- Dr. Czapp
- Dr. Dahlman
- Dr. Patel
Switching EHRs - A Practice Shares Its Story
Patricia Czapp, M.D., Annapolis
 In 2009, our practice of five family physicians migrated from one EHR platform to another. It was like going from a Dodge Dart to a brand-new Lexus. The Dodge was familiar to us, even comfortable, and we had learned to work around its limitations. The Lexus was unfamiliar, yet it was shiny and new, elegant and sophisticated. It was more than just the electronic equivalent of a filing cabinet, as it promised to provide all the tools necessary to meet NCQA Level 3 Patient-Centered Medical Home recognition as well as Meaningful Use criteria. Our old platform clearly could not do either. It was time for a change, because our practice wanted to be able to demonstrate quality and outcomes not just at that point in time, but well into the future, long after the EHR adoption incentives were to sunset.
Our practice successfully migrated to the new platform. We are now well into the optimization phase, building tools that allow us to deliver better care, at both the patient and population level. We have found that the new technology provides a number of benefits, including a more efficient delegation of responsibilities among the clinical staff, a resulting increase in free time for physicians in the exam room, decision support which helps ensure that care is consistent and thorough, and positive feedback from our patients that we’re paying such close attention to them. From colleagues who are seeing the benefits of our EHR, here are some things to consider as you take the next steps towards your practice’s digital transition:
Your chosen vendor should be feverishly working on its product to be ready for ICD-10, to meet Meaningful Use criteria, and to be certified to support e-prescribing controlled substances, to name a few timely stressors. Don’t be shy about asking the vendor to demonstrate its commitment to those and other projects. Have the vendor show you a timeline, and then ask what type of guarantee is offered that deadlines will be met.
Is the vendor familiar with the current quality and reporting initiatives and challenges facing physician practices, locally and nationally? Can its product support Patient-Centered Medical Home care, PQRS, population health measures and disease registries? How about reporting features that are accessible at the user level?
What training and ongoing support will the vendor provide such that your practice can go from “Meaningful Possession” (bought the system) to Meaningful Use (actively engaging physicians and patients in EHR features that enhance care)? What if your practice pursues a new quality initiative that will require some software “build” – will the vendor work with you? If so, how?
Finally, you need to have confidence that your vendor “owns” the process of assuring your practice succeeds in its ability to report, measure, and act on data so that you can demonstrate value. You need to know if your vendor can deliver. There should be no extra modules to buy or subcontractors that you need to find. Your vendor should be your partner throughout the process, from implementation to optimization and beyond.
EHRs As Groundwork for Practice Transformation
Holly Dahlman, MD, Timonium
 I have always considered myself a forward-thinking person. In fact, I even made up my mind to be a doctor at the age of three! After selecting a career in internal medicine, I joined a group practice and quickly experienced the challenges of managing patients in an old-fashioned paper chart office. The complexities of patient management, documentation, communication with specialists, retrieving information from hospitals, and refilling prescriptions was overwhelming in the old style practice. It seems that each year, the patients who would have been in the hospital in the previous era of medical practice were showing up at the office, needing urgent attention and substantial coordination of care.
In 2006, I branched off and founded Green Spring Internal Medicine, LLC. Our Phase I goal was to achieve a “paperless, wireless” medical office, with the full implementation of electronic health records and a computerized practice management system. We chose eClinicalWorks as an integrated solution, after investigating various software options over the course of a year. Now, five years later, it is clear that we chose well. eClinicalWorks has continued to adapt with the times, achieving ONC certification for Meaningful Use with its Version 9 software. In addition, eClinicalWorks has already implemented eprescribing, a patient portal that incorporates personal health records and lab results, bi-directional interfaces with Quest and LabCorp, and a registry feature that facilitates research to improve our practice and identify high-risk patients.
Many practices are only now beginning their search for an EHR system. Our experience both picking a system and using it, now for many years, may be instructive. Here are a few tips:
- Doctors should only consider certified, HL7-compatible products. The federal government makes lists of those EHRs that have been certified, and if you’re considering one that’s not, you could run into trouble down the road.
- Look beyond the product itself to the financial strength of company—number of customers is a good indicator. Further, what specialties has the vendor penetrated? You want to choose a partner that will be around for the long-haul, and will make investments in enhancements that suit your practice.
- Read your contract carefully. Who owns the data on your patients? What security safeguards are documented in the contract? What are the company’s backup and disaster recovery policies? Lease vs. buy … internet/SAAS—data ownership, security, backups DR.
In June, I will be presenting in a webinar on our practice’s process for picking a vendor. During the webinar, you will have the opportunity to identify what’s most important to your practice and develop a customized RFP to guide your buying decision.
