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HEALTH LEADERS
November 2006
By Gary Baldwin
Providers share some lessons learned en route to clinical documentation automation.
If you ask James Holly, M.D., if there are any misconceptions about electronic medical record systems, be prepared to sit a while. An outspoken champion of clinical IT, Holly has used an EMR at his multispecialty group practice for eight years. The 26 physicians at Southeast Texas Medical Associates have retired their paper charts, using an EMR to document all aspects of clinical care. Holly, chief executive officer of the Beaumont, Texas-based group practice, led the automation charge because, as he puts it, delivering high-quality healthcare simply demands it.
But physicians like Holly remain a minority, as only some 10 percent of physician practices have automated their clinical recordkeeping, according to most estimates. Hospitals, too, remain burdened under the heavy yoke of paper charts. Many run partially automated, hybrid electronic-paper environments. Like Holly, executives involved in hospital deployments invariably can talk at length about the misconceptions of advancing documentation into the modern age. Here are five common EMR myths.
- All EMRs are alike.
Physicians paint with a broad brush when it comes to EMR technology, assuming that all software products are basically alike, Holly says. Vendor claims may figure into the perception; a multitude of EMR vendors market to physician groups, each trumpeting its ability to solve medical group documentation needs. But there are vast differences among software packages, says Holly, who uses an EMR from Horsham, Pa.-based NextGen. Southeast Texas Medical Associates expanded three years ago, adding physicians from a group using an EMR from another vendor. SETMA tried to convert the data into its own system, but gave up, Holly says. “Their ERM was totally unusable,” he says. “It was $250,000 down the drain.”
One problem stems from a lack of data compatibility among competing vendor systems. Another is the absence of a common standard of what constitutes an “electronic medical record.” To some, the hallmark of an EMR is discrete data capture. To others, it is the ability to store scanned images electronically. The federal government has stepped into the fray, asking the Chicago-based Certification Commission for Healthcare Information Technology to set baseline standards for EMRs. The certification effort is under way, and last July the group announced that some two dozen EMR vendors (including NextGen) had passed muster. But Holly debunks the certification standard, calling it “watered down.” He advises physician groups looking to buy an EMR to look beyond certification. “They need to see the software working,” he says. Only then, Holly argues, can physicians begin to see the distinctions among software packages.
- EMRs are a fad.
Many physicians dismiss EMR technology as the latest healthcare trend—one not likely to last, Holly observes. “Physicians think if they ignore it, it will go away,” he says. “But the EMR is more than a fad. It is the future.” Because EMR technology can be embedded with clinical decision-support tools, it enables physicians to make more informed clinical decisions in an era when medical knowledge is exploding, Holly observes. SETMA has incorporated clinical practice guidelines in its EMR around a number of common chronic conditions, such as diabetes and hypertension.
But decision support is only one reason Holly thinks EMR technology will become commonplace. In his view, it is only a matter of time before Medicare will mandate the technology. “Medicare will say, ‘If you can’t provide an electronic record to support your billing, we won’t pay you.”
Anticipating the growth of pay-for-performance measures, other medical groups are implementing EMRs to prepare for what they describe as an inevitable shift in healthcare reimbursement. To groups such as Integrated Health Associates, a 110-physician primary-care practice in Ann Arbor, Mich., the technology is partially a defensive measure. IHA is in the midst of rolling out a NextGen EMR across its 25 sites. The group has participated in several quality initiatives with managed care plans in Michigan, says Carlotta Gabard, vice president of administrative services. But health plans relying strictly on claims data did not get an accurate picture of the level of quality the practice was delivering, she says. “We were graded down for not having chronic heart failure patients on ace inhibitors,” she says. “But 16 of our 17 CHF patients were.”
Gabard figures that by electronically documenting the care that is delivered, the practice will have a better shot of meeting P4P requirements down the line. “Medicare measures will become even more demanding,” she says.
- The technology is the hard part.
If EMR veterans share one common belief, it is that adapting workflows and business processes to the technology—not the technology itself—is the hardest part of implementation. Furthermore, they add, no amount of preparation is enough. “You can not appreciate the unknowns until you implement,” says Tim Weir, chief administrative officer at the Olmstead Medical Center, a 63-staffed-bed community hospital with an affiliated medical group of 132 clinicians based in Rochester, Minn.
Olmstead began deploying an EMR across its 14 clinics five years ago, an effort that is still under way, Weir says. The protracted deployment is due in part to the fact that Olmstead has served as a beta site for its EMR vendor, Scottsdale, Ariz.-based InteGreat. Even so, adjusting to the EMR has been a challenge, Weir says. “Some individuals find it difficult to adapt to using computers as part of clinical care,” he says. “Change management sounds easy, but you need to spend a lot of time looking at process flows.”
