Electronic medical records: How implementation will affect staffing

Some practices may be able to cut staff. But others may hire, and some may shuffle responsibilities.

By Pamela Lewis Dolan — Posted Oct. 5, 2009

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One practice installed an electronic medical records system and cut 12 staff members. Another practice added two full-time employees.

These two very different scenarios help underscore one truth: The only definite aspect about determining post-EMR staffing needs is that there is no magic formula.

A variety of factors come into play, including practice size, scope and, most importantly, the practice's goals. What happens in terms of the number of staff -- and how the EMR changes what that staff does -- will largely depend on the problems the practice is looking to address with automation.

If the goal is to reduce costs, the end result will look much different than if implementation is to improve quality of care or to change a practice's branding, said Rick Mullins, vice president of knowledge and consulting services for Sage, a global technology solutions and software supplier.

There are some assumptions about staff changes that are easy to make, experts say. Any job that was strictly paper-based prior to implementation, for example, will need to be overhauled or eliminated.

Other changes are not so easy to predict, and could depend on how willing your employees are to adapt and learn new skills.

Define the practice's goals

Mike Doyle, CEO of Carlsbad, Calif.-based Medsphere, which installs the VA-created VistA EMR in hospitals and physician practices outside of the Dept. of Veterans Affairs system, said he strongly believes that the more specific a practice's goals, the better the outcomes.

Practices "should quantify what their goals are and work to achieve those quantified goals," he said.

"They should be able to say, 'If we are seeing 20 patients per day on average, our goal is to see 10% more within two years and eliminate paper records within some defined time ... and we'll have this much savings, which is going to allow us to attract two or three more practitioners and increase the value of our practice,' " Doyle said.

Chad Kerr, clinical consulting lead for Ingenix Consulting, a subsidiary of UnitedHealth Group, agrees with the value of setting tangible goals. But most practices, he said, should start by setting broader goals, such as improving patient care.

"Some have this vision of Xanadu. That they just drop the thing in and somehow things are going to get a lot better. Unfortunately, I think some were sold a bill of goods from the EMR vendor about how easy it is and how seamless it is. Most underestimate [the transition process] greatly, particularly in the way of staffing," Kerr said.

The first few months after implementation will likely require additional staffing and resources, Kerr said, an outcome many practices aren't expecting. Lack of preparation can cause a major backlash from staff members and generate or compound their unwillingness to make necessary changes to workflow and job descriptions.

Eric Pifer, MD, chief medical officer and president of El Camino Hospital's Los Gatos (Calif.) campus, said it's also important to assess how efficiently a practice is already functioning before setting post-implementation staffing goals.

"If the practice isn't already spinning like a top, it can get ugly" after EMR implementation, said Dr. Pifer, who worked as an informatics officer for the University of Pennsylvania Health System when it rolled out EMRs to its outpatient practices.

He said because most small practices already run with a lean staff, it's unlikely an EMR will enable a work force reduction. But, he said, a new system can result in different roles for existing staff, as day-to-day procedural tasks change or as gained efficiencies open up opportunities for expanded duties.

How one practice cut jobs

When the Fort Wayne Neurological Center, a multisite practice in Fort Wayne, Ind., started the process of adopting an EMR, it had one specific goal -- eliminate paper charts.

Steve Smith, general manager and CEO of Allied Physicians, which owns the practice, said he knew the elimination of paper charts would mean a loss of job security for the people who managed them. But the plan for how the staff reduction would be carried out was gradually developed in the two years it took the practice to complete implementation.

And in the end, it was the unwillingness of some staff members to adapt that helped shape the way the practice changes played out. Positions were either eliminated or absorbed by those team members who were willing to take on new responsibilities. Evaluation of existing needs led to some changes as well, he said, as in some cases, positions previously held by registered nurses were filled by medical assistants.

Efficiencies gained with the new records system -- beyond what had been anticipated -- resulted in more savings than anticipated, Smith said.

The practice realized a net gain of $430,000 from increased revenue and cost savings, which included a net staff reduction of 12 people. Before adopting the EMR system, the center had about 165 employees.

Mullins said practices that achieve buy-in from staff members early in the process will be able to set specific staffing goals more quickly. When the staff is excited about the impending implementation, they can then help define how their job responsibilities will change .

