Taming the Beast

So, how's it going? With that new EMR, we mean. Or with your practice management upgrade. That new dictation software working out for you? We're just asking because, well, we have a little confession to make: until we completed our first Physicians Practice Technology Survey, we didn't really know the answers to questions like these.

It's tough to get a realistic grip on technology use in private medical practices. What's truly going on with technology in the trenches of clinics? What software tools are physicians really using? What's just hype? We didn't know. Oh, sure, we can suggest processes for planning your EMR purchase, or explain how to use certain technologies to maximize efficiency, or help you evaluate this gizmo or that piece of software. And we'll continue to do so.

But as for what's actually happening in practices around the country? We were starting to feel a little like sex therapists before the Kinsey reports were published: We knew how to operate all the equipment, but were pretty clueless about what people are really doing behind closed doors.

That's why we're so grateful to you, our readers, for telling us all your tech secrets. A whopping 384 of you responded to our online poll, providing a snapshot of technology as it truly is.

So here's your chance to see what your competitors and colleagues are up to, judge the state of your practice and the industry as a whole, and take some realistic action.

The EMR flood

You can't talk about technology and medicine these days without talking about electronic medical records (EMRs). President Bush is even talking about them -- encouraging them in his last two State of the Union addresses.

A surprising 41 percent of you say you already have a fully implemented EMR. Another 16 percent expect to buy an EMR in the next 12 months. We didn't expect to find so many of you already up and running.

It might be that practices with EMRs were more likely than others to complete our survey. Still, it's clear that EMRs are not just for the early-adopters anymore.

But that doesn't mean they are perfect. A sign of trouble? Twenty percent of you say you have an EMR but haven't fully implemented it yet.

That's odd.

Perhaps many of you were just getting started when you filled out our survey. But a more likely explanation is that a lot of you have made a major investment in software you can't quite figure out how to run properly.

It was easy for the half of you who reported your EMRs were up and running within a month, but nearly one in four of you told us you're just "not there yet." EMR vendors make varying promises about implementation times, features prices, integration with existing software, and other issues. 

"I was told by the EMR vendor that all implementation could be completed for the opening of my new office in four months. It has now been 17 months and the system is not yet fully implemented," one physician complained. "Success: I'm still waiting!"

Here's another tale of woe: "When we were first looking at purchasing practice management and electronic medical record software over two years ago, the distributor and vendor's marketing techniques were impeccable. They painted a picture of products that would literally do everything any busy practicing provider would want and at an affordable price. The actual demonstration using patients and data that had been pre-loaded for this specific purpose worked without a flaw. Each and every one of the reference sites contacted gave an A rating to the products.

"However, when the sale was made and implementation began, the honeymoon was over. The first indication that things might not run smoothly was the arrival of two large boxes containing mountains of technically challenging software and manuals that I, with a greater than average knowledge of IT, couldn't even understand. Sometime later, the experienced technician that was to load the software didn't arrive. Rather, a local IT person loaded the software with the experienced technician on the phone giving directions. After loading, the software didn't work as described. My questions to the vendor were answered by 'you need more software to do that.'"

But far more common are success stories. One physician bragged about "efficient and complete documentation, accurate billing and coding, letters by fax to referring physicians on the same day, savings in cost ... ."

Another physician wrote, "We are almost completely paperless after one year, and I would never go back. We are better organized. Our office is neater. We never lose a chart. We are connected to both our lab and our hospital so retrieving results is easy. We need at least one-third less people to work in our office ... It has been a work in progress, frustrating at times, but also exciting and fulfilling. It has been paying off in a big way financially."

Clearly, it's crucial to do as much homework as possible before your purchase. Test software yourself using a case typical for your practice instead of just watching a slick demo. Ask specific questions about how the implementation is done and seek contractual promises of satisfaction.

Many complaints were aimed at products that coupled a less-than-stellar, afterthought practice management program with an EMR. Practices found documentation went fine, but bills weren't getting out the door. The billing components of the management software just weren't up to the task. Integration with existing management software also seems sticky. It's buyer beware. Full integration isn't easy because so much medical software products (especially older practice management systems) were built using proprietary coding. A lot of that coding is quirky. It's not so easy to make it mesh with a newer, proprietary EMR system. If a vendor promises it can integrate with your existing software, great. Just ask for very specific details and proof that it will work.

