Electronic Medical Records

Electronic Medical Records Feature Story

An EHR that delivers results

Written by LaShonza Alexis February 2012

Arizona doctors credit EHR with helping them grow their practice into the largest of its specialty in the state.

Before implementing an electronic health record (EHR) and practice management (PM) system, Drs. Goodman & Partridge, OB/GYN was a seven-provider specialty practice. Today, the Chandler, Ariz.-based practice has 37 providers, including 26 physicians in seven offices, and is the largest OB/GYN practice in Arizona. In addition, it has boosted bottom-line revenue by more than 26 percent.

Perhaps even more astounding than its revenue growth, the practice also has been able to reduce expenses by more than $1.5 million a year while improving patient care and satisfaction. The practice credits much of this growth to an EHR system that has virtually eliminated paper from operations and provided invaluable, extra features, such as customizable templates, automated recalls and marketing ROI reports.

Much of the cost savings the practice has realized can be traced to a reduction in paper costs and transcription fees, but it also comes from greater efficiencies gained at each of the practice’s offices. For example, multiple providers can work in the same chart at once, all offices share the same chart information and real-time billing information is available for instant analysis.

Most importantly to the providers, the EHR system has helped Drs. Goodman & Partridge, OB/GYN deliver better patient care. The practice communicates more effectively with women about their pregnancies and personal health; it also helps patients stay involved in their health and adherent with their care plans.

Eliminating paper saves millions
Drs. Goodman & Partridge, OB/GYN went live with its EHR system on May 1, 2005. The most immediate and tangible financial benefit for the practice was eliminating paper from daily operations, as well as the labor involved in recording and sharing patient data on paper.

With seven providers at the time, the practice employed four full-time, in-house transcriptionists who were paid $31,200 each per year. Four “chart runners” each were paid $19,968 per year plus mileage reimbursement to drive charts between the practice’s various locations. (In order to best accommodate the practice’s OB/GYN patients, Drs. Goodman & Partridge encourages patients to visit whichever location is most convenient for each visit. Paper-based charts, therefore, had to be routed to the right location for each scheduled visit.)

The practice had long faxed prenatal information to local hospitals for unexpected and expected patient visits, but implementation of the EHR eliminated the need for chart transport between offices and hospitals. By sending prenatal records through its EHR system, the hospitals and on-call physicians can review any patient’s previous and current conditions.

The practice’s IT staff helped providers transition to the EHR by taking advantage of the system’s template editor. During training and rollout, physicians and other providers worked with electronic documents that were nearly identical to the paper forms they were used to. Furthermore, the system’s document builder allowed staff members to design files similar to those their transcriptionists created.

By initially customizing the forms and files to mimic the paper-based processes providers and staff were familiar with, the practice quickly gained crucial buy-in. Over time, the practice gradually has enhanced its templates to collect more relevant information at the point of care, but still using formats preferred by providers.

IT staff members have developed several customized templates for the practice to document procedures that require specialized equipment and specific documentation. For example, when the practice recently began offering urodynamic testing, the IT staff developed a custom template to record the procedure using the providers’ specific input, while integrating the new service with the template suite providers access daily.

Today, it would require 22 transcriptionists and 22 chart runners to support the 37 providers if the practice still used paper records. Factoring in inflation, switching to an EHR has saved the practice more than $1.4 million a year in salaries plus more than $86,000 annually for 215,280 reimbursed miles.

The paper costs alone are significant. Each provider schedules 25 appointments a day on average, or 925 appointments total daily for the practice. Before the EHR system, each appointment created at least six sheets of paper for the patient’s chart, which translates to 5,550 sheets a day and more than 1.5 million sheets a year. What’s more, the practice receives 30 requests a day for medical records and sends about 35 requests per day to other locations.

With the EHR, the practice has eliminated the need to fax 975 sheets per day, or 19,500 sheets a month, just for the clinical staff. The billing staff used much more paper. Combined, the annual paper expense savings equal about $62,272. Based on our current growth, the practice estimates an annual labor and paper cost savings of $2.9 million by 2013.

However, the benefits have extended to more than just expenses. Through a partnership with its IT vendor, the practice now runs reports in its PM system that were nearly impossible with paper records. It can instantly view which higher-reimbursement procedures have not been paid, for instance, or which health plans are not paying according to the fee schedule, or how long claims have been outstanding.

By following up on the claims shown in these reports, the practice has increased its revenue by 26 percent, decreased outstanding A/R by 76 days and overturned hundreds of denials. These claims account for millions of dollars the practice did not collect before adopting the NextGen Ambulatory EHR and NextGen Practice Management systems.

Automating functions ensures better patient care
On the patient-care side, the ability for multiple staff members to work in a patient’s chart is now a reality. The lab department can simultaneously input test results while the triage department can log a phone call and the billing team can access the record to find documentation for a claim appeal. It all adds up to much smoother operational, fiscal and patient-care processes.

One example is the system’s automated recall feature, which has been invaluable to the practice. This function helps patients follow their health/pregnancy-management plans by reminding clinical and front-office staff about follow-up appointments, treatments and testing.

