow for them to be added later will save the physician from regretting his of her EMR decision down the road.

But doing that homework is harder for a small practice that cannot easily afford a consultant, said Dr. Spencer. "I think that needs to be on the vendor side and part of their consultation. More vendors need to sell themselves as consultants."

Changing industry

Liz Rockowitz, regional manager for the eastern division of Beacon Partners, said she has noticed that more experienced vendors have learned to create systems more adaptable than the "cookie-cutter" solutions initially offered.

Early adopters who wanted customizable systems could get them, but at a price far out of reach for many practices.

Slone said she has worked with clients who said no to customization because of the cost, but then realized, almost immediately, that the systems didn't fit their needs. "It's like putting in a scarlet pink carpet when you know you hate scarlet pink, but it was the cheapest. So you put it in, then complain about it."

Callahan said his company's solution -- an approach that is becoming more common with other vendors -- was to build a system easily customizable by the user. That has allowed his company to sell to physicians in 31 different specialties, he said.

But the solution for other vendors has been to remain cookie-cutter and reach out to niche markets, according to Rockowitz. Some vendors have entered the market with systems designed for a particular specialty, for example, or for a certain practice size.

Vendors are making systems more affordable, plus easier to use and maintain, experts say. One major change has been moving the servers to remote data centers instead of hosting the data locally, according to Cox.

Remote hosting not only allows the physicians to access the data from almost anywhere with Internet access, but it also reduces the costs of maintaining a locally hosted server.

"When vendors started hosting products and making the data available online, the rest wanted to do it. I'm surprised now when I see one who won't," Cox said.

While similar trends have emerged across the board, each system is still unique, experts say.

Once again: Be prepared

To ensure a successful implementation, practices must do their homework, said Belinda Pirtle, founder and president of CARR Instructional Design, a consultancy based in Washington, D.C.

Practices should analyze current work flow, determine how they would like the work flow to exist after EMR implementation, then take that chart to each vendor and ask them to provide a system to match it, she said.

"If this vendor can't do it, there's enough EMRs out there to find what you need," Pirtle said.

No vendor has everything, warned Rockowitz. But "everyone has pain points. You measure pain points versus cost."

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Analyzing work flow

Experts say it doesn't matter whether you create a fancy flow chart or a simple list. A good look at how a practice does things will help determine the needs for an electronic medical record as well as identifying inefficiencies. A work flow analysis should capture every move from the time the patient makes the appointment to the end of that encounter.

Processes to include in your analysis:

  • Patient communication
  • Patient check-in
  • Retrieval of charts
  • Documentation of the patient's chief complaint
  • Documentation of the clinical exam
  • Ordering of tests or labs
  • Patient check-out
  • Medical correspondence between other physicians or specialists
  • Billing

Each process should include these elements for the current system and for how things might change with an EMR:

  • Players involved with each task (front desk clerk, nurse, physician, billing clerk)
  • Steps involved
  • Variables and how they are handled (i.e., if test result is positive or if patient needs referral, etc.)

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Consumer interest in e-health

Experts say patient demand eventually will drive a lot of the health care trends being pushed by the federal government, including data exchanges. The Louisville Health Information Exchange conducted a study last year to gauge the public's knowledge of and perspectives on a proposed health information bank. The study included telephone and Web surveys and focus groups.

Results of telephone survey

59% said they would use an electronic personal health record bank.

31% said they wouldn't use it.

10% weren't sure.

35% wanted free use of an EHR bank.

4% were willing to pay $2.50 per month.

9% were wiling to pay $5 per month.

7% were willing to pay $10 per month.

4% were willing to pay $15 per month.

80% of respondents between ages 23 and 65 were willing to pay to use the service.

17% of people older than 56 were willing to pay for the service.

Of the 69 households that had children younger than 23 in the house, 69.9% were willing to use the service and 30.4% were willing to pay for the service.

Source: Louisville Health Information Exchange

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PHR-on-a-phone has hangups

At the Towards the Electronic Patient Record conference in Fort Lauderdale, Fla., in May, Boston-based Medical Records Institute joined with AllOne Health Group to launch a test project that stores personal health records on a cell phone.

The launch created a buzz around the Broward County Convention Center, as several TEPR attendees downloaded the program onto their own cell phones. But the company acknowledged it is still working out some bugs -- mainly, those issues that render the technology virtually useless in an emergency.

Stu Segal, vice president of integrated operations for AllOne in Wilkes-Barre, Pa., said the first objective was to make the system secure. It stores patient data behind a password-protected, encrypted channel developed by Diversinet, a Toronto-based company that develops wireless technology.

But the security also locks out access. Without a password, an emergency responder might not even know a PHR exists, and couldn't get data from it anyway.

Segal said the company is working on a "break glass" feature that would allow emergency access to limited information, but still protect against identity theft.

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