EMR: Questions Come Before Answers

The buzz over electronic medical records is incessant, and the array of choices widens all the time. If you fear that you’ve fallen behind your colleagues in introducing this new technology into your practice, rest assured that you haven’t.

There’s no question about the direction in which medical records are moving—away from paper and toward the electronic gathering of health data from a variety of physicians and other sources. The question is how fast? Concerns about the quality of care, patient safety, privacy and the cost of care have stimulated both public and private initiatives. Walk into any professional trade show and you’ll find exhibits by vendors that either offer a stand-alone EMR product or that have added EMR capability to previously existing products. Specialty societies such as the American Academy of Family Physicians (AAFP) are aggressively promoting EMRs.

Physicians should not panic into buying a system in haste and making a poor decision. Step back and ask the right questions in the right order before moving ahead with EMRs. The best place to start isn’t the federal government, specialty societies, vendors or payers, but your own practice. Physicians should revisit their practice mission and goals, take the pulse of the practices information technology readiness, conduct an operational assessment, develop a good understanding of EMRs and other information technology that is currently available and then look at specific vendors and their products.

Mission and Goals

It’s essential to know your mission and goals before investing in supporting information technology. If you’re a small practice in one location, do you plan to remain that way, or will you expand by increasing the number of physicians and/or locations? At how many hospitals and ambulatory surgery centers do you practice at, and will that situation remain the same or change? There are always a number of practices that can’t answer these questions, or that have multiple opinions but no consensus among the physicians. Put rather bluntly, if you don’t know where you’re going, EMRs aren’t going to take you there.

Technology Readiness

Most physicians who have recently completed their training set up their new practices with EMR support from the outset. If your practice is currently dependent on paper records, however, you’ll need to think not only about which EMR is right for you, but how to transition out of your current situation. Several physicians respond to the potential introduction of EMRs into their practices with what I call the “over my dead body” speech. They are concerned because the physicians in their practice lack consensus on the EMR question, and they don’t know that smart EMR vendors will accommodate differences in physician readiness and preference by allowing multiple options for inputting data. For example, some physicians prefer to continue dictation, while others like hand-held devices.

Operational Assessment

All practices have strengths and weaknesses. Do you know yours? Look at every aspect of your practice operations, including, but not limited to, medical records. Here’s my reasoning: EMRs and other information technology solve problems, and you want to know what problems exist. Your chances of selecting solutions that address your vulnerabilities are better if you know where you’re starting.

Operational assessment should start with your patients. Some questions to ask yourself and your staff are:

· How do patients contact your practice to make appointments – only by phone, or electronically as well?

· How do you collect demographic information form patients?

· Can you verify insurance before patients arrive, so you minimize your claim denials?

· How do you transfer demographic and insurance information into the patient’s medical record?

· Do you ask patients for the same information at multiple points in the office so they must repeat themselves?

· After you see patients, do your visit notes require transcription?

· How do you enter test results into you medical record, and how do you convey information to patients?

· If referrals come form other physicians, how does that information get into the record?

· How do you handle information from hospitals where you admit

· How do you deal with patient requests for prescription renewals?

Use these questions to walk yourself through different patient interactions. As you see, the suggested list of questions is long, but I think they help to make the point clear. You must know what currently happens in your practice if you want to make a good decision about the future.

Understanding the Options

Many physicians request advice on selecting a vendor before they have a good understanding of the EMR functions. The question goes beyond EMRs to an understanding of how other forms of information technology can help you. The boundaries between the products are blurry, and you need to review not only EMRs, but also ways in which all technologies, including your practice management system and website, can work together to meet your needs.A good website can be a great benefit to your practice and deserves consideration. Your practice’s website, if constructed carefully, can bring you operational efficiencies, financial gains and improvements in quality of care and documentation without the high cost and difficulty of transition that EMRs involve. If the physicians in your practice are technology-shy, starting with an interactive website can help them become comfortable with IT.

Many physicians have a limited idea of the value of a practice website. They think of it as a resource for information about the practice such as locations, physicians, services that you provide, and contact information. A website that contains this important information is a good start. By adding HIPAA-compliant interactive features that allow patients to communicate directly with your practice, you can do even more. Examples of such features are pre-registration pages that collect patient demographic information prior to a visit and verify insurance information prior to the appointment, features that allow existing patients to request appointments and/or prescription renewals, on-line bill paying, and provision of on-line advice to existing patients.

