EMR: Finding a Vendor Who Tailors to Fit

Is there an EMR package out there that will truly reflect your practice's workflow?

BY LESLIE GOLDBERG, ASSOCIATE EDITOR

To expect that a practice will willingly decrease productivity over an extended period, invest countless dollars in hardware, software and staff time and receive no guarantee of successful implementation makes doctors understandably wary of investing in an EMR system. This was one of many pertinent findings revealed in our reader survey in last month's issue. Ophthalmologists are simply not willing to invest in an EMR system until they are assured that it will meet the needs of their particular practice.

In many cases, vendors feel that they can meet or exceed the expectations of skeptical ophthalmologists if given the proper practice requirements and if practices invest the necessary amount of time to bring their system “live.” This, they say, will give users a much greater chance of a successful implementation. Remember, this is a long-term commitment and no one should expect productivity to reach pre-EMR days for at least six to nine months.

Below, we hope to teach you a bit more about the way EMR systems are designed and to give vendors a chance to teach you what needs to be asked and answered in order to get the package that best suits your needs.

Workflow vs. Template Design

Before we delve into vendors' insights, it is important to understand the two different schools of design upon which EMR systems are based: workflow and template. It is critical to gauge the personalities and technical abilities of your practice prior to starting EMR implementation to ensure that the solution type chosen matches the practice using it.

A workflow design is based on a single screen that captures the entire visit. This design typically presents all of the data on the same screen. Users populate the data either by different data-entry fields and/or pop-up windows. This design is typically easier to learn because there are not multiple screens that can confuse users.

The simplicity of the design also increases the odds that all physicians in the practice will be able to use the system, easing the implementation process. In addition, by remaining within a single screen, all of the data from the visit can be reviewed in real time, which can lead to faster visits or visits where more time is devoted to patient care.

The standard objection to a workflow-based design is that customization is more limited than with a template-based design. Typically, customization is limited to the content of the dropdown menus and customizing reports and pop-up windows. While this limitation may require practices with highly unusual workflows to seek a template solution, practices with more standard workflows will find that this will lead to a faster and more predictable implementation and support of the system.

EMR solutions designed to have data entered via a series of screens that the user navigates through have a template design. From a user's standpoint, the workflow resembles navigating through a Web site, with data entered on each page. The visit takes place over the span of several pages. Typically, these solutions will be able to produce a series of reports and letters at the conclusion of the visit, which aggregates the data entered on the different pages.

The advantage offered by the template design is that it is usually more customizable, as each individual screen can be modified. It has been the experience of practices with technically savvy physicians and staff that they can receive a greater degree of satisfaction with this type of design because they have the ability to modify the system themselves to create a customized solution.

The downside of a template-based design is that it tends to be more complex to implement and use. Adopters of this design must be made aware that there will be an increased amount of training time involved as well as increased cost. Additionally, the ability to constantly customize the solution can lead to an implementation that never becomes “complete.”¹

Physician Concerns

“Instead of EMR systems designed for what a practice needs, medical practices have to adapt to what EMR systems offer,” says Mitchell Wolin, MD, who practices in Greenville, SC. “For example, many practices use scribes to enter data. Ideally, EMR should have the smooth ability to enter data by voice dictation.”

Dr. Wolin dislikes reviewing EMR records because of the volume of “irrelevant” material he must wade through. He says he has seen innumerable examples of factual errors in EMRs because of the automatic fill-in features.

“EMRs do not currently communicate effectively with other systems, so the ability to streamline obtaining results of labs and MRI scans is not aided by EMR in general,” says Dr. Wolin. In his opinion, “it is insane to be essentially forced to implement an EMR system in my solo practice.”

Patrick Caskey, MD, of North Bay Vitreoretinal Consultants, Inc., has spoken with a number of colleagues who have implemented EMR systems, and the general impression is that the EMR experience has been moderately unfavorable. He says that some of the specific concerns that were voiced are:

(1) The systems are cumbersome and require substantial ongoing technical management, which generates significant monthly expenditures.
(2) The EMR reduces patient throughput at least initially, which impacts profitability and efficiency.
(3) The seemingly ubiquitous dropdown menus result in a need for the use of scribes to enter data, which increases overhead and may negatively impact the patient's experience.
(4) The reduced efficiency, which seems to be a common problem with the EMRs, is not outweighed by the government incentives to implement the systems.
(5) The systems seem to promise a lot but, in practice, they appear to need more development before they will become a tool to help physicians to be more efficient.

Dr. Caskey says that several of his colleagues would like to return to their pre-EMR status but are unable to do so because of the significant resources, both in time and money, that it has required to convert to EMR.

If a practice chooses to go with a fully customizable program, then there are considerable increased risks. “Most systems that fail offer [full customization] as their option. What happens is a practice will focus on developing the content and workflow and never go live or have a very long delay in the process,” says Jim Messier, vice president of sales and marketing for Medflow. “This causes delays in implementation, significantly increases your cost, takes valuable physician resources and, once you have the system that you think will work, you and your practice are the only ones that can support it.”

Mr. Messier says another big risk is that after customizing the system and then adding updates and upgrades from the EMR company, there is a high likelihood of having things which were custom programmed at the outset breaking because of changes to the code or database of the system. “Here again you will be on your own to make the necessary changes and fixes to adapt to the new update,” he says.

There are doctors out there who are truly interested in implementing EMR but need these issues resolved before making such a large time and financial commitment. Let's now look at solutions and suggestions offered by vendors.

Customization is Key

Features available in one system might be radically different from those in another. Physicians must do their due diligence, evaluating potential vendors and researching the features that they need to run their offices efficiently.

