Page 1 of 6 How the Clinical Customization of an EMR Means Good Business: A Case Study of Queen City Physicians Pam Coyle-Toerner, M.H.H.A.* and Louise Collins, R.N., B.S.N., C.R.N.I. This article describes a case study of Queen City Physicians, a 38-provider internal medicine and pediatrics practice spread over eight locations in the Cincinnati, OH area. The authors share steps taken and lessons learned that can ensure success for any small to medium practice, from vendor/system selection to go-live. The financial feasibility of EMR systems is also discussed. Key words: Electronic medical record; undercoding; HIPAA; workflow; prescription management; transcription; computerized patient records. INTRODUCTION Only a few years ago the true electronic medical record (EMR) was considered the Holy Grail of the medical community, and even then, was only for large medical practices and hospitals with budgets big enough to finance such an undertaking. In reality, many of those initial purchases turned out to be nothing but expensive paperweights. Now, there is the promise of a substantial payoff through efficiency, better coding, and adherence to HIPAA compliance requirements. Coupled with decreased hardware and software costs, higher tax deductions, and good financing programs, practices large and small can afford an EMR that works. In this case at Queen City Physicians, a 38-provider internal medicine and pediatrics practice spread over eight locations in the Cincinnati, OH area, it was the looming Health Information Portability and Accountability Act (HIPAA), requiring secure electronic transactions, that first drew attention to the need for an EMR. Secondly, the doctors were literally leaving money on the table due to undercoding. Level IV and V care was often taking place, but the paper-based record keeping made it hard to prove it. Although rarely billed, this is especially true for Level V care, which is the most scrutinized by payors. the doctors were... undercoding Level IV and V care. Finally, the practice needed efficiency from a workflow perspective. Like medical offices everywhere, the staff were constantly chasing paper charts, and the time wasted looking for information or even waiting on hold to place a prescription order was taking staff away from their primary charge: taking care of patients. In the fall of 2001, Queen City Physicians implemented A4 Health System s HealthMatics EMR. It has meshed with the workflow, drawn significant respect, buy-in and participation from providers and supporting staff, eliminated the need for paper charts and cut wait time to place prescription orders to zero. The practice is much closer to HIPAA compliance. When a case is made with insurance companies, it takes minutes to provide comprehensive documentation that stands up time after time.
Page 2 of 6 Doctors are coding more accurately, the office is staffed leaner and more appropriately, and the practice is financially healthier, even with the five-year financing arranged to install the System. Implementing an EMR is a difficult and resource-intensive undertaking, but with the right vendor, resources, commitment, and attitude, it is attainable. Below, there is a discussion of steps taken and lessons learned that could ensure success for any small to medium practice. STEPS TO ENSURE SUCCESS Choose a vendor with a system that can closely mimic your current workflow and a team that is committed to your success. Queen City Physicians chose A4 because the practice could customize the system to match its own care preferences and workflow patterns. A4 had the capability to interface with a large variety of practice management systems. Training and implementation... was to be completed in phases... The vendor s implementation team was as committed as the practice was to success. The team leader assigned to Queen City was a career nurse prior to joining A4; she understood the intricacies of a physician s mind and provided valuable insight into training and customization. She and her team were available from the initial planning through implementation at the very last site, providing advice through the process. A4 also helped to see how the EMR would reduce administrative costs through efficiencies on lab, messaging, and script processing, and although the practice has never used transcription, it is important to note that an EMR can eliminate the need for this costly service. Get a commitment from the top down. Unless your leadership understands the value of undertaking an endeavor of this magnitude, it will fail. HIPAA regulations are forcing us to change the way medical practices do business, but financial and workflow benefits speak to doctors. Show them how their lives will be easier and their practice will be more profitable if they whole-heartedly commit. Resolve that failure is not an option. This will require a large financial commitment. The leader needs to believe in it and be willing to take all steps necessary to ensure its success, including thoroughly learning the system him/herself. Provide a place for staff to train and customize the system. Training and implementation at each of the offices was to be completed in phases, so a training room at the largest office was established and outfitted with equipment purchased for the last site to go on-line. The space was not large 11 feet by 14 feet but it served its purpose. The only additional purchase was an extra server to create the mock environment. Outside of initial buy-in, customization is the most important part of implementing an EMR. The more the system is customized to your practice patterns, the faster and more accurately practitioners and staff can document each visit. For example, the pediatricians spend a significant portion of their day doing well-baby visits. A4 showed the practice how to program fast tracks to easily lead providers through these routine examinations, including documenting developmental milestones, weight and measurements, and immunizations. Options were narrowed down to those applicable to a particular visit type by age.
