eciding to adopt an electronic
medical records (EMR) system
is an important medical practice
decision. A medical practice’s main
challenge is dealing with the fact that
an EMR system will change the way
everyone, including the physician,
works (Table).
Impact on the Medical Practice
A 2005 study funded by the Robert Wood Johnson Foundation and the Office of the National Coordinator for Health Information Technology reported that approximately 25% of physicians use some type of electronic health record system.1 In
April 2007, the American Academy of Family Physicians (AAFP) surveyed a random sample of 4,000 active AAFP members to identify the number of physicians using an EMR system in their medical practices.2Roughly half of the 459 respondents were
either using an EMR system in their practice (37%) or were setting up such a system (13%). The survey also reported that the number of family physicians using an EMR system has consistently increased since 2003. There seems to be a trend in EMR system implementation by which practices consisting of more than 10 physicians are more likely to have a system in place or to be in the process of fully implementing
PRINTER-FRIENDLY VERSION AT CLINICALONCOLOGY.COM
•
D
The EMR System:
What Does the Physician
Need To Consider?
C
YNTHIAL. D
UNN, RN, FACMPE
Senior ConsultantMGMA Health Care Consulting Group Cocoa Beach, Florida
R
OSEMARIEN
ELSON, MS
PrincipalMGMA Health Care Consulting Group Syracuse, New York
Copyright © 2008 McMahon Publishing Gr
oup unless otherwise noted.
All rights r
eserved. Repr
oduction in whole or in part without permission is pr
one (Figure 1).3 In solo practices and those consisting
of 2 physicians, approximately 12% are using an EMR system. As a practice increases in size, it becomes essential to find systems that will consolidate informa-tion and provide simple methods of communicainforma-tion.
Practice Assessment
Adding technology to a medical practice changes documentation method(s), work flow, billing prac-tices, scheduling, medical record access, and commu-nication/messaging (Figure 2). It is important to keep the end in mind. With a fully implemented EMR sys-tem, how is a practice expected to look? How does a physician interact with the EMR system in day-to-day flow? The EMR system is a tool, not the end result. Reengineering of some current work processes will be required, and planning for these changes must occur for a successful outcome. It is important that an EMR system meets specific needs as well as facilitates change in practice processes and eliminates manual functions and analysis of data.
There are many clichés about leadership, most of which are true. Leadership in health care, as in most industries, does indeed start at the top. Solid executive leadership does make things happen. Physicians should have discussion with their management team before the EMR system is implemented. The following questions should be asked and answered:
• Why add technology—what is the practice trying to achieve?
• Which processes should change?
• How will success be measured 1 year after the transition is completed?
The concept of change management also has to be discussed. Introducing major change into any work-place can create stress and confusion and lead to other, unanticipated changes. A medicalpractice— large or small—is no exception, and introducing new technologies such as an EMR system requires significant change. It is critical to step back and think about a practice and its employees:
• Can the practice make the transition?
• Can the staff, including the nurses, understand and manage the process?
• Has the impact of the change been discussed with everyone, so that they have a clear understanding of the impact on their personal future?
Employees often fear that technology will replace them and perform their functions—they need reassur-ance. In most cases, initially adding technology will not result in a decrease of staff but could result in changes in job duties and functions as the practice becomes more computer-based.
The introduction of change management and tech-nologic efficiencies in an organization will enable an assessment of how a practice can realize the benefits of an EMR system. To begin, an understanding of the terminology and components of the EMR system will enable a practice to determine the right features to
People Big picture Culture Integration vs functionality Individual motivation Fear of computerization Personnel cost Systems Legacy vs new Availability Best of breed Vendor strategies Interoperablility Portals/single sign-on Integration Devices/mobility Business Practice
Clear vision and priorities Strategic plan
Work flows
Process vs task orientation
Access and security Data ownership
Patience and time
Table.
Inherent Challenges
For Adoption of an EMR System
EMR, electronic medical record
Copyright © 2008 McMahon Publishing Gr
oup unless otherwise noted.
All rights r
eserved. Repr
oduction in whole or in part without permission is pr
include and define the requirements necessary to establish a successful implementation, and then ulti-mately select a vendor that has the longevity to sup-port current and future needs.
