Electronic Medical Records for the Physician Practice Strategies for Navigating the Quagmire

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Electronic Medical Records for the Physician
PracticeStrategies for Navigating the Quagmire

• Kevin Kennedy, MHS, CPHQ, CPHIT
• Director of Quality Improvement
• October 24, 2008

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Institute of Medicine Reports

• To Err is Human, Building a Safer Health System
  (1999)
• Crossing the Quality Chasm A New Health System
  for the 21st Century (2001)

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Institute of Medicine Report To Err is Human

• Top 10 Causes of Death in 1998
• Heart Disease 724,269
• Cancer 538,947
• Stroke 158,060
• Lung Disease 114,381
• Medical Errors 98,000
• Pneumonia 94,828
• Diabetes 64,574
• Motor Vehicle 41,826
• Suicide 29,264
• 10. Kidney Disease 26,295
• Estimated

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The Right Care forEvery Person Every Time.

• Stephen Jenks MD, Former DirectorQuality
  Improvement GroupOffice of Clinical Standards
  and Quality
• Centers for Medicare and Medicaid Services

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Electronic Medical Records (EMR) Avoid Medical
Errors

• Availability of records
• Enhance communication
• Provide decision support
• Reduce medication errors
• Improve quality measures
• Provide economic benefit?

Bates, David MD, Family Practice News, October
15,2004
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Medicine is a Very Communication Intensive
Industry

• Enhanced communication between physicians,
  settings, and patients can
• Coordinate chronic disease management and
  medications
• Improve quality of referrals and consults
• Avoid medical errors that lead to liability

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Electronic Medical Records

• At the turn of this century, . . .the average
  industry was investing 8,000 per employee on
  computer technology, health care was spending
  1,000.
• By now, if you belong to a frequent shopper club,
  your grocery store almost certainly has far more
  computerized data than your healthcare
  provider..."

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Electronic Medical Records

• "With almost three-quarters of physicians in solo
  or small-group practice settings, it is critical
  to recognize not only the financial barriers, but
  the greater need for technical assistance in
  implementing electronic health records, compared
  with physicians in larger healthcare settings
  with existing support systems. . .

Anne-Marie Audet, Vice President The Commonwealth
Fund
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Primary Objectives

• Describe EMR basics
• Discuss the six stages involved in adopting an
  EMR system
• Assessment, planning, selection, implementation,
  evaluation, and improvement
• Share our experiences with clinics in Nevada and
  Utah

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I just dont see how doctors can stay in the
game unless they are somehow plugged into an
electronic medical record

• Tufts-New England Medical Center, CEO, The Boston
  Globe, Feb. 10, 2006

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HIT vs. EMR/EHR

• Health information technology (HIT) is a general
  concept
• Electronic medical record (EMR)/electronic health
  record (EHR) is a specific concept relating to
  systems having the ability to capture data from
  various sources for clinical decision support at
  the point of care

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The Burning Platform for EMR Systems

• During the 1990s, EMR system adoption was
  usually limited to larger organizations
• Currently, 20 to 30 of outpatient clinics use
  EMR systems (20 in NV and 30 UT)
• Estimated that 50 to 60 over the next several
  years
• Small outpatient practices expected to be fastest
  growing sector for EMR system adoption

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What Are Benefits of EMR Systems?

• Improved care
• Views of entire medical histories
• More efficient workflow reduce the paper chase
• Generate patient specific reminders
• Reference medical research and protocol data at
  the point of care to enhance diagnostic and
  treatment plans

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What are the Benefits of EMR Systems?

• Reduction of errors
• IOM report
• Coding confusion, illegible documentation, poor
  information management contribute to errors
• EMR systems improve documentation and
  communication and assist in managing critical
  information

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What is the Business Case?
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Return on Investment (ROI)

• The amount of time it will take your practice to
  re-coup the dollars spent on the EMR project.
• Process of confirming that the system is
  delivering anticipated benefits.
• Is it required? No, But it will help in
  demonstrating, evaluating, and assessing the
  success of the project.

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Financial Benefits

• Reduction in Costs
• Storage space
• Transcription services
• Staff time pulling and filing paper records

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Reduction in Costs

• Some vendors state an ROI is possible within 12
  months while others state over three years
• Low hanging fruit is reduction in transcription
  costs
• Potential staff reduction or reallocation
• If average physician needs four FTEs for support,
  this number can be reduced by at least one FTE
  with an EMR

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Increased Revenues

• Many providers down-code to prevent claims from
  being denied
• EMRs assist providers in coding to assure that
  the correct codes are used with support
  documentation
• More accurate coding can decrease claims denials,
  increase reimbursement rates, and improve cash
  flow via shorter billing-to-payment cycles
• EMR is vital tool for improved reimbursements
  through pay-for-performance initiatives

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The Big Picture
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The impact and expectation of cost-justifying
patient safety IT initiatives using a traditional
ROI must evolve to focus beyond the financial
benefit. It must encompass overall patient
safety, patient satisfaction, and employee and
physician satisfaction benefit categories

• L.M. Newell Whos Counting Now? ROI for Patient
  Safety Initiatives, Journal of Healthcare
  Information Management

