William G. Bates, MD, MBA

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

 

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

 

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

 

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

 

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

 

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

 

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

Are your colleagues in private practice who have made the transition to a system of electronic medical records (EMR) satisfied with their decision and experience? Yes and, on some points, less than yes.

For practices that—perhaps, like yours—haven’t made the leap, the question is: What’s holding them back?

In this concluding installment of a two-part article on EMR, a panel of three ObGyns and one ObGyn practice administrator talk with Moderator G. William Bates, MD, MBA, about, in the case of two practices, the work of bringing EMR into their offices. Two other panelists describe their practices’ calculated reluctance to discard paper processes right now.

Why have you and your partners adopted EMR?

Shuwarger: Our practice quickly identified the direct and indirect benefits of bringing technology to bear on our processes. Paper records were often illegible, misplaced, or being used by another staff member. We recognized that to meet our internal goals for growth, increasing patient safety, and streamlining processes, we would have to adopt an EMR solution that met those needs.

Hall: Our practice was drowning in paperwork. An exam room was recently converted to hold more charts, and two warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to ongoing costs and storage problems.

What efficiency gains have you achieved?

Shuwarger: Forest Women’s Center is able to see more patients in the day because our ObGyn-specific EMR system has a “Patient Portal” that enables patients to enter all their history and complaint-specific information in advance of a visit. Another efficiency is the time gained by never searching for lost or misplaced charts. We also like the ability to access our records 24-7-365.

Hall: The patient’s chart is readily available. Hours of searching have been eliminated, and patients’ questions, lab reports, and prescription refills can be managed with very few steps. The physician can record recommendations and treatment plans, which the staff relays to the patient. Records take about the same time to finish, but they are much more complete and legible, with dramatic gains in safety for the patient and improved liability protection for the physician.

Which features provide the greatest value?

Shuwarger: The patient portal that I mentioned is a great time saver for us. We were amazed at the acceptance and rapid adoption. Even our octogenarians love it. Universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation when it is time to file or appeal claims.

Hall: Immediate access to a clear, legible, and complete patient record provides a solid foundation for our medical decision making.

How have your patients reacted to your conversion from paper to EMR?

Shuwarger: At the beginning, there were people who resisted the patient portal, but when they saw for themselves how it enhances the visit experience and helps their physician address their needs, they became vocal proponents.

Hall: Our patients are impressed with our knowledge of their history, with the fact that reports are immediately available, and with how responsive our staff is to their needs. Rather than creating a barrier to communication, TabletPCs allow them to see images of their own procedures, illustrations, treatment outlines, and even education videos. Flow sheets help mark their progress or encourage them to better adherence. Many seem pleased that their medical records are so cutting-edge. Their confidence in our medical skills appears enhanced.

 

Has your vendor met expectations?

Shuwarger: No—our vendor exceeded our expectations. We had experience with technology vendors before—“We’ll overpromise and underdeliver” was their mantra! With our EMR vendor, however, our preparation was outstanding, the training was thorough, and implementation went better than any we had experienced. Our uptime has exceeded expectations. Enhancements have been well thought out.

And customer support was good at first but now is even better.

Hall: The program is extremely powerful, with an excellent architecture, but its flexibility is also its main limitation. Recently, core clinical content for primary care medicine has been added, but specialty content remains severely limited. Value-added vendors have developed—at additional cost—excellent form-editing tools and specialty forms, and a vigorous users’ community is generous in sharing forms and workflows. But untold hours were required to develop clinical and office workflows, document templates, and just to discover all the options in the system. The learning curve was huge, and further automation requires the skills of a computer programmer.

Our EMR and practice management systems are interfaced but not integrated—even though the same vendor developed them. The problem is that the interface requires several translation programs and multiple servers to implement. Our dependence on our network engineering firm to maintain our bank of servers and interfaces is worrisome— and costly.

Training on our system was inadequate. The basics of the system were covered but, beyond that, we are just now able to shift into second gear. Much of the system’s potential remains untapped.

What is your approximate return on investment?

Shuwarger: We’ve grown receipts by 20%, year over year, since going with our ObGyn-specific EMR system. The rise in revenue is related directly to increased productivity, a reduction in lost charges, and improved collection from third-party payers because we can provide better documentation. At the least, our EMR system has returned $3 for every $1 spent, not counting intangibles.

Hall: Charge capture is much more complete and accurate, with readily available codes and guidelines. The greatest savings are in chart transcription, management, and storage.

Ongoing maintenance and upgrade costs, including hardware and networking software, have gone far beyond our initial investment, however. Problems with training and initial workflow design have slowed our return on investment. But we’re making progress in that direction.

Are features lacking that would bring greater efficiency?

Shuwarger: Our labor suite wants data from our ACOG obstetric record to flow into its system to avoid the need to reenter data manually. And our practice’s physicians want the labor and delivery summary to populate our EMR. These issues of interconnection will be worked out as CCHIT certification (see “EMR certifying body arises from the private sector,” page 62) brings disparate systems into proximity.

Hall: Physicians aren’t computer programmers. We practice medicine, not EMR system development, and we are rarely on top of the “best practices” in practice workflow. Many of us who work with EMR may wish to customize a system to the way we practice, but that is not the best way to proceed. A robust and comprehensive specialty-specific set of clinical content that can be loaded as a unit and easily updated is going to provide far greater efficiency than an infinitely customizable basic program.

I look forward to being able to integrate our private medical record with a central data repository, in which interactions with other specialists and medical centers—not the faulty memory of patients—provide a more accurate background and reduce costly duplication of our increasingly stretched medical resources.

 

Why haven’t you and your partners adopted EMR?

Page: We recently converted to a new practice management software system, and we want to have all systems working properly and efficiently before implementing an EMR system. All options and processes must be reviewed before we implement EMR for the practice. These options include voice-activation software integrated with the EMR, practice process changes, and practice workflow adaptation.

VanMeter: For our independent practice, with five locations, the initial cost of hardware and software is clearly an early concern. With a rapidly changing hardware environment, once a decision is made, the technology that was proposed may be obsolete before being implemented. Then the continuing cost of hardware and software upgrades—read: “the newest gadget”—and maintenance is also a major budgetary item that we need to consider.

As with most medical practices, our organizational structure is flat. If we were to implement a client-server application, we’d need a systems administrator—and that again increases the cost to the practice. Then we’re faced with the question of how we best utilize this person. Or do we outsource this function? And outsourcing then raises a concern of timely responsiveness to major system problems that may extend downtime, prohibiting the use of your EMR system.

Today, telecommunication costs have plummeted, so the costs of a T-1 line [for high-volume Internet access] and high-speed Internet service are not as onerous as they once were. But a major expense will be to retrofit all our offices (wiring, etc.) to adapt to an electronic environment.

Overall, this is a young industry. I compare it to what we saw with video-tape technology in the 1970s: You had to choose between Beta and VHS formats. Once you made that decision, you paid a premium for the early technology.

