The Cheapskate's Guide to the EMR

For the last several years, I have been presenting a talk entitled "The Cheapskate's Guide to the Electronic Medical Record," which focuses on ways that small practices can implement electronic medical records (EMRs) with lower upfront costs and with less disruption to their productivity. Below are a few specific hints to make your EMR implementation more cost-effective.

1) Don't Throw Away Your Electronic Data

If you are thinking about implementing a lifetime medical record in the near future, then be sure that you are saving your current transcriptions to be placed in the EMR. Once an implementation begins, it is invaluable to have months' or years' worth of old dictation preloaded.

2) Save Money by Negotiating Training A software vendor will typically charge $120-180 per hour for an implementation manager. This may be money well spent, but often that rate applies to lower value items such as "desktop teaching" and even secretarial tasks, like setting up meetings and phone calls. Be sure to negotiate what constitutes billable time from your implementation manager. Desktop teaching about a particular software program (eg, "click here to open this window, then click this button") can often be executed by a nurse or other user of the software from a nearby practice. Since the prices charged by the software vendor are so high, there is plenty of room for cost savings. Of course, preserving your right to seek such teaching on the market has to be negotiated prior to signing the contract.

[A real cheapskate might also try to insist that the opening implementation PowerPoint presentation not be a billable item.]

3) Interfaces Are Expensive, But They Save Money

Interfaces with lab are expensive to build initially, but they are invariably cost-effective. Human beings, such as nurses, medical office assistants, and physicians, are very expensive. They are too expensive to do simple repetitive tasks, such as transcribing labs into the record. Getting interfaces in place early introduces improvement in workflow efficiency that helps to reduce emotional resistance to the change brought on by the electronic record.

4) Think About Soft Costs and Workflow

Since most physicians don't have a background in business, they tend to lose sight of "soft costs," like the price of the physician's time when conducting an inefficient process. A typical physician in an outpatient setting is worth $250 per hour in billings. A medical records assistant or an office nurse may cost $10-30 an hour. Therefore, it is important to move as much of the factual EMR data entry to these lower-cost employees as possible. Examples would include entry of new medications, document preparations, and some history-taking by way of organized templates. You don't need to be a physician to ask if the patient smokes or when their last mammogram was. This doesn't lower the costs of the EMR, but it makes its use much more buyer-friendly. There are many other soft costs that having an EMR can help you reduce: lab letters and referral letters and follow-up orders. All these are repetitive processes that typically include recurring phrases (eg, "thank you for seeing my patient") and information such as demographics and lab results that can be brought into the document automatically. The take-home message is to avoid buying low-value services, spend good money on high-value services, and look for workflow improvements that save money and improve quality.

Dr. Brewer is an associate professor in Department of Family Medicine of the University of Tennessee, Knoxville. He has led the implementation of the electronic medical record in the family medicine residency program.