Primaris Press Release
Originally Published in |
Contact: Matt Heger Primaris Communications Department (800) 735-6776, Ext. 136 |
EMR Implementation Spells Increased Efficiency & Satisfaction to Docs & Patients
by Jeanne Thoma, MS, BAPhysician Services Program Manager, Eastern Missouri
Dr. Kirby L. Turner and his colleagues at the Kneibert Clinic in Poplar Bluff recently celebrated the first anniversary of their successful electronic medical record implementation, but the last gift they want is paper. In fact, they have a basement full of charts awaiting disposition, because the clinic is now truly paperless.
Their process to this end followed a well-planned course. And generously, MSMA Board Member Turner is happy to share with his Missouri colleagues just how they did it and what they have learned. This is his story, Dragnet-style: just the facts.
Located in Southeast Missouri for over fifty years, the Kneibert Clinic is situated directly behind the Poplar Bluff Regional Medical Center-South. The practice is open seven days a week and is home to 19 physicians and 4 nurse practitioners specializing in family medicine, internal medicine, pediatrics, surgery, urology, optometry, and mental health. Their desire to bring treatment to a new level inspired them to undertake this workflow change, and they can now rest assured that everything is very up to date at the Kneibert Clinic.
As a Primaris Program Manager working with Medicare to engage physicians in electronic medical record ( EMR ) implementation, I looked forward to visiting the Kneibert Clinic. They were one of the early applicants to DOQ-IT, a Medicare-funded program that ultimately will assist physicians in submission of care management data to a clinical warehouse. Their stated reasons for EMR were improving care, meeting evidence-based guidelines, and reducing errors. They were focused on data management and wanted to be able to easily access quality measures and benchmarks along with alerts. Unequivocally, those goals have been met and they have a great story to tell.
I was struck by the calm atmosphere of this large clinic. There were no charts in sight. Only Dr. Turner was expecting me, but every doctor's desk was clutter-free -- no charts, no phone messages, not even sticky notes. Physicians and nurses were working everywhere with slim tablets and laptops—a countertop, leaning against a door jamb, or at a nursing station, three in a row (photo) where only one worked previously. Gone is the flurry of the chart search, the medical assistant looking for the chart left in the exam room or inadvertently carried off by the physician, or the just-plain-missing chart. Absent are the stacks of charts on the doctor's desk awaiting dictation approval, lab sign-off, and initials or signatures.
After the discontinuation of paper charts, and Kneibert can attest to this, the time that these record-seeking activities consumed is even more apparent. There is now an efficient clinical process at work, patient-centered and family-friendly. Kneibert Clinic is a happy group and by all accounts, a pleasant place to work. They did not lose one employee as a result of this implementation!
They are constantly asked how they did it. Insofar as their process, they followed W.E. Deming's Principles of Total Quality Management – plan, do, evaluate, correct, and review again. Their use of an EMR Committee who did the heavy lifting of vendor assessment & selection was one of the keys to their ultimate success.
The EMR Project Team had one Physician Champion, James Wilkerson, M.D., and a Steering Team consisting of 5 MDs, 1 NP, 2 LPNs, 2 administrators, 1 business office staffer, and 2 IS managers, one acting as project manager.
The committee began meeting in October 2003 and undertook the following:
- Discussed and set goals of the committee
- Discussed reasons for evaluating EMR systems
- Developed the list of features and requirements they would use to evaluate the different systems. The criteria developed by this committee are noteworthy and can be viewed in five broad categories: workflow, clinical management, charge capture, templates, and interfaces. (Figure 1)
- Reviewed and discussed information about a number of different EMR systems
- Sent a defined set of questions to a number of vendors (Figure 2)
- Reviewed responses to these questions along with other information and surveys from medical magazines
- Chose 5 vendors to demonstrate their system to the committee in a 1.5 to 3 hr. presentation
- Evaluated the products and selected 3 vendors to return for a full day hands-on demonstration for the committee members
- These 3 vendors were evaluated using the criteria shown in Figure 1, but with columns added to input Scale of Importance [3 =Very Important, 2=Important, and 1=not as Important;] and for Rating [3 =very good, 2 = good, 1 = poor, and 0= doesn't do.]
- Narrowed these to 2 vendors from whom references were requested, contacted, and interviewed by the committee
- Site visits were arranged which took 6 committee members to Branson and West Plains , Missouri . Their site reviews included talking with physicians and nurses and observing use in a real clinic setting.
