Call them half measures, interim steps, the low-hanging fruit. Call them what you will, but many medical practices are solving pressing problems in clinical record keeping by adopting computerized systems that fall short of full-blown, structured data entry electronic medical records systems.
"It's a general trend," says C. Peter Waegemann, executive director of the Medical Records Institute, a for-profit company based in Newton, Mass., that promotes the use of EMRs. "The larger the organization is, the more likely it is that they'll implement what I call a component of an EMR. There are really very few successful large implementations that are comprehensive because they are so expensive and it entails re-engineering and retraining."
That said, smaller medical groups, clinics and even small hospitals have been doing quite well installing complete EMR systems, Waegemann says. Current market penetration of full EMRs is estimated to be between 5% and 15%, according to industry analysts, as would-be adopters confront the high cost of acquisition and the disruption of their practices while physicians and staff learn the devices.
A viable option for many physician executives has been to roll out one piece of an EMR. Their choices range from image-capturing systems, to charge capture devices on personal digital assistants (PDAs), to partial EMRs, to full EMRs that can be purchased in components and rolled out piece by piece.
Here are few different approaches to incremental installations of an EMR:
Everyone at Lexington (Ky.) Family Practice Associates knew they had a serious problem with charts.
"Because of our volume, we might see 175 patients a day," says Susan Miller, practice manager for the group of seven physicians and two physician assistants.
Adding to the chart traffic was the filing of returned transcriptions and lab results and, "on a typical day, we'll take 800 to 1,000 phone calls, and about 40% of them would require a chart to be pulled," she says.
After the group added a satellite office in 1998, shuttling charts between two sites made things worse.
"By the spring of 1999, we were setting up ad hoc committees on how to deal with these different kinds of records," Miller says. "We were seeing patients without their medical records, and that made us very uncomfortable."
Miller had spent about a year looking at various systems, including several full-featured EMRs, but rejected all of them. "To jump straight into a point-of-care, provider-entry system from a paper record is a huge departure," Miller says. "It's like light years."
What Lexington bought instead was an image-capturing system developed by Advanced Imaging Concepts of Louisville, Ky. Using the AIC system, doctors still take notes on paper, but the documents are scanned into the system as, in effect, computer-formatted pictures.
The software tags each picture with a limited list of searchable, structured data fields, including patient name, date of birth, patient account number, document number and scan date. A high-speed T1 data line connecting the two Lexington clinics allows ready access to the computerized patient records, including lab reports and prescriptions.
"I love it," says W. Jeffrey Foxx, M.D., a Lexington practitioner for 20 years.
"The biggest thing is you don't have to hunt for charts anymore. I think it's probably a great interim step. It's also an affordable first step."
AIC has 62 installations, ranging from a single-doctor practice to a 119-physician multispecialty group, says Ed Kenney, vice president of sales and marketing. The software costs $7,995, plus $795 per user. A small scanner typically used at the front desk to input insurance cards and patient demographics costs another $995, while a scanner for patient records runs about $4,000. The company charges a 12% annual fee for upgrades.
Miller says Lexington spent less than $150,000 for its system, which includes 55 personal computers, one in each of 32 exam rooms and the rest in various offices. There are also four high-speed scanners, servers and backup systems, wiring in both offices and software. Doctors reduced dictation expenses by $1,800 to $2,500 a month. Employee morale zoomed.
"I've had no turnover (of office staff) since October 1999," Miller says. "I've had someone tell me, 'I'll never leave here because I can't imagine working with charts again.'"
Most of the Lexington doctors look up patient records on computers in the exam rooms, while one still prefers to thumb through paper records, Miller says. The system can be programmed to automatically pull a "mini-chart" on each patient that could include the past six months of prescriptions and lab results, plus records of the past two patient encounters. The mini-charts can be viewed on the computer or printed out for physicians who prefer paper.
Healthcare consultant John Bogacz of West Springfield, Mass., has been looking for years for a computerized medical records system he could recommend to his
clients, mostly one- to five-physician specialty practices. Bogacz has tested AIC's IMPACT.MD system and calls the offering "a fancy computerized filing system," not an EMR, but that's not a bad thing, he says. A system that incorporates the fast and familiar paper note is a blessing.
"Every EMR is trying to force doctors to practice in a certain manner. I don't think I'm going to tell any two of them to practice in one way and they're going to do it."
Docs and data
Denver Health is a publicly owned integrated system of 12 Denver school clinics, 11 community health centers, a hospital and a trauma center and 900 doctors, nurses and other health professionals.
Doctors at Denver Health lacked access to patient charts on about half of their patient visits, according to Andrew Steele, M.D. Steele splits his time between his practice of internal medicine and his role as the director of medical informatics at Denver Health.
In 1999, the system retooled its image scanning and repository system in a collaborative effort involving its own IT professionals, outside consultants, Siemens Medical Solutions Health Services of Malvern, Pa., and LanVision of Cincinnati. The installation recently won an award for outstanding achievement in applied medical informatics from the Association of Medical Directors of Information Systems.
Some Denver Health physicians still rely on paper charts for their patients, but at a minimum all additions to their charts are scanned into the system, Steele says. Other Denver Health doctors use almost exclusively the charts stored in the electronic repository, reading them on 21-inch or 17-inch monitors in the exam rooms or at central computer stations.
The system cost about $1.2 million for hardware, $1.2 million for software and another $1 million for services.