Similarly, no one knows which EMR system will prevail over time. The early players are paying for the cost of startup and research and development. As time goes on, we all know that costs should fall—significantly.

Another concern that we have is the long-term viability of the software vendor. Until recently, most applications were developed by small independent firms. Their product was a proprietary one—for which only they have the code and only they could manipulate. If that vendor goes out of business, we’d be left to find a new system, and incur all those implementation costs again.

I think we’ll see a major consolidation of vendors over the next several years— one that leaves only premier vendors with superior products in the market.

As a final concern, and perhaps most important, the role of the federal government weighs heavily on our minds. We believe that, very soon, Washington will mandate EMR and how they are to be accomplished. We also believe that the feds will require integration of medical practice EMR systems with the systems of hospitals, third-party payers, and other medical providers. Our belief is that money may become available—like the funding recently authorized for hospitals to subsidize software and maintenance costs—that will defray the cost of implementing an EMR system in our practice. When this comes to pass, we don’t want to have to reinvent the wheel.

What economic barriers does EMR present?

Page: The economic barrier is really not capital expense but the perception that, for a significant period, EMR will require additional time from the medical staff, which reduces the number of patients seen by a physician and, therefore, affects compensation.”

VanMeter: It seems that, when you purchase an EMR system, you have to comply with the way it works. The tail wags the dog. More flexibility in how a system works at the level of the individual provider would make it more economical in terms of productivity.

What features are lacking that causes you to delay adoption?

Page: Successful voice activation and complete handwriting functionality from laptop to chart.

Are there political barriers to adoption?

Page: EMR represents change, and this is always difficult for larger physician groups. Some physicians are still hesitant to make the transition to an EMR from a paper chart, even when the benefit of EMR is proven. Others are hesitant because they are not acclimated to using a computer in the setting of a patient visit.

VanMeter: First, and foremost, the buy-in of all physicians in a group is needed. In my group of 16 physicians and two nurse practitioners, this is tough—especially when age ranges from 31 to 67 years (four in their 60s and close to retirement). Finding consensus on a system will be difficult for that reason alone.

 

Second, for physicians who are in the twilight of their career, there’s hesitancy to spend a large sum on a new system that, for them, is going to have a relatively short life span.

Third, and last, I am concerned about up-coding. Although an EMR system may allow you to document a level-4 or level-5 service, is that truly necessary for the patient’s problem? With a yeast infection, for example, is a level-4 or level-5 service appropriate, even if the documentation supports it?

CASE A medical practice in disarray

An ObGyn reported the following signs of a problem to a colleague: “Our practice was literally drowning in paperwork. An exam room was recently converted to hold more charts, and 2 warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to the ongoing costs and storage problems.”

What are the treatment options?

Electronic medical records (EMR) have progressed from arcane, slow, cumbersome documentation systems to sophisticated, complex, comprehensive ones. These modern systems hold the potential to reduce administrative and management costs by 30% or more, improve clinical workflow, reduce medical errors, facilitate communication between patient and physician, and enable analysis of data for best practice methods, best outcomes and identifying risks and complications.

For practices like the one described in the preceding paragraph—not a fictional account but actual testimony provided by an ObGyn—EMR offer a powerful potential solution to the problems that result from an overwhelming amount of paper documentation, correspondence, charting, claims, and financial transactions. In this article, I offer a general introduction to EMR; in the next (August) issue of OBG Management, I’ll speak with a group of ObGyns and medical practice managers about their experiences—and inexperience—with EMR.

Progress and paradox

Physicians and scientists have made substantial progress over the past 25 years in pharmacotherapeutics, diagnostic technology, procedures, and treatment protocols. In obstetrics and gynecology alone, consider the array of technologies—3-dimensional ultrasonography, minimally invasive surgery, receptor-specific drugs, in vitro fertilization, long-acting reversible contraceptives—that have advanced the quality and effectiveness of care. Yet little progress has been made in the process of caring for patients.

The fact is that physicians, and other health-care providers, are rooted in paper-based processes that sustain inefficiencies, increase costs, and defy the gains that other industries have made by adopting electronic technologies for handling information. Why are we so stuck?

The state of EMR

EMR—of varying functionality—have been available for longer than 20 years. Early models were developed by physicians who had an interest in software coding and design, and were of limited functionality, arcane, and difficult to use in a clinical setting. Some of those early models, and even a few commercial systems in use today, rely on scanning paper documents into computer files. Such systems may eliminate some paper and facilitate document retrieval, but they do nothing to ease management of the complex transactions of health care, and they do not address handwriting illegibility.

Development of complex EMR systems was limited by primitive technology, inadequate distribution channels, and programming that was cumbersome and expensive to maintain. But these barriers have been overcome with fast processors, inexpensive and abundant memory, broadband Internet connectivity, and programming languages that facilitate automated software development.

Modern EMR systems are not simply data repositories: They also support workflow from the beginning to the end of a patient’s consultation with a health-care provider—an event that generates multiple transactions with multiple recipients. A single consultation may, for example, generate orders for lab tests, imaging studies, a surgical procedure, consultation with other physicians, prescriptions, and counseling, and record the subsequent financial transaction. EMR systems by necessity interact with multiple organizations, institutions, instruments, and other software systems. To software developers, and to the clinicians who use their systems, the challenge is to deftly navigate the complexities of health care.

Forces accelerating adoption

Momentum from the Executive Office. In 2004, President George W. Bush set a goal: nationwide adoption of EMR—to include all medical practices—within a decade. In a speech that year at Vanderbilt University Medical Center, the President said: “One of the amazing discrepancies in American society today is we’re literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper.”¹

Certifying body arises from the private sector. Subsequently, the US Department of Health and Human Services (HHS) established the Office of the National Coordinator for Health Information Technology and the American Health Information Community. The sweeping goal of these bodies? Better health care by application of information technology and creation of standards for certifying EMR systems that provide core functionality.

 

In response, 3 private sector health information management groups jointly formed the Certification Commission for Healthcare Information Technology (CCHIT; www.cchit.org). In 2005, this private-sector entity entered into a contract with HHS, to, in the commission’s words, “develop and evaluate certification criteria and create an inspection process for healthcare information technology” in 3 areas:

• Ambulatory EMR for offices
  
• Inpatient EMR for hospitals and health systems
  
• The network components through which EMR share information.
  

The work of this body is ongoing.

Pay-for-performance pushes the issue. Today, insurers—federal and private— are mandating adherence to standards of care for maximal reimbursement of services. These reimbursement schemes, called pay-for-performance, or P4P, are based on providers delivering documentation that specific protocols are followed and outcomes are monitored. The point is that it will be nearly impossible for physicians to comply with insurers’ P4P requirements unless that documentation is in an electronic format.