A full understanding of EMR system functionality requires familiarity with some of the terminology and configuration options available. Although selection cri-teria will be based on the deliverable functionality of the EMR application, a base knowledge in the following areas is essential for navigating systems and vendors: • EMR system configurations;
• connectivity and networking; • hardware.
EMR System Configurations
The term “configuration” refers to how a system is going to be set up and where the data will be stored. Will there be a server in the office, or would a server based at a third-party data center or the hospital data center be a better solution? Cost, speed of access, and security must be measured when this decision is made. There are 2 primary EMR system configurations to consider: client-server application and
remote-hosted system.
CLIENT-SERVER
APPLICATION
This type of EMR system resides on site at the med-ical practice. The medmed-ical practice owns the software and hardware and is responsible for many of the tech-nology support functions: data backup, disaster recovery, database maintenance, security, Internet distribution for remote access, and information tech-nology (IT) support. The practice is responsible for maintenance and updates. It is the experience of the consultants that client-server applications are usually upfront purchases with annual upgrade and mainte-nance fees that are 18% to 22% of the initial cost—that is, these rates have been experienced in several engagements across medical practices of various sizes and specialties. It will also be important to con-sider and budget for professional IT staff to establish and maintain high-availability (redundant) servers, Internet access, business continuity plans, network and database administration, security and intrusion detection plans, and data backup.
REMOTE-HOSTED
SYSTEM
An application service provider (ASP) system is host-ed from a remote data center and can often be distrib-uted through the Internet (Figure 3). Upgrades are deployed regularly to subscribers by the vendor, also by way of the Internet, usually without any need for the practice to install disks or make changes to the server. Data storage and backup are done at remote sites, and data are stored at data centers for disaster recovery. ASP systems are usually sold by monthly subscription, which includes fees for upgrades, support, maintenance, security, data backup, and data storage. They are
FPs, family practitioners; GPs, general practitioners; OB/GYNs, obstetrician/gynecologists
Figure 1.
Percentage of physicians
using electronic medical records.
Specialty P er c entage 25 20 15 10 5 0
FPs/GPs Internists OB/GYNs Pediatricians All Others 20 22 12 16 15 Practice Size Pe rc e n ta g e 40 35 30 25 20 15 10 5 0 Solo Partner 3-10 11-20 21+ Doctors Doctors Doctors
10
13
15
26
39
Copyright © 2008 McMahon Publishing Gr
oup unless otherwise noted.
All rights r
eserved. Repr
oduction in whole or in part without permission is pr
becoming more attractive to practices of all sizes. Often community hospitals offer an EMR solution to physician practices that provides links to the hospital information system. The EMR system may be offered in a configuration in which the hospital hosts the client-server application and/or provides remote access via an Internet connection. Physician practices that are consid-ering hospital-offered software packages must be cau-tious and take time to review the software for applicabil-ity to the practice rather than to the hospital setting. Often, software used by hospitals for inpatient services is inefficient in the physician office setting, where the focus is on managing the encounter information. The following questions should be considered: Is the software best suit-ed for an inpatient environment? Are the components oriented around the inpatient record and therefore more cumbersome to use in the ambulatory (office) setting for documenting patient encounters? Or is the software a best-of-the-breed solution for the outpatient environ-ment with interfaces to the hospital information system?
Connectivity and Networking
INTERNET
CONNECTIVITY
The Internet is vital in health information tech-nology. An ASP system depends on the Internet, and client-server applications require some Internet con-nectivity to obtain information from outside sources. A practice’s Internet connection must facilitate the trans-mission of large files, such as images and data-rich documents.
The Internet may be the conduit for the transmission of orders, including prescriptions, and the receipt of test results and other communications, including elec-tronic claims and remittance advices.
INTERFACED
CONNECTIVITY
At some point in the EMR system selection and acquisition process, the question of replacing an existing practice management (PM) system is raised. It may seem that an integrated solution—the same
Figure 2.
Health information-sharing system.
• Demographics • Laboratory • Orders/Results • Ad Hoc Reporting • Data Analysis • Eligibility • Analysis • Referral • Demographics • Immunizations
Copyright © 2008 McMahon Publishing Gr
oup unless otherwise noted.
