TO EMR OR TO NOT EMR

1. TO EMR OR TO NOT EMR That is probably no longer the question.

2. WHEN TO EMR? • At some point most office will have to adopt some form of Electronic Medical Record. • By planning ahead you can make the process less painful. • Many of these processes you may already have implemented.

3. HOLT FAMILY PRACTICE • We are a small group practice in a bedroom community of Lansing. • 4 1/4 Physicians and 1 Physician Assistant. • Practice started in 1979. • We launched our EMR in December 2003.

4. We had discussed the possibility of moving to an EMR over the past several years and the cost seemed prohibitive. Things were working OK doing things the way we were doing them. There did not seem to be enough benefits to justify the expense. Then in 2002 we hired a new partner to help replace our senior partner who had cut back. He brought with him about 800 charts. We were out of room. Looking at a $50,000 building expansion made an EMR look more attractive.

5. PLAN AHEAD • Organizing your charts can make the transition easier. • Having a good Problem List and Medication list can make it so you can quickly get started entering patients. • Decide where you are going to put the paper charts. Onsite vs. Offsite.

6. PLAN AHEAD • Spread some of the Equipment purchases over a couple of years. Thus lessening the financial strain. • Find out what equipment you are likely to need for any EMR and let that guide your purchases.

7. LOOK AT OTHER OFFICES • If there are office near by that have an ERM it can be helpful to make a site visit and get a feel for an office that has an Electronic Chart. This can help you visualize this type of system in your office. • Road Trip.

8. HOW WE WENT ABOUT IT • We had a Practice Management system that used “Dummy Terminals” • We began replacing them with PCs a few at a time. This allowed us to continue our old system and prepare for the future. By 2003 We had already replaced all of our Front Office and Billing Department terminals with PCs.

9. HOW WE WENT ABOUT IT • Watch for sales…I found that Dell cuts its prices significantly at the end of the year. So if you figure what you might need and watch their site you can save by buying after Christmas. • Dell also has a Health Care site that does give you somewhat of a discount.

10. HOW WE WENT ABOUT IT • We looked at several different products and finally settled on A4 now part of Allscripts. • There were several reasons: • Cost. • Ease of Customization. • Several other sites fairly close so we could look at others using the software. • Integration with P.M. software.

11. HOW WE WENT ABOUT IT • We found out what equipment was compatible and purchased the provider and nursing laptops in 2002, again spreading the cost over several years. • We contracted locally for pulling wires, etc. • We started with a minimum set of equipment planning on expanding. We have since purchased several printers and desktops.

12. HOW WE WENT ABOUT IT • We have an unfinished portion of our basement so we have the luxury of keeping our paper charts on site. This eliminated any storage costs and allowed us to reduce what we felt we had to scan. We still pull a “paper” chart occasionally to scan more items.

13. THE PEOPLE • Not everyone will be in the same place. • Opting out is not an option. • You have to have a champion. This will probably be the office Geek = TechnoDoc. If that is you then you will have to take a “Patience Pill” • Get an idea of everyone’s level of computer comfort. There will be a big range.

14. THE CHARTS • We elected to scan only the last 3 yrs progress notes and just the most recent studies, labs, xrays etc. We scanned the last 3 yrs of consults when the patient had more in the paper chart. • We entered people as we went along by entering problem list and meds as well as scanning about 4 days in advance. Then recheck the day before.

15. THE CHARTS • We brought the paper chart into the room as well for the first 2-3 visits then would mark it so it did not need to be pulled again. • After 2 1/2 years we moved all our paper charts to the basement. We still see people that have not been entered so we grab their chart see the patient and then they get entered after the appointment.

16. THE COST • Emotional. • Time. Providers and Staff. • Financial.

17. THE COST • EQUIPMENT = $45,000 • SOFTWARE = $66,000 • STARTUP = $20,000 • TOTAL = $131,000 • Startup includes training both at A4 and onsite as well as equipment installation and setup.

18. THE COST • Productivity will be down for the first 4-6 months and should be back to at least pre EMR levels by the second half of the year. • Different individuals will be “up to speed” at different times as they will have different comfort levels. • We have not reached a level of productivity above our Pre-EMR level.

19. THE COST • It will be stressful and initially the days will be longer. • There were a few tears and maybe a few explicatives, but no body quit and by October even the people least comfortable at the start admitted they would not go back to the old way.

20. THE BENEFITS • THERE IS NEVER A LOST CHART. • Remote access. You can securely access the EMR from anywhere you can get remote access. This allows you to finish charting at home after hours. Review a patients chart the day before their visit. Access your chart while you are admitting someone at the hospital.

21. THE BENEFITS • Labs come directly into the chart as they are done. • When a consult, path report, or other test results are received you can immediately look in the patients chart. You no longer have to wait for a chart pull. • Internal messaging is essentially email and can be handled just as fast.

22. THE BENEFITS • Prescription refills are handled right on the patient’s medication list. • Faxing prescriptions and E-Prescribe even to PBM’s like Medco. You can’t believe how much time this saves and the patients really like this “cool” feature.

23. THE BENEFITS • There is data out there about increasing the number of 99214 visits that you will do in a day. This will depend on how much your practice had been working on this level of coding before your implementation. We had been aggressively training ourselves for several years. We have seen a minor increase for our physicians and a greater increase for our Mid-levels. We also all feel more comfortable with our coding as it is all checked by the EMR software,

24. THE BENEFITS • Our financials have mostly improved in staff costs. • We used to dictate 85% of our visits. • We had several people whose jobs were purely related to the paper chart either finding it, running it, or filing paper.

25. THE BENEFITS • The direct interface from the EMR to the PM has allowed us to reduce our billing staff by about 1/2 FTE. • Our printing costs are also radically reduced.

26. 2003 • Front Office = 8.5 FTE for a salary of $171,572. • Billing Department = 3 FTE for a salary of $ $126,707 • Transcription = 1.5 FTE for a salary of $48,417

27. 2005 • Front Office 6.5 FTE = $156,360 • Billing Dept. 2.5 FTE = $98,171 • Transcription Occasional = $500.

28. COST REDUCTION • FRONT OFFICE = $15,213 • BILLING DEPT = $28,536 • TRANSCRIPTION = $47,900 • TOTAL = $91,649 • Our front office staffing is now down to 4.75 FTE and this has held constant. • We have added an Internet based Patient portal that we hope will continue to support these reductions.

29. OTHER BENEFITS • Direct faxing of referrals from EMR. • Patient Safety. All scripts checked for drug interactions and allergies. • Quality improvement. HEDIS, DOQIT. • Reporting capabilities allow for improved performance on physician performance programs like E-Blue and other similar programs.

30. Other Benefits • When you have a computer in the room with a patient you also have immediate “at the bedside” access to other internet resources ie. Epocrates, MDConsult, Firtst Consult and a multitude of patient education resources that you can access and print for the patient.

31. Pharmacy Management • Many EMRs are adding additional Pharmacy/Formulary resources including RxHub which can track your patients prescription usage including those from other providers. This also allows you to to participate in E-Rx incentive programs such as the new Medicare incentive.