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Implementing EMR without Fear
A well-planned approach to EMR has transformed our practice.
MICHAEL J. HARRIS, MD

Our 7-doctor, 5-office retina practice in northern New Jersey was quite efficient but suffered from many of the typical problems of a multi-office practice. Patients were often seen in different offices and although we would try to transport the paper charts to the proper office, this often led to misfiled or lost charts. Photographic images stored in in 1 office were not accessible in other offices. Patients calling after office hours with an urgent problem were often seen without a chart, making care difficult. Quality assurance programs were cumbersome. Clinical research required an enormous expenditure of time to pull and manually review charts 1 at a time. Transcription costs for referral letters were a rising economic factor. Billing costs were also rising. Pulling and photocopying charts for audits or disputed insurance claims was time consuming and expensive.

Clearly, the solution to our problems was a combined electronic medical record and practice management software system that solved these problems. Here, I'll explain how we successfully achieved that goal.

A FALSE START

Approximately 5 years ago, I contacted 2 fledgling EMR companies with general ophthalmology software. After seeing their products, I began working with 1 of the companies to develop a retina-specific EMR program. The company recognized that retina practices are particularly well suited to EMR and that the system would be cost effective. I met with the software developer 1 day a week for almost 2 years, detailing our requirements and designing the template for their system. For my efforts, I was offered stock in the company. However, the contract required that our practice utilize the EMR system in our practice and serve as a demonstration site in order to receive the stock.

After 2 years of development, the company felt that the system was ready to be marketed. However, I did not feel that the product was ready for our practice to use. It did not adequately document a fundus drawing to allow billing for extended ophthalmoscopy. In addition, the referral letter generated by the system was rudimentary and not unacceptable. Most importantly, the program slowed the physician down in the exam room. I would not purchase the system for our practice, nor could I recommend it to others, so I asked that my name not be associated with the system and we parted ways.

WE MAKE OUR CHOICE

Soon thereafter, the other EMR company I had contacted, IO Practiceware, returned to show us the progress they had made with their system. I was impressed that their system was much more malleable and easily customized to the needs of individual practices. They agreed to work with us to make the software work better for retinal specialists. After 6 months, I felt that their system was functional and I recommended purchasing it for our practice. Was it perfect? Far from it, but we felt that it was the best system on the market. In addition, IO agreed to continue to improve the software for retinal practices.

We discussed our goals for the practice's use of the new system. Then we discussed finances. The cost for our 5 offices was $150 000 for the hardware. The list price for the software was under $200 000 but we received a discount for our consultation services. Maintenance was less than $20 000 per year for the combined EMR and practice management system. This compared quite favorably with what we had been paying for our Medical Manager practice management maintenance agreement.

We projected increased revenue as well as decreased expenses from the software. Revenue increases would be obtained by utilizing physician time saved in dictating to see more patients. Secondly, billing logic in the software would help us confidently bill for all services we had performed, instead of defensively undercoding. We were shooting for increased revenue of 2% as a result of implementing the system.

We also wanted to achieve significant expense reductions. Our goals were to reduce transcription costs, and to reduce the head count in the billing department. As the
IO system creates both the claim and the referral letter automatically from the clinical findings we record in the exam room, we expected savings sufficient to create a return on investment within 2 years.

SOME STRESS, THEN SUCCESS

The system was installed in all 5 offices and we began using the practice management software for appointment scheduling and billing. The new system provided many more functions than our old practice management system. Even with great on-site training and support, the first week was stressful at the front desks while our staff was getting used to the new software. IO personnel were on-site in all our offices to help. By the second week, the staff said that the system was "not so bad" and by the third week, the front desk actually began to enjoy the new system.

The remote offices were connected to the main server by a T1 line and all data was backed up to a remote server. Still, we were worried about crashes, T1 lines going down or loss of billing information. Remarkably, no problems have occurred in the first year of use.

After a few weeks, the first insurance payments began to come in. We were reassured that the billing software was functioning. Over the next few weeks, we fine-tuned the other practice management functions of the system, including recall notices, accounts receivable management, procedure productivity, and other utilization reports.

