• September 2008 FEATURE ARTICLES •
PHRs/EHRs/EMRs: Case History
The Second Time Around
A California practice learns lessons from their first EMR and integrates their PM with a new, on-demand EMR for an improved bottom line and clinical workflow.
By Thomas Mohr, M.D.
In 2000, I founded Pediatric Partners, which
at the time was a single-site practice with three physicians
located 60 miles northeast of San Diego. Like most small
practices, Pediatric Partners found itself experiencing massive
inefficiencies in our front and back office operations. At the
time, we were using an outside billing company and our legacy
practice management (PM) system was presenting constant staff
issues dealing with insurance verification, accurate patient
demographics and patient scheduling.
These process breakdowns resulted in the
practice experiencing growing denial rates and DAR of more than
90 days. In order to execute our practice’s vision of not only
growing our current location but also expanding, we needed to
find a solution that would deliver consistent administrative
outcomes. In 2001, we began leveraging an on-demand PM and
billing service.
By 2005, after one previous attempt to
install an electronic medical record (EMR), the group revisited
choosing and installing a new EMR solution. One that if done
correctly, would allow us to deliver better patient care along
with achieving consistent financial results. The decision to
install a new EMR did not come lightly for the group based on
our past experience. If this new system was going to work for
the group, I felt we would need complete buy-in from all of our
locations and staff, making for one of the most challenging
decision-making processes our group had ever experienced.
Selection
We began the process by forming a selection
committee that was represented by physicians from all locations
as well as administrators and staff. Our goal was to bring
together key stakeholders from all facets of the group,
including some that were against implementing a second EMR. We
spent a good deal of time discussing our concerns related to
cost, our current PM system and impact on workflow. As part of
this process, we gathered industry research from third-party
resources on EMR vendors and critical factors to take into
consideration when selecting one.
The whole process took several months but was
well worth it. We eventually narrowed the number of vendors down
to three, including our current PM vendor. We agreed that a
completely Web-based system was a core requirement due to the
natural cost savings and flexibility of that model in
conjunction with our growth strategy. Training and workflow were
also concerns due to the previous system’s lack of functionality
in terms of data entry and retrieval.
Regardless of the vendor selected, our goal
was to streamline office workflows and then create a
detailed training, implementation and support plan prior to
implementation.
With those requirements and goals in mind, we
selected an EMR system from our current PM and billing vendor,
athenahealth. They had just launched a new on-demand EMR service
known as athenaClinicals, which could be integrated with our
current PM and billing platform. An additional benefit to the
company’s centrally hosted EMR system was a new back-end service
operation we did not have with our software-based EMR. Our hope
was that this clinical service and
additional document management functionality would be more
scalable and help with our current clinical workflow issues.
Installation and Training
Soon after the selection process, we put
together a "super group" of users that consisted of preselected
physicians throughout our nine locations. This would act as
phase one of the implementation, allowing us to work through any
implementation concerns or issues. This group included
physicians with negative impressions of the former EMR in hopes
of their acting as core advocates and trainers for the new EMR
during the remaining implementation cycle.
After implementation, training and two months
of system use by the super group, we moved on to other
locations. The vendor worked with us to create a detailed
implementation and training schedule along with having their
staff on site. Additionally, we requested that physicians work
with the system during off hours to get a better sense of the
functionality and how they would incorporate the EMR into their
normal patient workflow, which proved extremely helpful in the
weeks to come.
The second and main phase of implementation
started with three of our largest locations with the greatest
patient volume, despite the vendor’s suggestion that we begin
with our smaller sites. We reasoned that going live at the
larger sites would augment our super group efforts and act as a
training guide for the remaining practices. Primarily due to the
Web-based nature of the system and our training process, all
nine of our locations went live in less than 12 weeks, making
for a far better experience than our previous implementation.
Most importantly, we had gained tremendous buy-in from providers
and staff throughout the group, which we attributed to our
weekly training sessions and formation of our super group.
Network Power and the New "Paperless"
By late 2005, all of Pediatric Partners’
locations were live on athenaClinicals and soon experienced
something beyond improved clinical workflow. At the time of
installation we had determined that, enterprisewide, our
physicians were receiving anywhere from 70 to 110 inbound faxes
a day per physician. With our EMR and PM system now on the same
network-based platform, we leveraged the clinical document
management service to integrate all the moving parts of our
practices — scheduling and billing, automated
coding, and clinical task management — into a single clinical
workflow system. This functionality proved critical for a few of
our smaller locations that did not have the same staff levels as
our larger sites.
With our EMR and PM service being part of a larger national network, all 74 of the 2007 PQRI reporting measures were automatically built into our operating system’s rules engine and alerted our staff to which PQRI measures apply to them.
Our group was now able to address any new
workflow issues and eliminate administrative errors via a new
"Virtual Clinical Back-Office" managed by the vendor’s network.
This back-end service began intercepting all inbound faxes and
reports coming into all office locations as each one went live,
converting them into electronic documents and then categorizing
them into clinical work buckets that were built directly into
each physician’s workflow. By indexing inbound faxes to the
correct patient and, if applicable, the original order, our new
clinical service provided us the basis to address closed-loop,
order-cycle integrity.
However, even with all of our lab results now
coming in electronically, there was still a massive amount of
paper coming into our medical offices. While this had been a
pain point with our first clinical system, our new EMR service
was able to scan and categorize every incoming fax, then match
specific clinical documents to existing patients and patient
orders. This gave our group an incredible amount of process
control on both the clinical and operational fronts. Not to
mention that the EMR service now managed the connectivity to our
labs and pharmacies, which significantly reduced the number of
calls into our practices.
Along with eliminating our group’s paper
congestion, we were now part of a network-based EMR that
provides all of our locations with continually updated
payer-specific coding rules, and evaluation and management
coding reviews at the point of care. This helps our providers
optimize reimbursement and begin dealing with new
practice-specific, pay-for-performance (P4P) payer contracts.
This was why one of our core objectives was to select a fully
Web-based system.
Gaining Control for the Future
In 2007, the group began to see the results
of our hard work in going live with this new clinical system.
That year, saw the implementation of a major new P4P program
from the Centers for Medicare & Medicaid Services known as the
Physician Quality Reporting Initiative (PQRI). Under the new
initiative, medical professionals that report on certain
quality-of-care measures given to Medicare patients can earn
incentives of up to 1.5 percent of their total allowed charges.
With our EMR and PM service being part of a
larger national network, all 74 of the 2007 PQRI reporting
measures were automatically built into our operating system’s
rules engine and alerted our staff to which PQRI measures
applied to them. This was a tremendous help in our ability to
participate in the program as well as helping to maximize
participation and reimbursement under the program. In 2008, PQRI
expanded to incorporate 119 performance measures. Our system is
now live with these measures in addition to two structural
measures with staff working to incorporate them into our patient
workflow.
Today, we still maintain a core super group
that looks to stay present with emerging industry trends like
P4P initiatives and determine any technology needs. We have
found that the over arching benefit of our on-demand EMR service
is that it enables our group to leverage a utility that
researches and qualifies, and is updated daily with new rules
and measures, allowing our group to optimize both our
administrative and clinical outcomes.
Thomas Mohr, M.D., is president and CEO of
Pediatric Partners Medical Group MPC, Temecula, Calif. Contact
him at pediatricpartners@msn.com.
