The value of computers is that they can store massive amounts of data, facilitate records processing, generate reports, and ease the process of the statistical analysis of outcomes and cost-control measures. Plus, EMR systems enable practice managers and clinicians to respond more quickly to patient needs and better control work flow.
The demand for the types of services that EMR systems can provide is fueling vast growth in the healthcare information technology market. Industry observers estimate the market for physician practice management and ambulatory healthcare information systems will triple in size by the year 2000 to $6 billion, rising at a rate of about 25% annually. Although there is considerable evidence showing EMR systems can save a medical practice time and money, realizing that promise can be a long and difficult process. There are many obstacles standing in the way of creating and implementing a computer-based patient records system.
The following is a look at what the experts--top systems specialists and seasoned systems users--have to say about making the decision to move to an electronic system, selecting the right system, avoiding potential pitfalls during system implementation and getting the most out of a system once it is up and running.
Embracing the paradigm
If you are grappling with the decision of whether to move ahead with the purchase of an EMR system, you probably need some basic education about your choices. You can start by taking a look at the white paper, A Return-on-Investment Analysis--Electronic Medical Records in the Outpatient Setting, published on MedicaLogic's World Wide Web site
(http://www.medicalogic.com). The paper, written by Kevin Renner, director of marketing for MedicaLogic in Beaverton, Ore., provides an overview of costs and benefits, an analysis of the different types of EMR systems, a look at where benefits are achievable and a detailed model of how to determine costs.
The MedicaLogic paper is a good starting point for managers unfamiliar with EMR systems or with how to conduct a cost-benefit analysis. Although it may not be possible to find a universal approach to determining benefits, the MedicaLogic return-on-investment analysis categorizes benefits in the following way:
The MedicaLogic paper also includes a lengthy bibliography that offers access to some of the managerial and organizational analyses that have influenced the paper's conclusions.
Other sources may be of interest as well. To help in saving time in the product evaluation and selection stage, there's an existing comparative analysis, The Automated Medical Record Vendor Resource Guide, published by consulting firm C.J. Singer. The guide compares all of the major automated record systems available today. To order, call 617-246-7585.
Another source is the Medical Group Management Association, which publishes a software directory of EMR systems providers.
A good way to get an idea of how different systems work is to visit another organization in your area that is already using an EMR system. You can arrange the visit yourself or the EMR producer may be willing to arrange it for you. "Test-driving" a product will give a hands-on feel for how well it works and what it does.
You can also see systems up close at trade shows. EMR companies are actively involved in shows such as those sponsored by the Healthcare Information Management Systems Society, the American Medical Group Association and the MGMA. Spending time with company representatives and gathering marketing materials to review is a good way to get a feel for the different EMR systems companies.
Selecting the system
Once you conclude the purchase of an EMR is a good idea, the next hurdle is selecting one that's right for you. Medical practices have a range of needs, so it's worth taking your time. A careful analysis of the variety of products and their associated costs will not only help control costs but also will help ensure that the product chosen will meet your specific needs.
"The most successful (decisions about) systems are in places where everybody is involved and is using the system," says Tom Schields, director of solutions integration for Reynolds and Reynolds Healthcare Systems of Dayton, Ohio. "Your EMR system users include physicians, administrators and everybody involved in patient care and service delivery, so it is logical to establish a selection committee with representatives from all of these disciplines to help assess how the EMR will fit into their life style," Schields says.
Walt Zywiak, vice president of Wakefield, Mass.-based C.J. Singer, says, "Systems are available with a wide range of functionality, so you need to carefully analyze the type of systems that will work best for you.
"One of the key questions to answer is, will physicians do their own data entry?" Zywiak says. "If yes, then you need to ensure that the system you buy will be appealing to the clinical staff."
There are several new features that make EMR systems appealing, Zywiak says, for example, the note generation feature, which facilitates the automatic creation, storage, and forwarding of clinic notes.
Other issues to consider when selecting a system are work flow and patient flow support, order entry and different levels of clinic support, Zywiak says.
"Some decisions are simple. For example, do you need to print out orders or do you want a more sophisticated system that provides automated links with a pharmacy to place orders or with labs to order tests?" Zywiak says.
Some systems can track and show status of orders and copy results back to patient records while alerting the clinician that the test has been completed. Some also can generate letters to patients .
It may be a good idea to use a formal request for proposals to get bids for a new system and for installation and implementation support. Although the RFP process can be lengthy, it's a way to learn about systems and the companies that sell them. Since your practice will be spending a lot of money on an EMR system, it's important that you and the EMR system vendor have a common vision of what's needed from the system now and in the future.
Regardless of how you organize the selection committee or the exact process for determining just which EMR system to buy, remember that the system you select will be expensive and, if all goes well, will be around for a long time. Don't let the frustration of selecting a system result in a rushed or bad decision.
Implementing the system
The process of getting an EMR system up and running is also time consuming and expensive.
"There are two major rules during implementation: First, EMR systems don't happen overnight. It takes time to integrate the system into the total operations of the hospital," says Mark Leavitt, President and CEO of MedicaLogic. "The second important thing to remember is not to make your implementation cataclysmic; be methodical and phase in your system."
To be realistic about how you are going to move from the product selection stage to the actual implementation, you will need to determine whether you have the staff and experience in-house to deal with all aspects of implementation. If you don't, you will have to contract out some of the work.
