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Choosing an Electronic Medical Record (EMR)
Presented at AAHCP 5/12/05 Orlando, Florida as part of the AGS Conference
Kevin G. Jackson MD
Geriatric Solutions, LLC
2255 N 44th St., #200
Phoenix, AZ 85008
kjackson@geriatricsolutionsllc.com
(602) 954-0444 Office
(602) 952-7146 Fax
So you are thinking of choosing an Electronic Medical Record (EMR). It is time to stop thinking and start choosing. I will argue that a paperless office is now easier than ever and will be more convenient for you whether you are a solo provider doing everything yourself related to patient care or a large multi-specialty group.
The benefits of electronic record keeping are: improved record keeping, improved recording and documentation of your examination and therefore potentially higher reimbursement, improved clarity of documentation, better communication of information when your patients are referred for consultation, and potential availability of your records at any location including out of town.
I will be discussing only computer based systems as my bias is that the small screen size and relatively puny processing power of most PDA’s poses limitations that a small notebook or tablet computer does not have. Others authors such as Dr. Edward Ratner have much broader experience with PDA’s.
Assess your needs
Number of locations: will you only connect in your home or office or do you need availability at the patient’s residence?
Number of users: assess not only your current users but try to guess the number of users over the next 3-5 years. Attempting to assess electronics needs more than 5 years hence is fraught with problems due to rapid changes in technology. Government mandate may also come into play over the next 5 years.
Need for immediate availability of information: if you need instant availability of information at the point of care you will need an ability to get onto the internet. A wireless card (our company uses both Sprint which the majority of our providers have and Verizon) offers a potential solution but is limited to a similar degree to a cell phone. Check with other users and check with wireless providers in your area as most of the larger markets offer at least two or more competing products.
Anticipated growth rate: growth rate can be notoriously hard to gauge. Make your best guess then make your plans. Many products offer licenses in groups (for example 10 licenses when you purchase the program then additional licenses are available for purchase in groups of five). If you are not sure about your commitment or have a very uncertain market then cheap is best. If your growth is much higher than you expected then you can pay to convert your old data when you choose your new system. A trusted vendor with a reputation in your community can steer you away from products that uses databases or other architecture that are difficult to convert.
Integration versus separate systems: when we started, I purchased an inexpensive internet based billing program (MARS) which worked quite well for us until we fully converted to an integrated medical record. Our medical record was through an ASP (i.e. a service where the user logs into a secure internet and the data and records are maintained at a cost by the provider of the ASP) that was subsequently discontinued and we were forced to choose a different EMR. I chose again to use an ASP but we became disenchanted with the quality of service, and at that time invested in our own server, purchased the same program outright, and maintained our own data. The cost has not increased even though we hired a full-time IT person to help us maintain our system as the number of users had increased to the point that our (number of users) x (the monthly fee to the ASP) was more than the cost of the program amortized over three years even with the addition of the salary for the IT person. Additionally, the IT person does many other tasks such as setting up new equipment, replacing printer cartridges, trouble shooting system issues in real time. Etc.
Potential size of the practice: if you have no idea about the potential for growth start small. You may even do what I have done in the past which is to use a word processing program. I created standardized forms for new patients (male plus female), templates for existing problems reflecting the five levels of office visit codes and stored the patients’ notes in their own file. In that office the charts were paper but the doctors paid for transcription. When my transcription bill hit over $1300 per month I calculated the cost of dictating versus the loss of productivity from doing my own notes, I determined that even with my rudimentary typing skills I was better off producing my own notes and they were done the same day. I did not have to wait until the next business day, make corrections, and then review again when the transcription came back. If you have a reasonably quiet area to dictate in then using a voice system may also make sense.. Today there are several inexpensive programs that are quite user friendly (see four examples below), and I would today choose to purchase one of these systems.
If you expect your practice to grow fairly rapidly, I would use an integrated system. An integrated system offers an EMR, scheduling, billing, and practice management packages in one integrated package. Large groups with sophisticated IT may prefer to purchase separate systems and integrate them themselves but this is beyond the financial means of most of you reading this article. The choice of software for large groups is a complex issue and requires the input of everyone who is using the software from the clerical staff to the CEO and providers. Large organizations need to plan carefully for these software decisions but this is beyond the scope of this article.
