Charting the Progress of EMRs

Does your practice have a room full of filing cabinets that are stuffed to overflowing with patients' charts? Or have you gone paperless, converting all of this critical information to electronic medical records (EMRs)? Adopting new technologies takes time, and physicians' offices today seem to be spread across the spectrum - from those with total use of EMRs, to those still researching their options, to those somewhere in between.

By most accounts, the concept of the EMR began to take hold a little more than a decade ago. One major milestone in creating electronic patient records was the 1990 study by the Institute of Medicine, "Computer-based Patient Record Systems: The Essential Technology for Health Care." The study set forth a vision for a computer-based, comprehensive health record that would be accessible by all of a patient's physicians. By mid-decade, however, standards, workflow, user habits, and technological capabilities did not yet reflect the vision, mainly because practices faced difficulties justifying costs, additional training resources, and changes to their existing systems.

Today, as technological capabilities and the needs of physicians' offices strike a balance, the value of EMRs is becoming evident: Numerous private practices and academic institutions have been using EMRs for several years now and say the time, effort, and resources have been well worth it.

Smooth setup

Susan Willson is director of patient care services at Rockford Gastroen-terology, a Rockford, Ill. ambulatory surgery center with 11 gastroenterologists. The practice had been "in a building phase - building all the templates" to customize its EMR when it purchased IMPACT.MD by Advanced Imaging Concepts Inc. about three years ago.

"The EMR that we use is based on dates - it's encounter-based," Willson explains. "As we got more patient history into the system, we were finding it difficult, for example, to find the last colonoscopy that the patient had if we didn't have that date. We needed a way to file that matched the way our charts had been organized."

The setup process went fairly smoothly, Willson reports. "We trained people and scanned all the charts in and had it up and going very quickly. It's a very easy system to use. The hardest thing is if you have a user who is not computer-knowledgeable. Most problems related to getting physicians accustomed to using a mouse and keyboard." By year's end, all but one physician in the practice will be accessing records electronically.

Why not get everyone on the bandwagon at once? It's best to take a deliberate approach to converting to electronic records, according to Bruce Kleaveland, a senior vice president of Seattle-based Physician Micro Systems Inc. The company literature emphasizes that "it is not necessary or practical to eliminate your paper charts from day one," and that the transition can take, on average, from six to 12 months, depending on patient volume.

'Incredible difference'

Willson says that the EMR has allowed her practice to reduce its payroll and increase productivity. "We have a woman in medical records who's leaving, and we won't be replacing that position. That's because of the EMR," says Willson. "We used to have four women who did nothing all day but look for charts. They are now scanning. A nurse can be looking at a patient's chart, billing can have the same chart open, and that has made an incredible difference in this office."

John Masiello, chief operating officer at Bergen Medical Alliance in Englewood, N.J., says his practice's return on its EMR investment was measurable in the first year. After beginning its search in 1999, the physician group chose Berdy Medical Systems' Smart Clinic. Masiello describes it as a "comprehensive, point-and-click" system that interfaces with the practice's existing billing software.

He says that "with very little training the physicians were able to document a patient encounter within a matter of minutes, and when finished they had a complete progress note." The result - which surprised the physicians - was an increase in the number of patients seen per day, from 85 to 105. The EMR system has also resulted in more accurate coding at a higher level - and a 27 percent increase in monthly billing revenues per physician.

Productivity has increased in other areas as well. "The amount of time spent locating charts, filing paperwork, locating misfiled paperwork, and refiling the chart is staggering," Masiello says. Now, "we no longer have to wait for the notes to come back from the transcription company, [and] chart audits are no longer stressful, as all the information is legible, complete, and at our fingertips." He adds that the EMR system's security measures, such as multiple passwords and password timeouts, have helped the practice to comply with HIPAA regulations.

On a grander scale

If EMRs are making a positive mark among group practices, do the same benefits apply in larger organizations? With proper planning, yes. At the University of Pittsburgh Medical Center (UPMC) Health System, composed of 17 hospitals in Western Pennsylvania, physicians realized the need to integrate inpatient and outpatient records - and to incorporate images into their EMRs.

According to G. Dan Martich, MD, executive director of electronic health records at UPMC, "We had niche products that worked well in pharmacy, in the ED, and in the ICU. Those products all worked very well in their domains. The problem was one didn't speak to the other."

At the same time, a group of UPMC's family practice physicians was testing the waters with products that worked in specific areas related to outpatient care. "Then we thought, where is the continuum of care?" recalls Martich. "How do we know that preventive tests, follow-ups, and ancillary care, like eye and foot care for diabetes, are being done? How about putting the patient at the middle, not thinking physician-centrically?" After a careful search, they chose Kansas City-based Cerner Corp. to partner in the development of a system that works for a large institution like UPMC.

Now, says Martich, "The look and feel of the information that was gathered at the office conveys to the inpatient record, and we've heard a lot of 'oh wow' stories already." For example, Martich recalls one patient who was suffering from numbness and tingling in his arms - and whose primary-care physician happened to be participating in the pilot of the new EMR system. He estimates that about a week's time was saved getting the patient treated by a neurosurgeon - time that otherwise would have passed as the physicians waited for the transfer of test results.

Similarly, UPMC has seen a 25 percent decrease in time required to fulfill a physician's request for a hospital bed for patients being admitted through the ED, which account for 30 percent of the hospital system's inpatient admissions. This translates into improved quality of care and increased patient satisfaction.

Still, acknowledges Martich, "We are a large health system and we struggle with the access of care" - and with confidentiality issues. "We're going to provide good security, but part of the burden is on the healthcare providers not to give up confidentiality while having access to this information."

Sure about security

Security and confidentiality concerns are fully addressed within UMPC's PAC (picture archival communications) system, whose development was spearheaded by Paul Chang, MD, director of the division of radiology informatics. Chang believes it is imperative that EMRs offer physicians the ability to access images, such as CT scans, electronically, rather than on film. This, he says, allows them to completely integrate all the information they need to make medical management decisions.

The need to balance security and patient confidentiality is particularly acute in a teaching environment, where physicians' and residents' needs to access particular files is constantly changing. "Any physician who has authorization can go to our film library and check on any film. We can go back post hoc and see who has monitored a particular case. It's too much of a medical management risk to come up with a system to restrict access to a changing and dynamic permission list," explains Chang.

Another requirement of a PAC system is that it has to give physicians fast access to diagnostic-quality images, regardless of the size of the image. Chang explains, "As a radiologist, all I do is look at images. Five to seven minutes to wait is OK because the patient isn't here. If you're an orthopedic surgeon with a patient in the room, [the image] has to be there in five seconds - the time it takes to take a film out of the jacket and put it on the light box. And today we send full-fidelity images within five seconds on the Web, no matter how big it is, integrated into our EMR."

Chang says that although PAC systems are traditionally designed for radiologists, he sees "images as a prerequisite to the EMR system," particularly as patients become increasingly savvy about what types of medical technology are available and may equate their use with quality of care. Willson agrees that EMRs are no longer a tool to be ignored. "The more you go into this with your eyes open, the better. I think it's the way of the future."

Joanne Tetrault, director of editorial services, can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the November/December 2001 issue of Physicians Practice.