The market speaks—loudly. Other forces are bringing clinicians to a reckoning with EMR:

• Some malpractice carriers offer a discount on premiums to physicians who document work using EMR
  
• Patients are asking for electronic access to their providers by way of Web sites and e-mail
  
• More and more requests for documentation from multiple interested parties to a patient’s care increase overhead costs and place greater demands on paper-based systems.
  

Physicians cannot meet these demands with paper-based record-keeping.

Reticence has been the watchword

Despite the external and internal forces that are driving adoption, physicians have, as a whole, been reticent to adopt EMR. The nonprofit Healthcare Information and Management Systems Society (HIMSS) reports that 26% of ambulatory practices have adopted EMR, but this penetration is predominantly in multi-specialty clinics and hospital-owned practices.² Few data exist on the penetration of EMR in single-specialty ObGyn practices; anecdotally, vendors estimate a penetration of 10% to 15%.

Why this slow pace toward something broadly acknowledged as key to the well-being of health care?

It means a change. Adopting EMR represents change; well-designed EMR systems streamline workflow in a practice by automating many functions, eliminating duplications of effort, and shifting roles from moving paper to managing digital information. Fear of change and resistance to change are the most common reasons that single-specialty ObGyn practices have not adopted EMR.

It costs. Expense is often cited as the reason why a practice has not adopted an EMR. True: Upfront hardware costs, software costs (license fees, subscription fees), implementation fees, and training costs add up. But a well-designed EMR system should provide a substantial return on investment (ROI) based on savings and on an increase in revenue.

It may be awkward. Some physicians cannot type well. They do not adopt EMR, therefore, because they fear embarrassment using a computer to enter clinical documentation in the consultation room in front of a patient.

On the plus side

On the other side of the coin, the advantages of EMR to physicians are several:

Documentation. EMR facilitate complete documentation of a patient’s visit, current needs and care plan, and record—thereby reducing the clinician’s liability and the risk of medical error. Functions include order entry, prescribing, accurate coding based on work-effort, tracking of outstanding lab tests, and notification.

No chart pulls. With EMR, patient chart pulls are almost nonexistent. A chart is available anywhere a computer is located, any time it is needed.

Decision-making. Probably most importantly, EMR provide clinical decision support by means of alerts (drug interactions, allergies) and reminders (need for follow-up, test orders).

Portal to the patient. Internet-accessed portals that are part of EMR systems facilitate asynchronous communication with patients. A patient can make an appointment, refill a prescription, and request educational materials through such a Web portal. Once an appointment is scheduled, the patient can enter her medical history so that it is specific to the appointment—a feature that is particularly useful when a woman knows the reason that she is visiting the ObGyn (“I’m pregnant,” “My cycle has changed”).

Such a patient-entered history can populate the EMR and contribute elements for appropriate coding. Furthermore, a Web portal in an EMR system enables the physician to reply to a patient with secure messages 1) about lab results, reminders, and appointments and 2) that deliver educational materials.

Keys to embarking on a successful transition

Because EMR are still used by only a small minority of practices, those that seek to move away from the paper record are almost always doing so for the first time. Uncertainty about the adoption adds to anxiety. There are, however, simple steps to take to maintain control over the adoption process and methodically manage it to a successful outcome.

 

Begin with the end in mind. The goal of adoption is not to purchase an EMR system; EMR are only a tool. The goal of the practice should be to transform its existing workflows to make significant improvements over the status quo. Before ever looking at an EMR system, you (and your colleagues, when applicable) must answer several key questions:

• What are we trying to accomplish?
  
• What is it about the status quo that we want to change?
  
• How will we measure success a year after completing the transition?
  

Determine whether you have the resolve to make the transition. As I said, adopting EMR represents change, and the proper motive for adoption is engineered change. Change, however, exposes the human element of transformation. The people who work in the practice are the true determining factor for a successful transforming project, so ask yourself:

• Do you know whether they are ready for change?
  
• Do they understand change?
  
• Are they threatened by it?
  
• Is there broad and vocal leadership backing the impending changes?
  
• Has the impact of the change been discussed with all people involved so they have a clear understanding of its impact on their personal future?
  
• And is the practice, as a team, prepared to go through the turmoil of change as a necessary step on a path to transformation?
  

Assess your sense of urgency—objectively. Because this transition represents a transformation, you’ll have to overcome significant inertia. Without a sense of urgency and aggressive, consistent management of this transition by the leaders of the practice, overcoming human barriers to change will be difficult.

A medical practice that addresses these 3 initial tasks sets itself up for a successful transition from paper to EMR. A good plan—in which goals are well defined and a sense of urgency is consistently communicated and supported by the practice’s leadership—has an excellent chance of resulting in the best possible selection and implementation of an EMR system and accomplishing the goals set for the practice.

In contrast, a transition from paper that begins with such a vague notion as “I guess we need an EMR eventually, so we might as well start now” is much more likely to spark turmoil among staff. The staff then embarks on a selection and implementation process that is heavily influenced by emotion and interpractice politics. They face a diminished opportunity for completing the transition efficiently and successfully.

Throughout this process, the staff should always bear in mind that this is a transformation that they plan, control, and execute. EMR are simply a means to an end—not the end itself.

Two types of systems, various material needs

There are 2 primary configurations of EMR systems: client-server applications and remote-hosted systems. The latter operate through an Application Service Provider (ASP). (See “What are the 2 types of EMR?”)

In addition to type of system, keep these material needs in mind as you plan:

Connectivity. Most medical practices rely on the Internet for a variety of functions; truly, the Internet has become a vital link in health-care information technology.

An ASP system depends on the Internet, whereas client-server applications require a dial-up modem connection or other Internet connectivity to obtain information from outside sources. I recommend purchase of broadband Internet connectivity because it facilitates transmission of large files, such as images and data-rich documents.

Hardware. All EMR require computers for data entry. One attractive option for a medical practice is the TabletPC, which is available from several manufacturers and which uses the Windows XP Tablet PC Edition operating system. Combined with a secure wireless network for moving from room to room, the TabletPC is a technological breakthrough for physicians to document information in a clinical setting. It permits cursive data entry using a special electronic pen, voice recognition entry, and keyboard entry. Whereas a desktop computer places a barrier—the monitor or screen—between physician and patient, a TabletPC emulates the flat, horizontal surface of a paper chart or clipboard.

Importantly, a TabletPC has all the functionality of a desktop computer. Although workflow varies from practice to practice, it can be said generally that most clinical personnel work best with a TabletPC because of its mobility and most clerical personnel work easily with a desktop computer.

The price of a TabletPC? Two to 4 times that of a desktop computer.

Infrastructure. Other devices—printers, scanners, wireless networks, digital cameras—are required to operate an EMR system. A practice that uses a client-server application must purchase a data server. One with a system that operates by remote access either requires a virtual private network (VPN) for secure Internet connection or must install an emulator (such as Citrix).