As of the writing of this article I am not aware of a perfect EMR for a home care practice. However, most of the current systems can be modified to suit your needs. Keep in mind that paying for customized programming is typically expensive, and upgrades to the programs sometimes do not accommodate your upgrade resulting in additional cost. Customized programs may also add bugs to your program that may be difficult to correct since you are the only user and software developers are notorious for blaming all issues on operator error.
Need for integration with hospital or other proprietary systems: if your system needs to be integrated with a hospital or other proprietary systems such as an IPA than your decisions will be guided by the compatibility of your system to the larger group. You will require knowledgeable IT support.
Budget: Family Practice Management recently assessed several inexpensive EMR’s which are all available for under $1000 including:
SOAPware www.docs.com
Amazing Charts www.amazingcharts.com
Springcharts www.springcharts.com
Cottage_Med mtdata.com/~drred/
ComChart www.comchart.com
If you are planning on purchasing an integrated system they tend to be more expensive. You will need to do your homework and may need the input of a local computer consultant before making your choice. If you are investing thousands of dollars in software, you will need to do due diligence prior to a purchase.
Basic EMR features
Note creation: for some users they may prefer input from alternative means other than keyboard such as writing on a tablet, voice (Via Voice or Dragon Dictating), and importation from a word processing program either done by yourself or from a transcribed note. In our practice we type the basic HPI and the plan (cut and pasting from a prior note is possible) and use point and click for the ROS and Examination or import the information from the prior note if is a follow visit when the patient is unchanged.
Basic interface: by this I mean, the look of the program. If the program does not “feel” right to use after you have played around with it for a short time then the program is not likely a good fit for you. Do not buy any program that does not allow you time to “mess around” with the program. If you are able to easily crash the program or easily get yourself into major trouble then do not buy the program.
Scanning and paper management:paper management is not easy whether you use paper chart or convert the charts to electronic data. Electronic data can be made more secure, and you will not need increasing storage space as your business expands. Old notes can be archived to a DVD to other evolving storage medium in the near future. If you have paper charts there are companies with high speed archiving software and scanners that can reduce years of medical records for thousands of patients to a handful of DVD’s for surprisingly little cost. You can then hire a company to shred your charts, and start entering new patient data into your new EMR. This process requires careful planning, and the transition is painful for big practices as all patient encounters are effectively new patient encounters. If you have good records with problem lists, up to date vaccination, medication, and allergies lists then it is best to have your clerical staff enter the information into your EMR even though it will entail paying overtime. The alternative is to reduce the ability of the doctors to see patients as efficiently as they had before and will fuel the dissent amongst any of the laggards that “knew that EMR’s were only going to mean more trouble and work”.
A fax press is great if you have 2 or more providers (look for a used fax press as we paid $800 which we were able to use for a year and a half before the growth of our practice necessitated the purchase of a new state of the art fax press with additional phone line capabilities and the newest version of the software for $4000). Our savings on paper, toner, and paid employee time more than pay for this technology. You will also need a multi-feed scanner either as part of an all-in- one unit or as a free standing unit. We purchased a Minolta multi-page (not duplex which are much more expensive) for under $300 to scan those reports that come by mail. Initially we shredded documents ourselves after scanning (faxed documents we keep for 1 week in case the fax does not go through) but as our shredding volume increased it became cheaper to hire a shredding company for $50 per month to shred our documents.
Integration with Practice Management and billing software: small systems and very large systems may wish to use separate systems for billing, scheduling, practice management, and as an EMR. The main benefit of an integrated system is the saving in time on multiple entries of data and ease of generating reports. For very small practices you will pay a premium for this service and large systems have architectures that may support integration of separate systems. An integrated system works very well for growing small and mid sized practices.
Database structure: check with your software vendor to ensure that the database is in common use and is supported by a company that is likely to remain in business
Prescribing module: a nice feature is a medication list that is in a structured form (such as imported from the PDR) and that is updated routinely. Look for a list that has three Medication lists: Chronic or regularly used medication which is maintained until discontinued or changed, an acute list which contains medication used episodically (prn use) or for short duration (such as a course of antibiotics). A feature that may not be present but is very useful (I would argue that it should be a priority) is a Discontinued medication list which should automatically move medication to the list when a time limited medication has been completed, and the ability to document the reason why a medication was changed (such as ineffective or significant adverse effect). If this feature is not present your chronic and acute medication lists can become very cluttered and you may find it difficult to document reasons for drugs to avoid either due to ineffectiveness or due to a significant side effects. Obviously an Allery list as part of the medication list or as a separate list is essential.