- A cost evaluation was prepared and reviewed
- A system was selected by the committee and the results presented to the Executive Committee, followed by presentation to the entire physician staff (See Figure 3)
The importance of this planning is obvious for a group as large as Kneibert Clinic. They had to be sure they were getting what they wanted. And while numerous available electronic records have much in common, their differences are not insignificant. Taking the time to really brainstorm and document interests and preferences will pay off when you get to try out a system OR when you visit a clinic that has implemented a record in which you are interested. As any EMR user will tell you, the sea change you are bringing to your way of practice and your office warrants a product that is absolutely right for you.
After the decision was made to purchase, there was never a dull moment. Nearly every month had major objectives. After super-user training, six months was the length of time from software installation to full-scale use. Each monthly milestone deserves discussion but space does not permit such in this article. Of particular note is the preloading of records. Conversion of all existing records was not an option for a clinic of this size and it was determined to preload specific data from each patient record seen in the last year or having an appointment in the future: face sheet, problems, medications, allergies, preventive care, immunizations. Physicians also selected items from the paper chart to be scanned into the EMR , such as test results, visit notes, etc. Lab results for the previous 10 months were loaded from their lab information system.
The postponement of full implementation (Go Live) was entirely due to the realization that even though a new system/new calendar year sounded like a good idea at the time, i.e. being on the new system January 1, the year-end and the holidays were not the time for any change of this scale. The month of January allowed for intensive training sessions and two weeks of transition time for use of the new record system. Thus, the comfort level was high at the actual go-live date, and even though the vendor had recommended reducing patient volumes for up to six months, Kneibert Clinic found that normal patient scheduling resumed after one week of using the EMR .
After one full year, physicians and nurses were asked to complete an evaluation of the EMR (Figure 4). Thirteen physician respondents rated their experiences and we'll share a few highlights where the ratings were consistently much or somewhat better:
Documenting visit (70%)
Prescribing new meds (85%)
Refilling prescriptions (100%)
Phone calls from patients (70%)
Finding information (92%)
Chart availability (100%)
Only one physician was undecided as to whether s/he would want to return to a paper chart system.
Anecdotal feedback is often the most revelatory. Dr. Turner believes one of the biggest changes for him involves following-up on abnormals. Before, he had a paper process, but it had a chance for error. Now, “there is no way an abnormal can get by him.” Abnormal results are flagged to ensure that appropriate steps are followed, and each referential note returns to Turner's desktop.
Another physician is enthusiastic about the prompting of U.S. Preventive Task Force guidelines and the reminders for preventive care, and feels a good EMR will “lead you down the path to do what ought to be done.” Others told me they are essentially done with their charting when they leave the exam room – tests have been ordered, prescriptions are written, and patient instructions are distributed. The doctors are home for dinner, have time with their families, and later in the evening may go online to review labs or test results.
Administrators are greatly relieved over compliance issues. There are no charts floating around. They can assure patient confidentiality, privacy, and security. The record notes whenever a record is accessed, when and by whom. Clinical notes for mental health patients are locked (“red keyed”) to everyone except the physician or his designee.
Turner says his biggest surprise is that he's learned to use it, and is excited because it has shown him, “There's a future for us as physicians. Healthcare cannot continue to escalate in cost and complexity. We must provide higher quality care in less time. To stay here, physicians must become more efficient.”
Now that they have a year of full implementation and record entry, Kneibert plans to make greater use of comparative data. They can compare their doctors to national standards and can undertake “peer review in a friendly way.”
As one of the oldest non-university, private clinics to sponsor a fully accredited CME program, Kneibert Clinic has always been committed to education as a means to enhance the quality of medical care provided in rural Southeastern Missouri . Now, the ability to easily extract meaningful clinical data from the EMR will enable the clinic to identify areas where educational programs can be developed to help physicians meet or exceed national benchmarks in patient care.
Whatever your reasons for EMR adoption may be, take heart in the resounding success of the Kneibert Clinic physicians. Patient visits increased by more than 4,000 in the year of implementation. Kirby Turner will tell you that it's a journey that will never be finished, but he and his partners should pause for applause: their notable adaptation to a new paperless workflow is a positive example for all Missouri doctors.
