Physiatry Practice Management Resources

The process of treating a patient involves a flurry of activity and data collection that ideally should enjoin at a single place and a single point in time: the patient chart at the time of the patient encounter.

For doctors to be efficient, accurate and compensated fairly, they must have access to information from every person -- clinical or administrative -- who dealt with the patient relative to the current treatment.

Not that the ideal always happens.

Getting that to happen is the attraction and promise of the electronic medical record. But the transition to EMR from paper charts, what with the expense, training, work flow change, potential privacy issues and other side effects, can be difficult, even for practices enthusiastic for the technology.

The anxiety is palpable. "The first week I was using the EMR I felt it was driving me instead of the other way around," said Thomas Troost, MD, partner of the three-doctor Washington (D.C.) ENT Group.

But proper preparation, training and support before, during and after the electronic transition can help melt any fears away -- or at least give you an idea whom to call if something goes wrong.

In time, Dr. Troost's anxieties faded, and he prefers an EMR over paper charts. "It became much easier to get at information I need when I need it," he said.

Prepare

One of the major reasons for buying an EMR is to improve what you see as an inefficient work flow. So if you're going to buy a system, you need to know what your current work flow is and what you want to change. Often, doctors who have made successful transitions look first to see if there's anything they can standardize in easy-to-fill templates. One doctor who did just that is Charles Roman, MD, a solo internist in Columbus, Ga., who employs a physician assistant and a staff of 15 at an in-house CLIA laboratory.

Before implementing the system from Irwindale, Calif.-based MedicWare Inc., Dr. Roman worked with a practice consultant to develop templates that represented processes used to treat his patients' most common problems, such as back pain, chest pain, diabetes, asthma and wheezing. The templates cover questions to be asked and include a list of commonly prescribed procedures and drugs.

Developing such a system made for a simpler-to-use system and a simpler transition from paper. Now, when either Dr. Roman or his PA sees a patient with one of the templated conditions, the patient's notes can be entered by clicking a mouse instead of typing. This eliminates the need for transcription. Dr. Roman said $3,000-per-month transcription costs were a major reason he decided to buy an EMR when starting his solo practice two years ago.

"The process outlined in the templates is not something I force on my PA, but as a guide, it helps keep us both on track," Dr. Roman said. The system does a better job than paper in coordinating "the massive amount of data we collect just in this office," he said.

In its preparation, Dr. Troost's Washington ENT Group wanted to figure out how its move to an EMR would affect its contact with patients and others outside the daily flow of the practice. The practice itself was looking for "total integration of the patient encounter from check-in to check-out and even with things that happen outside the office, such as lab tests," said Barth W. Doroshuk, the group's chief operating officer.

The group considered, then nixed, the idea of patients filling out questionnaires electronically -- too many patients, many of whom are senior citizens, likely would be uncomfortable using computers, Doroshuk said. The solution was to let patients fill out their data on paper, have the receptionist enter it into the EMR, then shred the questionnaire.

The group also realized it needed a "communications gate to the outside world, which is still primarily paper-based," Doroshuk said. For example, most labs it deals with don't have an EMR. So certain office staff are assigned to scan in records faxed from other groups.

Train and support

After that advance work to find out what your EMR can do, the next step is to train everyone -- fellow doctors, nurses, assistants, staff -- to make sure they can carry the EMR to its hoped-for potential. Often the manufacturer of your system will help provide that training.

At the Washington ENT Group, its EMR software vendor, A4 Health Systems of Cary, N.C., trained doctors and staff in their office and in A4's offices. Each employee and doctor had at least one week of training.

The training was done "carefully and diligently," Doroshuk said. After each of the multiple training sessions, the staff had a "debriefing" in which they could discuss problems they are having with the system.

Training did not stop when the system was put in place. The group has refreshers and support training every six months. Also, internal training is ongoing. Topics range from normal office procedures to computer policies.

It's important that the system stay current, Doroshuk said. If people responsible for entering information get behind in their work, doctors may be forced to work with paper and electronic data at the same time. That would be more confusing and less efficient than had the practice just stuck to paper records.

The preparation that practices make beforehand can make the training phase and transition easier than expected.

For example, the Brewster (N.Y.) Medical Group needed only a few hours of training to get rolling on its EMR system, from iMedica of Mountain View, Calif.

Jeffrey Michaelis, MD, an internist with the group, said the training was "pretty straightforward." He added, though, that the practice spent two months beforehand having nurses work on paper forms that replicated what the screens on the system would look like, making the transition easier. Most nurses were able to use the new system comfortably after only an hour or so of practice, Dr. Michaelis said.

Making life simpler

By following these steps, practices that have successfully implemented EMR systems find that they do make life easier.

The Washington ENT Group's system has shortened patient stays at the office. When patients sign in, the time is automatically entered and a message pops up on the wireless computer of their physician. In the exam room, the doctor can quickly access all information related to the patient: specialist notes that are scanned in, lab test results, notes from previous visits, etc. And most of the notes on that encounter can be entered with a few clicks on pre-set options. Finally, the doctor enters instructions and prescriptions, and by the time the patient checks out, all of that information is available at the front desk.

"We pride ourselves on the fact that a patient rarely has to pay more than a one-hour parking fee, or that patients who come here on their lunch hour will make their 2 o'clock meeting," Doroshuk said.

Dr. Michaelis said the payback in terms of dollars on his new system results from two features. First, because the system automatically suggests the procedure code, he believes he is better able to bill at the right level. Second, because it eliminates the need for pulling charts, once he enters all of his patients into the system, he should be able to eliminate one full-time clerical position at his office.

When implemented with care, electronic medical records can and do work for many doctors. "Electronic [medical] records provide an answer to a single question that you hear over and over: 'Where is that piece of information?' " said Pat Wise, executive director of CPRI-HOST, a Bethesda, Md.-based consortium of EMR advocates.

Written by: Larry Stevens AMNews Staff

Additional Information

• Patient arrives. Receptionist enters the patient's name. Patient information appears on the screen. Receptionist verifies the information. The system logs the time.
• An alert pops up on the computer of the nurse or medical assistant.
• The patient is brought to the exam room. The nurse or assistant asks a series of pre-set questions and indicates patient responses on the computer
• When the nurse or assistant completes the input, the patient's physician receives a message that the patient is waiting in a specific room.
• The doctor examines the patient and enters information in the physician section of the EMR.
• After the exam, the patient goes to checkout where printed patient instructions and prescriptions are waiting. The receptionist's computer displays billing and follow-up information.