Kent W. Blakely, MD, was at the airport working on charts during a layover when a patient called seeking a refill on a narcotic prescription.
He knew that the patient, calling on a weekend, expected to speak with someone who didn’t have access to medical files.
“I said, ‘Let me pull up your record here,’ ” recalls Dr. Blakely. “You could hear a pin drop in the background. I said, ‘You didn’t make your appointments for the last three times and you’re really not due to get any more.’ What a great tool this is!”
Dr. Blakely, a rheumatologist in private practice in Kearney, Neb., is referring to his electronic medical record system or EMR—an approach to recording patient data that being adopted by rheumatologists across the country.
Jump Into EMR Adoption
For many practices, the start-up phase is the most challenging part of adopting an EMR. Herbert S.B. Baraf, MD, expects the EMR system that his 11-physician rheumatology group in Wheaton, Md., is installing to go live in June; that is about six months later than originally planned—and after more than a year’s worth of installation, training, practice redesign, and unexpected costs.
“Anyone who looks at this as a plug-and-play purchase doesn’t understand it,” says Dr. Baraf. “This is a very complicated thing and it requires physicians to roll their sleeves up and jump in.”
Dr. Blakely, who began using the EMR when he opened a new solo practice in January 2006, says that, by the end of the first month, his nurses were in tears. Richard H. Blau, MD, a rheumatologist with a private practice on Long Island, N.Y., can relate. He had installed an EMR system in 2003 as one step to a paperless office.
“This is not easy. It’s not painless either,” he says. “Each time I added a new software module, such as a document manager or computerized fax, my staff was initially skeptical. However, after a week of use and a little training, they all were able to appreciate the benefits of the new programs.”
Thus, Dr. Blau sides with others who make it to the other side of the EMR adoption mountain and report a beautiful view.
Bits, Bytes, and Benefits
Mark L. Robbins, MD, MPH, has been using an EMR for nearly 15 years at Harvard Vanguard Medical Associates, a 600-member multispecialty group in the Boston area. The system’s top benefits include better communication and coordination among physicians treating a patient and the ability to track trends—such as lab results—to pick up subtle changes in a patient’s condition.
Future benefits include the ability to report quality-of-care measurements and health outcomes needed to participate in pay-for-performance initiatives.
“The computers help you take a disease like rheumatoid arthritis or lupus and create your own tracking systems for following patients over time, and then export that in a format that ultimately you will be reimbursed on,” says Dr. Robbins.
Paul H. Waytz, MD, who leads a 10-member rheumatology practice in Edina, Minn., believes the EMR system installed four years ago paid for itself through lower staff and transcription costs in about 18 months.
“I would never go back,” he says. “I’m not much of a techie, and I was able to learn it—and I don’t have any paper notes.”
Even Karen S. Kolba, MD, who says EMR technology has saved neither time nor money for her solo practice in Santa Maria, Calif., would not choose to return to pen and paper.
“The advantage is that I now have better documentation,” she says. “If I were ever audited, I could point to it and say, ‘Look, here are the things I did on this patient,’ and those things probably weren’t all there in my dictated notes.”
What’s the Cost?
The expenses associated with moving to EMR vary so widely that the oft-touted “$20,000 per physician” may be too general for planning your budget. Here are some actual EMR setups used in rheumatology practices and their costs.
Large, multi-office group practice: Installation costs are still being tallied at Arthritis and Rheumatism Associates P.C., the largest rheumatology practice in the Washington, D.C., area. As of November, Dr. Baraf, the managing partner of the practice, estimated that nearly $500,000 would be invested in the system, including hardware, software, new phone lines, and start-up expenses such as chart extraction and scanning.
“We’re in multiple offices, and that involves linking the offices by high-speed wireless or wired technology,” says Dr. Baraf. “It gets to be fairly expensive the more offices you have.”
Some of the costs were unanticipated. For example, three-year-old servers had to be replaced, adding $50,000 to the original cost estimate.
Mid-sized group practice: Arthritis and Rheumatology Consultants, a 10-physician practice in Edina, Minn., invested about $350,000 on EMR software, hardware, and start-up costs in early 2003. Software licenses cost $9,400 per provider; hardware and training costs were about $125,000, says Dr. Waytz, a partner in the practice.
More hardware was needed when the physicians decided to give up on their original goal of using wireless laptops. “Each doc and nurse had a small laptop that we carried from room to room,” he says. “It wasn’t reliable, it was cumbersome, and the laptops were too small. It wasn’t working right.”