I can report that we have achieved our Phase I goal with success. The office runs efficiently with the help of two committed staff members who are cross-trained in administrative and medical assistant responsibilities. Finding the right staff involved trial and error but was worth the effort. It became clear that cross-training was important, as utilizing the computer system has a learning curve that does not lend itself well to temporary help. The staff is enthusiastic about technology. Paper that is generated or records that are brought to the office are promptly scanned into the computer system, and no paper charts exist in the office. eClinicalWorks provides a logical structure for office functions and record-keeping that has so greatly reduced the amount of paperwork and repeat phone calls that the staff never works overtime and I spend an average of less than an hour handling messages and paperwork after the last appointment. The patients appreciate a much quieter, organized, timely and private office setting. I frequently receive complements from colleagues on the quality of communication received from the office and have become a local consultant on EHR implementation.
Green Spring Internal Medicine is now moving on to Phase II of our development. We have dual goals in 2011: achieving Meaningful Use and becoming a Patient-Centered Medical Home. The two goals are complementary and will encourage our practice to expand its use of health information technology to achieve them. ONC certification and HL7 compatibility of our software has helped to assure us that our aims are within reach. In addition, we made the important decision to migrate from our current client-server installation of eClincialWorks, where the system runs on a server in our closet, to the software-as-a-service (SaaS) edition, where the system runs “in the cloud” and all we require to access it is a reliable, high-speed internet connection. Moving to SaaS will help us minimize our capital costs, with servers being the most expensive equipment the practice owns and maintains. It will also allow future upgrades and security fixes to be handled seamlessly by the vendor, and some features that we currently pay for, like the patient portal, are bundled for free. In the future, it seems that very few practices will choose client-server over SaaS. Based on our experience SaaS is the wise choice.
We have further support from the Maryland Health Care Commission, as our practice has been selected as a Multi-Payor PCMH Pilot Program Site. In addition, an MSO associated with CRISP will be assisting in the technical aspects of expanded implementation—even though I am already using an EHR, the MSO can provide subsidized technical services associated with achieving Meaningful Use, a real value to my practice. With the help of these partners and others in our “medical neighborhood”, we expect our PCMH to further excellence in patient care, communication, and coordination. We also anticipate an increase in staff and provider engagement and satisfaction. In the long run, we expect to achieve cost-savings on a number of levels.
Many features of the latest version of eClinicalWorks’ software are integral to our goals. This technology is key to the transformation of our practice into a Patient-Centered Medical Home (PCMH). The American College of Physicians defines PCMH as “ a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.” Click here for more from the ACP on PCMH.
The achievement of PCMH is a tall order, especially for a small practice. By necessity, some functions of our medical home will have to be outsourced. It is a good thing that internal medicine doctors are networkers by nature. Now, the networking mindset is supported by computer networks! We eagerly anticipate the benefits of statewide health information exchange (HIE) which will assist in reporting and updating disease measures, health outcomes, vaccination status, and communicating with outside entities. Though security concerns are oft expressed, the improved patient safety that will result from HIE is of critical importance. HIE also stands to create more seamless transitions for patients across the local healthcare system, improving efficiency of care and decreasing redundancy. Ultimately, I envision that patients will have much greater access to their health records as well, empowering patients to understand and engage in self-management and to achieve their own goals.
Like many others, I believe patient-centered care is the future, and technology offers remarkable tools for us to put the patient at the middle of everything we do. We must also recognize that the healthcare landscape is changing dramatically around us, and as physicians and small business owners we must innovate and adapt in order to find a business model that lets us fulfill our goals. At least for my practice, adopting technology early and remaining committed to using it and using it well has helped position Green Spring Internal Medicine to survive and thrive in the future.
"No Substitute for Hands-On Experience"
Shashank Patel, MD, Olney
 Our EHR story began in 2009 when our practice was accepted into the Centers for Medicare and Medicaid Services’ EHR Demonstration Project. We had been planning for several years to implement an EHR but due to the presence of older doctors, financial issues, and moving locations we continued to put off the transition each year. EHRAs we were familiar with the requirements of the CMS EHR Demonstration Project, we generally knew what EHR features our EHR had to have; nonetheless, we embarked on a fairly rigorous process to narrow our choices and select a product that best met our needs.
With the CMS requirements in hand, we used resources offered by the state of Maryland to identify qualifying EHRs that offered discounts. This helped narrow the list. Given that we are a small practice with two physicians and one nurse practitioner, our initial criteria also included cost. While there are some very robust EHRs available, we concluded that they were better suited for practices of 25 to 100 providers. They also generally required significant upfront and ongoing support costs. Still, we found several fully-functional systems that seemed appropriate for a practice of our small size and limited means.
In the hands of a skilled salesman or IT support professional the demonstrations given by the company usually are very smooth and fast. Most of the patients they demonstrate already have medications, allergies, medical history and physical exams preloaded which makes every patient visit seem incredibly fast and easy. What is not shown is the time-consuming task of entering in 10 years worth of patient diagnoses, medications, surgeries, and social history. Providers and practice managers should be sure to ask vendors how they recommend dealing with this vital historical chart data.