 

People. Physicians and staff in the practice are always the key to success when implementing an EMR system. Consider a vendor’s ability to assist with the human variables of change management when you assess systems. Even the best EMR cannot save a practice from a poorly planned and executed transformation.

Going shopping

Many physicians want an EMR system to support the conventional process in their practice. This is a prescription for failure! Instead, evaluate the design of an EMR system for its ability to facilitate change in the process and in roles, and to eliminate manual functions and analysis of data.

One EMR system may appear to be the same as the next, but differences are revealed in the way that they optimize workflow. Generic systems may support several primary care medical specialties well, but may impose inefficiencies in other specialties—particularly in niche specialties. Similarly, a specialty-specific system works well for the specialty for which it was designed but is inefficient in another specialty. Approximately 80% of clinical workflow needs may be met by a generic EMR system, but the 20% that are specialty-specific can make the difference between success and failure.

Ensure that the sales presentations you attend address:

• the needs of your practice
  
• the criteria for success that you defined during planning.
  

Require vendors to provide a demonstration that emphasizes the high-frequency daily tasks of your staff, such as documentation of new and return OB patients, annual gynecologic exams combined with gyn problems, collection of histories, and review of lab results. A well-designed EMR, especially one specific to your specialty, should be intuitive and should not disrupt the workflow.

When you arrive at a choice of an EMR system, assess the learning curve that you’ll have to climb for the system to become fully functional. Remember that salesperson? He, or she, gave a slick presentation but you didn’t settle for a dry description; you were sure to try the system live to discover how easily you can learn to navigate its functions.

At last: Implementation and training

EMR vendors develop implementation and training programs to establish their system in a practice and bring it live. These programs are based on vendors’ experience with their product.

As you prepare for your EMR system, keep this in mind: One that’s been well-designed is more than a repository of data. By design, it also reengineers workflow for optimal practice efficiency, safety, and financial management.

Pearls for welcoming a system

Use EMR incrementally. Do not change from paper to electronic abruptly while you, your colleagues, and the staff are learning the system. Vendors of EMR systems design pathways by which physicians ease-in, so to speak, to EMR in a way that minimizes any drop in productivity and loss of revenue. It’s wise to ask vendors about their plan for implementation and training before you sign a contract to purchase.

Expect that it will take 12 to 24 months to convert the practice completely. The time from paper to electronic records depends on the size and age of a practice. In my experience, the half-life of converting an ObGyn practice is approximately 15 months; by 24 months, the records of approximately 95% of active patients will be entered into EMR.

 

Don’t scan all paper records into EMR. Scanning indiscriminately is expensive, disruptive, and doesn’t contribute to ongoing clinical excellence. As part of the conversion process, vendors have methods to enter critical clinical information into the electronic system for uninterrupted use. Instead of wholesale scanning, therefore, be selective and scan only clinically relevant materials—the past several Pap smear results, mammogram reports, operative reports, consultant letters, and similar predefined clinical documents. This usually suffices for ongoing clinical care and avoids excessive expenditure of time, energy, and money.

The promise we talk about needs to become actual

As I noted at the outset, fewer than 25% of physicians have EMR, and estimates are that no more than 10% to 15% of ObGyns have adopted a system. Yet experience has demonstrated: A well-designed EMR offers physicians streamlined workflow, the ability to provide better care, and more time for leisure.

To move the flow and utility of medical information properly into this century, the next step, I urge, is for physicians to recognize the value of EMR, set goals for implementing a system, and reengineer their practice for maximal clinical efficiency, patient safety, and financial gain.

CASE REVISITED: Good outcome; no recurrence

One year later, the ObGyn whose practice was in disarray told a different story: “The ‘Patient Portal’ section of our EMR system is a great time saver. We were amazed at the acceptance and rapid adoption—even our octogenarians love it. The universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. The EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation.”

CASE A medical practice in disarray

An ObGyn reported the following signs of a problem to a colleague: “Our practice was literally drowning in paperwork. An exam room was recently converted to hold more charts, and 2 warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to the ongoing costs and storage problems.”

What are the treatment options?

Electronic medical records (EMR) have progressed from arcane, slow, cumbersome documentation systems to sophisticated, complex, comprehensive ones. These modern systems hold the potential to reduce administrative and management costs by 30% or more, improve clinical workflow, reduce medical errors, facilitate communication between patient and physician, and enable analysis of data for best practice methods, best outcomes and identifying risks and complications.

For practices like the one described in the preceding paragraph—not a fictional account but actual testimony provided by an ObGyn—EMR offer a powerful potential solution to the problems that result from an overwhelming amount of paper documentation, correspondence, charting, claims, and financial transactions. In this article, I offer a general introduction to EMR; in the next (August) issue of OBG Management, I’ll speak with a group of ObGyns and medical practice managers about their experiences—and inexperience—with EMR.

Progress and paradox

Physicians and scientists have made substantial progress over the past 25 years in pharmacotherapeutics, diagnostic technology, procedures, and treatment protocols. In obstetrics and gynecology alone, consider the array of technologies—3-dimensional ultrasonography, minimally invasive surgery, receptor-specific drugs, in vitro fertilization, long-acting reversible contraceptives—that have advanced the quality and effectiveness of care. Yet little progress has been made in the process of caring for patients.

The fact is that physicians, and other health-care providers, are rooted in paper-based processes that sustain inefficiencies, increase costs, and defy the gains that other industries have made by adopting electronic technologies for handling information. Why are we so stuck?

The state of EMR

EMR—of varying functionality—have been available for longer than 20 years. Early models were developed by physicians who had an interest in software coding and design, and were of limited functionality, arcane, and difficult to use in a clinical setting. Some of those early models, and even a few commercial systems in use today, rely on scanning paper documents into computer files. Such systems may eliminate some paper and facilitate document retrieval, but they do nothing to ease management of the complex transactions of health care, and they do not address handwriting illegibility.

Development of complex EMR systems was limited by primitive technology, inadequate distribution channels, and programming that was cumbersome and expensive to maintain. But these barriers have been overcome with fast processors, inexpensive and abundant memory, broadband Internet connectivity, and programming languages that facilitate automated software development.

Modern EMR systems are not simply data repositories: They also support workflow from the beginning to the end of a patient’s consultation with a health-care provider—an event that generates multiple transactions with multiple recipients. A single consultation may, for example, generate orders for lab tests, imaging studies, a surgical procedure, consultation with other physicians, prescriptions, and counseling, and record the subsequent financial transaction. EMR systems by necessity interact with multiple organizations, institutions, instruments, and other software systems. To software developers, and to the clinicians who use their systems, the challenge is to deftly navigate the complexities of health care.

