The State of the EMR: Gaining Traction, Showing Results
by Lisa A. Fratt
 Healthcare
facilities and physician practices large and small are investing in
electronic medical records to improve patient safety and quality of
care while cutting cost and putting behind them the inefficiencies of
paper records. A variety of facilities tell how they've taken the
plunge - and offer advice for those ready to make the jump.
The concept of an electronic medical record (EMR) has existed for more
than 20 years. Yet U.S. healthcare providers have been slow to embrace
the idea. Economics is a major barrier, says Peter Waegemann, CEO of
Medical Records Institute (Boston). "While we need the EMR for a
variety of reasons - patient safety, costs, quality of care -
individual physicians, clinics and hospital don't realize an immediate
return on investment (ROI) with an EMR," explains Waegemann.
Economics extends beyond the micro level; British and Australian
governments have invested $12 billion in EMR projects. The U.S
government commitment of $100 million over a decade seems paltry in
comparison. The big picture in the U.S. shows that only 9 to 12 percent
of U.S. providers have invested in an EMR, says Waegemann. Other
estimates go as high as 15 to 20 percent infiltration in physician
offices and 20 to 25 percent for hospitals. But things are looking up
as a recent study in Health Affairs shows that one-third of small
practices have an EMR in the plans over the next two years.
Deane Morrison, CIO of Capital Region Healthcare and Concord Hospital
in Concord, N.H., agrees that nearly no one has a complete EMR
portfolio. But most U.S. healthcare providers have deployed components
of the EMR, says Morrison. "In the acute care/hospital setting, the EMR
consists of a collection of applications that work in concert to bring
all of the pieces of the paper medical record into what appears to be a
single system." The applications include nursing assessment and
medication administration, transcription, radiology images and reports,
historical documents and physiological monitoring and may include
decision support and computerized physician order entry. On the other
hand, the electronic health record (EHR) - a term often, but wrongly,
used interchangeably with EMR - consists of many EMRs across different
hospitals, clinics, pharmacies and health insurance companies, explains
Waegemann.
This month, Health Imaging & IT
visits with a handful of providers that have embarked on the EMR
process to learn more about the hows and whys of the EMR. We're also
taking a look at some of the challenges - and finding there is plenty
of good news.
Consider:
- Healthcare facilities earn an ROI as medical records staff and transcription costs are cut.
- Patient safety is greatly enhanced via the elimination of the stereotypical chicken scratch notes and medication orders.
- Information is available in real-time and in multiple
locations, allowing physicians to maximize their time while providing
better patient care.
- The EMR is a richer, more complete picture of the patient. It can
be mined to alert patients, such as following the Vioxx incident.
- Electronic records can advance care as on-call clinicians have a
better knowledge of the patient's condition. For example, if a cardiac
patient is admitted to the hospital on Friday night, an EMR-equipped
cardiologist may release him sooner than a conventional provider as he
has a more complete understanding of the patient's condition.
While the benefits are real and fairly consistent, the EMR selection
and deployment processes are not standard. "There is not one straight
avenue to success. Every experience is different," cautions Waegemann.
The rationale
Although the federal government is touting EMRs and could create
incentives or disincentives to spur on adoption, there are a variety of
other reasons for implementing an EMR.
Take for example Associated Cardiology Consultants, a six-site
cardiology practice in New Jersey. The practice grew out of a 1994
merger of three practices, each with its distinct charting processes;
some placed x-rays and labs in the front of paper charts. Others put
them in back. "It was confusing," recalls Executive Director John
Morris. Hence the first EMR goal: a standard chart. The practice also
aimed to provide access to patient charts across its offices, decrease
transcription costs and search the medical record for research
purposes. Improved billing and collections also was key. "Doctors tend
to undercode. An EMR provides clear documentation of the patient visit,
so that we can code appropriately," explains Morris. The practice
deployed Amicore Clinical Practice Management on tablet PCs in December
2000.
Alegent Health, a nine-hospital regional integrated healthcare delivery
system in Omaha, Neb., has implemented a series of Siemens Medical
Solutions applications including Soarian Clinical Access, INVISION
bedside charting system, Soarian HIM (health information management),
Siemens Pharmacy and SIENET PACS to create a comprehensive EMR
solution. A new all-digital hospital provided the impetus for an EMR
that could be gradually rolled out across the organization to provide
real-time access to the latest clinical information to provide better
quality, more efficient care. "We can hardwire quality with this system
by building evidence-based order sets into Soarian," says CIO Ken
Lawonn.