Problem list: the problem list may represent a series of choices from a menu or a structured free text system or some combination. Ensure that the list will be useful for your practice.
Reminders and communication: pop up reminders are a nice feature either to provide messages about meetings for the group such as a monthly staff meeting or about a patient such as the existence of a living will on file.
Health Maintenance: make sure the guidelines are recognizable such as the ADA or the AHA. You may have to add this yourself or pay as a separate module.
Additional features that may be available or useful
E-prescribing: systems exist to not only send an electronic prescription but provide for a notification to be sent to the prescriber when the prescription is filled allowing for tracking of compliance. Drug interaction programs may be available as part of these systems or as separate modules, however, be careful if you do geriatrics as they may not be useful for multiple (>7) medications and may not cover OTC or homeopathic medications well or at all.
Customizable: allows for custom screens or the addition of standardized testing such as the Braden scale
Modules for specialists: have screens specific to specialists
Labs and other tests directly imported into the medical record: sometimes even when this is possible the information may be attached as an image which takes a tremendous amount of computer space and does not allow for trending or graphing unless the values are manually entered. Also, when using a slow connection such as a phone line whether it is land based or wireless the time to view a document stored in such a manner can be painfully slow. This feature is very useful if the text is directly inserted into your database so that graphs, trending, statistical analyses, etc. can be performed.
The joys of a paperless practice
As previously described a paperless office is possible without spending a fortune. I will describe what we have done below although there are other programs and other means to do this. Our initial investment in technology was minimal but as we have expanded our practice has spent less than $50,000 for a system that is paperless, HIPAA compliant (an insurer recently gave us the only 100% HIPAA assessment of any of the 100’s of practices that they have assessed), meets the needs of our users , and is fully available anywhere in the world where we have access to the internet. Other useful features are: ease of communication with other physicians, no chart racks, and improved management of information flow including billing.
IT support
For very small groups you may not need a support agreement other than that which is provided by your software vendor(s). If you are proficient in internet based software systems you can handle minor problems yourself. However, as a home care provider your main job is seeing patients. Often a support contract with a local software group (as always insist on local and current references) is desirable. Our practice elected to hire an IT person early on but we used a group initially paid on an hourly basis. We hope to grow fairly aggressively and have made an investment in human capital. Remember to keep your long term (>5 years however) goals in mind.
Securing your information: it is not always a mistake to be paranoid. Our practice has temporarily lost information but we have, to date, managed to recover our data fully. Each problem has caused us to add increased levels of protection and redundancy. I will describe our system below. Remember, when dealing with computer systems, paranoia is a good thing. You can never have too many fail safe mechanisms. However, you must be proactive as computer people do not always appreciate the critical nature (for both medical and legal reasons) of our data. A group I was working with previously reacted to the anger of physicians when their notes could not be recovered by exclaiming that the data was not lost, they just could not find out where in their system it was located. I wish I had had the presence of mind to ask what the sound of one hand clapping is as I am sure I would have gotten an answer.
Choosing hardware: we have bought refurbished and new and have trouble and success with both. You will likely choose a system based on Microsoft XP professional which allows you to connect remotely (the home version does not so factor the cost into your computer selection). Do not believe you need state of the art systems as data files require very little band width. We have several thousand patient records and are dealing with mega- not giga-bytes of data. I know there are die hard Mac fans out there. Yes the apple operating system is superior but your choice of products and compatible equipment is less and often more expensive. The good news is that you will have fewer programs to review.
Overcoming computer phobia
I am amazed about the computer phobia that exists even amongst some younger people and people (such as doctors) who you would think are technologically sophisticated. Training, training then re-training is the only way. Also, you need to be flexible as the problems that users encounter may herald flaws in the system. Try to re-create the problems with the person having trouble. However, you may find that some of your staff is not trainable to your system. If other people are working with your system well, and if after repeated attempts to educate a user fail then you need to fire that person, and hire someone more teachable. Our group hires unusually bright people even at entry levels of our business. We also pay accordingly. Generally, you get what you pay for.