Forces accelerating adoption

Momentum from the Executive Office. In 2004, President George W. Bush set a goal: nationwide adoption of EMR—to include all medical practices—within a decade. In a speech that year at Vanderbilt University Medical Center, the President said: “One of the amazing discrepancies in American society today is we’re literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper.”¹

Certifying body arises from the private sector. Subsequently, the US Department of Health and Human Services (HHS) established the Office of the National Coordinator for Health Information Technology and the American Health Information Community. The sweeping goal of these bodies? Better health care by application of information technology and creation of standards for certifying EMR systems that provide core functionality.

 

In response, 3 private sector health information management groups jointly formed the Certification Commission for Healthcare Information Technology (CCHIT; www.cchit.org). In 2005, this private-sector entity entered into a contract with HHS, to, in the commission’s words, “develop and evaluate certification criteria and create an inspection process for healthcare information technology” in 3 areas:

• Ambulatory EMR for offices
  
• Inpatient EMR for hospitals and health systems
  
• The network components through which EMR share information.
  

The work of this body is ongoing.

Pay-for-performance pushes the issue. Today, insurers—federal and private— are mandating adherence to standards of care for maximal reimbursement of services. These reimbursement schemes, called pay-for-performance, or P4P, are based on providers delivering documentation that specific protocols are followed and outcomes are monitored. The point is that it will be nearly impossible for physicians to comply with insurers’ P4P requirements unless that documentation is in an electronic format.

The market speaks—loudly. Other forces are bringing clinicians to a reckoning with EMR:

• Some malpractice carriers offer a discount on premiums to physicians who document work using EMR
  
• Patients are asking for electronic access to their providers by way of Web sites and e-mail
  
• More and more requests for documentation from multiple interested parties to a patient’s care increase overhead costs and place greater demands on paper-based systems.
  

Physicians cannot meet these demands with paper-based record-keeping.

Reticence has been the watchword

Despite the external and internal forces that are driving adoption, physicians have, as a whole, been reticent to adopt EMR. The nonprofit Healthcare Information and Management Systems Society (HIMSS) reports that 26% of ambulatory practices have adopted EMR, but this penetration is predominantly in multi-specialty clinics and hospital-owned practices.² Few data exist on the penetration of EMR in single-specialty ObGyn practices; anecdotally, vendors estimate a penetration of 10% to 15%.

Why this slow pace toward something broadly acknowledged as key to the well-being of health care?

It means a change. Adopting EMR represents change; well-designed EMR systems streamline workflow in a practice by automating many functions, eliminating duplications of effort, and shifting roles from moving paper to managing digital information. Fear of change and resistance to change are the most common reasons that single-specialty ObGyn practices have not adopted EMR.

It costs. Expense is often cited as the reason why a practice has not adopted an EMR. True: Upfront hardware costs, software costs (license fees, subscription fees), implementation fees, and training costs add up. But a well-designed EMR system should provide a substantial return on investment (ROI) based on savings and on an increase in revenue.

It may be awkward. Some physicians cannot type well. They do not adopt EMR, therefore, because they fear embarrassment using a computer to enter clinical documentation in the consultation room in front of a patient.

On the plus side

On the other side of the coin, the advantages of EMR to physicians are several:

Documentation. EMR facilitate complete documentation of a patient’s visit, current needs and care plan, and record—thereby reducing the clinician’s liability and the risk of medical error. Functions include order entry, prescribing, accurate coding based on work-effort, tracking of outstanding lab tests, and notification.

No chart pulls. With EMR, patient chart pulls are almost nonexistent. A chart is available anywhere a computer is located, any time it is needed.

Decision-making. Probably most importantly, EMR provide clinical decision support by means of alerts (drug interactions, allergies) and reminders (need for follow-up, test orders).

Portal to the patient. Internet-accessed portals that are part of EMR systems facilitate asynchronous communication with patients. A patient can make an appointment, refill a prescription, and request educational materials through such a Web portal. Once an appointment is scheduled, the patient can enter her medical history so that it is specific to the appointment—a feature that is particularly useful when a woman knows the reason that she is visiting the ObGyn (“I’m pregnant,” “My cycle has changed”).

Such a patient-entered history can populate the EMR and contribute elements for appropriate coding. Furthermore, a Web portal in an EMR system enables the physician to reply to a patient with secure messages 1) about lab results, reminders, and appointments and 2) that deliver educational materials.

Keys to embarking on a successful transition

Because EMR are still used by only a small minority of practices, those that seek to move away from the paper record are almost always doing so for the first time. Uncertainty about the adoption adds to anxiety. There are, however, simple steps to take to maintain control over the adoption process and methodically manage it to a successful outcome.

 

Begin with the end in mind. The goal of adoption is not to purchase an EMR system; EMR are only a tool. The goal of the practice should be to transform its existing workflows to make significant improvements over the status quo. Before ever looking at an EMR system, you (and your colleagues, when applicable) must answer several key questions:

• What are we trying to accomplish?
  
• What is it about the status quo that we want to change?
  
• How will we measure success a year after completing the transition?
  

Determine whether you have the resolve to make the transition. As I said, adopting EMR represents change, and the proper motive for adoption is engineered change. Change, however, exposes the human element of transformation. The people who work in the practice are the true determining factor for a successful transforming project, so ask yourself:

• Do you know whether they are ready for change?
  
• Do they understand change?
  
• Are they threatened by it?
  
• Is there broad and vocal leadership backing the impending changes?
  
• Has the impact of the change been discussed with all people involved so they have a clear understanding of its impact on their personal future?
  
• And is the practice, as a team, prepared to go through the turmoil of change as a necessary step on a path to transformation?
  

Assess your sense of urgency—objectively. Because this transition represents a transformation, you’ll have to overcome significant inertia. Without a sense of urgency and aggressive, consistent management of this transition by the leaders of the practice, overcoming human barriers to change will be difficult.

A medical practice that addresses these 3 initial tasks sets itself up for a successful transition from paper to EMR. A good plan—in which goals are well defined and a sense of urgency is consistently communicated and supported by the practice’s leadership—has an excellent chance of resulting in the best possible selection and implementation of an EMR system and accomplishing the goals set for the practice.

In contrast, a transition from paper that begins with such a vague notion as “I guess we need an EMR eventually, so we might as well start now” is much more likely to spark turmoil among staff. The staff then embarks on a selection and implementation process that is heavily influenced by emotion and interpractice politics. They face a diminished opportunity for completing the transition efficiently and successfully.

Throughout this process, the staff should always bear in mind that this is a transformation that they plan, control, and execute. EMR are simply a means to an end—not the end itself.

Two types of systems, various material needs

There are 2 primary configurations of EMR systems: client-server applications and remote-hosted systems. The latter operate through an Application Service Provider (ASP). (See “What are the 2 types of EMR?”)

In addition to type of system, keep these material needs in mind as you plan:

Connectivity. Most medical practices rely on the Internet for a variety of functions; truly, the Internet has become a vital link in health-care information technology.

