Electronic Medical Records for the Physician Practice

Strategies for Navigating the Quagmire

Kevin Kennedy, MHS, CPHQ, CPHITDirector of Quality Improvement

October 24, 2008

Institute of Medicine Reports

• “To Err is Human, Building a Safer Health System” (1999)

• “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001)

Institute of Medicine Report “To Err is Human…”

Top 10 Causes of Death in 19981. Heart Disease 724,2692. Cancer 538,9473. Stroke 158,0604. Lung Disease 114,3815. Medical Errors 98,000*

6. Pneumonia 94,8287. Diabetes 64,5748. Motor Vehicle 41,8269. Suicide 29,26410. Kidney Disease 26,295

* Estimated

““The Right Care forThe Right Care forEvery Person Every Every Person Every

Time.”Time.” Stephen Jenks MD, Former Director

Quality Improvement GroupOffice of Clinical Standards and Quality

Centers for Medicare and Medicaid Services

Electronic Medical Records (EMR) Avoid Medical Errors

• Availability of records • Enhance communication • Provide decision support • Reduce medication errors • Improve quality measures • Provide economic benefit?

Bates, David MD, Bates, David MD, Family Practice NewsFamily Practice News, October 15,2004, October 15,2004

Medicine is a Very “Communication Intensive” Industry

Enhanced communication between physicians, settings, and patients can:

• Coordinate chronic disease management and medications

• Improve quality of referrals and consults• Avoid medical errors that lead to liability

Electronic Medical Records

• “At the turn of this century, . . .the average industry was investing $8,000 per employee on computer technology, health care was spending $1,000.

• By now, if you belong to a frequent shopper club, your grocery store almost certainly has far more computerized data than your healthcare provider..."

Electronic Medical Records

"With almost three-quarters of physicians in solo or small-group practice settings, it is critical to recognize not only the financial barriers, but the greater need for technical assistance in implementing electronic health records, compared with physicians in larger healthcare settings with existing support systems. . .”

Anne-Marie Audet, Vice President

The Commonwealth Fund

Primary Objectives

• Describe EMR basics

• Discuss the six stages involved in adopting an EMR system– Assessment, planning, selection, implementation,

evaluation, and improvement

• Share our experiences with clinics in Nevada and Utah

“I just don’t see how doctors can stay in the game unless they are

somehow plugged into an electronic medical record”

Tufts-New England Medical Center, CEO, The Boston Globe, Feb. 10, 2006

HIT vs. EMR/EHR

• Health information technology (HIT) is a general concept

• Electronic medical record (EMR)/electronic health record (EHR) is a specific concept relating to systems having the ability to capture data from various sources for clinical decision support at the point of care

The Burning Platform for EMR Systems

• During the 1990’s, EMR system adoption was usually limited to larger organizations

• Currently, 20 to 30% of outpatient clinics use EMR systems (20% in NV and 30% UT)

• Estimated that 50 to 60% over the next several years

• Small outpatient practices expected to be fastest growing sector for EMR system adoption

What Are Benefits of EMR Systems?

• Improved care– Views of entire medical histories– More efficient workflow – reduce the paper

chase– Generate patient specific reminders– Reference medical research and protocol data at

the point of care to enhance diagnostic and treatment plans

What are the Benefits of EMR Systems?

• Reduction of errors– IOM report– Coding confusion, illegible documentation,

poor information management contribute to errors

– EMR systems improve documentation and communication and assist in managing critical information

What is the Business Case?

Return on Investment (ROI)

• The amount of time it will take your practice to re-coup the dollars spent on the EMR project.

• Process of confirming that the system is delivering anticipated benefits.

• Is it required? No, But it will help in demonstrating, evaluating, and assessing the success of the project.

Financial Benefits

• Reduction in Costs– Storage space– Transcription services– Staff time pulling and filing paper records

Reduction in Costs

• Some vendors state an ROI is possible within 12 months while others state over three years

• Low hanging fruit is reduction in transcription costs

• Potential staff reduction or reallocation– If average physician needs four FTEs for

support, this number can be reduced by at least one FTE with an EMR

Increased Revenues

• Many providers down-code to prevent claims from being denied

• EMRs assist providers in coding to assure that the correct codes are used with support documentation

• More accurate coding can decrease claims denials, increase reimbursement rates, and improve cash flow via shorter billing-to-payment cycles

• EMR is vital tool for improved reimbursements through pay-for-performance initiatives

The Big Picture

Time

Net c

ost o

f doi

ng b

usin

ess

cost

“The impact and expectation of cost-justifying patient safety IT initiatives

using a traditional ROI must evolve to focus beyond the financial benefit. It

must encompass overall patient safety, patient satisfaction, and employee and

physician satisfaction benefit categories”

L.M. Newell “Who’s Counting Now? ROI for Patient Safety Initiatives”, Journal of Healthcare Information Management