Concord Hospital has taken a gradual approach to the EMR process. The
process began about 10 years ago with online nursing assessments,
bedside barcoding and electronic medication administration via
McKesson's Care Manager. Since then, it has expanded to include
McKesson's Horizon Medical Imaging PACS and Horizon Physician Portal as
core EMR components. Morrison explains the rationale for this approach.
"The EMR is not just about getting the information online, which does
not transform data into usable information. It's about re-engineering
processes and changing the way information is collected."
Poudre Valley Healthcare in Fort Collins, Colo., decided to deploy an
EHR, rather than an EMR, across its hospital and outpatient clinics as
well as some local private offices. The implementation includes
Meditech's Enterprise Medical Record for the hospital and Meditech LSS
for outpatient clinics and private practices. CIO and incoming College
of Health Information Management (CHIME) President Russ Branzell
explains, "This provides one integrated health record across sites. If
a patient visits an outpatient clinic, the core elements of the visit -
allergies, treatments and medications - are shared and available."
Benefits & results
Benefits of the EMR come on multiple fronts. There are clinical
benefits, workflow gains and even financial pluses. "The No. 1 and 2
reasons for deploying an EHR [or EMR] are patient care and patient
safety," states Branzell. "Doctors practice better medicine with an
EMR. There is so much more information in a more organized way," sums
Tom Goodwin, director of clinical information systems for MIT Medical
of Boston, which uses Allscripts TouchWorks.
For example:
- Physicians can graph lab results for a high cholesterol patient over time.
- Legible prescriptions reduce medication errors.
- Anytime/anywhere access to the complete patient record eliminates guesswork.
- Compliance
with clinical guidelines increases. For example, facilities can
electronically review charts of heart attack patients to make sure they
are on aspirin therapy.
Workflow can be transformed with the EMR. Morris points out, "Today's
doctors want a life. With an EMR, they can complete paperwork at home
late at night." Practices are more efficient. Associated Cardiovascular
Consultants increased physician staff by 33 percent with no increase in
support staff.
Conventional wisdom does not equate the EMR with immediate ROI. Indeed,
Morrison cautions, "For many components there is no return until all of
the pieces are in place." Associated Cardiovascular Consultants touts a
three-year ROI due to $150,000 annual reduction in transcription costs.
The practice also saves $25,000 annually on malpractice insurance
because its provider realizes the value of clear notes and electronic
prescriptions. MIT Medical reduced its medical records staff from 12
FTEs to eight and reassigned two of the remaining employees to other
duties.
There are miscellaneous benefits, too. Concord Hospital was able to
mine its EMR to determine the number of patients with diagnoses that
require wound care to clearly establish the need for a new wound care
center.
Lessons from early adopters
Although there are multiple paths to EMR success, there are some
guidelines that can boost the odds for a successful implementation.
Clinician buy-in is essential. "Resistance to change can come from all
corners including physicians, clinicians, transcriptionists,
pharmacists and IS," notes MIT Medical's Goodwin. Branzell suggests a
proactive approach. "A successful implementation is clinically led,
owned and designed and IS-supported," adds Branzell.
"Define your goals," says Morris. "This will help steer the
decision-making process." For example, if access is a goal, the
solution should provide web access, which is not universally available.
There are IT challenges as well. With an EMR, dependence on technology
skyrockets. If an interface goes down, users can lose their only access
to information. "The system must be architected for high-availability
and redundancy. It's important to realize the interdependency of
systems and think through batch environments" says Alegent Health's
Lawonn. He recommends redundancy at all levels - including power, data
center cooling and networking. Alegent Health relies on SAN (storage
area network) storage in multiple locations. The hospital also beefed
up its clinical support staff, relocating some help-desk analysts to
the floor and offering one-on-one bedside training. Other new staff
members include a medical director of informatics and a clinical
informatics specialist.
