EMR without Fear
approach to EMR has transformed our practice.
J. HARRIS, MD
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.
sample electronic record (not a real patient) illustrates how Dr. Harris can easily
access and review a patient's history.
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
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
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
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
►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
Retinal Physician, Issue: May 2006