Richard J. Baron, MD; Elizabeth L. Fabens, MD; Melissa Schiffman, MD; Erica Wolf, MD
Acknowledgments: The authors thank their office staff for their courage, flexibility, and support throughout this project. Without their willingness to try something new, implementation of the electronic health record would not have been successful. They also thank business manager Debbie Preite for her leadership and willingness to learn more about computers than she ever thought she could, or wanted. Finally, they thank Cheryl Norvell for manuscript assistance and Steve Downs, Holly Humphrey, and David Reuben for their encouragement and review of an earlier draft of the manuscript.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Richard J. Baron, MD, Greenhouse Internists, P.C., 345 East Mt. Airy Avenue, Philadelphia, PA 19119; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Baron, Fabens, Schiffman, and Wolf: Greenhouse Internists, P.C., 345 East Mt. Airy Avenue, Philadelphia, PA 19119.
We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment.
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Community Medical Center, Toms River, NJ
August 9, 2005
Electronic medical records: does it have to be expensive?
Dear sir, I have had electronic medical records in my office for the last three years. I created a simple template from Corel Wordperfect for consults, follow-ups, colonoscopy and upper panendoscopy reports which I print out as soon as they are typed. My referring physicians get reports by fax on the same day. Wordperfect lets me search the database by dates or by names. Back up on a USB disc is done within minutes by the end of the day. Cost of Corel: approximately $100, laptops cost less than a thousand. Electronic medical records should be affordable and user friendly. I feel that the patient's medical records should be kept separate from demographic data. EMR is for the physicians' convenience and the thrust should come from us and not from the third party payers. Sincerely, Chakrapani Prakash, MD FACP
HOWARD J HOMLER
August 6, 2005
I read Dr Baron's description of his group's experience with EMR. I doubt that his experiences are not unique. As a solo practitioner in internal medicine, I come across a variety of EMR formats when I review the medical records of new patients.
In general, I am appalled by the way data is presented. In many cases, the date of the test is buried in a mixture of account numbers, birthdates and other distractions. Once the data is printed, it surprises me how much paper is wasted for just one or two test results.
Although it might be easier for a statistician to get the data sought for quality of care purposes, there is something missing that is at the core of our internal medicine training---thoughtful reasoning.
I see the template boxes checked, but little comment regarding the subtle findings. There is not much narrative. I simply confort a group of boxes with little check marks in them. There is rarely any comment about the patient's emotional reaction to diagnosis or treatment, or considerations regarding the financial burden that the patient is facing or even discussions between the physicians that are treating the patient.
I agree legibility is a benefit, but it is like getting a skeleton of data without the meat. In my practice, I've tried to make my progress notes legible by typing them out and then sending them electronically to the other health care providers sharing in the care of the patient (with the patient's permission). It may not be as easy determining the matrix for RBRVS coding, but it communicates key concerns and invites teamwork and cooperation.
Then again, I'm a dinosaur...
Gary M Levin
August 5, 2005
Letter to Editor
The article by Barons, Fabens,Schiffman and Wolf emphasizes EMR is just round the corner AND over the cliff.
This was a well written documentation of the painstaking process these physicians endured in this transformation of their practice(s). The adoption of EMR is a radical social re-engineering of the work task and workforce. Physicians' work routines are unique not only between specialties but within the specialty itself.
Ethnography is the study of work task and adaptation to automation such as we find in instituting an EMR. Anyone involved in EMR evaluation and selection should look for significant ethnographic reference for the system(s) they are considering for their clinic/office.
Although the article appears in the Annals of Internal Medicine it should be widely read and perhaps republished in JAMA for general dissemination.
As a coordinator for a regional health information organization, and while I am a proponent of EMRs for many reasons I also see the stress and increased workload on physicians during the conversion.
The conversion process will be much easier for younger physicians for many reasons"¦.the time invested will be utilized over a longer practice life-time. For those physicians over 55 it will be a greater effort, not impossible, and for those over 60 who may be retiring within five years it will be most challenging in terms of return on investment of time and money.
I believe standardization will be most important at the level of data input as well as system interoperability. Those physicians in residency training may be trained using one system, and then experience a huge transition when entering private practice, or during career changes.
Whether the practice is large or small significant difficulties arise at the level of physician-EMR interface. Significant training time must be allotted, even before the system goes "active".
Gary M. Levin M.D.
Coordinator Inland Empire Regional Health Organization
Mark A. Faron
Mercy Medical Group
August 11, 2005
MMG EMR Experience
Dr. Baron and his partner's perspective on implementing an electronic medical record (EMR) demonstrated the pitfalls associated with this difficult task. Our group has had a different experience. Mercy Medical Group comprises 160 doctors and includes internists, family practitioners, pediatrians, and ob/gyn's, and is owned by the Sisters of Mercy Health System. With the financial backing of the health system, we researched several EMR vendors and chose Misys because we had been using their practice management system, which interfaced with their EMR. Having the health system's support and financing was a significant advantage over an individual group of doctors starting an EMR.
Our pilot group of 4 internal medicine doctors went live in March 2003. The doctors and staff each had about 8 hrs of training before going live and continued support afterwards. Misys provided workflow recommendations, training, and support in our early development of EMR implementation. We redesigned our workflow and had excellent support from the IT department and the EMR project managers throughout this period. To better familiarize themselves with the EMR, the doctors were using the EMR for office visits and printing the notes for the paper charts for a few weeks before going live. The doctors also spent time entering patient data into the EMR for several weeks before going live. Entering this data is a major hurdle for transitioning to an EMR and we have not been able to find a way around it.
