Implementing an Electronic Medical Records System-You Can Do It

Implementation of an electronic medical records (EMR) system is neither a fast nor a simple process. For some practices it takes years to get physician buy-in, make a decision, train staff and convert to digital records.

Explore this issue:
January 2007

Texas Ear, Nose & Throat Specialists in Houston looked at EMRs for three years and almost bought products on two separate occasions.

We backed off, like on the eve of the wedding, said practice administrator Louise Eddy. No matter how good the product looked, if we couldn’t make this work for our physicians, we knew it would fail.

Finally, the 25-physician practice found an EMR system that provided an integrated audiology component and an ENT-customized progress note that was easy to edit and complete. If it’s too hard, you can’t get anybody to do it, Ms. Eddy said.

Her practice and others have also discovered that an EMR system is not cheap. While some physician groups have paid per-physician fees of $5,000 to $18,000 to implement the system and $1,000 to $3,500 annually for customer service, a 2005 study in the journal Health Affairs puts the cost even higher. The journal estimated $44,000 per physician in initial costs and $8,500 per physician in yearly maintenance expenses.

Numerous studies have shown that cost is the biggest reason for low adoption rates. And yet, most practices who successfully implement an EMR system report a return on investment (ROI) anywhere from a few months to a couple of years. On a national level, an estimated $80 billion could be saved annually with an EMR system, according to studies by Health Affairs and the RAND Corporation.

You have to look at the expense over time, said Ronald Kuppersmith, MD, of Texas ENT & Allergy in College Station. A lot of people look at the numbers and say ‘this is a lot of money; I don’t make that much.’ But you have to compare it to your existing costs. In our situation, just by eliminating dictation, we paid for the software licenses.

D. Thomas Upchurch, MD, Chief Medical Officer of the EMR company AllMeds, said most practices see a return on investment in six to seven months. If somebody’s not that busy in their practice, they won’t make money on the EMR initially, he added. It’s done by saving costs at several levels and helping the doctor see one or two more patients every day. What every group should do is run a very careful return on investment analysis before putting in a system.

Physician Support Essential

Another barrier to EMR usage is lack of support from practice physicians, according to a study by the Medical Group Management Association (MGMA) Center for Research, University of Minnesota School of Public Health. In addition to cost worries, some doctors are concerned about loss of productivity during the transition, whereas others are uncertain about the ability of physicians to use the technology.

The first step starts at the top, with buy-in among the practice leaders, Dr. Upchurch said. In today’s business world, such a ‘top-down’ attitude may seem anachronistic, but the scale of an EMR’s implementation and the emotional magnitude that can accompany it require steadfast direction from those who have made the decision.

D. Thomas Upchurch, MD

D. Thomas Upchurch, MD

I purposely did not pick the product myself, Dr. Kuppersmith said. I made sure that every doctor-we had four at the time-looked at a variety of products and made the decision. There has to be buy-in from everybody or you end up in big trouble.

He added that people don’t like to change. An EMR not only changes what the physician does, but also what most people in the office do.

Although physician buy-in may be more difficult in a larger practice, Ms. Eddy said that all 27 members (25 doctors and two physician assistants) of her practice came on board. You have to have 100 percent physician buy-in and intimate physician participation in the integration process. There has to be a designated implementation team that includes physicians, and is empowered and supported by the rest of the group.

Why Go to All the Trouble?

There are hundreds of EMR systems available. An excellent source that describes EMRs and what they do is ( ). This site and other references note the many advantages of EMRs: they reduce mistakes; replace paper patient charts with computer records; automatically capture each and every service; store physician notes, X-rays, prescriptions, and other medical information; remove time-consuming dictation and transcription; and seamlessly move data from the back office to the billing staff.

In written testimony about EMRs to the US House of Representatives in April 2006, Jack Price, Vice President of Health Information and Management Systems Society (HIMSS) Analytics, said, Simple things such as replacing the bad handwriting of harried physicians move health care providers toward more accurate treatment of patients while reducing the time staff and pharmacists devote to dealing with drug interactions or prescribing issues.

Workflow is improved with user-friendly screens to locate patient data, consistent electronic data sets for every patient, and the elimination of duplicate records, Mr. Price said in his testimony, adding that digital documentation helps meet standards set by the Health Insurance Portability and Accountability Act (HIPAA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Centers for Medicare and Medicaid Services (CMS), and other agencies that have oversight of hospitals and clinics.

I think the real benefit is that you can provide better care with an electronic medical record, Dr. Kuppersmith said. There is so much information in medicine that there’s no way you can keep up. EMR systems are starting to provide details that you might not remember. In addition, they provide information on drug interactions and notify you of potential problems.

Getting Started

Once the decision is made to purchase an EMR, consider the following recommendations from physicians and EMR providers:

First, set goals. Define what the system needs to do. Then select a physician champion, preferably one of your practice’s most influential physicians, and bring everyone on board. While this is easier in a solo practice, a larger group will need a team that must include the physician champion and a manager to help implement the system.

Ask colleagues about systems they’ve purchased and attend EMR presentations at association meetings. Find out if the EMR system you’re considering will interface with your current physician practice management (PPM) software. If not, you may need to purchase a compatible PPM-EMR system. Additionally, look at all the capabilities your proposed EMR will handle, to see if they meet your needs. For example, most EMRs will enable physicians and staff to create and complete tasks, find information, view labs, write prescriptions, and create patient notes.

An ASP or Client-Hosted Server?

Consider alternatives. The traditional EMR system includes a data server located within the physician’s office; patient information is therefore stored onsite. If the upfront cost of this client-hosted server is too hefty, ask the EMR provider if you can pay for it in monthly installments. Another option is an application service provider (ASP), where the patient data is located off-site on the vendor’s Web site.

