Are You Ready for EMR?
Advice for practices still "on the fence."
BY PETER J. POLACK, M.D., F.A.C.S.
I have been evaluating electronic medical records (EMR) systems for much longer than I have been practicing ophthalmology. I definitely come from a family of early adopters. My father, who was also an ophthalmologist, was one of the first physicians in the country to have Medical Manager's electronic practice management system (EPM). I would frequently hang out at the technical exhibits at different ophthalmology meetings, checking out the latest in computerized office systems. What I eventually learned from many years of observation and experience was that the selection of the specific EMR software product should be the last step in the process, although most physicians think it is the starting point.
As the "techie" columnist at Ophthalmology Management, I have received numerous e-mails from practices asking my advice on which EMR system to buy or my opinion on a particular vendor's product. And unfortunately, I think most of them have been a bit frustrated with my answer: I can't really answer that. What I suggest to them is that they ask themselves, what do I want the EMR to do for me? What problems am I hoping it will fix? Do I want to get rid of the hassles and confidentiality concerns of paper charts? Am I running out of space for storing records? Do I think it will help me take better care of my patients? Do I need to see a return on my investment? Do I want to be on the cutting edge? Or do I just see EMR as something inevitable and I want to get a jump on it?
| Six EMR "Do's and Don't's" |
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| EMR for the Smaller Practice |
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Physicians and administrators of smaller practices usually have some key questions as they contemplate a conversion from paper records to EMR. This short Q. and A., with answers provided by Ron Sterling, an independent consultant from Sterling Solutions (www.Sterling-Solutions.com), should help answer these questions: Q: What should I be looking for in a vendor? A: Smaller practices need to ensure that the vendor will have the resources to guide you through the implementation process, as well as support your practice going forward. Though the practice may be small, you need to have the support and response mechanism in place to assure that you can get access to your patient records. Be sure that you understand what the vendor expects of you and the expertise that you will need to use their product. For example, some products require a more sophisticated support person than you will find in the smaller practice. Q: What about cost? A: In general, practices are looking at $30,000-$50,000 out-of-pocket costs for the EMR per doctor. You will have to give each person in the practice access to the EMR and you will want to invest money in components that are protected from a catastrophic failure. However, you will also have to incur a number of additional internal costs that are beyond the vendor's bill; for example, training time for staff and the time needed to enter initial information into the EMR. Initial information can include medical history, and previous test and procedure dates. Q: How can the investment pay for itself? A: For the smaller practice, benefits from office efficiencies may be difficult to attain. Regardless of how efficient your office is, you will need someone to greet patients and answer the phones. Additionally, most practices need even more help during the initial phases or EMR activation. Paybacks from EMR for the small practice will occur from decreased transcription expenses almost immediately, and a lower level of medical record expenses starting 6 months after the system "goes live." Other paybacks will comefrom more effective coding and the tracking of all services provided to a patient. Q: Will EMR increase patient satisfaction? A: EMR absolutely improves patient satisfaction because the doctor and staff can instantaneously access the medical record to address an issue. Patients' anxiety will be decreased when they can get an answer to a question or clarify an issue in a shorter time frame. For example, your triage staff can instantaneously access the EMR to answer many patient questions and requests. Indeed, some studies are showing that an EMR and electronic support for patient services are starting to affect patients' choice of medical practices. Q: How should we approach staff training? A: Staff training should include training on the EMR system, as well as training on the new procedures to be used in the practice. Note that practices should allow plenty of time for training and testing to insure that you minimize the effect on patients. Training can be especially challenging in the smaller practice since staff may need to learn more about the product and support themselves. Q: Will we need an outside consultant? A: Implementing an EMR requires a variety of skills that few smaller practices have. From complex computer issues to software setup and practice workflow, practices need to redesign themselves to use the EMR. Lacking such expertise, practices should consider the project management and subject matter expertise that will be needed to successfully deploy an EMR. Q: How long should it take to go from beginning implementation of EMR to achieving a well-functioning system? A: After you sign a contract, it will take at least 4 months to get started using the EMR. A well-functioning system can be achieved when the practice fully acclimates to the EMR in another 3 to 6 months. However, many practices fail to achieve a well-functioning system due to inappropriate products, poor EMR setup and lack of will. EMR implementation is a difficult process, because the EMR affects every patient and employee, every practiceprocess and action. Practices implementing EMR have to realize the effect of the EMR and seriously consider the effect of the change to their practice and patients. |
Assessing Specific Needs
At Ocala Eye, one of the largest multi-site practices in the state of Florida, we realized several years ago that we were quickly running out of storage space for our paper charts. We could either rent more space or bite the bullet and start thinking about electronic records. Someone had suggested to us scanning all of our records to save space. Although this would have been a quick fix, what we really wanted was a good long-term solution. And because we are a multi-specialty practice involved in clinical research, we knew that we wanted the capability of mining our patient data. Only an EMR system would give us this capability.