Still, the most effective way to evaluate EHR systems after isolating two or three candidates on a short list is to spend multiple hours testing out the systems prior to purchase. We believe there is really no substitute for this hands-on experience. In addition to viewing the online and in-person sales demonstrations we asked that we be able to login to each system and spend our free time on evenings and weekends exploring them. We tried on our own creating new patient visits, repeat visits, physical, and pre-ops. We used this time on our own without the presence of any sales pressure to write down questions and concerns that arose and then scheduled a subsequent demo during which the salesperson could show us the answers. One of the most helpful things that any salesperson told me was that he had had one physician demo the system almost 26 times before committing. That reassured me that I could take my time and ask as many questions as I wanted. It’s critical to have all concerns addressed prior to purchasing.
Here are some other important considerations, based on our experience:
- In the end, we settled on a system that seemed to fit best how we used to enter data into a paper chart. Since the layout and thought process of data entry and decision making generally paralled what we were already doing, we felt the effort of transitioning could be minimized.
- We also spent some time calling physicians who used the systems we were considering. We also visited some colleagues in person. We found that many physicians bought EHRs only to end up using perhaps 20% percent of the functionality available.
- For our short list of products, we projected out five years of costs of maintaining the system. While our second choice had a slightly lower upfront cost, once we factored in the annual fees for the support of each particular component, we found it more expensive in the long run.
- Finally, many of the bells and whistles that are demonstrated during the sales pitch generally have an attached cost. While the iPhone support is a neat feature, it is likely that you will use it infrequently while paying several thousand dollars over a five year period.
One regret we do have is not exploring more thoroughly with local hospitals their plans discount EHR pricing and pilot programs they might have. In fact, many community hospitals are now participating in the regional extension center program as MSOs. Shortly after purchasing from our vendor we found out that a local hospital was offering discounts on our second-choice system. The price would have been comparable to the system we chose, but it may have changed our final decision.
From the time we chose our system to when the implementation was complete turned out to be a very stressful period. We felt a particular urgency because of to our need to qualify for the CMS EHR demonstration. Our vendor knew what date we were shooting for and was very helpful in ensuring we met that deadline. If we made one mistake prior to implementation, it was not taking time to streamline some of the inefficiencies that existed in our practice, as the EHR tends to amplify those inefficiencies.
Once the system is live, it may take three months, or six months, a year, or more to really feel its full benefits. There could be an initial drop in revenue as your team adjusts to new workflows and the presence of the technology. Some of the features will turn out to be harder to use than others, and require persistence, patience, and even further training. I consider myself fairly technologically knowledgeable; however, I found that my partner (whose skills on the computer basically involve hitting the power button) adapted to the system much faster than I did. In all honesty, during the first few months of EHR being live, questioned whether it was worth it. But in time I saw that it was. Over the last year, I have been able to find shortcuts and time-saving measures that greatly improved my efficiency and satisfaction. Further, I have positioned myself well to recoup much of the initial cost through reimbursement incentive programs.
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Addressing Common Concerns
1) EHR will ruin my relationship with patients. Think of EHR as a tool to enhance your patient-physician relationship, not replace it. Patients have come to expect their physicians to take advantage of technology. In the exam room, configure the furniture so that you are always face-to-face with your patient. The computer should be no more obtrusive or distracting than was the paper chart. In fact, patients like to view the screen along with you. And think about the value a patient portal brings to the relationship as well.
2) I can't afford EHR in my practice. Think again. Shop around. Take advantage of subsidized servicesoffered by MSOs through Maryland’s REC program. Apply for incentives: federal, local, and those that payers offer now and in the future. Finally, consider this: there will be a tipping point when more of your colleagues than not will have EHR. They will want to share patients only with other practices using EHR so that they can meet Meaningful Use criteria. Also, you will want to attract new talent to your organization. That talent will not be attracted to a paper chart practice.
3) My practice partners and staff are technophobes. This will not work. How do your partners and staff answer the question, “Why are we adopting EHR?” If they see the big picture: to improve clinical care, you are on the right track. Your practice's EHR adoption will be successful if your staff and partners view it more as a marriage (long-term commitment) than a matter of focusing just on surviving the go-live (wedding).
4) My productivity will suffer. One measure of EHR adoption is how quickly a practice regains (and even exceeds) its pre-implementation volume of visits. It might take two weeks. Or six months. Or more. How to shorten the timeframe: monitor the post-go-live proficiency of all of your staff. Identify those who are struggling and provide them with focused support. Ask your vendor to provide you with tools to monitor staff and physician proficiency at go-live and beyond.
5) I don't believe the governmental financial incentives will materialize. While we are hearing reassuring words from Washington about the preservation of those monies, DON’T do an EHR implementation just for federal incentives. Do it because you want to position your practice to be able to demonstrate value (improved outcomes and decreased costs) to payers, who will be demanding such data when our fee-for-service world is replaced by one that purchases value. Think about the value of care you want to provide not just next year, but ten years from now.
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