“Customization is one of those features that vendors will claim they have, but unless users know to ask the right questions, they won't really know if the system is truly customizable until the first time they go to make a change and the system doesn't support it,” says Mary Ann Fitzhugh, vice president of marketing for Compulink Business Systems. “Oftentimes, customization is seen as something cosmetic — changing screen layouts and such. But that's really not what it's about.”

What customization is really about is delivering you an EMR system that can reflect your practice's daily workflow. It is about providing you with a product that will — in time — reduce practice costs and increase the time you spend with your patients. A good EMR system is flexible and allows you to modify templates easily to match your practice's workflow. How do you ensure that you are getting a good system? And how to address the concerns of doctors affiliated with large institutions such as a hospital where customization for specialists is particularly challenging?

After soliciting the advice of 15 EMR vendors, we've developed the following list of customization-related questions you should ask in order to find the EMR system that will work best for your practice.

► How customizable is your EMR system? The ability for the practice to easily customize an EMR system is critical to both the overall usability of the system and how well it supports the provider's clinical workflow. Since each physician within the practice has his own unique requirements, how easily can the system adapt to the requirements? It pays to ask specifically which features can be customized and who can perform the customizations.
► How much of your workflow will the EMR system integrate and address? Providers only realize the full time savings and clinical benefits of a system if the entire workflow — end-to-end — is integrated and automated. If re-keying of data is required or some function is not automated, the entire benefit of moving to EMR can be undone. Some specific questions to determine how much of the workflow an EHR system will address include:

• Is the practice's e-Prescribing system completely integrated with the EMR system? For example, can it automatically send and receive patient medications and allergies to the prescribing system?
• Does the EMR support integration with your specific instruments?
• What features are provided to speed entry of clinical data and exam findings?
• Is a fully integrated Web-based patient portal available to provide electronic patient Web registration and updating of medical record information?
• What is the expected learning curve for the staff, technicians and physicians?
• How easily does the system interface with the ophthalmic test equipment (HRT, OCT, fundus cameras, etc.)? If the system is not ophthalmic-focused, how are the results interpreted from the test equipment and integrated as part of the workflow?

► What kind of guarantee is provided by the vendor that the practice will be able to successfully implement their EMR system successfully — and within a reasonable period of time?
► How many years of EMR implementation experience does the vendor have and how many practice implementations have been conducted? These two questions are related. Moving the clinical workflow to EMR is a major step for a practice. Decision makers should select a vendor that has both the proven experience and the commitment to help them successfully implement their system. Nothing will slow down your clinical workflow like a botched EMR project.
► How dynamic and adaptive is the system in addressing the requirements of individual procedures, or subspecialties?
► Can the electronic chart mimic your current paper chart and the needs of each physician within the practice? Again, if the EMR system is not ophthalmic-focused, how effective will it be in assisting and aiding in diagnosis analysis and coding of the patient visit? Will additional scribes need to be hired?
► How does the system securely integrate multiple office environments? How does it meet HIPAA requirements?
► Where can I see the system in action and visit doctors that practice in my specialty?
► How long does the implementation process last and how does the company help to support me through this first phase?
► Most importantly, what is the cost and effort involved to bring the practice online and make it more productive?

Template Customization

Every vendor queried has the ability to customize its EMR templates. Most allow customization to be carried out by the practice, although some offer to customize templates as a part of their maintenance fee.

VersaSuite offers different tiers of customization. They scan in each doctors paper examination chart and place an overlay on it to make their chart editable electronically. They can change the workflow per a doctor's request and are able to change the workflow on the fly or redesign what the practice wants seen and not seen.

Quickview Medical says that more difficult changes such as adding a new procedure or billing codes are performed by them and are covered by the annual support and maintenance agreement.

NextGen provides custom-designed ophthalmology interface screens to speed data capture, ophthalmic examination templates, more than 150 prepared operative notes and data-review screens designed for chronic conditions. The company says that many doctors choose to make the customizations themselves to have the exam screens look exactly as they want them. Alternatively, they offer customization services, where they will analyze a doctor's needs and customize the system for them.

Compulink offers preformatted ophthalmic subspecialty templates, all of which can be further customized. In addition, they have a screen editor that allows practices to customize their own screens. Alternatively, the company offers customization services, where they will analyze the doctors' needs and customize the system for them.

iMedicWare is an ophthalmic-specific EMR system and comes with pre-packaged templates. Practices also have full control to modify each template to the specific requirements of each doctor, specialty or for the entire practice. The system allows the practice to manage templates either via grouping of exam components and their elements or simply defining new components and their elements. The practice has full control over these templates and does not require the vendor.

MDoffice's EMR system design allows the user to customize templates to their specific needs or create their own from scratch. The customization feature is user friendly and does not require the user to have any IT background. MDoffice EMR is bundled with a ChartDesigner application which lets the user customize their templates including the workflow. Templates can be customized down to the color, position of information in the template and what should be displayed.

Medflow's position is to take full responsibility to customize the templates in order to fully support the client. The Medflow system is fully customizable from a content perspective, so a client can create their own pick-lists, letters, forms, consents, patient education materials, text macros plans and follow-up visits, providing a great deal of flexibility in the user content. Templates are also inter-linked so a practice could begin with a general ophthalmology visit and then determine they need a more specific workflow and move to the plastics or pediatrics screen to get a more specifically defined input.

While there are many issues that still need addressing, if you are in the market for an EMR system, please listen to the advice provided by the very people you will be evaluating. Visit a few ophthalmology practices that currently use the top EMR systems on your short list. While it is the vendors' responsibility to provide you with a tool that will best help your practice run more efficiently and cost effectively, it is your job to find the vendor who best fits your practice's needs. OM