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As difficult as it is for multi-specialty groups to justify the cost of an EMR, it’s doubly hard for the two- and three-physician practices that dominate the medical landscape. A survey conducted in 2002 by ACGroup, a health-care research and consulting firm based in Spring, Texas, found that while 38 percent of university and staff-model physicians were using an EMR, less than 1 percent of community based physicians were.

When they first appeared, ASP model systems seemed like a perfect solution for smaller practices, but some have since fallen short of the mark. One of the most well-publicized failures occurred last year when GE Medical Systems notified users that it would no longer support Encounter, its Web-based EMR product, which meant that providers would loose access to patient records. Among those who scrambled to find alternatives was Orly Avitzur, MD, a solo-practice neurologist in Tarrytown, New York. “It was extremely unnerving, but despite that, I’m still very enthusiastic about EMRs,” she says. Avitzur switched to Amazing Charts and was able to cut-and-paste most of the data from Encounter to the new system.

In recognition of the problems faced by small practices, the American Academy of Family Physicians announced in January that it plans to develop an ASP-type EMR that will use an open-source software, which has no licensing fees. Plans are to make the system available for as little as $150 per month, including training and support.

Regardless of the size of a practice, implementation of an EMR is daunting from start to finish. Just finding the product that best suits your needs is no small feat: How do you choose from more than 200 EMR providers?

Yates visited vendor booths at health information conferences. Eventually, he developed a list of all the features he’d seen and then rated their importance to his practice on a five-point scale: required, useful, nice, neutral, and not helpful. He seriously considered only the companies that had all features he’d rated as required, which left just a few contenders. From there, he considered the vendors’ financial stability with input from his accountant.

Advanced Healthcare, a 250-physician multi-specialty practice in Milwaukee, used a similar process. A committee charged with selecting an EMR created an extensive list of features and functions grouped by major EMR components, such as automated documentation, computerized physician order entry, and clinical workflow automation. The group then determined which features would be essential, nice to have, or frills, and rated vendors on whether they did or didn’t have the feature, or when they didn’t, whether they could articulate a time period for making it available. A front-runner throughout the process, Epic Systems won the nod from the committee, according to Marc Olsen, MD, a family practitioner and official physician champion of Advanced’s EMR implementation. The practice started its selection process in 1998, and will complete the EMR installation this year.

The types of features considered important vary depending on your practice set-up and the problems you want to solve, but in general, easy, fast usage and affordability are essential. Another important consideration is whether the product will interface with other systems and equipment in your office. “If you have stand-alone EMR, billing, and scheduling systems, they’re not very functional if they don’t integrate. You need to look at the suite of products used and how they communicate,” advises Olsen.

Beware: Some EMR vendors have done more to make a practice’s various systems “talk” to one another than others. “A few of our people went to [a technology conference]. It was a little disappointing that they heard from vendors that their systems were proprietary, don’t talk to others, and they can’t make them interface,” Krienke reports. Whether part of an EMR or purchased separately, scanners, and fax servers are vital for incorporating documents into the EMR received from external sources.

Given the instability in the EMR vendor community, assessing the staying power of a company may be more art than science. To determine whether one is a good match for your needs, Mytych suggests finding out about its customer base and pace of growth. “If you’re an orthopaedist but the vendor doesn’t have many of those types of practices, the product probably won’t meet your needs,” he explains. Likewise, “if it’s a relatively inexpensive product and they only have a few customers, will they be able to maintain minimal support?”

The reliability of EMR systems is a common concern of practices during the selection process. However, at least for client-server applications, the risk of crashes and lost patient records is quite low as long as you institute appropriate back-up measures and choose a system with a well-structured database.

You might consider hiring a consultant to help clarify practice needs and sort through vendor proposals. The decision to do so should turn on whether there is sufficient in-practice expertise to conduct a thorough and timely evaluation. Be careful, however, to locate one with experience specifically in EMR systems.

The complications of deciding whether to purchase an EMR system and selecting a vendor pale in comparison to the challenges of actual implementation. Those who have been through it say the key is good planning and consensus about use of the EMR. “You can’t have a pocket veto sitting around the table. To have some continue to use paper records [after implementing an EMR] is inefficient and a failure,” says Doroshuk.

That point is not lost on Kenneth Mitchell, MD, the chair of the board of directors of Austin Diagnostic Clinic, a 125-physician multi-specialty practice in Austin, Texas. The practice implemented the GE Medical Systems Logician product in November 2000 and is behind in achieving budgeted savings from the system, largely because not all physicians have fully adopted it. “Doctors are using it at all different levels. Some only review lab results and sign dictation, while others do virtually 100 percent of their charting and dictating in EMR,” he reports. At the time of installation, the practice was spending about $110,000 per month on transcription, which has since been cut by 25 percent, but still has another 25 percent to go before achieving projected levels.

