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

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'Slow and steady' the best approach to going paperless

Common mistakes include converting too fast and underestimating how much time and training offices need

From the July-August ACP Observer, copyright © 2006 by the American College of Physicians.

By Janet Colwell

PHILADELPHIA—Over the past year alone, physician salaries have shot up 30% at the four-physician Evans Medical Group in Evans, Ga., a suburb of Augusta. New revenue-producing strategies should boost that to an 80% increase next year—due in large part, said a physician member, to its electronic health records (EHRs) system.


Some physicians who have converted to electronic records are reaping big payoffs in revenue and efficiency.



And in New York, the internists and subspecialists with Murray Hill Medical Group currently enjoy income that runs between two and three times the national average. According to founding partner Jeffrey P. Friedman, FACP, that bounty is likewise due to the practice's commitment to going paperless.

Although they work in very different practice settings and parts of the country, both Dr. Friedman and Evans Medical's Robert J. Lamberts, ACP Member, told attendees at an Annual Session presentation that their embrace of information technology had not only increased revenue but had made their respective practices much more efficient.

The key to moving away from paper is not to panic, said Dr. Friedman, at the "Practical Steps Toward a Paperless Office" session. "Converting is not an event," he pointed out, "but a process of gradually weaning staff off paper and helping them adjust to new technology and workflows." The best approach to that process, he added, is to "leave gaps between the big changes to allow for adjustments in between."

Both he and Dr. Lamberts pointed out that one of the worst mistakes you can make when converting to electronic systems is to underestimate the upfront time and effort needed to ensure success down the road. Buying the first EHR you see, skimping on time or money for training, or trying to do too much at once are almost certain roads to disaster.

"This is the biggest investment for your practice other than going to medical school and residency," Dr. Friedman said. "It's either going to make your practice or lead to mayhem."

The paperless suite

Most physicians focus on EHRs when they think of computerizing their office. But truly going paperless involves a whole suite of changes touching every part of the practice—and giving you plenty of opportunities to implement one electronic tool at a time.

Murray Hill Medical, for example, installed a small electronic billing package back in 1992 when it had only four physicians and two associates on staff. As the practice grew, it added new components: electronic scheduling in 1995, an EHR and lab interface system in 1997, and Web-based scheduling in 2001. (The group now includes close to 40 physicians.)

Over the last few years, the practice has continued to expand its paperless suite by adding online prescription refills and referrals and self-service online bill paying. Patient e-mailing is slated to be introduced next year and the practice is working to develop a computerized kiosk where patients can register and prepay copayments.

Evans Medical, with three medicine-pediatrics specialists and one family physician, started out with a paper-electronic hybrid system 10 years ago and gradually went entirely electronic. Over the years, the practice has added lab interfaces, electronic fax service, document scanning and indexing, and directly interfaced EKG/spirometry. It has plans to add bone density scanning and electronic prescribing soon.

With any and all of these systems, it’s critical to research products thoroughly and to involve staff in the process, said Dr. Lamberts, who is senior partner at Evans Medical. “Never buy a system without a test drive,” he said, “and always bring staff along to try things out.”

Both speakers recommended consulting ACP’s Practice Management Center for help selecting the right system. The Center’s "EHR Adoption Road Map" outlines the stages of implementing an EHR—from preliminary research to selection, installation and enhancement—and suggests tools and resources to use in each step.

Avoiding implementation pitfalls. During the session, Drs. Lamberts and Friedman offered the following tips to smooth electronic transitions:

  • Take enough time. Training should take place outside of patient care and allow enough time to get everyone up to speed on new software. Dr. Friedman said that Murray Hill conducted several months of formal training classes followed by one month of practice with the EHR software before going live.
    Training time varies from a few days to a few months, depending on how the new process affects workflow, said Dr. Lamberts. For example, adding a fax service took very little training and people adapted easily, he said, while training physicians to enter charges directly into the EHR took longer because it was a major change in their routine.
  • Enter most useful information first. Particularly when purchasing an EHR, enter the most useful information into your paperless charts first, such as lab results and medication lists. This will encourage other physicians to use the system.
  • Preload data when possible. Hire college students to preload charts with the most common diagnoses, medications and orders. Also, preload the most active patients with multiple problems in advance.
  • Ease doctors in. When Murray Hill bought its EHR, not all the physicians converted to the new system at the same time. Instead, the practice staggered their conversion schedules. When physicians went live, the practice cut their office hours in half for the first one to two weeks to allow them to adjust to the software and have time to pre-load their next day’s patients before leaving for the day.

And if you want to get doctors on board, don’t mandate immediate conversion, Dr. Lamberts said. Instead, get physician champions to try out new systems. If they succeed, other physicians will follow. It also helps, said Dr. Friedman, to go live during the practice's slow season.

The payoffs

It may take a while for everyone to buy into the switch from paper; eliminating dual processes such as paper and electronic phone messages, for example, is a common problem. But eventually the benefits of a paperless office become apparent.

“You have more income and spend less time on documentation,” Dr. Friedman said. Both physicians said some of the improved income physicians enjoy is due to more appropriate coding. Dr. Lamberts also pointed out that when physicians enter codes directly into the patient record in the exam room, the data captured is more accurate with fewer rejected claims.

Evans Medical also uses the system to give feedback to physicians about their billing and to link physician reimbursement to quality and productivity.

"With computerized financial reporting we can see exactly what's going on and what we need to change, he said.” The practice discovered undercoding on E/M procedures, for example, as well as missing charges for labs, procedures and draw/handling fees. “All of these represented missed income,” he noted. “With computerized reporting, we were able to much more aggressively go after outstanding money owed us by insurers and patients.”