Figure 1. Criteria for Selection of EMR
Workflow
Messaging, tasks, results management
Ease of use
Medication, problem and allergy list maintenance
Copy previous visit or move parts of visit forward to current visit
Chart by exception
Standard default normal for most diagnoses
Show normal action plan for diagnosis showing medications, labs, x-rays with one-click ordering
Clinical management
Accommodates multiple chief complaints
Handle “oh by the way”
Obtain latest information on problems and medications
Prescription management
Health maintenance tracking and reminders
Patient education information display and print
Body part display – drawing and marking
Photos of injury/disease linkable to chart
Charge capture
E & M code checking
Chart information can be taken by physician to hospital or nursing home
Charges can be documented and entered while at hospital or nursing home
Access system from home or anywhere else outside of clinic
Previous test results can be viewed and graphed
Referrals can be created and tracked
Templates
Use with or without keyboard
Voice entry into template fields
Insert voice points that transcription will type and auto insert
Patient chart view will be different by physician and by specialty
Reports to analysis outcomes/treatment
Order lab/xrays with diagnosis checking
Physician can use dictation or paper form and have someone else enter information into templates
Ease and cost of customizing templates
Interfaces
Interface with medical equipment-EKG, Holter, spirometry
Interface with practice management system, laboratory, radiology, hospital system, patient link
Scan and link paper documents to patient's chart
Use PDA for some parts of EMR
Off-site back-up system available
Receive discount on malpractice insurance
Figure 2. EMR System Information Request
Company Name:
Product Name:
Number of years company has been in business:
Number of years providing EMR product:
Age of current product:
How often product is updated:
Number of current customers:
Breakdown by number of physicians in group:
1 – 10
11-20
21-50
51-100
> 100
Number of multi-site groups:
Provide references of clinics in 21 – 50 range.
•
•
•
What physician specialties are using your product?
Please provide the following information by year for the last five years:
Total number of customers:
Number of new customers per year:
Total company revenue:
Amount spend on R&D:
Amount of net income (loss):
Please provide the following technical information.
Hardware platform:
Operating system:
Database management system:
Point of care devices:
Wireless devices:
How is your product priced?
Figure 3. Benefits of Electronic Medical Records
(as documented by physicians after moving to EMR)
• HIPAA: Unlike with paper records, access to EMRs can be restricted so that staff access to records is based on job function. Audit trails track record access and usage.
• Reduce transcription cost
• Reduce medical records department cost
• Reduce number of FTEs per physician
• Chart copying expenses reduced
• Malpractice premium discounts from 5-10%
• Improvements in charge capture range from 3-15%
• Reduce claims denial
• Increase in average charge per visit from11 – 62%
• Prescription refills take less time. 15 minutes reduced to 3 minutes
• Lab results filed electronically reducing time to manually file
• Nurses time looking for patient information is reduced 20-80%
• Electronic referrals reduce the time it takes to do paper work to refer a patient
• Patient satisfaction and loyalty improved.
• Instant access to chart for answering questions and providing educational materials.
• Physicians have more face-to-face time with patient because of less time searching for information
• Better health maintenance follow-ups
• Charts always available. Don't have to wait for chart to be pulled to answer phone call questions or refill prescriptions
• Access charts from home, hospital, etc
• With charts being electronic, there is no issue with illegible or unreadable te x t
• Assists with E& M coding compliance
• Aids in meeting HCFA and other regulation guidelines
• When problems are documented in the EMR , an ICD9 diagnosis code is automatically assigned reducing the time spent looking for the correct code
• A Medical Group Management Survey (2004) of members' practices showed that the Number 1 technological need for 2003 was EMR
Figure 4. EMR Survey One Year After Implementation
Sample Questions for Physicians
When documenting a patient visit do you:
Use the tablet PC in the exam room
Use a piece of paper, then enter into EMR
Print off summary page, write on it, then enter into EMR
Print off last visit, write on it, then enter in EMR
Look at patient chart on PC before entering room, see patient, enter information into PC outside of room after visit
If you do not take your tablet PC into the room, please indicate why.
Rate the following forms (5 = excellent, 1 = poor):
HPI form
Acute visit form
PMH/PSH form
Family/Social history form
Risk factors form
ROS form
PE form
Problems form
Test management form
CPOE A & P form
Patient instructions form
Rx Refills
Sample Questions for Nurses
How would you rate the following duties comparing EMR use to before EMR (much better, somewhat better, same, worse, no answer)?
Working up a patient
Prescription refills
Phone calls from a patient
Working up a patient, you do which of the following?
Use the tablet PC
Use paper, then enter into PC
Write on printed summary, then enter into PC
Print last visit, write on it, then enter in PC
Other
When updating patients' medications, do you?
Ask patient if meds have changed
Read off meds from the chart and change them if needed
Other (patient brings in meds or a list)
MO-06-28-DOQ JUNE 2006
This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri , under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.