How one practice added jobs

When the Diabetes & Endocrine Associates of the Treasure Coast in Vero Beach, Fla., implemented an EMR system, the only position the practice planned to eliminate was in medical records.

The three-physician practice, which was already running with a small staff, planned to retrain the medical records staff person for a new role. Offering new training opportunities was a key way the practice tried to make EMR implementation a positive experience for its employees, said Denise Tonner, MD, a partner in the practice.

Mullins said he has seen this approach in many of the practices he has worked with. Rather than approaching EMR implementation as a way to reduce staff, practices are investing in current employees.

Training staff to learn new skills can help grow the practice, Mullins said, as employees take a role in defining how the practice will operate moving forward. "If they are engaged in something, they will adopt and embrace it willingly."

Kerr said many small practices are concerned that information technology staff will be needed after adoption. But, depending on the type of EMR system you choose, that may not be necessary, he said.

A locally hosted system, the type often used by large practices, would likely require IT staff, either in-house, or via an on-call support contract. But many small practices are going with application service provider models, which means the server and data are stored online instead of in-house.

Even practices that do have to add staff may find money can be cut from other areas or may even find an additional revenue stream.

"In my experience," he said, "that's what we've seen -- some organizations were able to shave a little bit off in staffing but shave quite a bit more in efficiencies and drive revenue faster with the turnaround on charging and so forth."

"I think the safest bet for organizations is to go in trying to pull a little from a lot of pools, rather than trying to hit hard in reduced staffing," Kerr said.

That was exactly what the Florida practice did. Eliminating dictation services alone saved the practice $15,000 a year.

Eventually the practice added two full-time employees and tripled the size of the practice.

The overriding approach, Dr. Tonner said, is that employees know they need to be flexible "and they will all have jobs."

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Where to get a return on your EMR investment

Converting to an electronic medical record system can result in cost-cutting. Although increased efficiencies may allow staff cuts, many practices retain and retrain staff.

Material costs: The cost of stocking paper file folders and printing paper can add up to thousands of dollars annually. A system with e-prescribing also can eliminate the costs of prescription pads.

Storage: Practices often have to pay rent to store some files offsite. Once files are scanned into an EMR, those costs will be cut. In-house storage areas can be repurposed as an exam room, creating an opportunity for increased revenue.

Workers' compensation claims: Practices spend thousands of dollars a year preparing files for workers' compensation cases. Most EMR systems will allow the claims process to be handled through e-mail, eliminating the price of copies, faxes and mailings.

Dictation/transcription: Many systems will allow physicians to dictate directly into an EMR, eliminating the need for transcription services.

Telephone use: Using an EMR, especially one with e-prescribing or online scheduling integrated into the system, can significantly reduce the volume of phone calls in and out of your practice.

Data destruction: To comply with patient privacy and security laws, many practices often hire outside companies to destroy paper files with personal health information. Eliminating paper will eliminate this cost.

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Communicating with staff can help curb anxiety

"My job is being replaced by a computer!"

That's probably what some of your employees thought when you announced the practice was considering adoption of an electronic medical records system.

In some cases, that fear may be well-placed. And some employees will feel threatened, no matter what you say.

But saying something is still key, experts say, regardless whether the end result of EMR implementation may be a loss of jobs.

David R. Donnersberger, MD, said that when his four-doctor internal medicine practice in Winnetka, Ill. adopted an EMR in 2007, the changes gave some employees an opportunity to assume new roles. Others left the practice. The staff made the decisions easy.

From the beginning, Dr. Donnersberger said he made it clear what the post-implementation expectations were going to be. Some staff members were not ready to meet those expectations.

"When they heard we were going with an EMR, they thought it was an appropriate time to retire," he said.

Being open about expectations with employees from day one will make the transition smoother and ensure no one is blindsided, Dr. Donnersberger said.

When employees feel they are a part of the process, they can help shape their post-implementation roles, even if it means that role is played out elsewhere.

Bob Kleinbauer, chief operating officer of Community Care Physicians, a multispecialty group in Albany, N.Y., said constant communication with his 30-member office staff raised the interest level.

Some of the physicians became so excited about the project that they pursued new career paths within the practice, and now serve as health information technology leaders.

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