Satisfaction

• Provider– Leave the office earlier

– Access patient information remotely

– Better understanding of the practice operations

– More time spent caring for patients

– Less time spent chasing charts, paper, and resources

Satisfaction

• Staff– Cleaner workflows – less waste– Better understanding of roles and responsibilities– Leave the office earlier– More advanced skill sets

• Patient– More information about the office visit– Better access to health information– Better organized office

EMR System Technical Options

• Interfaced practice management (PM) and EMR systems vs. integrated– Terms often used interchangeably although difference

can be significant

• Interfaced – independent applications that talk to each other

• Integrated – share common master files– All modules usually come from a single vendor or

two closely linked vendors

Hosting Options

• Application Service Provider (ASP)– Lease EMR application and network, hardware

and IT maintenance services– Beneficial for smaller practices lacking IT

expertise – Significantly reduces initial investment

Hosting Options

• On Site– Clinic purchases software license, network

servers, operating systems and employ or contract for maintenance

– System backups completed on site– Security issues are clinic’s responsibility

So, how does a clinic even begin the process?

Challenges of EMR Transition

• Failure to plan properly

• The horror stories - systems going down

• Problems with vendors

• Change is difficult

• Investing in EMR but not fully utilizing the product

The Six Stages of EMR Migration

Stage 1 - Assessing Your Readiness

• Challenges and financial impacts involved in successful EMR implementation can’t be ignored

• Critical that physicians and management evaluate whether your practice is ready to take on the challenges

Assessing Readiness

• Decision-Maker Buy-In– Does everyone agree on the goals and

expectations for the EMR system?– Do you have a physician champion?

Assessing Readiness

• Staff Buy-In– Is your staff capable and enthusiastic about

installing an EMR system?– Will the key staff members have the patience

and willingness to be involved in the transition?

Assessing Readiness

• The Learning Curve– Can your practice afford the financial impact of

reduced patient volume for a 2-3 month period?– Will the physicians have the time and patience

for an EMR system transition period?

Assessing Readiness

• Practice Management Integration– Have your physicians and management

carefully considered the differences between an interfaced and integrated system?

– What is your level of satisfaction with your current PM system? Are you willing to trade it for a new integrated system?

Practice Tasks During Assessment

• Assess current workflow

• Begin/continue regular staff meetings

• Assign physician champion

• Organize EMR selection team

Stage 2 - Practice Tasks During Planning

• Write down the clinic goals and priorities (these should be agreed upon previously)

• Translate goals into available EMR system functions and features

• Address concerns of staff with lower levels of readiness

• Develop a timeline and project plan

How to Select an Electronic Medical Record System

“A natural tendency might be to call a few vendors.. and ask them for a demo. Stop. Unless you want the vendors to control the selection process, you need a plan.”

K. Adler, Family Practice Management, February 2005

Stage 3 -Vendor Selection

• Use translated goals list of functions and features – your rating system

• Create a clinic-specific case scenario

• References and sites visits – don’t skip!

• Additional hardware and support plans

• Negotiating a contract

Partners for Patients ElectronicHealth Record Market Survey

American Academy of Family Physicians Center for Health Information Technology

Stage 4 - Implementation

• Workflow analysis – have a plan for changes (roles, scanning, handoffs, etc.)

• Data conversion, interfaces, testing

• Recovery and security planning

• Training – iterative and “super users”

• Go-live – modify workload

Major Workflows Associated with the Patient Visit

• Scheduling• Check-in/registration• Authorizations• History and physical• Provider’s SOAP process

(Subjective/Objective/Assessment/Plan)• Labs/imaging/medication orders• Referrals• Checkout• Billing

Stage 5 - Evaluation

• Workflow analysis – identify problem areas

• Additional training/learning

• Check progress towards initial goals

• Using data in your EMR to improve care

• Ongoing checks – all staff (workarounds?)

Stage 6 - Improvement

• Workflow analysis– Identify bottlenecks, possible role redesign

• Using data to check progress– First step is checking data integrity – never perfect– Next – set goal(s) and track progress– Find “best practices” internally and externally

• Use the EMR to its capacity

Experiences Thus Far“The transition is a process NOT an event”

• Difficult to generate specific ROI but it is possible to have a general idea of ROI

• Sometimes too many choices with EMR vendors – one size does not fit all

• Clinics find it challenging to use 100% of system capacities

Summary

• EMR is a valuable tool to improve outcomes

• EMR helps to deal w/complexity of decisions being made under time constraints

• EMR can help reduce medical errors and liability risk

Discussion

Contact Information

Kevin Kennedy

702-933-7311kkennedy@healthinsight.org

This material was prepared by HealthInsight under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS). The contents presented do not necessarily reflect CMS policy.

Publication #: 9SOW- NV-2008-00-020