Connecticut Group Easily Implements Document-Based EMR

Cardiology Practice Options
by Deborah J. Neveleff

Deterred by real or perceived obstacles such as high costs and a steep learning curve, cardiologists in many practices are reluctant to install electronic medical record (EMR) systems. They still want the potential improvements that come in care quality and efficiency, however.

To avoid the obstacles other groups face with EMRs, some cardiology groups are choosing to implement document-based electronic medical record systems rather than EMRs that require extensive data entry. A data-entry EMR requires physicians and staff to type information into a structured database that they can use whenever a patient chart is needed. Many of these systems require physicians to change their practice patterns to meet the needs of the EMR.

In contrast, a document-based EMR requires no change to physician practice patterns. Practices don’t need to transcribe data or enter notes that had previously been handwritten. Instead, lab reports, images, and other documents are scanned and imported directly into the system, allowing users to access an image of these pages on screen.

More Benefits, Lower Cost
Cardiac Specialists, PC, a 10-member practice in Fairfield, Conn., chose to implement SRS Freedom Chart Manager from SRS Software, in Montvale, NJ (at www.srssoft.com), a document-based EMR system. “Because the system does not require cardiologists to change their practice patterns by inputting data at the point of care, our group has enjoyed several benefits without incurring the time and money typically associated with EMR implementation,” says Robert Hendler, FACMPE, the group’s administrator. “Our cardiologists’ practice patterns are basically the same, but the EMR enables them to be incredibly more efficient.”

The first benefit is improved patient care. All records are immediately available, enabling speedy decision-making based on full information. “Furthermore, patients who call their physicians with a question receive a much quicker response,” Hendler says. “We have two locations and admit to several hospitals, so physicians are out of the office quite often. Prior to EMR implementation, a non-emergency message might sit on the doctor’s desk for several days. Now, the cardiologists have 24-hour on-line access to all patient records. Patient calls are messaged to the doctors within the EMR system, and the chart is attached.”

A second benefit is financial. “With EMR implementation, we were able to eliminate three full-time medical record staff positions, saving the practice about $100,000 a year,” Hendler says. “The EMR has also eliminated the need to purchase chart supplies, saving us another $5,000 to $10,000 per year.”

Increased Efficiency 
A third benefit relates to efficiency. For example, chart retrieval is much more efficient, and charts are never lost. “At times, all practices temporarily misplace or even lose paper charts,” Hendler comments. “With an EMR, that problem is a thing of the past.”

Also, the system imports typed transcriptions directly into the EMR. “This means that we are getting access to dictated letters and visit notes much more quickly and efficiently,” Hendler says.

Cardiologists themselves have become more efficient as well. “The cardiologists can access patient information much more quickly,” Hendler observes. “They are now able to squeeze in an extra patient or two each day due to this increased efficiency, thereby increasing practice revenue.” 
 
Quick access to charts allows the practice to offer better service to referring physicians, Hendler continues. “If a referring physician calls to inquire about a case, our cardiologist can quickly pull up the chart and discuss the patient without having to put the caller on hold while frantically looking for the chart,” he says.

Not surprisingly, professional satisfaction has increased since adopting the EMR. “The physicians are thrilled with the system,” Hendler says. “They no longer need to stay late to review charts and make phone calls. They are able to complete almost all of their work during standard working hours, because the system makes it so much easier to keep up with their workload. They know they are giving better service to their patients, and they feel good about that.”

What’s more, since the administrative burden on the whole practice has been reduced, the tension level in the office has fallen as well, Hendler adds. In many ways, the system has made a positive impression on patients as well. “Patients know we are using a computerized medical record system,” he says. “We have a computer in every examination room, which patients don’t necessarily see in other medical offices. This feeds their belief that our practice is on the cutting edge.”

After only two years, the practice has already seen a return on its investment in the software. “We have more than broken even on the software, in part because the cost of the system is much lower than that of a typical EMR,” Hendler says. The cost of document-based EMRs can be as low as one-third the cost of data-entry EMRs.

Hardware Required 
But Hendler cautions that a robust computer network is needed regardless of the type of EMR adopted. “We spent a lot of money on computer hardware,” he notes. “We didn’t have computers in every examination room, and the computers we did have were not integrated. We also needed to purchase printers and scanners. So the amount of time that passes before a positive return on investment is realized will depend heavily on the hardware that exists in the practice.”

Document-based EMR systems can be implemented in a practice much more quickly and easily than data-entry systems can, Hendler says. “The strength of a document-based system is managing documents,” he explains. “These systems do not have a module to document point-of-care visits, in which physicians point and click their way through an examination. Rather, the physician documents a patient encounter in the traditional way, either by dictation or by writing notes. Then the resulting documents are scanned or imported into the system. Therefore, the training required is much more limited. As a result, the probability of successful implementation is higher with a system of this kind, while the more complex systems face a higher implementation failure rate.” SRS says its Freedom Chart Manager’s implementation success rate has been 100% over the past five years.

No data entry was required for the practice to begin using the new system. The cardiologists at Cardiac Specialists needed only about 20 minutes to learn the basics of the system and call up the scanned patient records on the computer screen, Hendler reports.

Improved Functionality 
The EMR is a repository of information that presents all of the medical records that a chart might contain in a user friendly and logical way, Hendler explains. “Dictated documents and images such as x-rays, problem lists, notes, and all other documents, can be called up on the screen,” he says.