Jennifer McDuffee of Nuesoft Technologies, a provider of PPM systems and ASPs, noted that from the end user’s standpoint, there is really no discernable difference between an ASP and client-hosted server.

Ronald Kuppersmith, MD

Ronald Kuppersmith, MD

According to Dave Ott, Vice President for Technical Services with NextGen Healthcare Information Systems (which offers both client-hosted and vendor-hosted servers), an ASP has a lower start-up cost because the hosting fee is billed monthly, so there is no initial outlay for server hardware, operating systems, installation systems, and the like. Any size group could deploy EMR using the ASP model, but typically the smaller physicians’ offices do not have the budget for IT and IT staff to support an internal network, he said.

Heather Caouette, a spokesperson for the EMR company eClinicalWorks, noted the different costs with their systems: the upfront purchase of a client-server, integrated physician management, and EMR solution would be $10,000 for the first provider and $5,000 for each additional physician; a subscription model (i.e., monthly installment payments) is $400 per provider, with decreases by 10% for each additional provider up to six; and with an ASP model, the cost would be $400 per month per provider plus a $100 hosting fee.

At Texas Ear, Nose & Throat Specialists, Ms. Eddy said that her group chose to have its own in-house server because practice members weren’t comfortable having patient data reside on someone else’s server. However, she believes that the ASP applications have a lot to offer, particularly for small group practices.

EMR Certification

Another option in determining the type of system to purchase is EMR certification. This year, the Certification Commission for Healthcare Information Technology (CCHIT), a nonprofit group formed by health IT associations and awarded a contract by the US Department of Health and Human Services, announced the first 20 ambulatory EMRs that met more than 300 criteria for functionality and security. The certified products are listed on its Web site: .

Although the concept of certification is widely approved, there was criticism that the first CCHIT process was geared to primary care, with requirements for templates covering well-baby check ups, ob/gyn visits, and other items not pertinent to specialty practices.

The CCHIT Web site noted that the 2006 Ambulatory EHR Criteria represent basic requirements that the Commission and its Workgroups believe are appropriate for many common ambulatory care settings. CCHIT acknowledges that these Criteria may not be suitable for settings such as behavioral health, emergency departments, or specialty practices and our current certification makes no representation for these. Purchasers should not interpret a lack of CCHIT Certification as being of significance for specialties and domains not yet addressed by CCHIT Criteria.

CCHIT spokesperson C. Sue Reber said that the Commission is likely to begin to address specialty certification within the next year, but will not deal with all specialties simultaneously.

Additional Tips from Providers and Physicians

Get references and do site visits.

Dr. Upchurch suggested that physicians ask for five or six references from an EMR company and that they pay site visits. In addition, he said to check on the retention rate for the EMR. In the US, about 50 percent of the practices chuck their EMR in a year or two. Why? It doesn’t work. They go to a show or somewhere and see a speech recognition program or some other fantastic stuff. They buy it and they don’t do the research first. Or they buy a system that doesn’t have the specifics for their specialty.

In his written testimony to Congress, HIMSS Vice President Price recommended that physician practices allow time to research-then go back and do some more research. Some practices studied 20 vendors.

Consider an EMR system customized for otolaryngologists.

A major pitfall, according to Dr. Upchurch, is choosing a vendor that does not have substantial experience delivering EMR solutions to ENT providers.

Ms. Eddy tells of one site she visited in Connecticut where a physician had spent 20 hours a week for six months designing their template. All I could think of was that nothing was going to work if I have to ask someone in our practice to spend 20 hours a week for six months…before we can even start!

With the systems that are really inexpensive, you get what you pay for, Dr. Kuppersmith said. You’re going to have to create all of your exams.

Train staff and physicians.

We did a phased implementation, Ms. Eddy said. We went live on the new practice management October 1, 2005. We spent October through February planning our implementation and designing our ENT template, layout, and workflow. We brought our first physician live on the EMR piece on March 1, 2006. We finished our last physician the first of November. It took us seven months to bring 27 providers live.

Her group rolled out system users one at a time. Each received two weeks with a mentor trainer. We didn’t think it was as important to do it fast, as to do it right, she said, adding that we made the transition so that there was no downtime in billing and collection or in reduction of patient flow.

Dr. Kuppersmith said his team spent a year choosing the system and six months preparing the staff with training and getting them more used to being involved in the flow of patient care so that they could help us get the system working. We’d have ‘Lunch and Learn,’ bringing in anatomy charts and teaching the vocabulary. You can have some people in your office for five or 10 years who have no idea what you actually do. We lost some employees along the way; they just weren’t ready to work on the computer.

A good ballpark for complete training and implementation within a small to mid-size practice is between eight and 12 weeks, Dr. Upchurch said. Of course, much of this depends on the practice’s individual complexities as well as their general availability.

Is It Time to Make the Investment?

In his remarks to the US House of Representatives, Mr. Price said an HIMSS random sampling of 2500 physician group practices around the country showed that 100% had a practice management system. However, only 26% had an EMR system, and most of those without an EMR system were not yet planning to purchase one.

EMR vendors and physician groups contacted for this article commented that an EMR system is the best way to realize maximum benefits, both in dollars saved and improved patient safety, process improvement, and provider-patient communications.

If it’s the cost alone that is keeping a group from implementing an EMR, Mr. Price said the HIMSS study noted that in some cases, clinics report doubling or even tripling caseloads-with a corresponding jump in revenue-and with only marginal increases in staffing. At the same time, many report that they more easily pass regulatory audits than ever before.

In conclusion, he said that small health care groups see many of the same advantages from using EMRs as larger institutions. In many ways, ambulatory-care applications are more personalized and data-rich, and affect an astonishing, near-total transformation of the business.

©2007 The Triological Society