Our system
Our practice has invested heavily in technology including the purchase of an integrated software package (AltaPoint) with 15 licenses, nine laptop computers, ten desk top computers, two servers (triple RAID servers with tape back up, a used then a new fax press, a color laser printer, an all-in-one multifunction device, an inexpensive multifeed scanner, six laser and three inkjet inexpensive printers, a VOIP (Voice Over the Internet Protocol) phone system, a high speed black combination scanner, printer, copier, six wireless cards for internet access from laptop computers, and several PDA’s that are gathering dust. I also bought a portable printer that I used for 1 day. Other than the PDA’s and the portable printer we are using all of the equipment except for our original fax press today. We have added and upgraded equipment as we needed it. For example, when we decided that our practice needed promotional materials and handbooks in quantities more than we good self publish with an inkjet color printer that we owned, we got quotes for printing brochures. The quote for booklets that were inferior in quality to those that we were self publishing was $780 for 1000 handbooks (78 cents each). We did an internet search and purchased a 25 ppm color, laser printer for under $600 and we now self publish our handbook in batches of 100 for about 35 cents each. We can also modify our booklet for patients in private homes, group homes or assisted living. We are now doing a modified version of our handbook for marketing to discharge planners at hospitals and nursing homes.
Our current system is evolving and improving constantly. I will not describe all of the systems we have or are working on but will describe our basic system from a provider’s perspective. Our system is entered via a remote connection using a secure password to enter our own server. The EMR has its own separate password unique to each user. We can only have 15 users online at one time as that is the number of licenses that we have purchased. We can buy additional licenses at a reasonable cost. Once logged onto the server, the provider goes to a file that we call “Labs and Images” where the provider can go to their file to review their labs and place those without any needed active attention into a “Lab to be Stored” file where the Medical Assistant (MA) will later move into the appropriate patient file. The system places a time stamp for the time of review. For abnormal labs, the provider either calls the MA for urgent or places with a designated color (we use orange) in the provider’s daily visit schedule with the orders for the particular patient. When the MA has completed the orders, the MA changes the color to brown indicating a completed task. The provider then “pulls” their patients onto a check in list. If the patient has had recent labs or consultations, the provider either reviews the information from home (which is usually quicker assuming broadband access to the internet). The provider returns to their file in “Labs and Images” to review their map that has been prepared by their MA. The provider may change the route or add patients or stops to the map. The provider follows their map which has been optimized as a feature of the Mappoint software that we use. As the patient is examined the note is completed, orders (if any) are entered into the “Plan” section and the expected return appointment is chosen. The patient is added to the unbilled patient list. One of our certified coders reviews the notes and contacts the provider for clarification of any billing issues that are unclear or inconsistent. Changes to the billing may only be made by the provider. STAT orders are called to the MA but all other requests are in the Plan section. Occasionally, there is no wireless access to the internet (think cell phone). The provider must then make written notes, and complete the note at home or the next time that they have a good signal. Luckily, this problem does not occur often.
Redundancy for preservation of data
Our data is precious. We have come close to losing vital patient data using an ASP and using our own system. We now are very paranoid and are investing in redundancy. To protect our data we have two servers with triple RAID hard drives (when information is written to 1 hard drive it is simultaneously written to all 6). Every day a tape back up is made and the most current tape back up is taken off site to be placed in a fire proof box. The preceding 6 days (one tape for each day of the week) is placed in a fireproof box at the office. We are in the process of opening two satellite offices and each office will have a server connected via a different internet provider than any of the other location with the same process at each for preservation of data. We want to be paranoid but safe. By the way, if you are thinking that your paper charts are safe think fire or water damage.
Summary
The time is right to move into the late 20th century and start connecting connected. The technology is available, affordable, and easy to acquire and use to become paperless. If you are not computer savvy you need not despair as it has never been easier. The hardest part may be finding computer consultants who can clearly listen to and meet your needs without overwhelming you with geek-eeze. If you do not understand, you are not stupid. This is not rocket science and it is not medical or nursing school. Your computer expert’s job is to inform you and make your decision easier. Move on to someone else if they do not make you comfortable with your decisions. Now, get out and get connected.
Resources
Online medically oriented business journals
Medical Economics www.memag.com
Physicians Practice www.physicianspractice.com
Family Practice Management www.aafp.org/fpm.xml
Memberships in societies such as the AAHCP
List server
Member expertise
Consultants: the main caveat is make sure that they know more than you do
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