After a visit, for instance, a provider’s note in the EHR to follow up with the patient in three months synchs with the PM system to be scheduled before checkout. Nearly three months later, the recall system will alert front-office staff members to remind the patient of the appointment. Soon, the practice will upgrade its telephone system so appointment reminders will be automatic.

Another feature that has improved patient care is the ability to upload ultrasound images into patients’ charts almost immediately after images are captured. After an ultrasound study is completed, the equipment burns the images onto a DVD, and that information is then uploaded into the patient’s EHR. (The EHR actually is capable of capturing images directly from the ultrasound device, which would eliminate the need for a DVD. However, the ultrasound manufacturer charges a significant fee to enable that feature, so the practice is still contemplating the upgrade.)

Regardless, an ultrasound and follow-up visit with a provider on the same day keeps the practice’s anxious obstetric patients and nervous gynecological patients from having to return for ultrasound results. This way, any immediate questions are answered and they can receive appropriate and complete follow up. Likewise, when obstetric patients visit the hospital, lab results and ultrasound images are immediately accessible electronically. The practice’s doctors can log in and access the patients’ charts as if they were in the office and see the most current test and medication data, which helps avoid delays, complications and potentially harmful duplicative testing.

New efficiencies, new patients, bright future
Prior to adopting its EHR, trying to quantify return on investment (ROI) was difficult at best. Like any growing practice, though, it was important to be able to track how new patients came to hear about Drs. Goodman & Partridge.

While operational and financial efficiencies are to be expected when automating a practice’s systems, the ability to report on marketing results was an unexpected, but welcome, addition. The system now allows the practice to collect data from patients, such as how they heard about the practice and what insurance they have, and track this data to determine the most efficient way to spend marketing dollars.

Here is an example: In May 2011, the practice determined most new patients arrived through PPO/HMO network directories and physician referrals. However, 153 new patients saw the office while driving by, 17 new patients came from billboard advertising, five from the Yellow Pages ads, two from the practice’s Adopt-a-Highway signs, two from magazine ads, one from a newspaper ad and 117 from the Internet.

Based on this type of reporting, aside from health plan networks and physician referrals, it is clear that the practice’s website and its search engine accessibility are crucial to its marketing efforts.

The practice also tracks when established patients recommend the practice to new patients. When they do, the established patient receives a reward, such as a gift certificate for a massage. This incentive program is also managed within our automated systems and helps encourage new patient visits while maintaining established patient awareness and satisfaction. Without the ability to track this data, however, it would be extremely difficult, if not impossible, to track marketing and patient incentive efforts with this kind of precision.

In fact, it is pretty safe to say that Drs. Goodman & Partridge, OB/GYN could not be the practice it is today without the capabilities of its EHR system. Eliminating the hassles of storing, handling and sharing paper has saved it millions of dollars, but the benefits extend to more than just digitization.

LaShonza Alexis is the billing supervisor at Drs. Goodman & Partridge, OB/GYN. For more on NextGen Healthcare, click here.

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A look at unintended consequences of EHRs

Written by Lou Ann Wiedemann February 2012

The industry needs to focus on building EHRs that decrease medical errors and enhance patient care.

Achieving high-quality, cost-effective care requires an integrated healthcare delivery system that includes hospitals, providers, specialists and, in some cases, long-term care. Navigating this continuum of care can be fraught with twists and turns that are confusing to patients and their care providers. Medical errors, hospital-acquired conditions, rapid implementation of electronic health records (EHRs), fragmented delivery systems and technology constraints are just a few of the many issues affecting healthcare quality and patient safety today.

In this healthcare environment, evidence of patient harm may not be glaringly obvious. For example, the interface between a laboratory system and EHR cannot be visualized by the healthcare provider. If high lab results indicating a myocardial infarction are not integrated into the EHR, thus notifying the clinical care providers immediately, several hours may pass before the patient’s symptoms are treated. As a part of continuous efforts to improve healthcare, most providers and organizations are investing large sums of capital dollars in health information technology.

While there is some reasonable evidence that EHRs can reduce patient safety issues, we must remember that the EHR has also introduced a whole new category of events that cannot be ignored in the rush to implementation. The healthcare industry needs to begin focusing on building EHRs that decrease medical errors and enhance patient care.

The cost of medical errors
Medical errors contribute to a significant loss of healthcare funds each year; the costs are often staggering. According to findings commissioned by the Society of Actuaries (SOA), measurable medical errors cost the U.S. $19.5 billion in 2008. This report demonstrates an opportunity for the healthcare industry to increase quality and patient safety. In addition, the report demonstrates a need for decreasing the cost of healthcare and increasing efficiencies in the continuum of care.

Since 2008, there has been no shortage of statistics indicating patient safety concerns and the cost of errors. Despite massive attempts to measure patient safety and increase quality of care, the Agency for Healthcare Research and Quality (AHRQ) reported in 2007 that patient safety improves at just 1 percent per year.

EHRs have been promoted as the key ingredient to better care coordination, a decrease in healthcare costs and improvements in efficiencies. However, realizing all of these benefits is often more difficult than expected. As organizations and providers continue to invest heavily in EHRs and health information technology (IT), there is an increased need to see the benefits of these systems.