All rights r
eserved. Repr
oduction in whole or in part without permission is pr
database structure underlies both the PM and EMR systems—is preferred. Vendors often shy away from developing new interfaces, and the initial costs can add thousands of dollars to the EMR system acquisi-tion, but a single-minded approach can result in a delayed EMR system implementation because the PM system must first be deployed. Another consideration is the replacement of a well-working PM system with a less-than-adequate PM system in the interest of an EMR system acquisition; when the billing and collec-tions process is disrupted, a gap in cash flow for the practice results.
Every practice must consider interfaces as a compo-nent of any EMR system implementation. For example, outside laboratory results will be coming into the prac-tice. Rather than having staff perform data entry of these results into electronic flow sheets from incoming faxes or images, interfaces can be used, at least for the higher-volume testing facilities.
NETWORKING
Practices can be wired or wireless. Wired network-ing may connote a busy office full of the latest equip-ment, but they can be an inefficient networking medi-um. Wireless networking is a viable and affordable alternative to traditional wired networking that offers the same benefits without cumbersome and limiting wires. It is very easy to integrate wired access with wireless, and many practices have both formats. In a wireless network, all of the computers broadcast their information to one another with radio signals. This can make networking extremely easy, especially when computers are set up throughout an office. Without wires, office space can be easily reconfigured as a medical practice grows and changes.
A wireless network has several major advantages over a wired network, such as reduced cost of instal-lation, flexibility, and convenient information access. Although desktop units or “thin clients” can be installed at nurses’ stations, wireless connectivity is also important for examination rooms. It is easy to appreciate the advantage of keeping a desktop unit out of the examination room, where patients and chil-dren may be left unattended.
Hardware
Laptops, desktops, pocket PCs, PDAs, and smart phones are just some of the many hardware choices. Selecting the right hardware for the right application by the right user is crucial to a successful implemen-tation. The selection of the workstation is probably one of the more interesting and exciting steps in the process of selecting and acquiring an EMR system. However, it should not be an early step in the process. Software vendor’s recommendations need to be con-sidered when hardware is selected. Some software applications can be supported only by specific end-user devices because of the design of the end-user inter-face. All applications have minimum requirements
DB, database; SAN, storage area network
Figure 3.
Remote hosting.
Redundant storage Interface engine Backup system
Disaster recovery solution
Operations Electronic data
interchange (EDI) Report analytics Upgrades and testing
Data Center
Copyright © 2008 McMahon Publishing Gr
oup unless otherwise noted.
All rights r
eserved. Repr
oduction in whole or in part without permission is pr
that must be met, but performance is generally bet-ter if hardware exceeds those baselines.
Two pieces of hardware require more considera-tion than might be expected: the scanner and the fax server. The business of medicine is communication, and much of health information is still communicated via paper. Both devices will be essential for conver-sion from paper charts to the EMR system, and to the daily processing of paper that routinely comes into the office.
An existing fax machine can be replaced with a fax server even before purchasing an EMR system. A fax server still allows the printing of faxes for paper charts, and staff will have the opportunity to learn the new technology in preparation for the full EMR sys-tem implementation. A high-speed scanner will help staff keep their “filing” current after the EMR system is implemented; it will allow conversion of existing paper charts (specifically, those components needed at the time of the patient visit) to electronic records for a chartless transition.
Summary
Technical issues such as hardware and connectivi-ty are often the first consideration when the EMR system is being considered, but more critical to a
successful outcome are operational and personal issues. Each physician in the practice must answer these key questions:
• What is the objective in implementing an EMR sys-tem? What is the problem that needs to be resolved? (This answer should be the driving point in the selection and implementation process.) • What is the preferred solution to automating the
medical record-keeping process?
• What must the EMR system do/provide for a group’s physicians to be willing to use it?
When the improvements an EMR system brings to the day-to-day operation of a practice are consid-ered, then the rest of the factors will fall in line to meet the vision of a given practice.
References
1. Health information technology in the United States: the informa-tion base for progress. Robert Wood Johnson Foundainforma-tion; 2006. http://www.rwjf.org/files/publications/other/
EHRReport0609.pdf. Accessed July 30, 2007.
2. AAFP survey shows number of FPs using EHRs continues to climb. http://www.aafp.org/online/en/home/
publications/news/news-now/practice-management/ 20070713ehrsurvey.html. Accessed July 30, 2007.
3. Terry K. Doctors and EHRs. Med Econ. 2005;82:72-74,77-78,80-84.
