• May 2007 FEATURE ARTICLES •
EMR/EHR
Planning Makes Perfect
A Colorado physician’s story shows a successful model for EMR implementation
from the ground up.
By E. Victor Brown, Associate Editor
It can be argued that patient satisfaction goes hand in hand with physician and staff satisfaction, so when health documentation gets in the way, no one can attain satisfactory results. However, the implementation of electronic medical records (EMRs) is far from
an automatic panacea. Just like a tailored suit or custom dress, EMR systems are often expected to fit the practice rather than the practice changing to fit the EMR. Yet, the best solutions should change the practice, when the change is for the better. For a Colorado-based practice, building an EMR system from the ground up meant a custom fit that all small and medium practices can tailor to their specific needs.
Alpenglow Medical, LLC is a Fort Collins-based primary care clinic providing outpatient medical services to adults. The clinic serves 70 percent Medicare beneficiaries, 28 percent privately insured, 2 percent private pay or uninsured, and less than 1 percent Medicaid. Begun as a solo practice in 1999 by Dan Griffin, M.D., Alpenglow has grown to include a second physician and one medical assistant, who collectively provided care in about 10,000 patient encounters. Today, the single practice has expanded to four as Griffin brings existing practices under the Alpenglow umbrella.
Like most small to medium practices, Alpenglow is a
reflection of the ethics, compassion and outlook of the founding
physician. However, unlike most practices seeking to tip the scales
toward patient care rather than paperwork, Alpenglow chose to design the
practice from the ground up around an EMR rather than converting after
establishing the practice. "Our goal at Alpenglow is to deliver
efficient, quality healthcare with no patient waiting time and 100
percent patient satisfaction," said Griffin. "The EMR is an important
component to achieving that goal."
Early Experiences, Early Thoughts
Griffin’s interest in creating a different type of
clinical practice was shaped early in his career as he saw how poor
documentation adversely affected the pursuit of high quality medical
care. "Coursework done for a certificate program through the Johns
Hopkins School of Medicine convinced me that solving the problem of
documentation was critical for a clinic to succeed as a business while
maximizing customer satisfaction, quality and staff efficiency,"
explains Griffin.
The early concept for the eventual practice centered
on an EMR from the beginning, allowing Alpenglow to start out moving in
the right direction to higher quality care, a streamlined practice and a
happy staff. At the time, conversations with peers on the subject were
less than encouraging. Some physicians believed that EMRs should allow
them to keep known, but inefficient workflows, while others felt that
anything electronic is good. "You have these people walking around with
their Palm Pilots and even if it slows them down and decreases their
efficiency, they feel that the technology needs to be embraced at all
costs," said Griffin.
For Griffin, it was uncommon to find physicians
willing to find out how the technology could be helpful, how it needed
to change, and how the workflow needed to evolve to create a happy
medium. As EMRs have further developed in the last several years, a new
category of users with EMR system experience arose. The challenge then
became sorting through the converts who felt that the system operations
were the best they could be and finding the few who recognized things
could be better.
Objectives
The physician’s top priorities for an EMR system were
to capture clinical encounter documentation in real time to increase the
quality of documentation, include the patient in the accuracy of
documentation, and to reduce malpractice risk through improved accuracy
and completeness. Additionally, he wanted a system that could serve as a
database for knowledge management of ideal clinical care.
Griffin intentionally avoided a template-driven EMR
in favor of a system that would allow him to build care management plans
for individual patients based on his own knowledge, training, ongoing
review of the literature, and Web-based clinical decision-support
services, and then store them for future application. "In the mid-90s,
you had to force the issue for any of the available products to be a
true health record so it was a partial solution at best that you had to
make work against its design," says Griffin.
As Griffin began to focus on the specifics of the EMR
in conjunction with the eventual practice goals, a clear picture of the
staff criteria began to emerge. The physician knew that it was
imperative to hire staff that shared his vision for service delivery,
patient care and full utilization of an effective EMR system. "One of my
main challenges with staff was that they often had worked elsewhere and
therefore had to be retrained to the new approach of mutual buy-in to
continuing education, both within their fields of study as well as with
updates to the eventual EMR system," says Griffin.