Page 3 of 6 Outside of initial buy-in, customization is the most important part of implementing an EMR. Another good example is upper respiratory illness. The practice built fast tracks for respiratory problems seen on a regular basis during cold and flu season, such as asthma, strep throat, and upper respiratory infection that included click-throughs to the top procedures and medications used to treat these illnesses. Customizing your system up front also ensures that you will use diagnoses and procedure codes that will be accepted by the insurance companies. A4 s system has a built-in E&M calculator that analyzes the encounter to ensure coding is appropriate to the care documented, which wards off auditors and increases revenue. Make customization and training fun and purposeful. The best way to customize and practice using the system was to enter the data from active paper charts together. As each doctor entered the information, he or she was able to identify fast tracks that should be built based on their own practice patterns. With the help of A4, the practice hosted EMR days when everyone would gather in the training room to enter charts and collaborate on how things should be set up. The ability to work together to create a customized EMR perpetuated the buy-in along the way. Doctors tend to be competitive by nature, so as a group they set a goal of entering 50 charts each and challenged each other to meet it. As they have learned the system, they become more intuitive, identifying new ways to use it. Entering active charts, however, did more than just acclimate providers to the system and provide a roadmap for customization. It gave the practice historical information on current patients to use once the system went live. Give your providers everything they need to ensure buy-in and success. The doctors and medical assistants were given handheld, wireless, thin client devices, which allow caregivers to connect to the EMR in real-time anywhere in the office. Doctors could also access the server from home if they were on-call. A4 provided training during times of the day that best accommodated patient care schedules, which gave them few excuses not to participate. One person learned the software behind the system so that when they had a problem, that individual could be the one to confirm that the system does work and lead them toward a solution, instead of letting them revert to the old paper chart. It s also important that it not be an all-or-nothing proposition. In the beginning, it is not imperative that every detail or action be executed through the EMR. When the doctors entered active paper charts, they did not have to enter every past ailment or minor surgery to create an effective chart. Even today, they know that if they don t see a particular drug in the system yet, it is OK to use a prescription pad. Become your own Information System (IS) person. Contrary to common belief, implementing an EMR does not require a dedicated IS specialist if you already have a good practice management system in place. A good vendor will provide all of the necessary training and on-going customer support. Practice real-life scenarios before the big day. Paper charts have a way of pushing the patient through the system: a chart shows up in a door; a sheet of paper lands in the lab basket. Now, staff would be sending and responding to electronic cues instead. For example, a patient checks in at the front desk, and a prompt appears on a nurse s computer screen for him or her to provide the initial consult and take vital signs. When the nurse is finished, the provider is prompted to examine and evaluate the patient. If immunizations or other orders are required, the
Page 4 of 6 provider sends the request electronically to the nurse or lab. prescription orders direct to pharmacies anywhere, pre-op notes to the hospital, and consult notes to referring physicians, anesthesiologists, and other providers. SUCCESSES In this case, the Ohio Board of Pharmacy had not allowed prescriptions to be generated from an EMR because of security and fraud issues. A4 and Queen City worked together to make a case for electronic prescriptions, and as a result of these efforts, Queen City became the first physicians group in Ohio authorized to send prescriptions from its EMR. Currently, they send electronic prescriptions to approximately 900 pharmacies. Although the whole process is designed to mimic the paper-based method, it is still important to take dry runs to ensure everyone understands their cues and that functions, such as fax and scanning, are working properly. MAKING THE TRANSITION The first day actually using the system went very well despite a fax issue with prescriptions that was later resolved. Doctors to set their own pace one decided he would complete EMRs for only new patients, yet another would aim to complete one per hour. A4 s staff was on hand to help and continued to build more customization as new opportunities arose.... doctors... set their own pace... Each successive go live was easier