In recognition of the continued challenges associated with using EHRs, AHRQ funded additional research to identify the unintended consequences of EHRs. The results of the research culminated in a guide designed to assist organizations and providers in anticipating potential problems associated with EHR implementations.

Unintended consequences
AHRQ defines unintended consequences as an unanticipated and undesired effect of implementing and using an EHR. These unintended consequences include increased work for clinicians, unanticipated workflow changes and repeat requests for system changes or upgrades. As these consequences occur, end users become frustrated with the system and software. As frustration levels grow, end users begin to develop workarounds or revert back to paper processes.

For example, a hospital has an electronic lab system that reports abnormal lab values. The physician prints out the lab report and adds handwritten remarks to the report. This handwritten information is not a part of the electronic version of the lab report and contains important clinical information. How does the organization incorporate the changes into the health record?

Another example: An organization has implemented computerized physician order entry (CPOE). Upon entering orders for a patient, the physician may be prompted to answer questions, such as, “Should the patient have nothing by mouth prior to the study?” In the past, these types of questions were answered by the clerk as the order was entered. The physician becomes frustrated with the prompts for information and reverts back to writing a paper order. He passes his paper order to the nurse, who then hands off the orders to the clerk who then enters the order into the system. The physician may have solved one problem, but he has created another. Now the order that the clerk entered has to be signed by the physician.

Both of the examples above can create additional risks to patient care and often negate the benefits of the EHR. The EHR processes were intended to speed up communication between care providers and the ability to provide patients with care (e.g., medication or x-rays). Because of frustration with the system and increased time to enter information, the EHR becomes a dreaded tool. The clinical care providers see the EHR as a tool that increases their time and effort and does not meet their needs; this does not promote trust that the system will assist them in doing their jobs. These unintended consequences must be addressed in order to reap the full benefits of the EHR.

Paper-based processes are not the only unintended consequences seen with EHR implementations. Other unanticipated results may occur when multiple systems are expected to interface with each other. What happens when the lab system does not interface with the EHR, or the interface is not working properly? For example, a patient’s lab report indicates a dramatically low potassium level. The information does not file in the EHR, or files in the wrong record. The physician does not know the level is low, misses writing an order for IV potassium and the patient suffers a heart attack.

The same type of issue can occur in the radiology system, pharmacy system or other modules expected to file reports or interface with the EHR. Monitoring the interface alone is not enough. If the organization knows that the report did not interface, it will take a manual entry to file the report, which is time consuming.

If the report files to the incorrect chart, it is almost impossible to detect. The interface worked correctly; it is not going to show up on a “reject” report. And yet, incorrect information is in the patient’s chart, and care providers are making decisions based off that information.

AHRQ further recommends that those utilizing EHRs should thoroughly understand the causes of their EHR problems in order to proceed with developing a corrective action plan. The guide also provides guidance on prioritization. Organizations or providers can review a series of factors that will assist them in identifying and prioritizing their unintended consequences. Refer to AHIMA’s article, “Unintended Consequences: Identifying and Mitigating Unanticipated Issues in EHR Use,” for more information on AHRQ’s report, recommendations and case studies.

Building better systems
The healthcare industry must begin to build better systems that address and promote patient safety and quality. The Institute of Medicine (IOM) reported in November 2011, “When designed and used appropriately, health IT is expected to help improve the performance of health professionals, reduce operation/administrative costs and enhance patient safety.”

In IOM’s report, “Health IT and Patient Safety: Building Safer Systems for Better Care,” the committee found that literature and reports of EHRs and patient safety were inconclusive. While some specific applications are successful in improving care, some case reports agree with AHRQ that some systems create new and unanticipated risks.

The report does suggest that a systems approach to implementation may increase patient safety. The implementation of EHRs involves many moving parts, such as clinical care providers, patients, registration, technology and organizational-specific issues. All of these moving parts create a complex healthcare delivery system. In order to build a better system, IOM suggests that developing a user-centered design approach is needed.

This approach would include appropriate and adequate testing and quality-assurance assessments. The final product should provide end users with the ability to receive and retrieve accurate, timely and reliable patient data. The report also calls for the Department of Health and Human Services (HHS) to develop new measures that will assess health IT safety and monitor for improvements.

Conclusion
Although EHRs may decrease some patient safety initiatives, there is no doubt that they also create many new risks. In AHIMA’s practice brief, “HIM Functions in Healthcare Quality and Patient Safety,” we outline the critical functions health information-management professionals perform in the delivery of safe, high-quality patient care. Utilizing the existing data within the health record can provide the necessary information to improve patient safety practices. Failure to understand these issues can increase risks to quality care and patient safety. Is it time to implement mandatory reporting of EHR events? Should HHS be responsible for overseeing these events and monitoring both the systems and organizations that have them? There is no doubt that in order to receive the ultimate benefits of an EHR, these issues must be addressed. As EHRs are rapidly implemented to meet the imposed deadlines of 2015, consideration of these issues must be taken into account.

Lou Ann Wiedemann, M.S., RHIA, FAHIMA, CPEHR, is a director of professional practice, AHIMA.

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Electronic Medical Records