"Ideally, I still believe in the concept of a totally searchable record," Steele says. "We looked at this as a way to ease our care providers along. Give them all a computer. Give them all Internet access, and get them used to retrieving data. We haven't gotten the efficiency of eliminating all charts, but we have gained the efficiency of having access to all the charts."
Systems based on personal digital assistants pick off specific EMR functions such as capture and prescription writing.
MDeverywhere of Durham, N.C., was developed to help mobile doctors, particularly those who make frequent hospital rounds, accurately note their visits, diagnoses and billing codes.
There are three primary problems targeted by the charge capture system, says Ben Feldman, chief operating officer for MDeverywhere: outright loss of information by physicians using paper-based notes, denial of claims for improper documentation and coding, and delays in submitting payment claims due to inaccurate or misplaced information.
"I saw one doctor come in with this glob of paper," Feldman says. "He'd put his billing notes in his lab coat and ran it through the laundry."
Charge capture, he says, "is the lowest hanging fruit to return the highest level of dollars. Eighty percent of all revenues is generated at the point of care, and when you have very, very complicated (reimbursement) rules, that leads to waste."
Practice manager Lisa Zajac of New England OB/GYN Associates, a six-physician practice in Brookline, Mass., says five of her physicians started carrying Palm-based charge capture tools late last year during office visits. They plan to use it on rounds in a month or so, as soon as they can integrate it with their scheduling software, she says.
"You will capture some charges you wouldn't capture before, but that's small compared with the biggest benefit from the system," Zajac says, which has sped up the practice's claims payment and processing time. "Definitely, the cash flow has improved."
Physician Micro Systems of Seattle offers portions of its full EMR system for
use as a prescription writer and as a repository to store and retrieve transcriptions as electronic documents.
Laura Zborilova is health information and clinical systems manager for Skagit Valley Medical Center, a 60-physician, multispecialty group in Mount Vernon, Wash., and a Physician Micro Systems customer. Zborilova says transcriptionists are trained to type ".D:" before transcribing the date on an encounter, thereby creating a searchable database field for that date.
Zborilova says the group started looking at EMRs about three years ago but abandoned the idea because of the expense. She approached vendors last year about selling her group a partial system, and only PMS responded.
"We pulled this project off for under $50,000," she says. "That was software, hardware, the whole thing. If you accept the premise that an EMR is the long-term goal, the attractive feature of this is the EMR is growing while we're getting a part of our records online."
Several e-healthcare vendors cut up and sell their patient records systems in pieces, but Allscripts Healthcare Solutions of Libertyville, Ill., has to be the teppanyaki of EMR slicing and dicing. The company, best known for its PDA-based prescription writer, acquired EMR-maker Channelhealth in January. By then, Channelhealth had whittled its EMR into eight salable slivers.
Cedric Priebe, M.D., a practicing pediatrician and chief medical officer for Allscripts, was reluctant to give specific prices but said some of the parts sell for as little as $100 per physician.
Andrew Gettinger, M.D., is associate medical director at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and as its medical director of information systems has been working to improve a homegrown electronic medical records system there. DHMC recently teamed with Allscripts to beef up its clinical note system, adding more clinical and administrative support functions to it, while hitching on several other Allscripts EMR modular functions.
DHMC is staffed by 300-plus physicians affiliated with Dartmouth Medical School and 250 physicians in clinics in New Hampshire and Vermont.
Gettinger advises his colleagues in integrated healthcare who want to do an EMR that few of the vendor-available software systems can handle both inpatient and outpatient needs and that none do it well enough to produce a perfect fit right out of the box.
Yet the hardest part of making the system work is the human element.
"Even if you bought today's leading system off the shelf, the energy is still around the installation," he says. "My counsel is to be very cognizant of where they are. Pay attention to the institutional culture. A lot of this has to do with how to get there."
Medscape, of Hillsboro, Ore., maker for 15 years of a full-blown EMR, in early 2000 launched its Encounter EMR, which can be leased for $99 a month. While the Medscape flagship product, called Logician, has all the bells and whistles of a full EMR, Arthur Leibowitz, a Medscape vice president, concedes it is "a very expensive product."
With Logician, Medscape is targeting the 150,000 physicians who work in large group practices. Using Logician also requires "a sea change in the way physicians practice," Leibowitz says.
"We said we needed to come up with something on the other end that does not require such a dramatic change and is not so expensive," Leibowitz says. With Encounter, users give up some flexibility and features found on Logician.
Medscape's AboutMyHealth sends, receives and stores e-mails that can be integrated with either Logician or Encounter. Plans call for launching an Internet-based lab tool this fall.
Still, doctors should not abandon the idea of doing "the whole shooting match" with an EMR, says Scott Yates, M.D., who started using Logician in October 1999.
Yates is president of North Texas Medical Group, a five-physician internal medicine practice with three offices.
Yates says that in September 1999 he designed his new office without a chart room knowing he would be using an EMR. It took him and his first employee, Amber Choate, less than a month to get comfortable with the functions on Logician and get the system working, Yates says.
Choate, who was no computer expert when she started, now is the computer system administrator. New doctors have learned to use the EMR in about two weeks.
"If you're going to jump in the pool, jump," says Yates. He says his plunge has cost about $150,000 so far for sofware, hardware and connectivity. The payback, he says, has been increased efficiency and improved quality of care.