Implementing an Electronic Medical Records System into Practice
by Terive Duperier, MD, FACS
Dr. Duperier is a bariatric surgeon and co-founder of the Bariatric Medical Institute of Texas in San Antonio, Texas.
Financial Disclosure: Dr. Duperier has no financial disclosures relevant to the content of this article.
Abstract
Electronic medical record systems are interesting and appealing on several levels, especially for bariatric surgeons. When implemented into practice, the technology capabilities of an electronic medical record system should be able to reduce the amount of paper in your office, streamline your office administration, enable remote access to practice information, increase collections, reduce human error, and offer seamless electronic submissions to the Bariatric Outcomes Longitudinal Database. This article will review how the staff at Bariatric Medical Institute of Texas, San Antonio, Texas, utilize our electronic medical record system and offer suggestions for practices who are considering investing in this technology.
Bariatric Times. 2011;8(2):26–29
Introduction
What is EMR? Electronic medical record (EMR) systems, sometimes referred to as electronic health records, are a set of databases that contain health information for patients within a given institution or organization, compiled from a variety of sources. Ideally, an EMR system should be able to reduce the amount of paper in the medical office, streamline office administration, enable remote access to practice information, and increase collections due to reduced human error. Specifically for bariatric surgeons, an EMR system ideally should offer seamless electronic submissions to Bariatric Outcomes Longitudinal Database (BOLD) and facilitate Center of Excellence (COE) compliance. This article reviews the experience of a bariatric center in implementing an EMR system into practice.
Background. Two years ago when my partner, Dr. Mickey Seger, and I founded Bariatric Medical Institute (BMI) of Texas, we wanted to invest in new technologies, including a stronger EMR system. We already had some experience with an EMR system at our old practice, but we found that that system lacked the flexibility to accomodate our new and growing practice. When we ultimately decided on our current EMR system, our initial criteria for use were very different than our current use of the system. We have since discovered that an EMR system can be utilized for more than an electronic filing system, but initially, electronic filing was our main purpose for implementing a new EMR system.
Once we opened the doors to our new practice, we discovered there were many things that occurred that we did not predict—and we learned this lack of predictability, in any practice really, should be a major consideration when deciding on an EMR system. In other words, when considering an EMR system, is it flexible? Can it be modified to a practice’s nuances? Let’s face it: A practice will change over time. Can the EMR system change and adapt with the practice?
Our own EMR needs at our practice have changed over the last two years as we learned what was possible and what was important to our practice. Our EMR system has adapted with us. We believe our experiences in selecting and implementing an EMR system into our practice might be benefical to other bariatric clinics who are considering utilizing an EMR system. There are several key factors to consider when evaluating EMR systems, and in this article we describe and discuss the factors we found to have the biggest impact on our decision-making progress when researching EMR systems for use in our clinic.
Initial considerations
Scheduling capabilities. Surgeons’ schedules change constantly, and it is impossible to predict what each day will look like. Keeping track of patient information with paper charts can be a logistical nightmare when the staff is trying to track information collected in the office and then combine it with data accumulated while a patient is in the hospital for a surgical procedure. With a web-based EMR, the staff and the surgeon can have access to the surgeon’s calendar and patient flow at all times. While this may sound mundane, from both the office staff’s and surgeon’s perspectives, having access to a surgeon’s calendar can greatly impact efficiency and patient flow, especially when the surgeon can access his or her calendar between cases at the hospital.
Ease of reporting. Over time, a practice will accumulate a substantial amount of information that can be analyzed and used to adjust the course of the practice. When evaluating an EMR system, an important question to ask is, “How easy will it be to ‘mine’ the accumulated data?” Reporting can be used in several ways. For example, a clinic can report on patient statistics or report on the metrics of its business. Being in our own private practice, we feel it is very important to follow performance metrics and the “dashboard” of information about the health of our practice and its efficiency and productivity.
Ease of communicating. We believe it is very important to correspond with our referring doctors about our mutual patients. The user should consider how the potential EMR system will enable the practice to communicate with referring physicians. Referring doctors are essential to any practice, and being able to easily send those doctors data on mutual patients is important. A good EMR system will make this easy for the practice to accomplish.
Customization. In my opinion, customization is double-edged sword. The more customizable an EMR, the more time investment is required on the user’s (and vendor’s) part to develop the EMR to a clinic’s specifications. In contrast, the more rigid a system, the easier it can be to implement, but the user might not be able to customize it later when a clinic’s needs change. Customizability can also affect the overall cost of the system (direct cost) as well as the indirect cost of the user’s time creating the customizations.
Cost. EMRs are expensive. Most systems cost more $30,000. There are also costs associated with the implementation, monthly licensing, and customization (plus the clinic’s internal information technology infrastructure). No matter what the user’s vision is currently, that vision may change in the future, and thus the EMR system will (or at least should) adapt to address the clinic’s needs. But important to consider is that there may be costs associated with this adaptation. Prior to settling on a system, the clinic should be fully knowledgeable of the cost of the system, the costs associated with its implementation, and the potential costs down the road that may be incurred when adapting a system to address a clinic’s changing needs.
