Maximizing Your EMR

It was the middle of the night, and one of Tim Baird's patients was in the emergency room. The ER doctor treating her needed more information before he could proceed. He was pretty sure he'd be unable to obtain the answers he needed at that late hour, but he called Baird's OB/GYN office anyway and had him paged. Baird awoke to the beeping of his pager, but rather than call the ER physician with what little information he could recall about that patient, he powered up his laptop and quickly downloaded her entire medical file. He was able to give the ER doc anything he needed to know to treat the patient immediately, including her updated lab work.

"The doctor in the ER was amazed," Baird recalls.

But Baird wasn't amazed. He says instant access to his patients' info anywhere, anytime is just one of the daily upsides to fully utilizing his practice's electronic medical records (EMR) system, which went live when his practice opened its doors in the summer of 2004.

It didn't happen right away, says Baird, but after about a year, he and his two physician colleagues at Women's Physicians of Jacksonville found themselves well-versed in and enjoying just about every application their system offered. After all, he explains, they couldn't afford not to. The practice spent $146,000 to implement the system, and it drops $1,600 a month on IT maintenance.

But Baird admits that the learning curve was a steep one.

"When you first start using your system, you're just trying to survive," he explains. "But after a while, several of the really nice components -the bells and whistles -start to become apparent. Then you pick the ones you're most comfortable with and you work hard to come up to speed on those."

Unfortunately, Baird and his colleagues aren't the norm when it comes to sucking the marrow from their EMR. Only between 9 percent and 16 percent of physicians' offices have EMR systems, and only a small percentage of those use the majority of the applications their EMRs offer. According to Rosemarie Nelson, a health IT consultant with the Medical Group Management Association (MGMA), there is no survey that shows what percentage of practices adopt their EMRs as robustly as did Baird and his colleagues - but she estimates that only 30 percent of practices with EMRs do the same.

"Generally, most EMRs go unimplemented," says Nelson. "And once fully implemented, they stall for one reason or another."

Why? "Change management," she says.

"It requires physicians to change the way they document their visits, and that's hard to do after years of paper charting."

But, Nelson adds, once a practice manages to get its physicians over that initial learning hump, the rewards can be amazing.

Maximizing office efficiency

Take, for example, interoffice electronic communications -the process by which doctors and nurses communicate about patients using computers or hand-held devices while the patient in question is in the office. Most EMRs include this function or it can be added on, but few practices take advantage of it -much to their detriment, says Pam Wostarek.

Wostarek, the regional implementation manager for Horsham, Pa.-based NextGen Healthcare Information Systems Inc., explains that a doctor employing this option can, for example, make notes on a handheld device about a patient during her office visit and instantly send those notes to a nurse, who may need to act immediately. In addition to enhancing efficiency, the device leaves an electronic paper trail.

"Doctors are used to walking out into the hall and talking to somebody during or after a visit -but that's not documented anywhere," says Wostarek. "This is better for everyone."

Some practices that really have their EMR systems on full tilt will go a step further by adding patient flow and tasking into the mix.

According to Don Shoen, CEO of MediNotes Corp. of Des Moines, Iowa, many EMRs, with proper manipulation, will allow physicians and their staff to track which patients are in which waiting rooms and how long they have been there. Some programs even allow doctors to view a stored photo of each waiting patient as they pass a cursor over diagrams of their various exam rooms. Knowing who is in which room eliminates the need for paper charts slipped into a file holder on each door, thus increasing patient privacy.

It also allows doctors to enter examining rooms with a ready apology if they know a patient has been waiting for an extended time, adds Shoen.

And tasking can flow from that. For example, once a patient is in an exam room and waiting to see the doctor, an EMR's tasking function can automatically alert the nurse or medical assistant that it's time to take that patient's blood pressure and vital signs. The EMR then provides a template into which the nurse can enter the patient's data. The system can be further configured to subsequently trigger an electronic message to the lab, telling staff there that it's time to draw the patient's blood. After that task is completed the doctor can receive a message on her handheld device telling her the patient is now truly ready.

"This offers a lot of great office efficiency," says Shoen.

Of course, he adds, this is not the first stuff you learn when your EMR is being implemented, and doctors shouldn't despair if they haven't come this far yet.

"The brain is like a sponge -there's only so much you can retain when you're first learning," Shoen says. That's why it's important for doctors and their staffs to keep coming back for more training, as many EMRs have seemingly endless applications that can be applied to help practice operations flow more seamlessly.

"It's like Microsoft Word - there are tons of features that so few people even know about or take advantage of," Shoen says.

Leveraging Communication

One EMR feature that several practices are beginning to reap the benefits of is preventive health and disease-management reporting.

To do this, explains Dan Pollard, director of product management at Misys Healthcare Systems, the practice staff sets the EMR to query all medical records and flag those of, say, all males over age 50. The system can then be set up to mail postcards to each of these patients informing them it is time to come in for a preventive colonoscopy. Or, if preferred, the system can merge with Microsoft Word and generate a list of names and phone numbers that staff can call to make appointments.

"This is a very important way to leverage the power of the electronic medical record," says Pollard.

Flowing from that concept, adds Nelson, is the patient portal. Rather than mailing postcards informing patients of preventive services, many tech-savvy practices will send patients an e-mail directing them to the practice's password-protected Internet portal.

Once they log on, patients can preregister for an appointment, find out what preventive care they are due for, and receive recent lab results along with lay-language interpretations.

According to Nelson, these services can speed up daily office duties tremendously, as many practices can take a long time to call patients with lab results. Often, before they do, the patient calls them, which can further interrupt office workflow. Unfortunately, says Nelson, only a small percentage of practices with EMRs take advantage of this capacity to build and use patient portals as another method of communicating with patients. It's just one of those oft-ignored features.

Others agree. "It would facilitate office visits incredibly if doctors were able to realize the impact of communicating with patients this way," says Lucinda Israel, also a regional implementation manager for NextGen.

That may change, though, once practices start adding the ability to schedule doctors' appointments through patient portals, says Baird. His practice is looking into that now, and he hopes to go live with it by the end of the year.

Not there yet

Many practices even fail to use EMR features that might be considered basic -including transcription,
e-prescribing, and lab and pharmacy interfaces - thus leaving them in the bells-and-whistles category.

Says Nelson, using simple electronic transcription applications -an
element of nearly all EMRs -allows patient visit information to be imported seamlessly into a patient's chart, thus skipping many formerly necessary steps. The upside of doing it is undeniable, she says.

"It allows doctors to increase productivity by one patient a day, and for most physicians, one patient a day across a year will pay for a
transcriptionist," asserts Nelson.

Nelson is also a big advocate of using an EMRs' e-prescribing tools, particularly when it comes to refills. If done the traditional way, this process entails many inefficient steps, but if it is performed electronically, it happens very quickly. And everyone's happier.

Tee Green, president of Greenway Medical Technologies, agrees.

"Take a traditional paper practice," he says. "A patient calls, says he needs a refill of Allegra. Nurse pulls the chart, sends it to the doctor.
Doctor approves it or doesn't approve it. Phone staff calls the pharmacy. This can take two or three days. If the patient calls a practice with a good electronic system, though, the request is sent to the nurse electronically, who messages the doctor, who has the chart right in front of him. He approves it and, in some systems, he can interface with the pharmacy directly."

Nelson says the day has not yet arrived in which the majority of practices are taking advantage of all the features included in their EMRs. The tide is slowly moving in that direction, but until then, Nelson is just happy to witness the small victories -occasional interest in patient portals, the willingness to dip one's toe into electronic transcription -that are occurring along the way.