American College of Physicians: Internal Medicine — Doctors for Adults ®


Interested in EMR software? Look before you leap

This is the first in an occasional series of articles by Dr. Carter on using electronic medical record (EMR) software.

From the October ACP Observer, copyright 2003 by the American College of Physicians.

By Jerome H. Carter, FACP

With electronic medical records (EMR) software in the news lately, physicians are hearing more and more about how the technology can improve patient safety, give fast access to patient records and even boost the bottom line of medical practices.

If you're like most physicians, however, you view those claims with more than a little skepticism. Almost everyone, after all, knows of at least one story in which an EMR installation melted down and the practice never realized any gains in cost savings, productivity or efficiency.

For most practices, the truth about EMR software lies somewhere in the middle. While EMR systems can be great clinical tools, not everyone is ready to take advantage of the technology.

This article will outline ways you can determine whether your practice is really ready to consider an EMR system and anticipate some common problems you may encounter in implementing EMR software.

Identify problems you want to solve

Before you even start thinking of looking at EMR systems, you need to set clear and objective goals for your practice.

These goals will give you a solid idea of what you hope to solve with EMR software, as well as objective criteria to help you evaluate different systems. Your list of goals will also serve as a yardstick to measure the success of your implementation if you decide to take the plunge.

Start by sitting down with everyone who will use the system—that includes physicians and staff—and ask them to identify the daily problems they would want an EMR system to address. Common workflow problems include the following:

  • communication breakdowns between practice personnel (the lost sticky notes problem);
  • follow-up of abnormal results;
  • reminders to contact patients who need preventive services;
  • tracking outside referrals (both pending appointments and results); and
  • keeping current with health plan rules for medications and consultations.

Once you've identified some of these larger goals, look at goals specific to your practice. Talking about nuts-and-bolts issues—reducing the costs of dictation, for example—will give everyone a chance to have input into the process. It will also increase buy-in from everyone who will be affected by implementation.

Some practice-level reasons to buy EMR software include lowering dictation costs; accessing records faster; tracking preventive medicine; reducing medication errors; meeting HIPAA regulations; improving reimbursement through more accurate evaluation and management (E/M) coding; and retrieving lab results online.

Built-in barriers to success

Once you know what you want to achieve with EMR software, you need to critically assess the factors within your practice that may be built-in barriers to success with EMR software. Because an EMR system will completely change how your practice functions, you need to try to predict how those changes will help or hurt.

There are two general rules of thumb to keep in mind when thinking about EMR software. First, at a very basic level, computers make things happen faster, whether you are looking up a lab value or creating a bill. While speed is generally viewed as a benefit, it can also be a liability. If you are under-billing for services using an EMR system, for example, it may take you longer to spot the mistake than if you were sending paper claims.

The reason has to do with the second general rule of computing: People tend to believe just about anything that comes out of a computer. To put a new twist on an old saying, "garbage in, gospel out."

Data entry mistakes and errors that arise when patient information is moved between computer systems (from a hospital lab system to your EMR system, for instance) can cause serious harm before being detected.

Computerizing records has other long-term implications that need to be considered. Here is a look at some considerations:

  • Staff turnover. EMR systems are complex and cannot be learned overnight. You won't see any gains in productivity unless you and your staff know how and when to use the different features of your system.

    High staff turnover rates will result in few personnel who really understand the system. That in turn can lead to data entry errors—or data that are not entered at all.

    Because EMR software is only as useful as the data it contains, proper staff training and low turnover are essential to a successful implementation. As a result, practices that have high levels of staff turnover will have problems making the most of EMR systems.

  • Data entry. Because EMR software helps physicians more accurately choose E/M codes and improve charge capture, the system you use to enter progress notes is a major issue. In my experience, different provider preferences in how notes are entered into the system are often a huge barrier to smooth implementation.

    The problem is getting everyone to agree on how progress notes are entered. Most notes are entered in one of four ways: typed by staff or physicians (using free-text or templates); dictations that can be e-mailed from the transcription service; voice recognition software; or pen-based entry systems that require physicians to use a series of drop-down menus.

    Each method has its share of warts. Continue using a transcription service, for example, and you won't save any money on dictation. Typing and template systems, on the other hand, are not easy or intuitive for many doctors. Voice recognition system performance still varies between users, and some physicians find the drop-down menus of many pen-based systems tedious.

    If it's not resolved, the issue of inputting patient date stops many EMR implementations in their tracks. Get a consensus on how data will be entered, and identify any dissension in your group before you choose an EMR system. Of course, the best solution is an EMR system that is flexible in this regard and allows for multiple data entry methods.

  • Physician work habits. Provider work habits are another "make-or-break" issue. EMR software changes workflow, and entering your data takes time. Those factors can affect the number of patients you'll be able to see per day, particularly in the first few months of getting used to an EMR system.

    It also takes time to learn how to use the system to write prescriptions, check labs, create the note and enter orders. Some physicians may be tempted to cut some data-entry corners, but if the doctors do not use the system consistently, much of the value of owning EMR software will be lost.

    Some process also needs to be in place to make sure practice personnel enter data in a timely manner. You won't succeed with an EMR system unless you have a good office administrator who can focus on details and is technology-savvy—or at least eager to learn. Does your practice have someone who fits this description?

Finally, consider these other issues that can determine whether an EMR system will become a great investment or an expensive mistake:

  • affiliations with hospitals or laboratories that would aid in getting online labs-or else, paper will continue to flow freely;
  • number of outside labs or consultants used (another source of paper);
  • the amount you can safely spend;
  • how the transition from paper to electronic will be handled, and by whom; and
  • buy-in from everyone affected.

Paying close attention to these factors will improve your chances of enjoying an EMR system's big benefits. It will also save you the high costs of failure in terms of money, provider goodwill, lost income and poor staff morale.

Jerome H. Carter, FACP, is director of informatics at the 1917 Research Clinic in the division of infectious diseases at the University of Alabama at Birmingham. He is the former Chair of ACP's Medical Informatics Subcommittee and edited "Electronic Medical Records: A Guide for Clinicians and Administrators," published by the College in 2001.


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