Hindsight can be 20-20. Take the example of Associated Cardiovascular
Consultants. The practice opted not to hire additional staff to enter
initial data into the EMR. "There was a lot of wailing and whining
among physicians that first year," says Morris. That's because the bulk
of the data such as family history and medication information are
entered on initial patient visits. Therefore, benefits aren't apparent
until the physician sees the patient several times. "It was penny-wise
and pound foolish," sums Morris.
Finally, integration is key. Alegent Health made a fundamental decision
to deploy best integration instead of best-of-breed solutions, says
Branzell. Concord Hospital also employed the integration approach.
McKesson Physician Portal is open and standard, so other vendors'
products like EKG and fetal monitoring solutions work within the
portal, says Morrison.
Future directions
Most sites refer to the EMR as a process rather than a product.
Organizations on the leading edge of EMR technology are looking forward
to the next levels, which include evidence-based medicine, richer data
mining and improved access for referring physicians and patients.
"One deep benefit is the transformation of care processes," states
Branzell. At Poudre Valley Healthcare, clinicians across the enterprise
are building plans of care that accommodate best practices in
documentation. For example, orthopedic surgeons can create standard
processes for a hip replacement including items such as timing and
length of physical therapy.
Currently, Associated Cardiovascular Consultants manually returns to
the EMR to review charts to ensure that all heart attack survivors
follow an aspirin regimen. The next version of Amicore Clinical
Practice Management will flag the record on the front end to
electronically facilitate evidence-based medicine.
MIT Medical is focusing on patient connections. It plans to deploy a
web portal that offers secure messaging to physicians. Other
applications include online prescription renewals and tracking tools
for items like blood sugar and cholesterol readings. Associated
Cardiovascular Consultants plans to offer referring physicians access
to charts, which will be critical as snowbird patients shuttle between
southern states and New Jersey. The practice also plans to enhance
patient access, allowing them to check medications and make
appointments online.
Conclusion
The EMR could be healthcare's Holy Grail, promising to enhance
medicine by enabling doctors to make best practices the standard of
care. Decision-making is facilitated by the availability of real-time
information at the point of care and anywhere it is needed for
decision-making. And medical errors plummet as electronic text replaces
handwriting.
Despite its promise, the EMR is not a slam dunk or immediate profit
center. It is best implemented gradually according to a well-developed
plan that involves all stakeholders from clinicians to pharmacists to
IT staff. Successful facilities plan extensively, anticipate
roadblocks, provide hand-holding and training for staff and are
proactive and future-oriented about the EMR, continuing to look for
ways that it can be used to drive improved patient care.
Rethinking EMR Disaster Recovery After the Storm: Lessons from Katrina
When Mary Bird Perkins Cancer Center in Baton Rouge, La., deployed
IMPAC ViewStation as its EMR several years ago, the radiation therapy
cancer treatment facility had not imagined the devastation its state
would realize in the wake of Hurricane Katrina. The hurricane not only
demonstrated the value of the EMR - but also revealed some holes in EMR
disaster recovery plans.
The three-site cancer center runs ViewStation over a wide area network
via Citrix. The application is hosted out of Baton Rouge via a T1 line
and handles front- and back-office functions, transcription, dictation,
imaging and medication.
"We believed our disaster recovery plan was solid pre-Katrina, but we
will add several layers in the future," says President and CEO Todd
Stevens. The plan consists of mirrored servers, RAID 5 architecture and
nightly backup to the tape library. But the center's proximity to New
Orleans, just one hour away, pinpointed some areas for internal
improvement.
External EMR disaster recovery plans require improvement as well.
"Conventional EMR thinking may not provide any different access to
records than to paper," reveals Stevens. That's because New Orleans
hospitals' servers were down and staff had to evacuate, so both the IT
infrastructure and manpower to push EMRs to other sites had
disappeared. For example, EMRs for 50,000 patients treated at New
Orleans Veterans Affairs Medical Center were airlifted to Houston,
where they could be accessed about four days after the hurricane.
After the storm, Mary Bird Perkins Cancer Center lost all T1 lines for
several days and did not expect them to return. The center planned to
set up satellite operations for its sites, but there was no way to
autoregister EMR data across the three copies of its database, and
staff would have had to manually update its main database. Fortunately,
T1 lines were back online sooner than expected, so the center avoided
the arduous task of manual updates.