System Selection
Once deciding on the EMR system criteria and the type
of staff he needed for success, Griffin spent a month reviewing
available systems. He ultimately chose Praxis EMR by Infor-Med primarily
due to its Concept Processing rather than structured templates. A
Concept Processor is an artificial intelligence software program that
learns from its user, and in turn, documents faster and better with each
patient encounter. The Praxis UpToDate decision support system contains
thousands of disease-specific templates referred to as concepts. "We
could build patient concepts based on our needs and preferences, or
import them directly from decision support software," explains Griffin.
Additionally, the Praxis system met his criteria for
charting and real-time documentation as well as task automation for
prescription writing, test ordering, generating bill information and
scheduling of return visits. This laid the groundwork for clinical
encounters that fit typical physician workflow and thought processes.
Once he selected a system, Griffin hired a local IT
consultant familiar with the healthcare sector to assist with hardware
purchase and installation. The IT consultant worked through a reseller
and Praxis to obtain recommendations for the purchase of hardware.
Griffin purchased Dell hardware via the Dell Website and was part of the
installation team. "Just because you’re going to EMRs it is unrealistic
to think that you are going to master the whole field, so you not only
need IT consults that understand the technology, but also the needs of
healthcare and HIPAA compliance," says Griffin.
Implementation
The team consisted of Griffin, the reseller, a Praxis
representative and the local IT consultant. They collectively set a goal
to complete training and testing in the week prior to opening the
practice to patients. Once completed, Griffin hired a nurse and office
manager and scheduled a week for the training. Users were responsible
for looking critically at the areas of the EMR that they would be using
and bringing questions, suggestions, and feedback on the EMR system back
to Griffin and the trainers.
According to Griffin, staff suggestions were integral
to the system’s success. Based on these suggestions, patient photos were
added to ensure correct patient identification without opening the
chart. New printers and a software upgrade were added so that clinical
information such as procedures, prescriptions and lab results could be
printed at the back nursing station, while administrative information
was available at the reception desk with ergonomic and easy access for
staff.
Griffin and staff spent a great deal of time
identifying what information should be transferred from the paper chart
to the EMR. Alpenglow scheduled 30-minute visits with each new patient
where relevant information from their paper chart was entered into the
EMR system. All additional relevant information was given to staff for
scanning, with the full paper chart placed in off-site or attic storage.
"We held a meeting to review what was actually in an ‘old chart’ and
discuss what information was relevant to an internal medicine practice
and what information providers and staff would access and use,"
explained Griffin.
In order to speed scanning of consults and other
documentation into the system, Griffin consulted with the vendor, who
developed a process for batch scanning and sorting information into each
patient chart via high-speed batch scanners. This improvement eliminated
hours of staff time per day. Additionally, Griffin worked with the
vendor to reduce current medication updates in the system from two
clicks per medication to just two clicks to activate the entire
medication list.
Staged Patient Implementation
To avoid creating a chaotic environment resulting in
poor system use habits by staff, Alpenglow initiated a staged patient
implementation that allowed the practice to focus on full utilization of
the system. "I was convinced that the success of this model heavily
depended on staff participation, which I was able to achieve through my
hiring criteria, the pursuit of individual buy-in, and making sure the
staff felt a real sense of open dialogue," said Griffin.
The goal of never having patients wait also was
integral to the rollout as well as the workflow of the resultant EMR
system. To accomplish this goal, Griffin and staff set up system test
dry runs of complete patient encounters in order to set reasonable
patient volume goals for the first week of actual patient care following
implementation. Alpenglow saw only six patients per day in the week
following training. The next week saw an increase to 12 patients per day
and 23 by the third week. "I wanted to eliminate patient perception of
the EMR as an inconvenience and felt that a short period of decreased
visits would ease the transition," said Griffin.
Ultimately, the staged implementation was a success
for staff and patients, with no downside and more than one unexpected
bonus. While some physicians might feel that implementing new technology
could cause concerns for patients, Griffin found just the opposite.
"What I mainly get is this perception that if you have this computer and
you’re making notations and entering notations into an EMR, then they
presume it reflects that you’re at the cutting edge with your medical
care," explains Griffin. "Consequently, the patients seem very excited."
EMR in Practice
With the EMR in place, a typical office visit begins
with physician and patient entering the exam room together, and then
accessing the electronic system. The opening screen shows a picture of
the patient, all demographic and insurance information, current lab and
X-ray reports, prompts from the disease-specific concept, and current
problem and medication lists.
