Every physician practice that installs an electronic medical record (EMR) faces the challenge of physician adoption, a challenge that is best addressed before the rollout begins. One way to support adoption is to offer physicians a real-life demonstration, so they can see that an EMR won't slow them down and that it will provide added benefits they couldn't possibly get with pen and paper.

When the New York Heart Center switched from transcribed notes to an EMR, they encountered and overcame many such challenges, and in record time. With 138 employees, including more than 20 physicians in 10 locations, they are the largest cardiology practice in upstate New York. Their offices have five nuclear cameras on site. They also have echo, vascular, protime and lipid clinics, and cover five hospitals with cardiac catheterization and peripheral labs.

Ric Smith is the New York Heart Center's director of operations. He first came to the Center as a patient, after undergoing bypass surgery. During an exam, Smith, who had left Ford Motor Company, explained that he worked selling resource scheduling and management software for a small vendor. His heart doctor expressed interest in having similar software installed at the Heart Center. Eventually, Smith directed the Center's installation of that software, and after completion they offered him the job at The Heart Center scheduling and managing doctor resources.

From 1983 to 2004, the New York Heart Center used transcription for getting doctor's notes onto medical records. This long-proven method became cumbersome as the Center's practice grew. Often, more than 10 days passed before a patient's referring doctor received the final note.

"The problem was the delay between the time of treatment and the time the paper was finalized," says Smith, "The referring doctors wanted the information on the patient they had sent in a much quicker fashion, so doctors spent a lot of time on the phone telling the referring sources about the visit."

Expense was another issue with transcription. In 2000, the Heart Center was paying approximately 15 cents per line or more than $250,000 per year in transcription costs. The doctors felt that if that money could be recovered, it could be better spent elsewhere in the practice.

Earlier, David Gorra, New York Heart Center's COO, changed their administrative structure to more align it with the corporate world. The restructure allowed for a director of operations, director of finance and an operations manager. It also made the administrators (Gorra, Smith and a few others) largely responsible for the business functions of the practice, while the doctors were responsible for the medicine. With strong support from Gorra and several of the practice's primary physicians, Smith investigated replacing transcription with an EMR.

Best of Breed, Lots of Money
As he studied the available products, Smith found EMRs pricey. The thought of replacing a $250,000 per year operating expense with a $1.2 million capital expenditure gave the administrators pause. "We realized it was going to be very costly putting this type of a system in the practice," says Smith. Gorra, however, was determined to make it work and asked Smith to continue his research. As time passed, EMR prices dropped while their capabilities increased, and Smith was eventually green lighted to make the final decision and purchase the EMR.

Smith found a consultant who was evaluating and ranking EMRs by how they best fit small, medium or large practices and hospitals, and offering suggestions and advice in several online forums. The consultant classified the Heart Center as medium to large and recommended a top dollar EMR. Smith studied his recommendations, but found he was most interested in Charting Plus from MediNotes. "What I liked most about the program was it solved the practice's biggest hurdle," says Smith. "The greatest problem in implementing an EMR is physician acceptance. If doctors won't use it, you've wasted your time and money."

Smith was determined to find an EMR that permitted doctors to continue to document notes in the manner to which they were accustomed. "It's easy for them to say, ‘This doesn't work for me,' so the more closely we mimicked what the doctors were doing with pen and pencil, or tape, the more successful we would be." Charting Plus also was considerably less expensive than those recommended by the consultant. Smith contacted MediNotes and arranged for a demo.

Matching EMR to PM
MediNotes' Charting Plus EMR impressed Smith with its template flexibility. Other EMRs he had looked at also contained templates. Renowned cardiology groups had even written some of them. However, most of them allowed very little if any modification. Smith felt this would be too restrictive for the New York Heart Center.

"One of the program's greatest strengths is it permits you to modify your templates yourself," says Smith,

"I can start with a blank template and create a new, fairly complex template that properly documents a process in under two hours."

Charting Plus' flexibility with templates meant the doctors would not have to unlearn methods they already used. "We could use its built-in templates, or customize them or build our own templates. The closer I could get to duplicating what the doctors wanted, the better chance we would have of successfully implementing the EMR," says Smith.

When the Heart Center switched from transcription to EMR, they also simultaneously installed a practice management (PM) solution that had its own optional EMR product. But package solutions do not fit with Smith's philosophy of going with a company's strengths. He feels that it is difficult for a package solution to do all things equally well. "The interesting thing about Charting Plus is it's an EMR only," he says. "It doesn't try to do different functions." It also linked well with the PM solution they chose for the Heart Center.

The Process Prevails
Onsite training began May and ran through July 2004. With 16 doctors on staff, the initial plan was to train four and then have those four train the next four and so on. The administrators decided that would take too long, so they moved to train all the doctors simultaneously. Smith asked MediNotes to muster all their available trainers, and the company delivered. "We drove the installation and training process probably harder than most companies would," he admits. "We had to make the process work with all the doctors at once, or we would have been forever trying to get everybody up to the same level of use."

Training began in earnest but proceeded slowly. Smith had the doctors focus on learning to use just a few procedure exam templates, such as echo and stress echo, a couple of times each day. "We eased the doctors and staff into using the templates," he says. "With their heavy schedules, we didn't want to burden them with constant use of the program."

However, administrators soon found themselves in the position of having to nudge their bosses toward compliance. Though the doctors gave them the power to set the training schedules for all staff, when it came to implementation, the physicians were reticent. Some believed it took only a few minutes for them to type a note and questioned the need for change. By timing them during dictations, Smith demonstrated that they actually took an average of eight to 12 minutes per note.

The administrators decided it was time to set a date for the end of dictation. They informed staff that after the July fourth holiday, there would be no more recorders and they could no longer type dictated notes. Still, some of the doctors were reluctant. However, once the primary physicians became proficient with the new system, it gave impetus to the rest of the staff. In the end, Smith's "no one left behind" training program paid off. The administrators eliminated transcription at the Heart Center in only 60 days.

Positive Results
After completing the training phase, Smith hired a full-time Charting Plus coordinator to be responsible for checking the system for incomplete or duplicate notes, template customization and ongoing training. Since then, the New York Heart Center has grown by seven physicians and three nurse practitioners, and all transcription costs have been eliminated, resulting in a nearly $300,000 savings each year.

The Heart Center doctors also no longer need to phone referring physicians to report on patient encounters, as was the standard practice back in the old days when transcribed notes took a week to deliver. Says Smith, "When a patient comes in today and we see that patient, that note can be transmitted to the doctor and on his desk before the patient turns the key in their car to drive away from the office."

To the New York Heart Center and referring physicians, that savings in time and cost translates into a major improvement in patient care. "With an EMR, having the information available immediately means the patient is treated better because the information is available right now."

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© 2006 Nelson Publishing, Inc

January 2006