An ASP system depends on the Internet, whereas client-server applications require a dial-up modem connection or other Internet connectivity to obtain information from outside sources. I recommend purchase of broadband Internet connectivity because it facilitates transmission of large files, such as images and data-rich documents.

Hardware. All EMR require computers for data entry. One attractive option for a medical practice is the TabletPC, which is available from several manufacturers and which uses the Windows XP Tablet PC Edition operating system. Combined with a secure wireless network for moving from room to room, the TabletPC is a technological breakthrough for physicians to document information in a clinical setting. It permits cursive data entry using a special electronic pen, voice recognition entry, and keyboard entry. Whereas a desktop computer places a barrier—the monitor or screen—between physician and patient, a TabletPC emulates the flat, horizontal surface of a paper chart or clipboard.

Importantly, a TabletPC has all the functionality of a desktop computer. Although workflow varies from practice to practice, it can be said generally that most clinical personnel work best with a TabletPC because of its mobility and most clerical personnel work easily with a desktop computer.

The price of a TabletPC? Two to 4 times that of a desktop computer.

Infrastructure. Other devices—printers, scanners, wireless networks, digital cameras—are required to operate an EMR system. A practice that uses a client-server application must purchase a data server. One with a system that operates by remote access either requires a virtual private network (VPN) for secure Internet connection or must install an emulator (such as Citrix).

 

People. Physicians and staff in the practice are always the key to success when implementing an EMR system. Consider a vendor’s ability to assist with the human variables of change management when you assess systems. Even the best EMR cannot save a practice from a poorly planned and executed transformation.

Going shopping

Many physicians want an EMR system to support the conventional process in their practice. This is a prescription for failure! Instead, evaluate the design of an EMR system for its ability to facilitate change in the process and in roles, and to eliminate manual functions and analysis of data.

One EMR system may appear to be the same as the next, but differences are revealed in the way that they optimize workflow. Generic systems may support several primary care medical specialties well, but may impose inefficiencies in other specialties—particularly in niche specialties. Similarly, a specialty-specific system works well for the specialty for which it was designed but is inefficient in another specialty. Approximately 80% of clinical workflow needs may be met by a generic EMR system, but the 20% that are specialty-specific can make the difference between success and failure.

Ensure that the sales presentations you attend address:

• the needs of your practice
  
• the criteria for success that you defined during planning.
  

Require vendors to provide a demonstration that emphasizes the high-frequency daily tasks of your staff, such as documentation of new and return OB patients, annual gynecologic exams combined with gyn problems, collection of histories, and review of lab results. A well-designed EMR, especially one specific to your specialty, should be intuitive and should not disrupt the workflow.

When you arrive at a choice of an EMR system, assess the learning curve that you’ll have to climb for the system to become fully functional. Remember that salesperson? He, or she, gave a slick presentation but you didn’t settle for a dry description; you were sure to try the system live to discover how easily you can learn to navigate its functions.

At last: Implementation and training

EMR vendors develop implementation and training programs to establish their system in a practice and bring it live. These programs are based on vendors’ experience with their product.

As you prepare for your EMR system, keep this in mind: One that’s been well-designed is more than a repository of data. By design, it also reengineers workflow for optimal practice efficiency, safety, and financial management.

Pearls for welcoming a system

Use EMR incrementally. Do not change from paper to electronic abruptly while you, your colleagues, and the staff are learning the system. Vendors of EMR systems design pathways by which physicians ease-in, so to speak, to EMR in a way that minimizes any drop in productivity and loss of revenue. It’s wise to ask vendors about their plan for implementation and training before you sign a contract to purchase.

Expect that it will take 12 to 24 months to convert the practice completely. The time from paper to electronic records depends on the size and age of a practice. In my experience, the half-life of converting an ObGyn practice is approximately 15 months; by 24 months, the records of approximately 95% of active patients will be entered into EMR.

 

Don’t scan all paper records into EMR. Scanning indiscriminately is expensive, disruptive, and doesn’t contribute to ongoing clinical excellence. As part of the conversion process, vendors have methods to enter critical clinical information into the electronic system for uninterrupted use. Instead of wholesale scanning, therefore, be selective and scan only clinically relevant materials—the past several Pap smear results, mammogram reports, operative reports, consultant letters, and similar predefined clinical documents. This usually suffices for ongoing clinical care and avoids excessive expenditure of time, energy, and money.

The promise we talk about needs to become actual

As I noted at the outset, fewer than 25% of physicians have EMR, and estimates are that no more than 10% to 15% of ObGyns have adopted a system. Yet experience has demonstrated: A well-designed EMR offers physicians streamlined workflow, the ability to provide better care, and more time for leisure.

To move the flow and utility of medical information properly into this century, the next step, I urge, is for physicians to recognize the value of EMR, set goals for implementing a system, and reengineer their practice for maximal clinical efficiency, patient safety, and financial gain.

CASE REVISITED: Good outcome; no recurrence

One year later, the ObGyn whose practice was in disarray told a different story: “The ‘Patient Portal’ section of our EMR system is a great time saver. We were amazed at the acceptance and rapid adoption—even our octogenarians love it. The universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. The EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation.”

CASE A medical practice in disarray

An ObGyn reported the following signs of a problem to a colleague: “Our practice was literally drowning in paperwork. An exam room was recently converted to hold more charts, and 2 warehouses held our overflow. Employees were constantly searching for records, and telephone messages were delayed for hours or days until the chart could be reviewed. Notoriously bad handwriting and incomplete documentation hampered good communication and good medical care. Transcription costs were out of control. Forms helped but added to the ongoing costs and storage problems.”

What are the treatment options?

Electronic medical records (EMR) have progressed from arcane, slow, cumbersome documentation systems to sophisticated, complex, comprehensive ones. These modern systems hold the potential to reduce administrative and management costs by 30% or more, improve clinical workflow, reduce medical errors, facilitate communication between patient and physician, and enable analysis of data for best practice methods, best outcomes and identifying risks and complications.

For practices like the one described in the preceding paragraph—not a fictional account but actual testimony provided by an ObGyn—EMR offer a powerful potential solution to the problems that result from an overwhelming amount of paper documentation, correspondence, charting, claims, and financial transactions. In this article, I offer a general introduction to EMR; in the next (August) issue of OBG Management, I’ll speak with a group of ObGyns and medical practice managers about their experiences—and inexperience—with EMR.

Progress and paradox

Physicians and scientists have made substantial progress over the past 25 years in pharmacotherapeutics, diagnostic technology, procedures, and treatment protocols. In obstetrics and gynecology alone, consider the array of technologies—3-dimensional ultrasonography, minimally invasive surgery, receptor-specific drugs, in vitro fertilization, long-acting reversible contraceptives—that have advanced the quality and effectiveness of care. Yet little progress has been made in the process of caring for patients.

The fact is that physicians, and other health-care providers, are rooted in paper-based processes that sustain inefficiencies, increase costs, and defy the gains that other industries have made by adopting electronic technologies for handling information. Why are we so stuck?