Certainly, having qualified staff will make your implementation easier. According to Leslie Schwen, a systems analyst at Providence Health Systems in Portland, Ore., the installation process is relatively manageable. "The front end of the Logician system (by MedicaLogic) is very easy for users to deal with, which in turn makes the job of providing technical support a lot easier," she says. Providence runs a 24-hour, seven-day-a-week operation.
"Our users go through training to learn the interface and, when we do get calls, the problems are relatively easy to resolve," Schwen says. "As far as the complexity of this system, it is one of the easiest I have had to learn in working with computer technology for twelve years."
Once it is installed, getting the system on the air is the next challenge. "Most groups start by implementing their EMR system in one division or department and then move it into other departments as the experience curve increases," says Schields of Reynolds & Reynolds. "The first users can also become leaders for the rest of the organization and provide training as well as pep talks when necessary."
Leavitt of MedicaLogic says, "When you implement an EMR system, there is such a significant change in how people work it is important that you deliver value to the users as soon as possible.
"Delivering value quickly helps to encourage clinicians to participate in the implementation process by focusing on high value functions first, such as prescription management," Leavitt says. "Later you can move to functions like clinic notes, which are more complicated and take longer to implement.
"It is also important to make sure everyone understands why you are implementing an EMR system," Leavitt adds. "An EMR system is not just administrative systems, it is a tool to drive customer service because it enables quick response to patient inquiries and reduces the time clinicians spend on paperwork, which allows them to spend more time on patient care."
Berkley Merchant, vice president of customer service at MedicaLogic, says, "Whatever you do, don't underestimate what it takes to implement an EMR system. They are not shrink-wrap software; it takes work to get them up and running and they will create substantial changes in your clinic's operations.
"One really big thing to remember is that when an EMR system goes live it is done in public, and the chance of looking foolish in front of peers or patients is a scary thing for lots of people who will be using the new system," Merchant says.
"The best path to a successful implementation is to plan the work and then work the plan; make sure everybody understands where you are going," Merchant says. "Don't try to do everything at once; you can adopt an EMR system over time using more and more functionality as you go along."
Merchant recommends having a few champions of the system, both senior clinicians and senior administrative staff, to take the lead. Make sure they are backed up by adequate technical support to take care of networks, printers and other equipment.
Reaping the benefits
It takes from six to 12 months to get data into an EMR system, says Schields of Reynolds & Reynolds. It's during that period that people start to see the range of benefits of the system. "You can do a lot more with an EMR system than just looking at medical records, including interfacing with existing financial systems, eliminating duplicate data entry and generating billings," Schields says.
"You do not have to be a computer expert to benefit from an EMR system, but you do need to be trained on how to use the system," says Weaver of Providence St. Vincent Medical Center in Portland, Ore.
Weaver's clinic, Westside Internal Medicine Clinic, uses the Clinical Logic EMR system. "This represented tremendous change for everybody," Weaver says, "but we knew we needed to face the challenges of managed care, accountability, increased ability to care for patients and a more efficient use of medical records. Our EMR system has helped us do all of these things."
Zywiak of C.J. Singer says training is key. "You need a champion in the organization who encourages people to make maximum use of the system and to even think of new ways the system can improve work flow or be used to study trends and outcomes," he says.
Implementing an EMR system is nothing less than a serious business process, a re-engineering process," Merchant says.
"To reap the greatest benefit, there are two key things to remember: Don't try to do it all on day one and, after initial implementation, the clinic has to make sure that it has complete emotional and intellectual ownership," he says.
"After a while your staff will learn how to adopt continuous improvement techniques through using the system," Merchant adds. "You can help achieve this by providing training or an experimental database that can function as a sandbox in which people can play around with new ideas."
Weaver says the benefits of the system have far outweighed the costs.
"I feel that the ambulatory medical record will be taking the lead in the future and these records will be able to integrate with patient records if they are properly automated," Weaver says. "We are now linked online with a hospital, and data can be exchanged readily between the EMR system in our clinic and the hospital, which has made life easier, made things faster and cut our costs."
Tom Landholt, a physician with Cox Health Systems of Springfield, Mo., says, "Family practice, especially with managed care, requires us to keep a close eye on operations. We have had a MedicaLogic EMR system in place for two years and constantly discover new ways to conduct work-flow analysis from an industrial engineering approach. This has enabled us to review how we are treating various types of patients while staying in compliance with managed care guidelines."
One out-of-the-ordinary use that Landholt found for the system was a result of his being asked to participate in a new treatment trial. "I was visited by a pharmaceutical company that was testing a treatment for a certain type of diabetes," Landholt says. "It was easy to generate reports on all of our patients that fit the test parameters. I was even able to write a letter and automatically merge it with patient addresses to ask if they would be interested in participating in the test. Without the EMR system this task would have taken days if we could have accomplished it at all."
To maximize the benefits of an EMR system will take hard work and effort from all parts of your organization. The road to success can be a long one. "The way to maximize your benefit is to maximize your use of the system," says Carol Owen, a 10-year veteran of health systems and now the clinic product manager for Visteon of Maitland, Fla., which specializes in integrated ambulatory software solutions.
"To really see how an EMR system can improve the quality of care and overall practice management, you need to work with each individual in the practice who can use the EMR system," Owen says. "It is important to remember that people learn differently, and some may need more attention than others. The bottom line is that you need to be patient and persistent."