The system also can import documents and data created on other systems. “For example, the EMR is interfaced with our digital nuclear stress testing system so that the images of the patient’s heart can be directly imported into the EMR,” Hendler comments. “It is also linked to our digital echocardiography system, so the data from those reports can be similarly imported.”

Clinicians can page through the record on screen as if reading a paper chart. But there’s an important enhancement: the documents are organized into meaningful sections, such as diagnostic tests, prescriptions, letters, and x-ray reports. Within each section, entries are organized by date. “Because of the electronic organization of documents, physicians can quickly find what they are looking for, without having to shuffle through a large pile of papers,” Hendler says.

In addition to document scanning capabilities, the system offers screens with templates, so that clinicians can type in the answers or print out forms, write on them, and then scan them back into the system. 
 
The system has a medication module, so that a physician can point-and-click to create a prescription. Then, the physician prints the prescription form to hand to the patients.

The system also has a messaging module. “This is an important workflow feature,” Hendler says. “A nurse can send a message to the doctor along with the attached patient record, allowing the doctor to respond to questions immediately. This feature facilitates communication among our clinicians, thereby streamlining our workflow, reducing frustration, and ultimately allowing us to provide enhanced service to our patients.”

Custom Made 
Finally, the system offers an optional module that provides search capabilities, so that physicians can gather practice-wide information on physicians’ practice patterns and outcomes to enhance quality improvement efforts.

“The system can be customized to serve physicians in any specialty,” Hendler says. “For example, we have developed various tools just for cardiology, such as a cholesterol log, a warfarin tracking sheet, and a pacemaker/ICD analysis log specific to cardiology patients.”

Among the only drawbacks of the document-based EMR is that it does not help to improve a physician’s accuracy and thoroughness of documentation or provide decision support, functions found in some data-entry EMRs. “Obviously, the choice of EMR depends on the needs of the particular group,” Hendler comments. “But physicians should carefully weigh the benefits of more complex systems against what those systems cost the practice in terms of time, money, and effort. It may not be a good trade-off.

“Then the practice should purchase the best system available that is consistent with the effort the practice is willing to expend,” Hendler explains. “Cardiologists and cardiology administrators should be cognizant of the fact that a full-blown EMR implementation is a big undertaking that requires a lot of training and planning.” 
—Reported and written by Deborah J. Neveleff, in North Potomac, Md.

Going Digital 
Use of EMR varies by group size

EMR Implementation Not Widespread
Fewer than 15% of cardiology-specialty medical groups have fully implemented an electronic medical record system and 19% are currently in the process of implementation.

This is one finding of a survey conducted as part of the “Assessing Adoption of Health Information Technology” project undertaken by the Medical Group Management Association Center for Research in Englewood, Colo., and the University of Minnesota School of Public Health in Minneapolis. More than 3,300 group practices participated in the project funded by the federal Agency for Healthcare Research and Quality in Rockville, Md. The survey was conducted in January and February 2005, and the results were published last fall.

Some 20% of cardiology groups plan implementation of an EMR within 12 months, and 18% plan to do so in 13 to 24 months, the researchers said. About 28% have no plans to implement an EMR within two years.

The survey also found that about 62% of cardiology groups maintain paper medical records filed in a record cabinet. About 4% use scanned images filed electronically using document image management systems (DIMS), about 13% use a dictation and transcription system combined with a DIMS, and 18% use an EMR that stores information in a relational database. 
—DJN

Adding Office Forces Decision
Before opening a second office, Cardiac Specialists, PC, did not have a pressing need for an electronic medical record (EMR) system. But after the 10-member practice in Fairfield, Conn., opened a second office, it decided to implement SRS Freedom Chart Manager from SRS Software, in Montvale, NJ (at www.srssoft.com). It did so in October 2003.

“We had been aware of the potential benefits of EMRs and had been toying with the idea of implementing one,” says Administrator Robert Hendler, FACMPE. “However, the main factor that drove our decision to purchase an EMR was the opening of a second office location. Our two offices are only 10 miles apart, and many patients are seen at both offices. But transporting the patient charts between the two offices became chaotic. We were constantly shuttling charts back and forth, which became a burden on the office staff. At times, we failed. The patient would show up for the appointment and the chart would not be there.”

The practice considered how to resolve this problem. “A messenger service would have been costly and would still be prone to mistakes or delays,” Hendler notes. “But we knew an EMR would solve our problem.” 
 
Nevertheless, the cardiologists had various levels of enthusiasm for an EMR. “Some physicians were excited, and were proactive in assessing different systems,” Hendler says. “But other physicians were not enthusiastic about the idea at all. However, when we were at the point of making the commitment to purchasing the EMR, we held a meeting with all the physicians and everyone agreed to move forward.”

Two factors helped ensure success. “First, when we began implementing the system, we started with the more enthusiastic doctors,” Hendler says. “Second, we implemented the system slowly, with a few physicians brought on board each month over 10 months. As a result of these two factors, the first few adopters were singing the praises of the system, and the remaining physicians were anxious to start.” 
—DJN

Copyright (c) 2006 Premier Healthcare Resource Inc., Morristown, NJ

Reprinted from Cardiology Practice Options, May 15, 2006, with permission of the publisher.