Solo practice: Dr. Kolba, owner of Pacific Arthritis Center Medical Group in Santa Maria, Calif., and Dr. Blau, owner of Arthritis Institute of Long Island, each purchased the same EMR system for their solo practices in 2003.
Dr. Kolba estimates she spent $15,000 on software, including a package that integrates data from her practice management software, and about $35,000 on hardware, including monitors and printers in each exam room, her office, nurse workstations, and the on-site laboratory.
Dr. Blau reports the software cost between $6,000 and $7,000, while hardware expenses rang in at about $800 per workstation for a total outlay of roughly $12,000. His facility was already wired to accommodate the networked computers.
Purchasing Tips
Faced with hundreds of EMR systems on the market, rheumatologists might do best by buying a system like the one being used by the physician next door.
“Seriously consider getting something that one of your friends already has—even if they’re in a different specialty,” Dr. Kolba says.
She chose a system on the advice of a consultant and has found implementation to be slow and sometimes frustrating. By contrast, a podiatrist who practices on her street is benefiting from Dr. Kolba’s experience with the system.
“He gets a lot of free advice from us, which is fine. I’m happy to share,” she says. “That’s definitely made his experience better.”
Dr. Kolba and other EMR-equipped rheumatologists urge their colleagues to buy a system only after they understand—or develop—the types of support needed to implement it successfully.
Two essentials to making the EMR work: general computer savvy and rheumatology-specific templates that correspond to an individual practice. If a physician’s office has no in-house information technology expertise, that will need to be purchased. Likewise, unless a physician has the skills to customize templates, choosing an EMR system with rheumatology-specific templates—or hiring someone to create them—will be required.
Other tips from rheumatology’s EMR leaders: Screen the company first, and then the product it offers: “There is tremendous turnover in the industry,” says Dr. Robbins, co-author of “Electronic Medical Records for the Physician’s Office,” an issue of the ACR’s Practice View (available online at www.rheumatology.org/products/coding/03emr_ack.asp). “The last thing you want to do is to load all of your patient information onto a system from a company that doesn’t have enough money to support the product, and the company goes under.”
Check the manufacturer’s references and be sure to ask physicians who are using the system whether they receive adequate support from the company.
Objectively compare systems: Dr. Robbins suggests preparing for a product demonstration by creating several clinical scenarios typical for your practice.
“Wrestle control of the demo right away by telling [the sales people] that you want to run through a clinical scenario,” he says. “Use that same clinical scenario to test and compare different systems.”
Think about the kind of medical note you want to create: “A lot of systems generate too much information,” says Dr. Waytz, recalling his own receipt of an eight-page note from a referring physician, only one page of which was relevant to the hand-off. More is not always better.
“There was seven pages of garbage,” he says. “And because it was faxed to me I have seven pages of paper here that I ended up throwing away.”
Lola Butcher is a medical journalist based in Missouri.
Implementation Pearls
Give Yourself Time to Learn the System
“You have to look at this as a marathon and not a sprint,” says Dr. Blau. “It took over a year for us to become paperless.”
At first, he used the EMR for only two patients a day, refining the templates bit by bit as he gained experience with the system’s capabilities. Similarly, he started with a single template—the one for osteoarthritis—and he chose a single nurse to learn the system with him. She then trained other nurses in the practice who, in turn, trained members of the administrative staff.
Prepare to Slow Down
“You must plan for a reduction in productivity, compared to scribbling in the paper record, which is much quicker,” says Dr. Robbins. “EMRs tend to slow people down, especially when they’re first learning it, and sometimes forever.”
The improved documentation by a template that forces physicians to record their decisions and actions may lead to higher reimbursement levels. Also, for many physicians, EMRs eliminate any dictation at the end of the day.
Establish Protocols to Tailor the System to Your Practice
The EMR purchased by Dr. Waytz’ group had no rheumatology-specific templates, so the physicians built them from scratch. One physician was designated to create and change the templates to correspond to the diagnoses, treatment options, and other information applicable to their practice. For the first year or so, the doctors met every six weeks to decide on which tweaks were needed.
“There are still some things that are superfluous and some that I want to add,” he says. “You have to have the group wiling to meet to say we want these choices.”
Reconsider Workflow and Staff Responsibilities
Dr. Blakely operates his practice with only a few staff members other than himself: an office manager and a part-time assistant who handle billing; a receptionist/scheduler; two nurses—one to room patients and one to do infusions; and a laboratory technician. The lean staff, which includes no transcriptionist or medical records staffer, is possible only because of the EMR system, he says.
