Choosing an EMR

1
Choosing an EMR

• Trevver C. Buss, MD
• Prairie Clinic, S.C.
• Chair, Medical Technology Committee

2
Prairie Clinic, S. C.

• 11 Family Physicians
• 1 Internist
• 1 OB/Gyn
• 1 Nurse Midwife
• 4 Physician Assistants
• Prairie du Sac WI (25 mi. NW of Madison)
• Independent Clinic, owned by MDs
• Located 1 block from independent hospital

3
Prior to 2003

• DOS-based electronic practice management system
  (Medic). Approx. 4 PCs and 10 dummy terminals
  for scheduling and administrative purposes.
• Physicians did not use PCs or terminals other
  than for rare research or word processing.
• Schedules were printed on paper for each provider
  and updated many times daily.

4
Prior to 2003

• Visual system used to identify pt. ready to be
  brought to a room.
• PC had a minimal network. It was physically
  attached to hospital, where its IT dept. managed
  our few PCs/terminals, as part of their network,
  for a nominal fee.
• The EPM contract was with the hospital, not with
  Prairie Clinic directly.

5
As of Summer 2003

• New building 3 floors, approx. 80 staff, 33
  Exam/Procedure/Consultation rooms, much larger
  footprint.
• Unable to keep the contract as it was with EPM
  provider (now Mysis). Requirement to upgrade to
  Windows-based system.
• Unable to use a visual system to identify the
  presence of a patient.

6
As of Summer 2003

• Use of EMRs increasing. Increased press
  regarding benefits. Use promoted by professional
  organizations and government agencies.
• Prairie Clinics interest in EMR
• Reduce redundancy (chasing charts)
• Customer service
• Quality improvement
• Evaluate Workflow/processes
• Enable other electronic resources
• Ultimately we wanted to reproduce our paper
  charts, but be able to query the info. easily.
• Save ???

7
Changes Necessary for PC

• Build a network (Servers, PCs, cabling, wireless
  hubs, etc.).
• Choose a Practice Management product.
• Choose an EMR product.
• Choose vendor for setting up network.
• Choose strategy for maintaining network, Help
  desk functions, licenses, security (contract out
  vs. hire IT staff).

8
Timeline

• 8-2001 Formed Med. Tech. Committee.
• First year of research included
• Viewing listserv from AAFP (learn about the
  marketplace).
• Educate committee members on available function
  of EPM and EMR systems.
• Survey providers re functions they felt were
  important in an EMR/EPM system (see attached).

9
Timeline

• First year of research included
• Reading AAFP, IT ACP journals.
• Develop list of approx. 100 vendors (mostly from
  ranks by HIMSS, KLAS and TEPR).

10
Types of Products

• Prescription only
• Text only
• EPM only
• Comprehensive EMR only
• MS-Access-style database (build your own)

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Other Decisions

• In-House vs. ASP
• Wireless vs. wired vs. blend
• Templating, dictation, chart by exception, voice
  recognition, scanning (how to get the data in).

12
Consider

• Interfaces
• Networking
• Security
• Messaging
• Coding (ICD-9, E/M)
• Interoperability
• Report Generation (clinical and business)
• Maintenance (network, licenses, security)

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Timeline

• 8-2002 List divided among committee members and
  narrowed to 24 vendors.
• Some of initial criteria
• Functionality/ability to become paperless
• Support
• Customizability
• Ease of use by end-user
• Standard DB structure
• Later Criteria
• Favorable references (using a tool we devised)
• Site visits
• Corporate strategy and history, ownership
• Demonstrations

14
Timeline

• Also evaluated companion to hospitals recent EMR
  purchase, programs avail. through group
  purchasing via 3rd party, and Marshfield Clinics
  product.
• 9-2002 List narrowed to 13 vendors including EPM
  only, EMR-only, and combined products.
• 11-7-2002 List narrowed to 8, financials
  requested from vendors.

15
Timeline

• 11-13-2002 List narrowed to 5, all provide
  in-house demos. Standard texts and tabulation
  tools were used for judging.
• 1-2003 Two finalists provide second demo, this
  time to all of clinic. Feedback from all in
  clinic taken into account re final decision.

16
Timeline

• Site Visits
• Richland Center (PMSI-Practice Partner) (early)
• BYU Health Services (Millbrook/Logician)
• Rockford GI (NextGen)

17
Timeline

• After final decision, but prior to contracting,
  one physician visited the corporate headquarters
  to meet with leadership. Had opportunity to
  assess corporate structure, commitment to steady
  calculated growth of product, strategy for
  maintaining market share, support for product,
  etc.

18
Timeline

• We initially went live only with the EPM. This
  transition required some training, but went
  smoothly.
• We did not start with end-user EMR implementation
  until 2-2004. This was then done in a step-wise
  fashion and continues today (telephone calls,
  tasks, medications, allergies, vital signs,
  immunizations, CC, HPI, SH, chronic diseases,
  PMH, )

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Key Points

• Buy-in depends on thorough research, physician
  champion(s), and involvement of clinic staff
  (committee) in selection process.
• A committee for selection should include members
  from nursing, administration, medical records, as
  well as physicians .
• This takes time. It will force you to review
  each element of your business, including work
  flow, which can lead to efficiencies (electronic
  and non-electronic).