On the upside, Mary Bird Perkins plans to convert to Microsoft SQL
early in 2006. "This will allow us to use transaction logs in the event
of a satellite failure from our main office," reports Stevens. SQL also
provides an electronic mechanism for transfer if a T1 line is lost; the
real-time switch means no interruptions to the server.
On the clinical side, the center has treated about 75 displaced cancer
patients, who had no time to gather medical records prior to
evacuation. The center relied on patients to share information and set
up a website and 800 phone number to track physicians who treated
patients, so that patients could resume treatment. One of the real EMR
payoffs will come as displaced patients exit treatment. "The electronic
record ensures that we will have an easy time communicating with other
providers," says Stevens.
Electronic records are facilitating care for other evacuees as well.
The Department of Health and Human Services is creating a database to
help evacuees access prescription drug records. The system could
contain records for prescriptions filled at large retail pharmacies up
to 90 days prior to the storm. Another program tracks patients' care at
shelters such as the Astrodome; the Astrodome program also communicates
lab results to offsite providers.
"The real advantage to the EMR is the ability to move thousands of
charts on tape," adds Ronnie Meadors, director of MIS for Mary Bird
Perkins Cancer Center. When the practice's Hammond and Covington
facilities closed their doors because of downed trees, patients were
easily able to continue treatment on Baton Rouge because all data were
electronically available.
Healthcare providers, like everyone in the Gulf region, are learning
and re-building, after the storm. "We need a distributable, portable,
secure EMR," states Stevens. Mary Bird Perkins Cancer Center may assign
a staff member to go to a secure offsite database to take calls and
electronically transfer information to other sites in the event of
another disaster.
"Katrina exposed short-sighted thinking about the EMR. The EMR is not
enough. Healthcare cannot take a laissez faire approach to disaster
recovery; it must be thought through to a higher level than most sites
have," concludes Stevens.
The EMR in Private Practice
One-third of small practices plan to implement EMRs in the next two
years, according to a study published recently in Health Affairs. Other
research indicates that financial gains are not necessarily a given for
small practices that deploy an EMR. The average practice recoups its
investment in 2.5 years and then begins to accrue profits, but a few
have experienced financial struggles after implementation. And gains in
quality are modest, says the study.
Successful small implementations are possible. Take for example Goshen
Medical Practice, a single physician internal medicine practice in
Goshen, Ind. Dicky Bhagat, MD, says eClinicalWorks EMR facilitates
enhanced efficiency and paperless operations. The EMR incorporates all
front- and back-office operations as well as progress notes, labs,
diagnostic tests, medications and treatment plans.
"It's unimaginable to return to paper," claims Bhagat. He calculates he
receives 20 to 40 daily prescription refill calls daily. With
eClinicalWorks, a staff member clicks on the patient summary and a
prescription can be auto-faxed to a pharmacy in 30 seconds. The
corresponding paper process takes 5 to 15 minutes per refill or the
equivalent of one FTE, says Bhagat. The EMR also copies historical
notes forward to facilitate efficient and complete coding. "I've
realized a substantial jump in income due to correct coding [vs.
undercoding]," explains Bhagat.
Bhagat offers a bit of financial advice. "Make sure you understand what
you are signing when you purchase an EMR." Some vendors require
practices to purchase hardware from them. "An off-the-shelf server
might cost $12,000, but a vendor might mark it up to $56,000," states
Bhagat. Support and services contracts warrant close scrutiny as well,
says Bhagat.
Diamond, Fera & Associates, a seven-physician, four-office practice
in suburban Pittsburgh, recently deployed a Misys EMR. "We wanted to
provide physicians with access to data from multiple offices, homes and
hospitals. Before the EMR, we dealt with significant problems as charts
were stored in different offices and frequently needed to be faxed or
transported to other sites," explains Joel Diamond, MD. "But the major
driver for the EMR was the promise of dramatic quality improvement."
The practice has seen hefty gains in quality. Medical errors -
especially those caused by hastily scribbled prescriptions -
misinterpreted data or lost or misplaced charts have dropped. The
practice has implemented decision support by incorporating drug-drug
interactions and allergies in Misys EMR.
Diamond, Fera & Associates has built best-practices templates, too.
The templates like one for sports physicals not only standardize care
but also boost workflow with one-click documentation. "We completed a
study with our local Blue Cross carrier that showed our documentation
of smoking has increased from 15 to 70 percent," continues Diamond.
