It's All in the Details: One Practice's Experience With Selecting and Implementing an EMR System

Metcalfe’s Law, as cited by Robert Metcalfe, inventor of the Ethernet, states that “the value of a communication system grows as approximately the square of the number of users of the system.” For the last six years, North Fulton Family Medicine has lived by that law and found it to be accurate beyond our dreams.

North Fulton Family Medicine, a primary care practice with three locations in the Metro Atlanta area, decided in early 1998 that the solution to dramatically lower reimbursements and higher costs was to implement an electronic medical record system. Since that time, we have experienced tremendous growth in patient volume and collections without having to proportionately increase staff size. In the spring of 1998, the search for an EMR system took on a life of its own. Dr. Thomas Bat, founder of North Fulton Family Medicine, and I began in earnest the search for the perfect system. Trips to the American Academy of Family Physicians Annual Conference and the Healthcare Information and Management Systems Society (HIMSS) annual meeting allowed us easy access to multiple vendors. Because of the large number of electronic products available to the physician, this turned out to be the most economical use of our time and efforts. Having seen several systems and been impressed by a handful, we then had to decide how best to eliminate them all and save one. Information obtained from the various sales people included product brochures, in-person demonstrations, online demonstrations, and specific references. Phone interviews with current users of these systems also provided a great deal of valuable information, not only about the product they chose but also about the other solutions they might have investigated. Narrowing the list to two vendors, we began the process of traveling to practices using each EMR to see them in operation up close and in person. From a solo practitioner in New Jersey to a seven-man group in Dallas, TX, we spent most of the summer of 1998 visiting current users.

During these visits, several things became apparent. Foremost among these was the fact that participation in the use of an EMR needed to be mandatory. That is, it obviously was not going to work if even a single physician announced that he or she was not going to change to a computer-based system but instead planned to continue creating SOAP notes and writing prescriptions on paper.

It was also apparent to us after the site visits that there needed to be a “go-to-guy” to champion the implementation process. Every successful EMR practice we saw had one such person. And while he or she did not have to be a physician—or even a clinical person at all—he or she did need to be someone who would keep the group excited and moving toward the goal of implementing an EMR. If the practice had any one person who was more computer savvy, then this person was an excellent candidate. The drive and enthusiasm generated by this champion helped most successful practices get past the inevitable small hurdles that cropped up during the process. We also noticed that the practices we visited that were most successful shared a common characteristic: They were highly motivated to change and to change for the better.

Finally, when the time came to make the actual decision and sign a contract to move forward, there was a degree of luck involved. Like any other choice between two or three products, there are so many variables that the absolutely right decision seems impossible. Here you have to realize that every EMR product has its good points and its less desirable points. There is no perfect solution. The important thing at this juncture is to move forward. Don’t let the magnitude of the decision itself prevent you from making one. As new users of EMRs realize soon after implementation of any product, the electronic world is so superior to the paper-based method that nobody I have spoken to would ever go back.

In September 1998, while attending the AAFP Annual Conference in San Francisco, Dr. Bat signed a contract to purchase the Health-Matics Electronic Medical Record by A4HealthSystems in Cary, NC, but the real process had just started. The next two and a half months were as busy as any I can remember. Our next big decision involved hardware. Choices for computer systems to run the program did not approach the variety that is available today. Servers of what type? Backup to tape or hard drive? Wireless or wired? Handhelds for all or desktop PCs? Thin client or fat? CRT monitors vs. the then very expensive LCD thin screen? Flat table surface or retractable arms?

Input received from the vendor’s technical support group helped a great deal, and of course we had budget constraints that drove many of our decisions. In the end, we opted for Dell Optiplex computers and a thin-screen monitor hardwired in the examination rooms, front office, and nurses stations. Our original office in Alpharetta was retrofitted for the systems, and the cabinetry in the new office in Cumming was designed for the in-room computers.