20
Key Points

• It is difficult to break out costs by item.
  Adding the EMR part was not exceptionally
  expensive, but required an incredible culture
  change in physician and nursing behavior. The
  latter has been harder than the former, involving
  a lot of staff time.
• Staff time can be expensive.
• Vendors will tell you interfaces are possible,
  but not just how difficult they are to create and
  maintain.

21
Key Points

• There will be rapid and slow adopters. You will
  be surprised by who some of them are.
• You will need to balance customizability of a
  program with dedication of resources to customize
  it.
• We thought our asst. office manager could manage
  most of the network, customize and train others
  on EMR/EPM, and act as support.
• We now have her as our EMR Goddess and a
  full-time IT person to manage the network,
  security, and hardware issues.

22
Miscellaneous

• In the end, there was room for negotiation and I
  feel our rates were fair.
• At the time, we had no resources for development
  of an RFP for the EPM/EMR. We constructed our
  own (see attached).
• We had a consultant to help with an RFP for the
  network. This was invaluable.

23
Strategies for Provider Buy-In

• Make data entry and retrieval as simple as
  possible.
• Demonstrate improved quality (telephone call
  response time, ability to do studies).
• Demonstrate time savings (if poss.).
• Demonstrate cost savings (if poss.).
• Peer pressure.
• May be able to improve documentation (and billing
  codes).
• Remote access to records.

24
What went well

• Find out what partners would want out of EMR, see
  Principles of EMR Important to PC.
• Whittle away at a large list, using those
  criteria
• Develop tools for Objectively evaluating
  references and demonstrations, see attachments.
• Investigate the staying power of the vendor in
  the marketplace.

25
What went well

• Summarize your opinions and ideally those of all
  committee members immediately after a demo, while
  they are fresh in your mind.
• Implement gradually. Remember this is a culture
  change, which is really hard.
• Ultimately have the whole clinic see a
  demonstration of products on the short list.

26
What went well

• Buy what you want when you need it. Your money
  goes farther when you wait to buy HW. Build
  guaranteed cost of future licenses into your
  contract.
• We are very proud that the stock of our product
  vendor continues to grow.
• Weve added 3-4 providers (8-10 users) without
  adding medical records or transcription staff.

27
What wed do differently

• Dont forget the costs of
• IT staff
• Customization of product (never-ending)
• Microsoft licenses
• Internet access, cabling, fiber?
• Add-on programs (ie. for scanning, PACS, payroll,
  report generation, etc.)

28
What wed do differently

• Thoroughly evaluate your workflow prior to
  implementation. This will save a lot of time and
  money. Let MetaStar help!

29
What wed do differently

• Id be a bit more specific with our RFP
• Specify reports you want to generate and whether
  there is an additional charge for the reporting
  software.
• Get details regarding charges
• Define a user, provider, what about MD extenders?
• Costs of initial training, follow-up training,
  and as needed training/support (on-site vs.
  Webex, including travel and hotel?)

30
What wed do differently

• Id be a bit more specific with our RFP
• Is the cost per application (EMR vs. EPM) or
  total?
• What is the cost of maintenance (does it include
  upgrades)? Usually around 18, should include
  upgrades.
• What if you want an ASP model?
• When asking how many sites are live, Id have
  them narrowly define the terms site, contract,
  physician, provider, and user (PC has 18
  providers, 14 physicians, and around 90 users).

31
What wed do differently

• Id be a bit more specific with our RFP
• Ask about bankruptcy.
• Is stock is publicly held? How has it done?
• What experience do the principles in the company
  have with software and the medical field?
• Re partner companies, ask about Medical-related
  companies (GE, Siemens, etc.)

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Prairie Clinic in 2006

• Not paperless yet, but getting closer.
• Dramatic improvement in response to, and
  documentation of, telephone calls.
• Electronic prescribing with alerts.
• Electronic messaging, incl. tasks
• Remote access to 80 of pts records via Citrix
  solution.
• Improved continuity of Care

33
Prairie Clinic in 2006

• Internet access (great for pt. education).
• Powerful intranet resource.
• Preventive health triggers.
• Improved workflow with documentation.
• Ability to quickly generate immunization lists.
• Faxing prescriptions and notes.
• Electronic filing cabinet (see Family Practice
  Management http//www.aafp.org/fpm/20040100/65cr
  ea.html)

34
Prairie Clinic 2006

• Access in exam room to hospital records.
• Access at point of care to reference labs.
• Access to clinic chart from home (helps to answer
  and document phone calls while on call).
• Access to clinic chart from ER (to clarify
  patients history).
• Access while on vacation, if you just cant let
  it go!

35
Coming Soon

• Bi-directional lab interface.
• Templates to reduce chart pulls (Warfarin,
  Diabetes, Quality studies).
• Scanning, which will enable a truly paperless
  world.

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Choosing an EMR

• Trevver C. Buss, MD
• Prairie Clinic, S.C.
• Chair, Medical Technology Committee