Return on investment. A return on investment may be difficult to measure. When purchasing an EMR system, the user will be making a subjective decision based on what the user hopes is an objective gain. The decision to buy an EMR system can be viewed as a personality decision. In other words, how much time and energy does the user want to spend to make the EMR system as good as it can be? This should be considered prior to purchase.
Customer service support and response times. Another important factor to consider when selecting an EMR system is the EMR company’s customer support. Are members of the support team easy to work with? Do they respond to their customers in a realistic timeframe? We recommend contacting some of the clinics who have purchased the EMR system being considered to validate whether or not they are happy with the system. Ask the EMR company’s customers specifically about the features of the system that are the most important to you. At our clinic, we speak frequently with our EMR liaison, and we take part in training sessions several times a year to ensure we are familiar with upgrades and are taking advantage of the system’s features. Make sure the EMR company you go with offers regular training to its customers and keeps its customers up to date on upgrades.
Data storage. Data storage may be more important to some practices than to others. When considering an EMR system, the user should determine if the data is stored offsite or onsite. Our decision was to store our data at a remote location, but some people may feel differently.
Billing and collecting. When considering different EMR systems, the ability to bill and collect should be a key feature of an EMR system. EMRs that contain a billing module can be useful because they enable electronic submission of claims, which are faster than paper claims. The extra steps it takes to submit a paper claim can create delays in provider payment. We believe the bill and collect feature of an EMR system should be one of the most important features a clinic should consider.
Other Important Considerations
Check the capabilities. If a practice is a Center of Excellence (COE) or plans to apply to become one, one important feature to consider when investigating different EMR systems is if the system can electronically submit data to Surgical Review Corporation (SRC) for COE accreditation. There are only a few systems that are capable of this. If submission of data for COE accreditation is not a feature of the EMR, then likely the center will need to hire a data entry employee to enter the submissions electronically through the SRC. This is definitely an important consideration, practicularly if it is a new practice.
Double-check the viability of the technology company. Make sure the technology company providing the EMR system is profitable and/or well funded so you do not have to worry about them going out of business.
Do not place too much emphasis on the EMR being compatible with the hospital. Many hospitals have their own EMR systems, which are not available for commercial purchase by private practices. Therefore, the ability to integrate an EMR system at a bariatric clinic with the hospital’s EMR system, in most cases, is not possible, at least not yet. There are currently a few EMR systems that can “exchange” information on a limited basis with hospital systems, but this does not exist for EMRs that are geared toward bariatric practices. In my opinion, this should not play a factor in the EMR decision-making process.
Confirm who owns the data in the EMR system and how to obtain the data if the practice decides to switch systems. When we converted our data from a previous system to our new EMR, it was difficult and time consuming, and it is still not completed two years later. Make sure the data can be obtained in a usable and seamless format in the unfortunate event that that practice needs to switch systems.
Check references. This is imperative. Talk to other practices using the potential EMR system and verify the system can do what is promised. An EMR vendor should encourage people and practices to visit offices in which their EMR system is installed in order to see the EMR work in real time. Our own practice knows and understands how anxiety provoking the decision to implement an EMR system can be and for these reasons, we are very open to having visitors to see how our EMR system works for us.
Don’t bank on the Recovery Act of 2008. Financial reimbursements are based on what is called “meaningful usage” of the EMR, which is fairly complicated and laborious. The more specialized a practice, the more difficult it can be to qualify to the financial incentives set forth in the Recovery Act of 2008. At most, physicians will receive $44,000 per physician over several years and, in many cases, this will not even cover the cost of the EMR system being purchased. There are many stipulations the government has set forth to qualify for meaningful usage, and in many cases practices might try to customize their EMR in an effort to qualify, thus increasing the cost even more. Therefore, I do not recommend purchasing an EMR system with the expectation that your practice will automatically qualify for the financial incentives the government has proposed, and I do not believe this should be part of the decision-making process.
Our Experience Using an EMR System
At BMI of Texas, we wanted an EMR system that would allow us to customize the system according to the procedures we commonly perform and the way we like to work. After a careful analysis, we chose a web-based system that included a customizable billing component in addition to the scheduling features and comprehensive patient medical record capabilities we wanted.
Our EMR system is present at every level of our practice. It starts right after seminar, when patients enter their information into a patient portal. This enables patients to enter their medical history and prescription information prior to arriving at our office for their appointment. This saves patients time in our office because they can submit their medications and medical information directly into the EMR system from their home.
We have found that everyday office details are streamlined when using an EMR system. Like most EMR systems, our system has a “fax server” that allows users to drag and drop incoming faxes into a patient’s file instead of printing and filing with a paper system. In addition, some EMR systems are developing “lab interfaces” whereby a patient’s labs can be electronically placed directly into their electronic record.
