Getting to Yes Is Not Enough

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Getting to Yes Is Not Enough

• David W. Bauer, MD
• Physicians at Sugar Creek

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Your position on EMR implementation in your group
is

• Have a functioning EMR
• Implementing now
• Considering adoption in the next year
• Possible future adoption
• No way!

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What is the most important barrier to EMR
adoption?

• Cost
• Productivity
• Acceptance
• Reliability
• Too many paper charts
• Other

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Productivity
Acceptance
Paper Records
Expense
Reliability
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Productivity

• Time needed to plan and implement
• Time needed to train
• Time needed to document

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Planning

• Many workflows in a paper-based office exist
  because of limitations or requirements of paper.
• Dont simply convert paper workflows to
  computerized ones.
• To prevent this, we must analyze existing
  workflows until they are fully understood, then
  create new, optimized ones.
• This takes time but is time well spent

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Training and Skill Sets

• Typing skills
• Windows skills
• EMR basic mastery
• EMR applied to workflow
• Simulation training
• Key Point Simulation training is critical

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Productivity

• Time needed to plan and implement
• Time needed to train
• Time needed to document

No Shortcut
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Potential Solutions
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Productivity

• Office visits
• Phone calls
• Prescriptions
• Billing

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Productivity

• Office visits
• Phone calls
• Prescriptions
• Billing

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Data Entry Facilitation

• Predefined forms for common, predictable data
  (e.g. diabetes, motor vehicle accident)
• Stored past medical history, etc., so doesnt
  have to be entered each time.
• Text macros for common phrases
• Voice recognition

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.statin
We discussed the various treatment options for
treating cholesterol. I have recommended starting
a medication for this condition. I have explained
to the patient that it is also important to limit
fats in the diet and get regular exercise. I
explained that rare side effects include liver
damage or muscle damage, and emphasized the need
to report muscle aches or abdominal pains
immediately. I also told the patient that
additional lab work is needed in two months.
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Productivity

• Office visits
• Phone calls
• Prescriptions
• Billing

• No need to pull charts
• Can be answered anywhere with network/Internet
  access
• Documentation in real time
• No need to file charts
• Able to forward message easily
• Legibility

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Productivity

• Office visits
• Phone calls
• Prescriptions
• Billing

• Insurance formularies
• Time savings for refills
• Allergy checking
• Interaction checking

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One by mouth daily for blood pressure
Predefined instructions and quantity save time
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5
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Non-Formulary Callbacks
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Penicillin
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Productivity

• Office visits
• Phone calls
• Prescriptions
• Billing

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Productivity

• Training time Must allow time for this, which
  will almost always cut into office hours.
• Novice user time Virtually every EMR will slow
  down the new user. Either fewer patients will be
  seen, or the physician will spend more time after
  hours documenting.

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Productivity

• Bottom Line
• Initial decrease in productivity
• Provider volume returns to baseline rapidly
• Chart note documentation takes longer, but
  results in better charts
• Office productivity increases dramatically

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Go-live
50 increase in patients seen
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Acceptance

• By patients
• By nursing
• By front office
• By providers

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How likely are you to refer a friend to our
office?
Go Live
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Paper Records

• What do we do with the thousands of paper charts?
• Ignore them?
• Scan them?
• Summarize them?
• Abstract them?

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Expense

• Software
• Hardware
• Network (within and between offices)
• Internal or external technical support
• Updates

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Any Offsetting Savings?

• Chart Creation
• Chart Storage
• Chart Management
• Searches
• Simultaneous Access
• Reengineering
• Staff
• Space

• Malpractice Premiums
• Increased Revenues
• Medically needed services
• Pay for performance
• EM Coding
• Dictation

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Chart Pull Savings
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Reduction in Material Costs
Average Cost 2.00 Per Chart with
Dividers 0.75 Per Chart without Dividers
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EM Coding Changes
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1999 and 2002 Distributions Applied to 2002
Visits
Similar benefits for new visits
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ROI -- Bottom Line
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Break-Even Point
Break-Even Point
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Reliability

• Dont Computers Crash?
• Yes.
• But so do paper charts...

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Northridge, California earthquake 1994. Medical
Building
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Medical Building Fire
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Medical Center, Houston Tropical Storm Allison
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Backup

• Web-based
• Redundant hard drives
• Removable media
• Key point make sure it is stored off-site!

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Productivity
Acceptance
Paper Records
Expense
Reliability
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Now What?

• The EMR is up and running
• How can we maximize impact on
• Quality?
• Productivity?
• Satisfaction?
• Return on Investment?

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"Christ the Redeemer" statue Rio de Janeiro,
Brazil
A message
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Does your office use email to communicate with
patients?

• Yes
• No

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Secure Messaging

• This is not your parents email!
• Must be HIPAA-compliant
• Must account for the new Federal Electronic
  Discovery Rules (in effect since 2006)
• These are part of your patients medical records.
• Must have a policy for retention and destruction.

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Great Wall of China
Connected multiple existing structures
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Does your office use e-prescribing?

• Yes
• No

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Electronic Prescribing

• Physicians
• Pharmacies
• Insurance coverage
• Formulary information

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Prescription Safety

• Over 3 million adverse drug reactions each year
  in this country
• Estimated 2 billion in adverse drug event costs
  per year
• 8th leading cause of death in this country more
  common than motor vehicle accidents

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Prescription Written by Physician
Prescription Taken by Patient
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Print
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Fax to Pharmacy
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Electronic
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The Colosseum, Rome, Italy
Multiple ways to enter
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Patient Data- Entry

• Bubble cards
• Secure web-based forms
• Home monitoring equipment

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Petra, Jordan
Hard work, carved out of rock
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E M Coding

• (Almost) nobody likes EM Coding
• We are afraid of overcoding
• We often undercode
• Both put us at risk
• The painful way

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• This note does not comply with CPT-99214 because
  of the following deficiencies
• Lacks 2 more organ system(s), or 4 more bullets
  in Exam
• Lacks 1 area(s) of at least moderate decision
  making

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Machu Picchu, Peru
Wiped out by smallpox
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Disease Management

• Recognizing, tracking, and intervening for
  chronic diseases such as diabetes, heart disease,
  smoking, cancer, etc.
• Why?
• Better outcomes for patients
• Savings for society
• Increased revenue for practice Pay for
  Performance

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Pay For Performance

• Aetna
• AHIP
• Blue Cross
• Blue Shield
• Cigna
• CMS/Medicare
• Health Net
• Health Partners

• Heritage
• Humana
• Medicaid
• Medicare
• PacifiCare
• United Healthcare
• Wellchoice
• Wellpoint

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Chichén Itzá, Mexico
Structured Data 365 Steps
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Structured Data

• Not only storing the item in the EMR, but also
  identifying what kind of item it is, the date of
  collection, whether it is abnormal, etc.
• Not all EMRs offer this. If not, walk away
• Because, you will miss out on one of the most
  important benefits of an EMR.

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Taj Mahal, Agra, India
A statement
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Speech Recognition

• Reasonably priced
• Highly accurate
• Reduced training time
• Can be used for navigation and commands in
  addition to note dictation.

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Summary

• Barriers to EMR adoption are real, and must be
  considered carefully.
• All barriers have solutions.
• A good EMR should eventually be cost-neutral at
  worst.
• An EMR is a great start but to really maximize
  use, consider the other wonders out there!