What about the tendency of EMRs to push administrative work onto physicians? Some of you made it clear there's good reason for concern. Take this, for instance: "Physicians and clinical staffers have taken on more clerical responsibility since we've gone 'paperless' because it's 'just one click' to submit the prescription to the pharmacy yourself or fax the notes to the consultant from inside the program. All the 'one more clicks' add up to minutes which, over the course of the year, represent decreased productivity.

"We're not looking for charts anymore, but we've replaced this activity with clerical clicks. We used to pull charts, attach paper clip messages, confirm appointments, check for results in the chart, and file. All those things [now] happen through technology. Now, we have to 'live message' into the patient's chart. The typing, writing and communication skills are completely different."

Still, those who managed to get through implementation generally were pleased with their decision to move ahead.

More than 80 percent of you who have an EMR say it made your practice's workflow more efficient; almost as many say you're getting a return on investment or expect to. Forty-two percent of you reduced staffing thanks to your EMR while only 8 percent said you needed more.

The investment is still a big one. While prices have dropped and become more consistent since the early days of EMRs, vendors tell us it can take as little as $1,000 or as much as $30,000 to get a two-physician office up and running. On the other hand, 40 percent of you who bought an EMR spent less than $500 per physician.

That's no surprise. It's possible many of you bought economy class tickets for your maiden voyage on the EMR bandwagon. Also, let's face it, when first purchasing a new technology, too many features can be a little scary. "We were not interested in bells and whistles," wrote one respondent. "We simply wanted the easiest system, with the quickest ROI. It had to be an ASP so we had minimal hardware headaches. That means that locum tenens easily learn the system. Every month, the system pays for itself."

Messy management

One downside of the EMR boom is that it may have encouraged practices to ignore their practice management systems -- the backbone of any physician office. One in three of you admit your practice management software is at least five years old, and some of you are using systems more than a decade old.

Yet you don't much like the management software you've been using all these years. Two out of three of said you wish your system did more. Better reporting and better integration topped the list of needs.

"It can often be difficult to figure out how to get what we want," writes one physician. We need "more flexible reports, without having to create a customized report, both the equations to select and manipulate data, and the page layout tool to format the output."

Another physician who complained about his software confessed that "we do workarounds on the reporting by importing raw data into a database capable of manipulation," rather than using the reporting provided by the software.

Expensive upgrades are another bone of contention. "Keeping up with maintenance fees is costly, and subsequently I have no support for the crashes that surface from time to time. I purchased the software because of its integration with [my EMR], but I have not found that plus to outweigh the minuses," explains a physician.

Old or new, management software isn't all it could be -- at least in the users' eyes.

Try some low-tech tricks

We also wanted to know your favorite tricks for making technology work. "Cussing," offered one. Others were a little more constructive, offering low-tech ways to make software work better.

Several recommended actually reading user manuals. "Take the time to know and understand the software. It will become intuitive after four to six months," as one physician put it. Even go so far as to learn some basic geek problem-solving: "I have learned some computer tech trouble- shooting techniques. It has saved me a lot of aggravation and expense."

Tablet PCs have lots of fans, too. These portable tools offer great mobility and look cool, too. "Using the tablet PC for patient notes, billing, etc., is incredible, and it has impressed many patients," raves one physician. "Especially when I get a call over the weekend, and I have their entire chart and history at a glance. I can also document the phone conversation."

PDAs are being used for everything from online CME to drug databases to charge-capture at the hospital to appointment and deadline reminders.

Some other ideas:

• Print work excuses on computerized prescription pads from pre-written templates instead of writing a custom letter each time.
• Use software developed for general business, not just the medical business, to meet some needs.
• Pull in-office music from Web-based sources.
• Use a cell phone voicemail instead of an answering service for after office hours. One practice saves $350 a month doing this.

Technology will not make or break any practice. But keeping up-to-date and taking some time to learn how to use what you've got can mean more peace of mind and fewer hassles.

Pamela Moore, PhD, is the senior editor of Physicians Practice. She can be reached at pmoore@physicianspractice.com.

This article originally appeared in the September 2005 issue of Physicians Practice.