Landholt advises streamlining procedures in the office before starting implementation. “If you automate a bad workflow, it’s still a bad workflow,” he says. Apparently this is a major stumbling block for many practices. Sterling reports that it’s not uncommon to see situations where only the physician has a laptop, so the nurse records the patient’s chief complaints on post-it notes stuck on the doors of exam rooms, which the physician subsequently enters in the EMR while conducting an examination. “That defeats the purpose of having an EMR,” he says.

Devoting sufficient resources to training is another must. Without it, a practice will never achieve the full potential of the EMR, and some implementations even fail. “In situations where doctors say ‘I can figure it out; I don’t need training,’ it’s always a disaster. In the really successful implementations, people pay for training and then afterwards when we follow-up, we always find things they can improve on,” says e-MDs’ Winn.

Another ingredient to successful installations: one or more physician champions willing to devote time and energy to keep the project on track.

Phased implementations work best, but an issue for each practice is balancing necessary productivity cutbacks with cash flow requirements. Advanced Healthcare went through a two-phase implementation, first initiating primary care physicians and larger clinics to the most basic features of the EMR, including order entry and coding. During that two-week period, affected doctors reduced daily visits by one-half. The next phase lasted six to eight weeks, during which staff became familiar with more sophisticated EMR functions like documenting and prescribing. After the EMR was implemented throughout primary care, a similar process took place in successive specialty areas.

Smaller practices using less complicated systems may not have the same level of disruption. For instance, Avitzur trained herself over a weekend and estimates she lost no more than one hour of productivity each day for the first week following implementation.

Still, for most practices the implementation process isn’t easy even with excellent training and support. Some of both clinical and administrative staff may jump ship because the change is simply too difficult. But those who tough it out quickly wonder how they ever functioned without an EMR. As Doroshuk puts it, “For people looking over our backyard fence, I’m saying the water’s OK. It’ll work out fine.” n