We reduced our patient appointments by 50% when we went live and over the next 2 weeks were able to increase back to our usual patient load. Our staff was somewhat skeptical at first, but having an effective office manager made the transition easier and now neither the doctors nor the staff would want to return to paper charts. It doesn't take long to forget the frustrations associated with paper charts.
The EMR has allowed us to improve our revenue slightly with better documentation and efficiency and we are able to see a few more patients a day. We are working to improve our auditing capabilities and move forward with pay for performance programs.
A complex project of this magnitude has had its frustrating moments and we have experienced power outages and problems with our servers, which our support staff has been quick to correct. The transition would have been much more difficult without their assistance and rapid response. Having our EMR and Quest lab interface was also a difficult process that again our support staff was able to make a reality.
Misys has also been very receptive to our requests to improve the EMR and each version raises it functionality. We have 35% of our doctors on the EMR and add another practice every 3 weeks.
We applaud Dr. Baron and his partners for implementing an EMR and enduring a difficult transition period. We feel that our experience was less painful because of the financing by our health system, the support provided by Misys and our IT and EMR staff, and because of more preparation before going live, which included workflow redesign, training, and data entry.
Mark Faron, MD
Mercy Medical Group, EMR Medical Director, St. Louis, Mo. 63141
Thomas Hale, MD
Mercy Medical Group, President
Linda Jesberg, RN
Mercy Medical Group, Sr. EMR Clinical Coordinator
Peter S Goltra
CEO Medicomp Systems, Inc.
August 17, 2005
Improving EHR Usability
To the Editor:
Dr. Basch's editorial and the reports by Baron, et al and Kaushal, et al cover well the spectrum of challenges facing us in the Medical Informatics industry as we build systems and system components. The biggest challenge is that cited by Dr. Baron: "A decline in productivity after implementation of an electronic health record seems inevitable". There are solvable reasons why this is currently true but need not be.
1. Usability: Much discussion has centered on ideas for standards and workgroups to solve the need to exchange health care data electronically (interoperability). The group that has been overlooked in this discussion is the doctors who will have to put the data in and use it at the point of care. We are all too aware that doctors did not go to medical school to become data entry clerks. When the electronic health record discussion starts to focus more on the usability of these systems at the point of care, then there will be progress.
2. Reward: Computers are excellent at aggregating and presenting information if it is clearly identified. As "free text" systems for medical information give way to structured data systems using point-of- care terminologies, it is becoming possible to view, ad hoc, patient charts in a problem-focused mode. The time saved thereby is substantial.
3. Safety: With medical information stored as data, programs can check information as it goes in for changes from the previous visit which meet certain criteria or check new data, such as a new prescription, contraindicated because of data in the medical history.
It is through avenues like those cited above that we hope to deliver systems that will improve productivity rather than impair it.
President Medicomp Systems, Inc.
President Medicomp Systems, Inc.
Scott D. Williams
November 14, 2005
EMR Implementation Challenges can be Minimized
The recent article by Baron et al. (Electronic Health Records: Just Around the Corner? Or Over the Cliff? AIM 142 (3):222-226) emphasized what can happen when clinics try to shortcut fundamental change management techniques. I would encourage your readers not to draw the conclusion from this article that it was the EMR that was primarily responsible for the problems encountered rather than the process failures in the clinic described.
As one of four state-based Quality Improvement Organization (QIO) teams that spent the last year piloting CMS' DOQ-IT project to assist small and medium sized primary care clinics in selecting and installing EMRs, we have developed the following list of some of the critical elements of success based on our observation of EMR selection and implementation processes in the 100 clinics we've worked with.
1. A physician champion and/or team leader (could be an office administrator) who is committed to the project, will listen to team suggestions, seek information from outside sources, take responsibility for final decisions, and move the process forward.
2. A team that includes representatives from every part of the office and that meets or otherwise communicates and problem-solves regularly.
3. Clear operational and financial goals (e.g., we want to improve care management, improve the billing process, decrease costs, etc.) that are broadly communicated and guide the EMR selection and implementation process.
4. A workflow analysis that highlights what processes need to be improved, which processes work well and should be preserved, and which processes must change to accommodate the EMR and optimize its potential to achieve the goals as well as improve overall office efficiency and quality.
5. Plans for altering workflow and choosing an EMR vendor that meets clinic needs.
6. Multiple vendor demonstrations (at least three) and at least one peer practice site visit without a vendor representative present.
7. A tightly negotiated and customized EMR contract that defines support (e.g., cost, response time, hardware, software, training, on-going fees, etc.)
8. An implementation plan that incorporates workflow changes, hardware and software training for all employees, and a plan for transferring chart data to the new system.
9. An employee who is responsible for system maintenance, updates/improvements, and continuous training.
10. Anpticipating and understanding that the process will result in a temporary loss of productivity and scheduling that allows flexibility and adaptation.
11. The tracking of metrics to evaluate whether operational and financial goals are being met and course correction processes as needed.
The description of this clinic's experience reveals serious shortcomings in at least half of these areas including those involving workflow assessments, vendor selection and contracting, and implementation. The authors conclude that "despite the difficulties and expense of implementing the electronic health record, none of us would go back to paper." But your readers should understand that the difficulties and expenses of implementing an EMR do not have to be as severe as those described in this article.
It's true that successfully selecting and implementing an EMR is more time consuming, complex and critical to a productive work environment than perhaps any other purchasing decision a clinic will make. But just as with complicated medical procedures, if done carefully and following proven practices, the pain can be anticipated and minimized and the outcome can be well worth it.
Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic Health Records: Just around the Corner? Or over the Cliff?. Ann Intern Med. 2005;143:222-226. doi: 10.7326/0003-4819-143-3-200508020-00008
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Published: Ann Intern Med. 2005;143(3):222-226.
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