Consequently, the practice can provide smoking cessation counseling
every three months to affected patients.
Misys EMR offers full integration of several applications including
practice management, document management and claims processing. Like
other EMRs targeted to small providers, the EMR does not integrate with
PACS for viewing of digital images. "I don't think I would want PACS
images in the EMR because of the storage space requirements," says
Diamond. Instead, he and his colleagues access the hospital PACS via
the web and radiology reports are scanned into patient charts. The
practice has utilized its EMR for other forms of digital imaging. Each
patient's chart contains a personal photo, so physicians can recognize
patients, and the practice also takes wound care photos and imports
them into the EMR.
Diamond looks forward to the next steps. Misys Patient Portal will
allow the practice to share information like lab or blood sugar results
with patients. "This should further improve quality and outcomes,"
opines Diamond. And Misys Connect will integrate hospital data such as
radiology reports and other digital information into the EMR,
eliminating some scanning.
The quality improvements are clear for Diamond, Fera & Associates.
The financial results are equally favorable. "We've seen a significant
return on investment. The EMR has more than paid for itself. The staff
goes home earlier and can not imagine practicing [medicine] without the
EMR."
An EMR Alternative?
The EMR field is large and ripe with options. It increased again this
fall with Dictaphone Corp.'s launch of mdEssential. The company dubs
the solution as an alternative to the traditional EMR.
The new system allows physicians to document encounters via dictation
and also produces structured patient data that becomes readily
available at the point of documentation. mdEssential uses speech
recognition technology to convert dictation to text documents. Then,
national language processing finds and extracts key clinical data from
the finished text documents. This information is placed in a database
that can be accessed, searched and organized.
Guthrie Clinic/Robert Packer Hospital deployed the precursor of
mdEssential - Enterprise Workstation - in January 2004 as a forerunner
to the EMR. The query-able system allowed the clinic to identify all
patients on Vioxx within 24 hours. The system, however, is not quite a
true EMR, says Frank Belardi, MD, program director for the Family
Practice Residency Program. It does not interface or download lab
results or digital images, and it does not incorporate medication
reconciliation. The clinic will integrate other EMR functionality such
as disease management protocols into Enterprise Workstation in the next
few months. It plans to deploy a full EMR by 2006 and will consider
options from multiple vendors.
October 1, 2005
About eClinicalWorks EMR & PM
eClinicalWorks is the leading provider of unified end-to-end ambulatory clinical information systems designed to for medical organizations looking to ensure first class patient care. The company¡¦s solution consists of two major components: eClinicalWorks EMR and eClinicalWorks PM. eClinicalWorks EMR allows physician practices to manage the patient flow, specifically letting practices access patient records immediately¡Xeither in-house or via remote access¡Xelectronically communicate with the referring physicians and securely send consult notes and clinical data. The second component of the unified solution, eClinicalWorks PM eliminates the roadblocks inherent in healthcare billing processes, allowing practices to submit claims electronically, track the status of claims and communicate online with payers to confirm patient eligibility, what services will be paid and when. For more information about eClinicalWorks products please visit http://www.eclinicalworks.com/products.php
About eClinicalWorks
eClinicalWorks is the leading provider of unified ambulatory clinical information systems. The company¡¦s EMR (Electronic Medical Record) and PM (Practice Management) solutions are designed to streamline a practice¡¦s front and back office operations to ensure superior patient care. Supporting AAFP¡¦s Partners for Patients and HIMSS EHRVA initiatives, eClinicalWorks has been awarded top industry honors including Best in KLAS¡¦ Ambulatory EMR (1-5) in 2004, the top Practice Management solution and Medical Records Document Imaging/Management System by TEPR 2004, the top EMR solution by TEPR 2003, the Frost & Sullivan ¡§Best Bang for the Buck¡¨ in 2004 and the 5-STAR rated EMR solution by ACGroup in 2002, 2003 and 2004. eClinicalWorks also has established a U.S. customer base of over 2,000 medical providers. For more information please call (866) 888-MY-CW or visit them on the Web at www.eclinicalworks.com.
Contact:
Dimple Dedhia, eClinicalWorks (508) 836-2700 dimple@eclinicalworks.com
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