Is your practice now feeling pressure to get with the (EMR) program? Are EMR systems ready for "prime time"? I put this question to John Pinto, of J. Pinto and Associates, a healthcare consulting firm specializing in ophthalmology. He says, "There is an industry-wide sense of inevitability about going paperless now, which was not present a decade ago. But EMR and electronic health records (EHR) adoption is still moving at a glacially slow pace in ophthalmology. I would venture that well under 10% of practices have made a full conversion. About half of those who have gone paperless are delighted. For the other half, the jury is still very much 'out.'"
For clients who are contemplating EMR/EHR, Pinto says that it's helpful to draw this analogy from medicine: "Imagine a new drug was available for your patients. Five percent of your colleagues are prescribing the drug, and rave about results. Another 5% prescribe the drug, but are still skeptical about safety and efficacy. Ninety percent of your colleagues are sitting on the fence and waiting to see how everything sorts out. If you're the kind of vanguard doctor in the first or second cohort, then perhaps you should plow ahead with EMR/EHR adoption. If you're in the last cohort, it's time to stay informed about developments and get your team ready for the inevitable day when the right time and product arrives."
Planning Is Key
Once you decide to plow ahead, planning your project is probably more important than the actual EMR system that you buy and could prevent you from making a very costly mistake (see sidebar: "Six EMR Do's and Don'ts") Once your plan is in place, and you have buy-in from key personnel, only then is it time to go shopping for any EMR program.
Ron Sterling, of Sterling Solutions in Silver Spring, Md., is a consultant who specializes in EMR implementation for medical practices. I asked Ron what advice he would offer to a practice considering which EMR system to purchase. He likens that decision to the purchase of a car. "In order to answer the question, 'Which car should I buy?' you need to ask yourself several questions: How many passengers does it need to carry? Does it need off-road capability? Will it carry any heavy cargo? Is reliability more important than cost?"
Sterling says when looking at EMR products, realize that there are actually four components to an EMR system:
■ Document/image management. How do you handle images from peripherals or scans of old records? How do you deal with incoming documents and images from other providers and hospitals?
■ Workflow. In the absence of a paper record, how will you manage the various messages and track patients who are in your office?
■ Patient services. How does the EMR help you figure out pending care issues for the patients based on their specific situation? How does the EMR support accepted care guidelines based on the patient's age, health and problems that may be part of P4P standards?
■ Charting. How will the EMR accommodate your documentation of patient visits and services? Does the EMR include documentation tools that you can effectively and efficiently use?
Some EMR systems cover all of these bases, although some are stronger incertain areas than others. For other, less-robust EMR systems, a third-party software solution may be necessary to fill in the gaps.
After looking at various solutions, we ultimately decided on the NextGen (Horsham, Pa.) integrated EMR/EPM product. Although it can be used out of the box, its real strength lies in the fact that it is essentially a software developer's tool and as such is fully customizable, not just for each practice, but also for each physician within a practice. Because we have our own full-time, in-house IT personnel (who develop software for other uses), we are able to take full advantage of this flexibility. However, a smaller practice probably does not have any need for such a level of customization. And there are many other excellent EMR products out there which could really improve a practice's efficiency, with little or no tweaking.
Costs and Payback
Sterling says that the initial cost of EMR — including hardware, software, implementation and training — can range from $30,000 to $50,000 per doctor, and can run from $500 to as much as $2,000 per doctor per month on an ongoing basis. Generally speaking, this will be relatively less expensive for larger practices due to economies of scale. Practices switching from handwritten notes to digital ones may find it difficult to calculate a return on their investment — they may need fewer employees pulling charts but now they need more staff to scan documents into the system. A practice that spends a lot on dictation, however, may recoup its investment in short order.