What EMRs Do

When you look at EMRs, consider their evolution, common functions, and potential benefits so you are well informed before you make a decision to purchase a particular product.

• Evolution. If you were practicing medicine a decade ago, you’ve probably heard of the term CPR (computerized patient record). CPRs were longitudinal records that captured paper records for later use. EMRs go one step further, and capture structured and unstructured data from both paper and disparate computer systems. Most EMRs are owned by a single organization such as a medical practice or hospital. Right now, most information that’s entered into EMRs is done at the point of patient encounter.

Just as CPRs evolved to EMRs, EMRs will evolve into electronic health records (EHR) that capture information from multiple health-care providers, from a variety of other databases and from patients themselves. Eventually, patients will be able to control their own document, called an electronic patient record (EPR).

• Functions. EMRs have many functions, and most physicians use some but not all of them. The major functions, in order of common use, are:

• view information such as problem lists, medications, and adverse reactions;

• document what happens during a patient visit; identify clinical issues such as drug allergies;

• decide clinical issues using comprehensive, up-to-date, and reliable databases and references;

• manage prescriptions by accessing formularies and routing Rx orders and renewals directly to pharmacies;

• order tests, imaging, & other studies;

• communicate securely with medical colleagues within and outside of the practice;

• code by matching ICD and CPT codes with details in visit notes;

• comply with privacy, security rules;

• aggregate data on individual patients into longitudinal records;

• manage chronic disease/conditions of individual patients;

• standardize disease management goals for groups of patients;

• query the system for reports on clinical issues for individuals and groups;

• conduct research; and

• incorporate information that comes directly from patients. When you’re talking with vendors, make sure you know what functions are important for your practice so you can be sure that the product you buy meets your needs.

• Benefits. EMRs have three important benefits. First, they can increase your operational efficiency by streamlining the ways in which you gather, organize and use patient information. Second, EMRs can improve your financial management by methodically and accurately documenting all that you do and by verifying the appropriateness of your coding. Third, EMRs can improve the quality of patient care by helping you document and retrieve accurate information on both individuals and groups of patients and by accelerating the accurate and secure exchange of patient information between you and other parties in the health-care system such as providers, pharmacies and other organizations that collect relevant information.

Selecting a Vendor

Once you are clear on your practice mission and goals, technology readiness, operational strengths and weaknesses, and general technology options, you can begin to contact vendors. Many vendors will encourage you to purchase everything from them, but don’t limit your thinking to just them. I think smart purchasers buy what they need and then deal with the interconnectivity among the vendors. Eventually, there will be standards for interoperability.

Successful Implementation

The technology aspect of EMRs is only half the story. Successful implementation depends on people, and EMRs that are a phenomenal success in one practice may be a costly failure in another. There are six keys to successful implementation:

• Set realistic expectations about your time frame and the difficulty of implementation. If you’re transitioning away from paper, allow 18 months from the start of your investigation until implementation and expect a bumpy road.

• Identify a physician champion who is not only interested in introducing EMRs, but who is willing and able to coach his peers through the process.

• Enlist the commitment of all physicians in the practice, including those who are comfortable with information technology and those who are not. EMRs should be a practice enhancement, not a tool that one or two technologically savvy physicians use while others retain their dependence on paper.

• Agree on timing that suits your practice. Some vendors permit practices to purchase a comprehensive EMR software package and phase-in the implementation of different modules. Others allow the separate purchase of each different module. Still others are inflexible and require all clients to purchase and implement their products in a way that meets the vendor’s, not the purchaser’s, needs.

• Pay attention to relationships between EMRs and other systems. Interconnectivity between EMRs, your practice management system, Web-based communication, lab and other systems isn’t automatic.

• Purchase the level of support that is suitable for your practice. Even if you have your own information technology specialist, you may need outside help from one or more vendors. Ask about initial installation, availability of the help desk, software fixes and upgrades, and special deals on hardware, software and Internet connectivity.

With so many efforts on both government and private fronts to get electronic medical records up and running, in one form or another, EMRs are the wave of the future. By getting started now, learning about all of the information technology systems available, you’ll be able to take your time and get there in a way that suits your specific practice.

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