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Satisfaction

• Provider
• Leave the office earlier
• Access patient information remotely
• Better understanding of the practice operations
• More time spent caring for patients
• Less time spent chasing charts, paper, and
  resources

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Satisfaction

• Staff
• Cleaner workflows less waste
• Better understanding of roles and
  responsibilities
• Leave the office earlier
• More advanced skill sets
• Patient
• More information about the office visit
• Better access to health information
• Better organized office

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EMR System Technical Options

• Interfaced practice management (PM) and EMR
  systems vs. integrated
• Terms often used interchangeably although
  difference can be significant
• Interfaced independent applications that talk
  to each other
• Integrated share common master files
• All modules usually come from a single vendor or
• two closely linked vendors

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Hosting Options

• Application Service Provider (ASP)
• Lease EMR application and network, hardware and
  IT maintenance services
• Beneficial for smaller practices lacking IT
  expertise
• Significantly reduces initial investment

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Hosting Options

• On Site
• Clinic purchases software license, network
  servers, operating systems and employ or contract
  for maintenance
• System backups completed on site
• Security issues are clinics responsibility

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So, how does a clinic even begin the process?
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Challenges of EMR Transition

• Failure to plan properly
• The horror stories - systems going down
• Problems with vendors
• Change is difficult
• Investing in EMR but not fully utilizing the
  product

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The Six Stages of EMR Migration
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Stage 1 - Assessing Your Readiness

• Challenges and financial impacts involved in
  successful EMR implementation cant be ignored
• Critical that physicians and management evaluate
  whether your practice is ready to take on the
  challenges

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Assessing Readiness

• Decision-Maker Buy-In
• Does everyone agree on the goals and expectations
  for the EMR system?
• Do you have a physician champion?

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Assessing Readiness

• Staff Buy-In
• Is your staff capable and enthusiastic about
  installing an EMR system?
• Will the key staff members have the patience and
  willingness to be involved in the transition?

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Assessing Readiness

• The Learning Curve
• Can your practice afford the financial impact of
  reduced patient volume for a 2-3 month period?
• Will the physicians have the time and patience
  for an EMR system transition period?

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Assessing Readiness

• Practice Management Integration
• Have your physicians and management carefully
  considered the differences between an interfaced
  and integrated system?
• What is your level of satisfaction with your
  current PM system? Are you willing to trade it
  for a new integrated system?

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Practice Tasks During Assessment

• Assess current workflow
• Begin/continue regular staff meetings
• Assign physician champion
• Organize EMR selection team

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Stage 2 - Practice Tasks During Planning

• Write down the clinic goals and priorities (these
  should be agreed upon previously)
• Translate goals into available EMR system
  functions and features
• Address concerns of staff with lower levels of
  readiness
• Develop a timeline and project plan

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How to Select an Electronic Medical Record System

• A natural tendency might be to call a few
  vendors.. and ask them for a demo. Stop. Unless
  you want the vendors to control the selection
  process, you need a plan.

K. Adler, Family Practice Management, February
2005
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Stage 3 -Vendor Selection

• Use translated goals list of functions and
  features your rating system
• Create a clinic-specific case scenario
• References and sites visits dont skip!
• Additional hardware and support plans
• Negotiating a contract

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Partners for Patients ElectronicHealth Record
Market Survey
American Academy of Family Physicians Center for
Health Information Technology
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Stage 4 - Implementation

• Workflow analysis have a plan for changes
  (roles, scanning, handoffs, etc.)
• Data conversion, interfaces, testing
• Recovery and security planning
• Training iterative and super users
• Go-live modify workload

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Major Workflows Associated with the Patient Visit

• Scheduling
• Check-in/registration
• Authorizations
• History and physical
• Providers SOAP process (Subjective/Objective/Asse
  ssment/Plan)
• Labs/imaging/medication orders
• Referrals
• Checkout
• Billing

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Stage 5 - Evaluation

• Workflow analysis identify problem areas
• Additional training/learning
• Check progress towards initial goals
• Using data in your EMR to improve care
• Ongoing checks all staff (workarounds?)

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Stage 6 - Improvement

• Workflow analysis
• Identify bottlenecks, possible role redesign
• Using data to check progress
• First step is checking data integrity never
  perfect
• Next set goal(s) and track progress
• Find best practices internally and externally
• Use the EMR to its capacity

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Experiences Thus FarThe transition is a process
NOT an event

• Difficult to generate specific ROI but it is
  possible to have a general idea of ROI
• Sometimes too many choices with EMR vendors one
  size does not fit all
• Clinics find it challenging to use 100 of system
  capacities

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Summary

• EMR is a valuable tool to improve outcomes
• EMR helps to deal w/complexity of decisions being
  made under time constraints
• EMR can help reduce medical errors and liability
  risk

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Discussion
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Contact Information

• Kevin Kennedy
• 702-933-7311
• kkennedy_at_healthinsight.org

This material was prepared by HealthInsight under
a contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services (DHHS).
The contents presented do not necessarily reflect
CMS policy. Publication 9SOW-
NV-2008-00-020