The state of EMR

EMR—of varying functionality—have been available for longer than 20 years. Early models were developed by physicians who had an interest in software coding and design, and were of limited functionality, arcane, and difficult to use in a clinical setting. Some of those early models, and even a few commercial systems in use today, rely on scanning paper documents into computer files. Such systems may eliminate some paper and facilitate document retrieval, but they do nothing to ease management of the complex transactions of health care, and they do not address handwriting illegibility.

Development of complex EMR systems was limited by primitive technology, inadequate distribution channels, and programming that was cumbersome and expensive to maintain. But these barriers have been overcome with fast processors, inexpensive and abundant memory, broadband Internet connectivity, and programming languages that facilitate automated software development.

Modern EMR systems are not simply data repositories: They also support workflow from the beginning to the end of a patient’s consultation with a health-care provider—an event that generates multiple transactions with multiple recipients. A single consultation may, for example, generate orders for lab tests, imaging studies, a surgical procedure, consultation with other physicians, prescriptions, and counseling, and record the subsequent financial transaction. EMR systems by necessity interact with multiple organizations, institutions, instruments, and other software systems. To software developers, and to the clinicians who use their systems, the challenge is to deftly navigate the complexities of health care.

Forces accelerating adoption

Momentum from the Executive Office. In 2004, President George W. Bush set a goal: nationwide adoption of EMR—to include all medical practices—within a decade. In a speech that year at Vanderbilt University Medical Center, the President said: “One of the amazing discrepancies in American society today is we’re literally changing how medicine is delivered in incredibly positive ways, and yet docs are still spending a lot of time writing things on paper.”¹

Certifying body arises from the private sector. Subsequently, the US Department of Health and Human Services (HHS) established the Office of the National Coordinator for Health Information Technology and the American Health Information Community. The sweeping goal of these bodies? Better health care by application of information technology and creation of standards for certifying EMR systems that provide core functionality.

 

In response, 3 private sector health information management groups jointly formed the Certification Commission for Healthcare Information Technology (CCHIT; www.cchit.org). In 2005, this private-sector entity entered into a contract with HHS, to, in the commission’s words, “develop and evaluate certification criteria and create an inspection process for healthcare information technology” in 3 areas:

• Ambulatory EMR for offices
  
• Inpatient EMR for hospitals and health systems
  
• The network components through which EMR share information.
  

The work of this body is ongoing.

Pay-for-performance pushes the issue. Today, insurers—federal and private— are mandating adherence to standards of care for maximal reimbursement of services. These reimbursement schemes, called pay-for-performance, or P4P, are based on providers delivering documentation that specific protocols are followed and outcomes are monitored. The point is that it will be nearly impossible for physicians to comply with insurers’ P4P requirements unless that documentation is in an electronic format.

The market speaks—loudly. Other forces are bringing clinicians to a reckoning with EMR:

• Some malpractice carriers offer a discount on premiums to physicians who document work using EMR
  
• Patients are asking for electronic access to their providers by way of Web sites and e-mail
  
• More and more requests for documentation from multiple interested parties to a patient’s care increase overhead costs and place greater demands on paper-based systems.
  

Physicians cannot meet these demands with paper-based record-keeping.

Reticence has been the watchword

Despite the external and internal forces that are driving adoption, physicians have, as a whole, been reticent to adopt EMR. The nonprofit Healthcare Information and Management Systems Society (HIMSS) reports that 26% of ambulatory practices have adopted EMR, but this penetration is predominantly in multi-specialty clinics and hospital-owned practices.² Few data exist on the penetration of EMR in single-specialty ObGyn practices; anecdotally, vendors estimate a penetration of 10% to 15%.

Why this slow pace toward something broadly acknowledged as key to the well-being of health care?

It means a change. Adopting EMR represents change; well-designed EMR systems streamline workflow in a practice by automating many functions, eliminating duplications of effort, and shifting roles from moving paper to managing digital information. Fear of change and resistance to change are the most common reasons that single-specialty ObGyn practices have not adopted EMR.

It costs. Expense is often cited as the reason why a practice has not adopted an EMR. True: Upfront hardware costs, software costs (license fees, subscription fees), implementation fees, and training costs add up. But a well-designed EMR system should provide a substantial return on investment (ROI) based on savings and on an increase in revenue.

It may be awkward. Some physicians cannot type well. They do not adopt EMR, therefore, because they fear embarrassment using a computer to enter clinical documentation in the consultation room in front of a patient.

On the plus side

On the other side of the coin, the advantages of EMR to physicians are several:

Documentation. EMR facilitate complete documentation of a patient’s visit, current needs and care plan, and record—thereby reducing the clinician’s liability and the risk of medical error. Functions include order entry, prescribing, accurate coding based on work-effort, tracking of outstanding lab tests, and notification.

No chart pulls. With EMR, patient chart pulls are almost nonexistent. A chart is available anywhere a computer is located, any time it is needed.

Decision-making. Probably most importantly, EMR provide clinical decision support by means of alerts (drug interactions, allergies) and reminders (need for follow-up, test orders).

Portal to the patient. Internet-accessed portals that are part of EMR systems facilitate asynchronous communication with patients. A patient can make an appointment, refill a prescription, and request educational materials through such a Web portal. Once an appointment is scheduled, the patient can enter her medical history so that it is specific to the appointment—a feature that is particularly useful when a woman knows the reason that she is visiting the ObGyn (“I’m pregnant,” “My cycle has changed”).

Such a patient-entered history can populate the EMR and contribute elements for appropriate coding. Furthermore, a Web portal in an EMR system enables the physician to reply to a patient with secure messages 1) about lab results, reminders, and appointments and 2) that deliver educational materials.

Keys to embarking on a successful transition

Because EMR are still used by only a small minority of practices, those that seek to move away from the paper record are almost always doing so for the first time. Uncertainty about the adoption adds to anxiety. There are, however, simple steps to take to maintain control over the adoption process and methodically manage it to a successful outcome.

 

Begin with the end in mind. The goal of adoption is not to purchase an EMR system; EMR are only a tool. The goal of the practice should be to transform its existing workflows to make significant improvements over the status quo. Before ever looking at an EMR system, you (and your colleagues, when applicable) must answer several key questions:

• What are we trying to accomplish?
  
• What is it about the status quo that we want to change?
  
• How will we measure success a year after completing the transition?
  

Determine whether you have the resolve to make the transition. As I said, adopting EMR represents change, and the proper motive for adoption is engineered change. Change, however, exposes the human element of transformation. The people who work in the practice are the true determining factor for a successful transforming project, so ask yourself:

• Do you know whether they are ready for change?
  
• Do they understand change?
  
• Are they threatened by it?
  
• Is there broad and vocal leadership backing the impending changes?
  