One very important step in our successful implantation of the EMR system was a three-day trip to North Carolina for “key-user training.” This was a 72-hour “train the trainer” program that allowed the more energetic and more involved users to gain more detailed experience with the system. Three days in a classroom full-time with a trainer made us appreciate the complexity of the system and also to fine-tune our new skills.

Servers were shipped directly from Dell to A4HealthSystems. There, software was loaded onto the servers, which were then shipped to us, accompanied by an EMR technician. The installation process was seamless enough, and while the A4 technician performed this task, the implementation specialist met with Dr. Bat and me. Brief lists were created to allow us faster access to our most common ICD-9 diagnoses, CPT codes, laboratory tests, medications, and patient education handouts. Physical exam and “Review of System” lists were also created to maintain uniformity and to speed documentation.

The staffers who attended the key-user training session assisted the implementation specialist in training the rest of our staff in the everyday use of the program. Every staff member received at least two hands-on training sessions, each lasting two hours. Finally the go-live date arrived. The night before, we conducted a three-hour dress rehearsal taking us through the entire process of patient registration and check-in, triage and documentation of the note, prescription writing, and check-out.

On December 17, 1998, we went live with the HealthMatics EMR. After that, we never created another new paper chart, never wrote another prescription by hand, and never dictated another SOAP note. Our nursing staff was asked to take the time to enter each patient’s problem list into the history section of the EMR. They were also asked to enter all of the patient’s current medications and allergies. If the visit was a brief one, more historical data was entered from the paper chart over the next few visits. When a patient was in for a complete physical, the nurses entered all of these initial data points into the system, along with a complete past medical, social, and family history. Within three months of go-live, we rarely had the need to pull a paper chart; soon after that we sent them all to storage.

Workflow issues are a great concern to physicians, being the creatures of habit that we are. Most physicians are concerned that a new computer system will dictate great changes in their workflow habits—“habits” being the operative word. One of the most important features of an EMR is its ability to accommodate different workflows or physician habits. Spending extra time and care with the implementation specialist will make the transition to an EMR smoother and will aid in the acceptance of the new workflow. There are certain to be some changes in an individual’s workflow, but they will be changes that are more likely than not to increase productivity, quality of care, and enjoyment of the job. As the weeks passed, we found ourselves “tweaking” the system on a regular basis. The phrase “work in progress” could be no better applied than to a recently adopted EMR system. Input from providers and staff helped tremendously in making the small changes that speed and simplify the process of seeing patients.

Now, six years after going live, it would be easy for me to say that the process was completely seamless and without any major hurdles. And while any problems we did encounter are overwhelmed by the success of the implementation, there certainly were some issues that I should address. For starters, acceptance of the new system was not unanimous. One physician was not happy with the decision to convert to an EMR and decided to leave us for another practice. That practice has also since installed its own electronic record.

Some staffers were not as computer savvy or willing to learn as were others. These people moved on, too. The total attrition was minimal, however, and in most cases these employees were not replaced be-cause of our decreased need for support staff with the new EMR. A great deal of our savings was due to the fact that we could now grow the practice volume without having to add additional staff.

One of the things we have been asked about most is the process of converting from paper to electronic records. Many would-be users of electronic records are leery of this process and are afraid of losing money or that it will slow them down to the point where they won’t be able to provide timely, adequate care for their patients. While this is an important concern, it seems to be a common reason cited for no decision being made to go forward with implementation. I would en-courage anyone considering transitioning to an EMR to lay those fears aside and proceed toward his or her goal. Another common concern is decreased practice volume caused by the EMR implementation. While there may be a temporary and slight decrease in the total number of patients seen in a given day, this decrease will almost certainly be overshadowed by the decreased costs associated with each visit and also by the more streamlined way in which visits are handled.