In an attempt to prepare for its EMR, Integrated Health Associates invested a year in convening workgroups that analyzed documentation templates and changed the software accordingly. In hindsight, the effort was overkill, says Gabard. Once the physicians began treating patients and using the software, the theoretical analysis did not fit well. “We are redoing much of the work,” Gabard says. “Reviewing the templates without seeing real patients did not add much value. We would have done better to just start with the system out of the box and customize as we implement. You do not understand EMR technology until you begin using it.
- The software is the expensive part.
EMR technology does not come cheaply. Holly’s medical group shelled out $750,000 for its first iteration eight years ago. And clinical documentation software for hospitals can reach into the millions. But budgeting for EMR technology can be tricky, veterans say. One common misconception is that the software represents the lion’s share of the expense. In fact, it is just the opposite.
“The system software is the smallest component of the cost,” says Gabard. “The technical infrastructure and the extra staff you need are much more.”
Gabard’s Integrated Health Associates began its EMR deployment with six full-time equivalents in its IS department, a number that has nearly doubled as the practice has hired additional programmers and data analysts. In total, Gabard says, the deployment has cost the group about $30,000 for each of its 110 physicians, or roughly $3.1 million. “Vendors soft-pedal the difficulty of implementing,” she says.
One area often overlooked in the EMR budget is training. Gabard hired contract employees to serve as software trainers. “They bombed,” she sighs. “There was too much to understand about how our physicians practiced medicine. It was too overwhelming for them.” Eventually, Gabard turned to existing staff to learn the software and act as “super-users.”
On hospital installations, training budgets can balloon, according to Sue Thomson, clinical process redesign consultant at Well Health, a York, Pa. -based integrated delivery network that has been deploying a clinical documentation system since 2002. Implementing an EMR “is a major process change, not just learning how to type,” she says.
WellSpan has relied on super-users to teach nurses, physicians and other clinicians how to use the software from Kansas City, Mo.-based Cerner Corp. But in 2005, when WellSpan began implementing a home-care inpatient documentation module for nurses, it neglected to budget for staff training time. Pulling super-user nurses off their shifts for training chews into their availability for clinical duties. So in 2006, WellSpan budgeted $1.2 million for super-users.
- Computers interfere with patient relationships.
Some clinicians balk at introducing computers into the care setting because they think the devices will be intrusive. Physicians imagine typing away on a keyboard rather than talking with a patient.
But Holly contends that having the rich array of personal health information online during patient encounters boosts the doctor-patient relationship. He recalls treating a congestive heart failure patient who wanted Holly to order a motorized scooter. But Holly knew the better course of action for the CHF patient was to remain ambulatory.
Holly used the EMR to pull up information about CHF, showing how inactivity is a major contributing factor. Then Holly created a personalized exercise plan based on the patient’s age, weight and heart condition. In the end, Holly persuaded the patient to stay off the scooter and on his feet.
Holly says the impressive array of clinical data he could generate with the click of a mouse impressed the patient. “Patients have come to expect more thorough documentation and more precise ways to improve their own health.”
Data Sharing: Part Computer Science, Part Political Science
Think automating one physician practice is a challenge? How about four of them looking to share data with one another? The Ann Arbor (Mich.) Health Information Exchange is attempting to do just that. Encompassing some 210 physicians, four group practices are simultaneously deploying individual electronic record systems and building a jointly shared clinical data repository. The exchange is similar to the many regional health information organizations now dotting the map, but with one key difference: The practices are all using the same EMR vendor, NextGen.
When the formerly paper-based practices began reviewing EMR systems, they figured that using the same vendor would give them a head start on data sharing, both with one another and with the local community hospital. “We made it part of the contract that NextGen would assist in the data sharing,” says Carlotta Gabard, executive director of the exchange. Each clinic maintains its own software and individual records, with the four clinics funneling certain data sets into a common clinical data repository that has grown to nearly 280,000 patient records, including patient demographics, medications, allergies and problem lists. The set-up also enables electronic referrals.
But pulling the local community hospital, St. Joseph Mercy, into the electronic loop has been challenging, Gabard says. The biggest issue has been how to set up data sharing between the hospital and the four group practices. St. Joseph sends lab results to the four practices through individual feeds, but it is looking to consolidate. “The hospital wants to avoid point-to-point interfaces with each practice,” Gabard says. “They want to use the exchange to send information to all the groups. That makes it a more sophisticated technical animal.”
The exchange may look to grant funding to help defray the costs, Gabard says.
—Gary Baldwin
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