• Has the impact of the change been discussed with all people involved so they have a clear understanding of its impact on their personal future?
  
• And is the practice, as a team, prepared to go through the turmoil of change as a necessary step on a path to transformation?
  

Assess your sense of urgency—objectively. Because this transition represents a transformation, you’ll have to overcome significant inertia. Without a sense of urgency and aggressive, consistent management of this transition by the leaders of the practice, overcoming human barriers to change will be difficult.

A medical practice that addresses these 3 initial tasks sets itself up for a successful transition from paper to EMR. A good plan—in which goals are well defined and a sense of urgency is consistently communicated and supported by the practice’s leadership—has an excellent chance of resulting in the best possible selection and implementation of an EMR system and accomplishing the goals set for the practice.

In contrast, a transition from paper that begins with such a vague notion as “I guess we need an EMR eventually, so we might as well start now” is much more likely to spark turmoil among staff. The staff then embarks on a selection and implementation process that is heavily influenced by emotion and interpractice politics. They face a diminished opportunity for completing the transition efficiently and successfully.

Throughout this process, the staff should always bear in mind that this is a transformation that they plan, control, and execute. EMR are simply a means to an end—not the end itself.

Two types of systems, various material needs

There are 2 primary configurations of EMR systems: client-server applications and remote-hosted systems. The latter operate through an Application Service Provider (ASP). (See “What are the 2 types of EMR?”)

In addition to type of system, keep these material needs in mind as you plan:

Connectivity. Most medical practices rely on the Internet for a variety of functions; truly, the Internet has become a vital link in health-care information technology.

An ASP system depends on the Internet, whereas client-server applications require a dial-up modem connection or other Internet connectivity to obtain information from outside sources. I recommend purchase of broadband Internet connectivity because it facilitates transmission of large files, such as images and data-rich documents.

Hardware. All EMR require computers for data entry. One attractive option for a medical practice is the TabletPC, which is available from several manufacturers and which uses the Windows XP Tablet PC Edition operating system. Combined with a secure wireless network for moving from room to room, the TabletPC is a technological breakthrough for physicians to document information in a clinical setting. It permits cursive data entry using a special electronic pen, voice recognition entry, and keyboard entry. Whereas a desktop computer places a barrier—the monitor or screen—between physician and patient, a TabletPC emulates the flat, horizontal surface of a paper chart or clipboard.

Importantly, a TabletPC has all the functionality of a desktop computer. Although workflow varies from practice to practice, it can be said generally that most clinical personnel work best with a TabletPC because of its mobility and most clerical personnel work easily with a desktop computer.

The price of a TabletPC? Two to 4 times that of a desktop computer.

Infrastructure. Other devices—printers, scanners, wireless networks, digital cameras—are required to operate an EMR system. A practice that uses a client-server application must purchase a data server. One with a system that operates by remote access either requires a virtual private network (VPN) for secure Internet connection or must install an emulator (such as Citrix).

 

People. Physicians and staff in the practice are always the key to success when implementing an EMR system. Consider a vendor’s ability to assist with the human variables of change management when you assess systems. Even the best EMR cannot save a practice from a poorly planned and executed transformation.

Going shopping

Many physicians want an EMR system to support the conventional process in their practice. This is a prescription for failure! Instead, evaluate the design of an EMR system for its ability to facilitate change in the process and in roles, and to eliminate manual functions and analysis of data.

One EMR system may appear to be the same as the next, but differences are revealed in the way that they optimize workflow. Generic systems may support several primary care medical specialties well, but may impose inefficiencies in other specialties—particularly in niche specialties. Similarly, a specialty-specific system works well for the specialty for which it was designed but is inefficient in another specialty. Approximately 80% of clinical workflow needs may be met by a generic EMR system, but the 20% that are specialty-specific can make the difference between success and failure.

Ensure that the sales presentations you attend address:

• the needs of your practice
  
• the criteria for success that you defined during planning.
  

Require vendors to provide a demonstration that emphasizes the high-frequency daily tasks of your staff, such as documentation of new and return OB patients, annual gynecologic exams combined with gyn problems, collection of histories, and review of lab results. A well-designed EMR, especially one specific to your specialty, should be intuitive and should not disrupt the workflow.

When you arrive at a choice of an EMR system, assess the learning curve that you’ll have to climb for the system to become fully functional. Remember that salesperson? He, or she, gave a slick presentation but you didn’t settle for a dry description; you were sure to try the system live to discover how easily you can learn to navigate its functions.

At last: Implementation and training

EMR vendors develop implementation and training programs to establish their system in a practice and bring it live. These programs are based on vendors’ experience with their product.

As you prepare for your EMR system, keep this in mind: One that’s been well-designed is more than a repository of data. By design, it also reengineers workflow for optimal practice efficiency, safety, and financial management.

Pearls for welcoming a system

Use EMR incrementally. Do not change from paper to electronic abruptly while you, your colleagues, and the staff are learning the system. Vendors of EMR systems design pathways by which physicians ease-in, so to speak, to EMR in a way that minimizes any drop in productivity and loss of revenue. It’s wise to ask vendors about their plan for implementation and training before you sign a contract to purchase.

Expect that it will take 12 to 24 months to convert the practice completely. The time from paper to electronic records depends on the size and age of a practice. In my experience, the half-life of converting an ObGyn practice is approximately 15 months; by 24 months, the records of approximately 95% of active patients will be entered into EMR.

 

Don’t scan all paper records into EMR. Scanning indiscriminately is expensive, disruptive, and doesn’t contribute to ongoing clinical excellence. As part of the conversion process, vendors have methods to enter critical clinical information into the electronic system for uninterrupted use. Instead of wholesale scanning, therefore, be selective and scan only clinically relevant materials—the past several Pap smear results, mammogram reports, operative reports, consultant letters, and similar predefined clinical documents. This usually suffices for ongoing clinical care and avoids excessive expenditure of time, energy, and money.

The promise we talk about needs to become actual

As I noted at the outset, fewer than 25% of physicians have EMR, and estimates are that no more than 10% to 15% of ObGyns have adopted a system. Yet experience has demonstrated: A well-designed EMR offers physicians streamlined workflow, the ability to provide better care, and more time for leisure.

To move the flow and utility of medical information properly into this century, the next step, I urge, is for physicians to recognize the value of EMR, set goals for implementing a system, and reengineer their practice for maximal clinical efficiency, patient safety, and financial gain.

CASE REVISITED: Good outcome; no recurrence

One year later, the ObGyn whose practice was in disarray told a different story: “The ‘Patient Portal’ section of our EMR system is a great time saver. We were amazed at the acceptance and rapid adoption—even our octogenarians love it. The universal access to data is of incalculable value. One of our physicians loves to go home early, have dinner, and then review his charts from home. The EMR improves my recordkeeping, makes encounter documentation more complete, and helps me avoid medication errors. Our billing staff loves the thorough documentation.”