Prospective EMR clients also have legitimate concerns about the safety of their data. We certainly shared that concern. Just as we sought to protect our paper charts from loss or harm, we also go to great lengths to protect our electronic data. In fact, in this regard, we definitely err on the side of caution. We back up to tape. We back up to a separate off-site server. And starting recently, we back up through a process called HealthMatics Assure that copies data hourly to a server in Texas where it is housed as near to real-time as is possible. With that solution, should we suffer a loss of data locally, we would be able to be up and running again within an hour of getting an Inter-net line established. That sort of security makes us all sleep well at night.

Another added benefit of the EMR has been our ability to communicate better with our patients. The most expensive piece of equipment in our office is the telephone. We spend more money on telephone time than any other one item or service. With the EMR and an associated online tool called Health-Matics Access, we can communicate securely, in a HIPPA-compliant fashion, with any patient who has an Internet connection (this probably includes more than 90% of our patient population). Using this online tool, we are able to send messages back and forth directly from and into the EMR, allow patients to view their lab results, suggest changes to their demographic data, send refill requests, and a variety of other things that previously took several phone calls.

Physicians who utilize EMRs will also discover another of their advantages over paper-

based systems: time savings. EMRs enable a practice (after the staff grows accustomed to and comfortable with the new system) to see more patients in a given day, since they are finished with each chart at the end of the visit and therefore have less chart work to do at the end of the day. An added bonus is that, by saving so much time, physicians are able to finish the day earlier, allowing them more time for family, fun, or other business-related issues.

In the six years since implementation, we have grown from seeing approximately 100 patients a day to nearly 400. We have moved our main office to a new suite that has triple the number of examination rooms, moved the Cumming office to a new suite with nearly triple the number of rooms, and as of September 2004, have opened a third office. Because we have stayed on top of the learning curve, we have been able to achieve goals that we only dreamed of in 1998. At this time, we have more than 50 employees, including providers. Eight physicians and eight physician’s assistants see more than 300 patients daily, and feedback from those patients tells us that they like the changes we have implemented. Probably the most rewarding of all the changes has been the fact that we are now providing a better quality of care than we ever have before. Patient outcomes, measurable now with the new system, are above par with the rest of healthcare. Collections have also never been higher and employee and patient satisfaction have never been greater. We have many patients who came to us because they had heard that we were “electronically savvy.” Like-wise, we have had prospective employees seek us out for the same reason.

Our efforts were recently rewarded when we were named as a 2004 winner of the Davies Award, given annually by HIMSS to the practices that utilize electronic records best in the country. Also, North Fulton Family Medicine was recently named the fourth runner-up in the 2004 Practice of the Year Award as voted by Physician’s Practice, Business Journal for Physicians. In the end, we have attained a level of competence with and utilization of our EMR system that is within the capabilities of any practice that adopts an EMR system of its own. We are not a practice of computer geeks; we don’t have the deep pockets of some larger groups; and we did not enter into the EMR world with a wealth of prior knowledge. We were, however, driven by an intense desire to be better physicians and a by a serious need to change the status quo.

What practices tend to learn in the early months after implementing a new EMR is that it is not the system or the software that makes or breaks them. One of my main points in speaking to prospective EMR users is that it is all about the company behind the system. Because almost any EMR will create a decent progress note and handle prescriptions and problem and medication lists, it becomes incumbent upon the buyer to look beyond the software itself. We have found that our EMR company has been more than attentive to our needs. In the July 2004 MD Net Guide article on implementing an EMR system, Don Trexler of Bienville Orthopedic Specialists stated that the “idea of a partnership” was an important driving point toward their own purchase of an EMR. We also found such a partnership with A4Health-Systems and have benefited from that partnership since its inception. The idea of a partnership brings the practice and the software vendor into a relationship that is mutually beneficial. Because relatively few practices have yet to implement an EMR, the market is still wide open to most of the vendors. Making the practice satisfied with its decision should be a vendor’s primary concern. Find a company, like we did, that will hook the wagon of their success to yours.