We were now ready to begin using the electronic medical record. Each physician in our practice sees approximately 50 to 60 patients per day with 2 to 3 technicians and 1 scribe. We devoted a Saturday to training 5 technicians on the EMR system. We set up PC's in our conference room and the vendor's staff conducted a full-day seminar with hands-on training on the system. The techs caught onto the system quickly, and the following week I began using the EMR in 1 office. I reduced my initial patient load in anticipation of problems.

I was surprised and pleased to discover that the problems I had worried about mostly did not happen. To be sure, there were quite a few issues, periods of confusion, and just plain headaches for both our staff and me in the first weeks of using the clinical system. The techs quickly adapted and soon came to love working on the EMR system. The hardest part was my adjustment to changes in the clinical record.

DOCTORS' LEARNING CURVE

Even with all the planning and the training, I was used to my paper charts. I knew where to look for history and exam elements and could quickly peruse the chart to recall who was the patient and what was the reason for today's visit. This was all present in the EMR but in a different location. Even though I knew how to operate the system, in the first few weeks everything took longer. IO made numerous design changes to incorporate our suggestions to improve the workflow. Once I became accustomed to the system, my speed approached and then surpassed where I was on paper. We instituted an internal training program for technicians and scribes and, as more staff became trained, an additional partner came on line each month. Four partners are now using the system in our main office and have started using the system in our satellite offices.

Currently, our doctors are saving time on each patient encounter by not having to dictate referral letters. Pre-programmed "final paragraphs" for our referral letters are linked to the appropriate impressions. For patients requiring more involved plans, the final paragraph can be dictated into a digital recorder and transcribed offsite into the medical record. The fundus drawing is accomplished easily with "drop-on drawings" for most findings such as tears, hemorrhages, lipid, drusen, and edema. Unusual findings can be drawn freehand onto the touchscreen or tablet PCs.

One of the most important differences between EMR systems is how quickly a physician can review a record and gain access to the key elements of the prior exams. If a patient had a temporary steroid-induced IOP elevation from an intravitreal kenalog injection, it is critical to the proper care of that patient that the physician know this when considering another injection years later. To address this need, my partners and I worked with IO to create a "highlights" screen. This serves as a cover sheet and includes all the key elements of present and past exams (see Figure on page 80). This screen also includes click-through links to the diagnostic tests such as angiograms and OCTs and offers easy access to all stored documents such as lab data and referral letters.

SIX KEY CRITERIA

If you are considering an EMR system, I believe you should evaluate each system on these 6 criteria:

►Does the software slow workflow? If it does, it is too expensive to use. New patients are easy for most EMR systems; the major difference is how they handle data from previous visits for returning patients. If it is not well organized, it will slow the physician.

►Can the system actually create time for the physician by eliminating most dictation?

►How easily can the clinical record and diagnostic tests be accessed from home in case of after-hours emergencies?

►Can the system actually increase income by insuring that all work done has been accurately billed? Internal billing logic should eliminate the MD from the ICD and CPT coding process. After the clinical findings have been entered, the software should select the proper codes for billing.

►Can the system reduce staff expenses for transcription, billing, front desk functions, and surgical scheduling?

►Can the system reduce vulnerability to audits?

Our experience has been positive in most of these areas. Quite frankly, implementation of new software requires a significant commitment on the part of the physicians and staff to make it work for a practice. It is not a decision to make lightly, and prior to purchasing any system, you should see it in action in a busy practice. However, we have found that the proper combined EMR/practice management software can be a terrific tool that will transform a practice. At the end of the day (or perhaps, at the end of the year), you can have a better-run practice, provide better patient care, see a happier staff, and improve profitability.

Michael J. Harris, MD, is a partner in Retina Associates of New Jersey, P.A., which operates 5 offices in northern New Jersey. He is also associate clinical professor at the University of Medicine and Dentistry of New Jersey. He can be reached via e-mail at mjharris628@aol.com