The patient is able to view the screen during the
interview as the physician enters relevant notes and reconciles
medication data. Following the examination, the patient and physician
return to the computer to enter any additional resulting information.
Griffin verbalizes all entries into the system while typing to ensure
accuracy, allow for corrections or additional patient input, and to
serve as an educational intervention. "I place a high priority on fully
answering patient questions, and we schedule appointments with that goal
in mind," said Griffin.
Alpenglow uses UpToDate, an evidence-based clinical
decision support tool, to access clinical information at the point of
care. Praxis is linked to First Data Bank, National Drug Data File Plus,
a national medication and clinical information database that allows
providers to select medications and obtain detailed information
including drug-drug and drug-disease interactions. Medications entered
into the medications section of the patient encounter form print
automatically to the front desk along with referrals ordered within the
patient encounter. The EMR imports, stores and displays laboratory,
radiology, and referral reports and stores media files.
After completing all documentation, physician and
patient leave the examination room together and go to the front desk
where prescriptions, test and referral orders as well as billing
information are printed. The front office staff has access to the
follow-up recommendations section of the clinical encounter and,
whenever possible, schedules the next appointment before the patient
leaves. At the conclusion of the visit, all documentation is completed,
with no pending data entry.
The medical assistant (MA) enters vitals, updates the
current medication list, and enters the primary and any secondary
complaints into the EMR system. The EMR interfaces with Quest, LabCorp
and PVH (the local hospital), and has a manual interface for entering
and converting to electronic format any results from smaller local labs
in Fort Collins, or reference labs that are not interfaced.
The MA also manages an electronic tickler system that
sends messages alerting when to check for lab results. The latest
upgrade of the EMR system at Alpenglow is being used to run
disease-specific reports on specific patient populations to identify
patients missing recommended services, or responding inadequately to
treatment.
Achieved Practice Goals
Since the implementation of the EMR system,
Alpenglow has met or exceeded the goals set by Griffin long before the
first patient entered the practice. Today, the practice only needs a
single MA for its two clinicians, saving the practice $30,000 annually.
Additionally, the practice has no need for a medical records staff or
transcriptionist, saving an additional $20,000. Also, gross revenues for
the practice have increased some 21.5 percent since 2002, with a
collection rate exceeding the goal of 90 percent.
On top of the financial savings, the practice now has
the ability to see more patients with the average maximum wait time of
just over two minutes once entering the office for scheduled visits. All
of this has allowed Alpenglow to become a far more compassionate
practice that can work with more patients experiencing financial
hardships where charges can afford to be written off. "I believe that a
certain amount of pro-bono work is morally the right thing to do and
something every well-run practice can afford to do," said Griffin.
Quality of life for staff has also increased with
staff working 4.5 days per week, physicians working 4 days per week and
everyone leaving the office each day by 5:15 p.m. Patient satisfaction
surveys show a 100 percent satisfaction rate overall and Medicare
fee-for-service population data show diabetes and mammography screening
higher than statewide and national rates.
Expansion and the FutureAlpenglow closes several days per year to allow full staff
participation in update training via live Praxis Web training. Every
employee is responsible for making notes about bothersome aspects of the
electronic system, and/or suggestions for improvement. Improvements are
made as identified, while pervasive or difficult issues are discussed at
monthly meetings with vendor assistance utilized for those issues that
cannot be rectified in-house. As icing on the cake to these results,
Griffin and Alpenglow Medical have been recognized with a 2006 Davies
Award in the ambulatory care category from the Healthcare Information
and Management Systems Society.
Although Griffin opened Alpenglow with an EMR system
in place, he has acquired three additional practices over the past seven
years, and has transferred the paper charts from these practices to his
EMR system. Griffin’s ultimate goal in these cases is bringing the lead
physician of an established practice in line with the Alpenglow EMR
systemic approach. "Our latest acquisition will be a challenge because
the office manager for 12 years will no longer be reporting to the same
person when the transition goes through, and they realize that I will be
telling their physician that he needs to change the way he does things
to make it a full benefit for them," says Griffin.
Although progress in the proper adoption of EMRs continues, Griffin
is among the growing group of physicians concerned about those who see
EMR implementation as only a business decision rather than equal parts
quality care improvement. "I think most people still view being a
physician as a privilege. If we can take that responsibility and then
spend some of our money—even if it’s a break even proposition—we can
improve care."