So if you don't want to buy (or lease) an EMR system, what other options do you have? You can either rent an EMR system or you can be a business partner to a lab or a hospital that can gain an economic advantage from having your practice linked to their system. Then, they might buy one for you.
By renting, I am referring to what's known as an application service provider or ASP. This is a company that hosts the EMR program on their own server and for a monthly fee gives you access to it via the Internet. The main advantage to this is that there are no significant upfront costs. The disadvantage is that you do not own the program and may not have access to the system if your Internet connection goes down. Another disadvantage is that you do not physically control your own database — in some cases it may actually be stored along with the data of other practices.
| Make Your EMR System Secure |
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| The security of your EMR data is a critical issue that can be compromised either accidentally or maliciously. It is important to
take a multi-tiered approach to security. Just as you would find
in your house, there are multiple points of entry. Before you have
an alarm system installed in your house, you map out a plan for
all points of entry. You would also control who has keys to the
house as well as the code for the alarm. The physical points of entry for your EMR system include your: ► Internet connection ► wireless zones: implement security in these zones or someone can drive by and sneak into your network ► ports on your network such as jacks: don't activate a wall jack unless a security device is in operation ► peripheral devices ► wiring closets: these are often located in a janitor's closet but should at least be in a locked cabinet. In addition to physical vulnerabilities, there are also organic ones. You can have all sorts of sophisticated security hardware in place but all of these are worthless if it is easy for an outsider to log into a computer. Fortunately, there are several things that you can do to protect yourself. ■ Have minimum password criteria. We require it to have greater than six characters and that it be complex, expire every 30 days and cannot be reused ■ Implement account locking. If the password is entered incorrectly five times, the account will automatically lock for one hour. This prevents what is known as brute force hacking. ■ Install auto-deactivation. At the EMR level, an account willautomatically lock due to inactivity if it has not been used for 45 days. ■ Educate employees about password security. These safeguards includes everything from forbidding passwords to be sticky-noted on computers to alerting staff members to methods of social engineering, or various ways that people can be manipulated into divulging their passwords. ■ Deny access to terminated employees. Don't forget to deactivate their accounts as soon as possible. |
Other practices may find themselves in the position of having either hospitals or laboratories offer to buy their EMR systems for them. For example, a pathology laboratory has offered to purchase an EMR system for a urology group in our area. Of course, the lab will want to choose the system that best suits their needs and they will also expect to get all of their pathology specimens in return. Congress passed legislation in 2006 exempting these arrangements from Stark anti-kickback violations.
Tangible EMR Benefits
There is no great need to rush ahead right now in implementing EMR, but slowly building pressure — accompanied by pay-for-performance (P4P) incentives — from Medicare and third-party payers is creating an imperative that will probably require all but the smallest practices to go electronic within the next 5 years.
William Constad, M.D., of Hudson Eye Physicians & Surgeons, Jersey City, N.J., is both an ophthalmologist and the IT specialist for his seven-physician practice. He is an early adopter who was implementing EMR at Hudson Eye at about the same time the rest of us were celebrating the Millennium in 2000. If you are concerned that EMR will bring more headaches than benefits, Dr. Constad can reassure you. He ticks off just a few of the benefits that having EMR has brought to his practice:
► greatly simplifies the monitoring of chronic conditions
► eliminates confusion caused by poor handwriting
► enables far more efficient billing
► allows for profitable participation in P4P programs
► enables efficient and accurate interface with sophisticated diagnostic equipment
► facilitates improved patient services, with the result that patients favorably view Hudson Eye as having cutting-edge technology.
The Clock Is Ticking
The benefits that EMR can bring to an ophthalmology practice are becoming more tangible with each passing year as systems improve and incentives become available. The rewards are real, but obtaining them involves a major, practice-transforming effort that requires a total commitment from everyone associated with the practice. No practice can expect to implement EMR haphazardly or half-heartedly and expect to succeed. Fortunately, we have the experience of Hudson Eye and countless other practices to demonstrate that the transition to EMR can be made in a way that benefits physicians, staff and patients. For practices that are still on the fence regarding EMR, that is important to know. OM
| Peter J. Polack, M.D., F.A.C.S., is co-managing partner for Ocala Eye, PA. Ocala Eye is a six-location, 10-physician, 140-employee multi-subspecialty ophthalmology practice located in Ocala, Fla. He can be reached by email at ppolack@ocalaeye.com. |
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