due to the growing experience with the system and further customization that benefited each site. A4 was there each time to offer support Queen City needed. See Figures 1 3, which illustrate typical screens in the system. AFFORDING THE SYSTEM It is true that EMRs are not inexpensive, but with HIPAA requirements and declining reimbursement, practices large and small cannot continue with a paper-based method. As a matter of fact, the increased revenue that results from implementing an EMR can not only pay for the system but also generate increased reimbursements. EMRs are not inexpensive... but [they] also generate increased reimbursements. Queen City found money to pay for the EMR in several ways: First, the practice looked for ways to reduce the cost of the EMR by relying more on themselves for customization and limiting the number of people who called A4 for technical support. Second, they looked at how the EMR would be more efficient and set goals for staffing the office more appropriately. For some practices, this means completely eliminating the need for transcriptionists, a
Page 5 of 6 huge annual expense. They also looked at how it would affect the nursing pool. By sending prescription orders directly from the EMR, they saved almost 300 minutes of telephone hold time in one morning alone. The time saved looking for charts would also free up staff for more important work. Fourth, they looked at improved cash flow. As discussed earlier, a more accurate and complete chart will usually yield a higher reimbursement, and indeed that was the case for this practice. For example, there was an internist who was very busy but typically undercoded his visits. The majority was coded as Level II or III, with less than 5% over a Level IV. With the new EMR, which has a built-in E&M calculator, he is coding more than 65% at a Level IV. Now, his documentation matches the great care he has been giving all along; the difference is that the practice is getting paid for it. Finally, the practice found ways to capitalize on its efficiency with creative partnerships. For example, they struck a deal with a large retail pharmacy to be the preferred pharmacy. The pharmacy pays for advertising on Queen City Physician s Web site and telephone hold message, and if prescriptions filled by their pharmacists aren t completed within 30 minutes of the fax order reaching their pharmacies, the patient pays nothing. With attractive financing plans offered through financial institutions and vendors as well as a tax advantage that allows practices to deduct all or part of the cost of the system in the first year, an EMR is affordable. This full EMR was financed through a bank over a five-year period at a variable rate currently at 4.00%. At the 18-month mark, Queen City Physicians is ahead of expenses through increased revenue, leaner staff, efficiency and partnerships, thereby putting them on track for an impressive return on investment (ROI). To note, the ROI from an EMR depends on whether additional revenue can be generated through more appropriate billing, and whether an organization will operate in a complete paperless chart environment, thus eliminating or reducing the need for medical records clerks. There are also tax benefits that a practice can take advantage of with an EMR. Queen City is following the tax guides allowing a deduction up to $100,000 for this year, and a straight-line amortization would have resulted in a deduction of approximately $18,000. As with all technology equipment, they maintain a more aggressive amortization schedule to account for the rapidly declining value of all technology items, and they definitely recommend that a practice have their CPA handle all tax calculations. Conclusion The adoption of an EMR system has allowed increased efficiency in this group s ability to provide services, heightened their billing accuracy and increased their reimbursement rate. By selecting a system that the practice could customize to match care preferences and workflow, keen attention to physician and staff needs, physician leadership, practice sessions and a vendor with exceptional customer service, they were able to capture 100% buy-in of an electronic medical record system. They expected a full ROI at two years with appropriate coding and staffing adjustments- and with financing handled entirely through a bank-they are ahead of expenses at the 18-month mark. The financial benefits from the system are an attractive bonus to realized goals of workflow efficiency, appropriate staffing, gains toward HIPAA compliance, thorough documentation, organization and, most importantly, better care for patients. n *President and COO, Queen City Physicians, 2753 Erie Ave, 2 nd Floor, Cincinnati, OH 45208; phone: 513-233-
Page 6 of 6 2810; fax: 513-871-2824; E-mail: Pamela_Coyle-Toerner@trihealth.com. Clinical Product Manager, A4 Health Systems, 5501 Dillard Drive, Cary, NC 27511; phone: 888-672-3282; fax: 919-851-5991; E-mail: t collins@a4healthsystems.com. Copyright q 2003 by Greenbranch Publishing LLC.