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		Going Electronic (continued) [ previous ] Small practices in a bind As difficult as it is for multi-specialty groups to justify the cost of an EMR, it’s doubly hard for the two- and three-physician practices that dominate the medical landscape. A survey conducted in 2002 by ACGroup, a health-care research and consulting firm based in Spring, Texas, found that while 38 percent of university and staff-model physicians were using an EMR, less than 1 percent of community based physicians were. When they first appeared, ASP model systems seemed like a perfect solution for smaller practices, but some have since fallen short of the mark. One of the most well-publicized failures occurred last year when GE Medical Systems notified users that it would no longer support Encounter, its Web-based EMR product, which meant that providers would loose access to patient records. Among those who scrambled to find alternatives was Orly Avitzur, MD, a solo-practice neurologist in Tarrytown, New York. “It was extremely unnerving, but despite that, I’m still very enthusiastic about EMRs,” she says. Avitzur switched to Amazing Charts and was able to cut-and-paste most of the data from Encounter to the new system. In recognition of the problems faced by small practices, the American Academy of Family Physicians announced in January that it plans to develop an ASP-type EMR that will use an open-source software, which has no licensing fees. Plans are to make the system available for as little as $150 per month, including training and support. Selecting features, choosing vendors Regardless of the size of a practice, implementation of an EMR is daunting from start to finish. Just finding the product that best suits your needs is no small feat: How do you choose from more than 200 EMR providers? Yates visited vendor booths at health information conferences. Eventually, he developed a list of all the features he’d seen and then rated their importance to his practice on a five-point scale: required, useful, nice, neutral, and not helpful. He seriously considered only the companies that had all features he’d rated as required, which left just a few contenders. From there, he considered the vendors’ financial stability with input from his accountant. Advanced Healthcare, a 250-physician multi-specialty practice in Milwaukee, used a similar process. A committee charged with selecting an EMR created an extensive list of features and functions grouped by major EMR components, such as automated documentation, computerized physician order entry, and clinical workflow automation. The group then determined which features would be essential, nice to have, or frills, and rated vendors on whether they did or didn’t have the feature, or when they didn’t, whether they could articulate a time period for making it available. A front-runner throughout the process, Epic Systems won the nod from the committee, according to Marc Olsen, MD, a family practitioner and official physician champion of Advanced’s EMR implementation. The practice started its selection process in 1998, and will complete the EMR installation this year. The types of features considered important vary depending on your practice set-up and the problems you want to solve, but in general, easy, fast usage and affordability are essential. Another important consideration is whether the product will interface with other systems and equipment in your office. “If you have stand-alone EMR, billing, and scheduling systems, they’re not very functional if they don’t integrate. You need to look at the suite of products used and how they communicate,” advises Olsen. Beware: Some EMR vendors have done more to make a practice’s various systems “talk” to one another than others. “A few of our people went to [a technology conference]. It was a little disappointing that they heard from vendors that their systems were proprietary, don’t talk to others, and they can’t make them interface,” Krienke reports. Whether part of an EMR or purchased separately, scanners, and fax servers are vital for incorporating documents into the EMR received from external sources. Given the instability in the EMR vendor community, assessing the staying power of a company may be more art than science. To determine whether one is a good match for your needs, Mytych suggests finding out about its customer base and pace of growth. “If you’re an orthopaedist but the vendor doesn’t have many of those types of practices, the product probably won’t meet your needs,” he explains. Likewise, “if it’s a relatively inexpensive product and they only have a few customers, will they be able to maintain minimal support?” The reliability of EMR systems is a common concern of practices during the selection process. However, at least for client-server applications, the risk of crashes and lost patient records is quite low as long as you institute appropriate back-up measures and choose a system with a well-structured database. You might consider hiring a consultant to help clarify practice needs and sort through vendor proposals. The decision to do so should turn on whether there is sufficient in-practice expertise to conduct a thorough and timely evaluation. Be careful, however, to locate one with experience specifically in EMR systems. Surviving implementation The complications of deciding whether to purchase an EMR system and selecting a vendor pale in comparison to the challenges of actual implementation. Those who have been through it say the key is good planning and consensus about use of the EMR. “You can’t have a pocket veto sitting around the table. To have some continue to use paper records [after implementing an EMR] is inefficient and a failure,” says Doroshuk. That point is not lost on Kenneth Mitchell, MD, the chair of the board of directors of Austin Diagnostic Clinic, a 125-physician multi-specialty practice in Austin, Texas. The practice implemented the GE Medical Systems Logician product in November 2000 and is behind in achieving budgeted savings from the system, largely because not all physicians have fully adopted it. “Doctors are using it at all different levels. Some only review lab results and sign dictation, while others do virtually 100 percent of their charting and dictating in EMR,” he reports. At the time of installation, the practice was spending about $110,000 per month on transcription, which has since been cut by 25 percent, but still has another 25 percent to go before achieving projected levels. Landholt advises streamlining procedures in the office before starting implementation. “If you automate a bad workflow, it’s still a bad workflow,” he says. Apparently this is a major stumbling block for many practices. Sterling reports that it’s not uncommon to see situations where only the physician has a laptop, so the nurse records the patient’s chief complaints on post-it notes stuck on the doors of exam rooms, which the physician subsequently enters in the EMR while conducting an examination. “That defeats the purpose of having an EMR,” he says. Devoting sufficient resources to training is another must. Without it, a practice will never achieve the full potential of the EMR, and some implementations even fail. “In situations where doctors say ‘I can figure it out; I don’t need training,’ it’s always a disaster. In the really successful implementations, people pay for training and then afterwards when we follow-up, we always find things they can improve on,” says e-MDs’ Winn. Another ingredient to successful installations: one or more physician champions willing to devote time and energy to keep the project on track. Phased implementations work best, but an issue for each practice is balancing necessary productivity cutbacks with cash flow requirements. Advanced Healthcare went through a two-phase implementation, first initiating primary care physicians and larger clinics to the most basic features of the EMR, including order entry and coding. During that two-week period, affected doctors reduced daily visits by one-half. The next phase lasted six to eight weeks, during which staff became familiar with more sophisticated EMR functions like documenting and prescribing. After the EMR was implemented throughout primary care, a similar process took place in successive specialty areas. Smaller practices using less complicated systems may not have the same level of disruption. For instance, Avitzur trained herself over a weekend and estimates she lost no more than one hour of productivity each day for the first week following implementation. Still, for most practices the implementation process isn’t easy even with excellent training and support. Some of both clinical and administrative staff may jump ship because the change is simply too difficult. But those who tough it out quickly wonder how they ever functioned without an EMR. As Doroshuk puts it, “For people looking over our backyard fence, I’m saying the water’s OK. It’ll work out fine.” n Gina Rollins is a free-lance writer based in Silver Spring, Maryland. This is her first article for Unique Opportunities®. 1 \| 2 @ 2003 UO Inc. www.uoworks.com 800-888-2047

	The ability to improve patient care is the only compelling reason to implement an EMR, according to Scott Yates, MD, the president of North Texas Medical Group in The Colony. However, he says, “If we provide better care and can prove it’s better, we may eventually get support for higher contract rates.” photo/ © 2003 reid horn