Like most EMR systems, our system has a tasking feature that allows office staff to communicate with each other about patient issues. This is important from a medico-legal standpoint, since these communications create a paperless trail for all patient communications. Our EMR system has nearly eliminated the use of paper notes in our office. Reminders and updates are now electronically posted to the patient’s file. When we login to our system, the welcome screen shows each user his or her list of tasks, including reminders to which he or she needs to respond.
Chart prepping is streamlined as well. For example, the user can look at a patient’s chart prior to the patient’s appointment and see what pieces are missing, including specified lab studies.
The surgeons of BMI of Texas use customized templates to increase efficiency. We created routine weight loss surgery templates for new and postoperative patient evaluations in addition to general surgery issues. We have also created templates for procedures in the operating room. We currently create our own operative notes in place of the hospital’s dictation system, which we have found to be faster and more accurate, and they can be easily reprinted if the operative note disappears from medical records. Since we implemented our EMR system, both of our surgeons have been nearly 100 percent complete and timely in regard to medical records.
The surgeons are also responsible for creating the billing tickets through the EMR system’s billing module at the time of surgery. We found it to be faster and more accurate if surgeons submitted the claims (online through the EMR) to our billing office at the time of surgery. This has led to more rapid (and accurate) posting of charges. It is customary that the procedure is billed by our office before the patient gets to the recovery room.
Nearly every bariatric practice has to create letters of medical necessity to help patients get approved for weight loss surgery. Having an EMR system allows the practice to merge the medical problems directly from their evaluations and create letters instantaneously. This streamlines the back office operations of getting patients approved for surgery.
At BMI of Texas, the ability to communicate with referring doctors has been enhanced by the EMR system. By maintaining doctor demographics while updating patient demographics, the practice can more easily communicate with referring doctors. The user can easily send the referring doctors copies of what the practice has done and what the practice is recommending. The EMR system enables the practice to keep the referring physicians in the loop regarding their patients, which we believe improves the doctor/patient relationship and decreases opportunity for miscommunication.
At BMI of Texas, submitting data to the SRC/BOLD database is also performed by the clinician electronically during each patient encounter. This has been designed to be part of the electronic workflow. Each encounter is submitted in real time, and no time is spent going back and submitting data.
When we established our criteria for selecting an EMR system, we decided that scheduling capabilities and patient data access were the most important features. For us, electronic billing was an afterthought. Admittedly, we underestimated the power of electronic billing because we did not know what we were missing. At that time, we did not realize the magnitude of the potential that an EMR system can deliver to a practice in terms of improved billing practices. Looking back now, I cannot overstate the improvements and changes our practice has experienced as a result of our electronic billing and collecting through the EMR system.
At BMI of Teas, we use a third-party vendor who serves as a liaison between our practice and the insurance providers. This electronic relationship between our EMR system and third-party vendor allows us to decrease transmission errors, thus increase the speed of payment. We were recently recognized by our third-party vendor as a member of its 99-percent club. In other words, 99 percent of the transactions we submit are error free. We could not have achieved this distinction without the billing and collection features of our EMR system.
Final post-purchase advice
1. Have two product implementations. When you purchase an EMR, someone from the EMR company usually comes to your office to implement the system and teach everyone how to use it. Our staff utilizes our system in different ways. Some people use the electronic patient charts, others spend most of their time with the billing features, while our schedulers use the scheduling capabilities. I suggest two training sessions because it is quite a transition moving to an EMR system and there is a lot of information for the staff to digest during the first training program. If the vendor comes back after the system has been in place for several months, then the staff is not so intimidated, will probably have a lot of questions, and can really learn how to take office productivity to a higher level.
2. Invest in your staff and consider providing double monitors and extra scanners. When you ask people to drop paper charts for electronic records, certain parts of the office require “extra” electronic equipment to maximize their utility. For example, our billing and scheduling staff found if very helpful to look at double computer monitors so they would not have to toggle back and forth between two active screens. A billing person can have the patient ledger on one screen while looking at the patient’s benefits on another. Also, the scheduler may be looking at more than one doctor’s schedule at the same time and using a double monitor makes that staff more productive. In addition, we invested in our staff by sending them to EMR courses/workshops, which has empowered them to suggest and initiate changes in the way we use our EMR system.
3. Encourage staff involvement for the development of new ideas to increase utilization of the EMR system. Find out what your staff wants to accomplish with the EMR system after they have been properly trained on the system.
4. Identify a “super-user” in your practice that can be the point person for questions and concerns.
Summary
Buying an EMR system is an expensive investment that needs to be well thought out and researched before taking the plunge. Try to look past the immediate needs of the clinic and plan for future goals and future growth. Once the EMR system has been selected and purchased, make sure to invest in the staff and let them grow into the system. Encourage the staff to feel empowered to suggest changes in the EMR system so that the clinic can maximize its investment.
Category: Past Articles, Review
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