And having an electronic system has enabled Evans Medical to implement revenue-enhancing innovations in scheduling and patient care, he added. The practice now uses its EHR, for example, to target groups of patients who are due for checkups or tests, such as infants needing immunizations or diabetics due for eye checks or foot exams.

“We run a report on all those active patients and send a letter or make a phone call,” he explained. “That’s increased our payments and set us up to participate in pay-for-performance.”

The practice is in the process of signing up for “Bridges to Excellence,” which rewards practices for meeting certain performance targets and can pay up to $20,000 per doctor per year, Dr. Lamberts said. “We plan to have some of the quality bonuses go to our staff,” he said, “so they will be motivated to make sure test results are entered correctly into the EHR” and to take the initiative in suggesting that patients get needed tests.

At the same time, practice efficiency—with less time spent on filing, phone and billing personnel—has led to lower overhead. At Murray Hill, for example, overhead costs have dropped from 55% to 39% of revenue, Dr. Friedman said. According to the Jan. 21, 2005, issue of Medical Economics, the industry average for internists is 55.8%.

Plus, the ability to pull up information quickly in the exam room has boosted patient compliance. Instead of just advising patients to get their blood pressure or cholesterol down, Dr. Lamberts explained, the physician can use the EHR to create an interactive, detailed risk profile.

“When patients see how much their risk score for heart disease would go down if they stopped smoking, for example, or reduced their blood pressure,” he said, “they are much more likely to take their medications.”

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Wave of the future: personal health records on the Web?

Imagine an electronic, permanent and comprehensive patient record that can be easily accessed by both patients and physicians. It could be a reality soon, according to an Annual Session presentation on personal health records (PHRs).

Presenter Kathy Giannangelo pointed out that PHRs allow patients to use the Web to e-mail their doctor, track immunizations, note mistakes in their record, transfer information to new physicians and stay current with test results.


Kathy Giannangelo: Personal health records could give physicians more complete patient information.



In return, physicians can access information not in their own records, such as patients' family histories, care by other physicians and results of treatment plans, said Ms. Giannangelo, manager of practice leadership with the American Health Information Management Association (AHIMA), a trade association of health information management professionals. While a doctor’s file may note that a patient received a prescription, for example, a PHR could provide more complete information such as whether the patient filled the prescription or why he might have discontinued taking it.

Because the PHR doesn’t rely on any one physician’s data, she said, “it promotes teamwork and saves time on having to repeat tests or track down information from other places where the patient has received care.”

It's particularly helpful for patients who see many physicians--the elderly or, studies show, those with chronic conditions.

Security issues

While most PHRs—like most physician records—are still paper-based, companies such as HealthcareAnytime, Patientrak or Medikeeper already sell products that allow consumers to store, retrieve and manipulate their PHR on a secure Internet server. These products let patients control the record’s content and to grant full or partial access to physicians, hospitals, insurers or others.

However, many patients—91% in a recent survey by Connecting for Health, a public-private collaborative sponsored by the Markle Foundation—balk at storing personal information online. The problem? Privacy and security concerns, Ms. Giannangelo said.

Those concerns should wane, she added, as more providers implement EHRs and the industry develops common data and safety standards.

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One physician puts EHR savings to work by hiring pre-med students

One of the first investments Mindi S. Garner, ACP Member, made in her new solo practice was to install electronic health records (EHRs). Despite the upfront costs of about $60,000, she's already seeing reaping not only financial benefits but mentoring opportunities as well.

Because the practice, which opened in Pittsburg, Kan., in December 2003, is running smoother and leaner with an EHR, Dr. Garner has not had to hire an office manager or billing personnel. Instead, she handles the financial end on her own, with the help of one receptionist and one nurse.


Mindi S. Garner, ACP Member, (at computer), gives local premed students a close-up view of a primary care practice.



She has put those cost and time savings toward handling her practice's burgeoning needs by hiring several pre-med students each semester from her alma mater, Pittsburg State University.

“The pre-med students were available and needed some clinical experience to see if they wanted to do this for the rest of their lives," she explained. "And I needed some help as my practice expanded, so it was a win-win.”

Learning about primary care

She started the program in early 2004 with one or two students. She now has 12 students who alternate working morning and afternoon shifts. While the students don't earn much more than minimum wage plus extra college credits, they get a close-up view of a fast-paced primary care practice while Dr. Garner gets some office support.

She lets the students answer the phones, bring patients to the exam room and record their vital signs and chief complaints. She also trains them in how to communicate with patients in a professional manner, only then letting them try out their skills by reporting back to patients on Pap smears, mammograms and other routine test results that come back normal.

Students are also invited to follow her on morning rounds at the hospital and help write encounter notes. Dr. Garner helps prepare them for formal attending assessments later in medical school by allowing them to give her formal presentations after they interview patients in the clinic. Senior premeds who have worked with her for more than a year have also been given more financial responsibilities, such as payment entry and handling unpaid claims—under Dr. Garner’s supervision.

She hopes the experience will inspire them to pursue a career in primary care or at least understand what the field is about. “They tell me that just being exposed to clinical scenarios and medications was valuable,” Dr. Garner said. “I think their experience will be even more helpful when they get out into their clinical rotations.”

It may be paying off already. Last year, one of her former student interns started a medical degree program at Baltimore's Johns Hopkins University, while another was accepted by Oklahoma State University in Tulsa and a third by the University of Missouri in Columbia. All say their experience working in a primary care office has given them an edge in their programs.

“They come away with a certain appreciation for what it’s like to be an internist, even if they don’t go into primary care.” They also get to work with information technology first-hand.

Over the last three years, Dr. Garner has added a fax server to her office, eliminating the need to print anything onto paper. With so many efficiencies gained through IT, she said, “I would not even consider practicing medicine without an EHR.”

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