By Pascal Helou
New York, NY - The first step to implement an EMR solution is to document the current office workflow that supports the patient encounter. This is a tedious, iterative and time consuming process that is critical to the success of any EMR implementation. Document exactly what happens when a patients sees a doctor. What forms do they fill out? What happens to those forms? Are they sent to other departments? What systems is data entered into? Who are the people involved and what do they do to move the process forward? Every detail, process, form, system, technology and person involved in the process has to be properly documented to fully understand the workflow of a patient encounter. This process involves many iterations and every person that is involved in the process before a complete understanding is gained.
Once this is documented, you can then identify areas that need improvement, steps that are no longer required, and areas in the process that can benefit from technology and interfaces that will be required to work with existing systems.
You start by eliminating any vendor that does not meet your minimum system requirements. The areas of focus will then be on the feature sets and whether they satisfy your current and future needs.
I will begin by the process by focusing on the underlying technology. Is the solution based on a server you keep in house or can you access the application on the Internet? The advantages to an in-house solution is that the system is much faster, is always available even if the Internet goes down and you have better control of your patient information since it stays in your office. The disadvantage is that there is a larger upfront cost and you have to maintain the server. The alternative is to “rent” the solution. You access the application over the Internet. The advantages are that you have access from anywhere. No or low upfront costs. No servers to maintain in-house. The disadvantage is that the system will always be slower than an in-house solution and will have higher monthly costs. Your data is out of your control and resides off-site. If the Internet goes down, your staff will have little to do till service is restored. Another thing to remember is when a doctor decides to change service; it is much easier to do it on your own terms with an in-house based server than with a hosted solution where you have no control.
Built in patient schedulers or an interface to your existing patient scheduler is critical to reducing errors. If you already are using a billing software that has a patient scheduler then you will want your EMR system to interface with your billing software. That way the staff can schedule a patient in the billing system as they have always done and that information is transmitted automatically to the EMR system. You don’t want to be in a situation where you have to enter the patient schedule into multiple systems. This greatly increases errors and reduces efficiencies.
You also need to consider who uses the patient schedule. The doctors and staff all use that information differently. The staff accesses the patient/doctor schedules from their computers. The doctors may prefer to have that information on their wireless devices. The schedule must also be able to be updated real time wirelessly…These are the types of scenarios that can seriously reduce the success of the project.
Patient tracking can help reduce patient waiting times. Tracking patients through your office will help determine where the bottle necks are and help you better plan your resources.
What physicians fear the most is that by switching to an EMR system the new process will slow them down causing them to see less patients in a day. Templates are key to decreasing the time required in the patient encounter. There are several methods of data collection. The first is predefined paragraphs of text. Paragraphs of text are created by the physicians who address a specific diagnosis, procedure or treatment. As the doctor performs their patient review, they select the predefined paragraph that best meets the patient ailment.
The flow through the system, how many clicks it takes to get to the information you need is very important to doctors. Reducing the time to do something and customizing the process to work with the doctor is critical to making the new system a hit.
EMR systems contain many areas for documentation. They typically include Patient Vitals, Family History, Illness History, Lab Reports, Dictations and Medications.
Patient Vitals – Reason for patient visit, chief complaint and patient vitals are recorded in this section.
Family History – Past family history, any allergies and current medications.
Illness History – Details for patient illness history.
Lab Reports – labs and diagnostic imaging reports. Some even allow you to import the actual test, scan or image for reference. Make sure the system as a HL7 interface if you would like the actual tests, scan or images directly sent from the lab equipment into the EMR system. This usually requires some programming but is worth while having all patient data in one location.
Dictations – There are several methods to handle dictations.
o Directly - Speak directly into a microphone and the system transcribes in real time. My experience is that busy doctors simply do not have the time for this since these systems are not totally accurate and require you to edit the results.
o Dragon Naturally Speaking - The most accurate and popular voice recognition software is Dragon Naturally Speaking. You dictate into the application and import the results into the EMR. This is more accurate but requires two steps.
o Templates combined with Dragon Naturally Speaking – You create templates that define in detail a particular problem. You simply select the most appropriate template and dictate the specific details. This is the best tradeoff since it is the fastest (other than dictating into a recorder and sending it out for it to be transcribed) and lowers dictations costs. You need to accept the fact that the end note is not perfect
o The last method is the fastest but most expensive. Doctors dictate as usual and send it out to be transcribed. The returned report is scanned into the EMR.
Medications – History of medications and prescriptions. Some EMR systems that are tied to an electronic prescription service allow you to electronically send the prescription directly to the pharmacist with a few clicks. This reduces costs and errors.
Conclusion
Choosing an EMR solution is a daunting task with so much at stake with more than 60% of all EMR projects implemented failing. The role I usually help clients with is project leader/manager. Clients have the most difficult part with selecting the right EMR solution, documenting workflows and implementation. The project can be a major success with the proper structure, planning, commitment and a team with the proper skill sets to deliver the right solution. You can always contact us and we will be happy to give you a free consultation and or point you in the right direction!
1 “Electronic Medical Records: Lessons from Small Physician Practices”, prepared by University of
California, San Francisco for the California HealthCare Foundation, October, 2003