EMR Implementation: One Day at a Time

No one ever said it was going to be easy, but most physicians who are in the middle of an EMR or EHR implementation—or have deployed one and lived to tell the tale—would argue that electronic records will make them better clinicians. It just might take a while and involve workflow disruption and financial impacts.

What can implementers entering the game expect? A lot of variability, says Kent Gale, founding partner and chairman of the board of KLAS. In a September report, the Orem, Utah-based research firm surveyed 146 organizations that had purchased and deployed EMR products and the depth of EMR adoption. A smaller hospital (200 beds) could attain organizationwide EMR use at a cost of between $4 million and $5 million, KLAS found.

Conversely, an organization with three hospitals implementing an EMR reported that it would cost $100 million, including implementation, additional equipment, consulting help and training, among other costs.

“A typical 400-bed hospital that buys a deep adoption product from Epic, Cerner or Eclipsys is likely to spend $20 [million] to $30 million,” says Gale.

Their depth of EHR adoption and implementation times also covered a wide range, he says. The quickest implementation reported was eight months from start to finish; the longest was three years. “The more typical implementation range is two years,” says Gale.

‘Never go back to paper’

In 2002, Randall T. Huling Jr., MD, president of Olive Branch Family Medical Center (OBFMC) in Olive Branch, Miss., decided to implement EMR technology to move clinical care forward. He purchased and implemented a NextGen EHR, and continued to use it after separating from his former practice and starting OBFMC in 2003.

“Anyone who tells you that it’s going to be an easy process is lying to you,” says Huling. “But I would never go back to paper. We fully embrace the value of what EHR has been able to do for us.”

Since going paperless in January 2004, OBFMC has increased revenue by approximately $650,000, while reducing expenses by more than $85,000 annually. “An EHR, along with our integrated applications, has allowed us to provide better patient care, increase the provider productivity from 2004 to 2008 by 10,000 visits, and increase [our fee] collection percentage from 68 to 72 percent,” says Huling.

The evaluation and management (E/M) coding and capture of performed procedures resulted in the average increase per patient charge from $157 to $172, he says. “Our annual expenses per provider and for the practice to maintain the EHR and its updates [are] easily offset by what is covered by the improved capture, E/M coding.”

Huling advises getting a clear picture of the workflow function and who will be handling what portion of clinical throughput. When OBFMC eliminated paper charts, some patients, without the physical reminder of holding their chart, forgot to stop at the front desk and pay their bill as they left. “We began to give patients color-coded folders with nothing in them [as] a reminder to stop by the check out station,” says Huling.

Practices also should plan for a slower patient flow—at first. “If you’re seeing 20 patients a day, cut that by half,” Huling advises. “Typically, if a provider has never worked on an EHR before, we train them in one week, where they might see one patient per hour. [But] in three weeks, they’re running a full schedule.”

Upgrades, implementations and frustration

Implementing an EMR or upgrading one takes considerable personnel power. Jorge Grillo, CIO of Canton Potsdam Hospital, says the 100-bed rural hospital in Potsdam, N.Y., is in the process of upgrading its Meditech EMR environment and integrating eClinicalWorks billing and practice management software for its 16 practices. In its basic form, Meditech is an EMR, says Grillo. However, “we will be using it as an EHR repository as we interface back in the eClinicalWorks practice management data, and use it provide a consolidated Medicare record of all data we can gather.

“[One of the biggest challenges] for rural organizations is its staff component,” says Grillo, who estimates that 50 to 60 employees will be involved in rolling out the new systems. “The problem is that there is a huge drain on organizations that are already running lean and if you pull someone out of the clinical environment about 10 hours a week, that’s a big hit,” he says.

Lost productivity was a frustration at Kaye, Allen & Duhaney, an independent practice located in Dallas, which implemented an Epic EHR in July 2009. “I used more profanity in the first six weeks of EHR implementation than in the previous six years of my life and it was probably the only thing that kept me sane,” says Alan G. Kaye, MD, FACP.

Kaye’s practice is aligned with Texas Health Resources, a system of 13 hospitals that serves North Texas and is based in Arlington. Kaye, Allen & Duhaney participates in Texas Health Physicians Group, Texas Health’s employed physician group organization, and the EHR implementation is required for Texas Health Physicians Group member practices.

Although Kaye characterized the implementation process as “exceptionally painful” and “difficult above what I thought would be the case in advance,” he nonetheless believes that he is a better doctor because of the EHR.

The EHR, which has been live for about a year and a half, thus far is revenue-neutral, according to Kaye. “The promise of more efficiency is, to some extent, a myth.” For example, in June 2009, before go-live, Kaye says his practice saw an average of 18 to 24 patients a day; in June of this year, he could only see 17 to 20 patients a day.

“There were dramatic impacts on productivity that extended for most of the first six months, until most of the most complex patients were seen at least once,” says Kaye. “I have not been able to see as many patients in a day as I was previously [using a paper-based system], but I am able to document much better and bill on the whole a little higher for many of the visits.”

Things are improving, especially as clinicians became more familiar with the processes, says Kaye.

Before going live, Kaye’s practice hired part-time help to convert paper records to the digital environment. “I was told you should plan a month to convert, but you should plan for a much longer period of scheduling time,” says Kaye, to allow for a protracted reduction in schedule to accommodate learning time.

All aboard?

Vance Chunn, CEO of Cardiology Associates in Mobile, Ala., a private practice with 28 cardiologists across five full-time and five outreach locations, expects to fully implement Allscripts EHR version 11 within nine months. The goal is to get physicians onboard with the technology and reporting meaningful use to CMS for at least 90 days in 2011.

According to Chunn, Cardiology Associates is spending six months to plan for the system’s integration, reviewing and revising workflows, then spending another three months to train and add doctors to the system.

Front-loading some of the work, Chunn and colleagues took a year to digitize paper medical records going as far back as four years, completing the task in May 2009.

Cardiology Associates will spend a total of approximately $1.3 million on the project, but with 28 clinicians potentially getting $44,000 each (equaling $1.23 million), Chunn says he believes the technology will be worth the investment.

Chunn is now training “super-users,” who understand the practice’s workflow, to train the 80 percent to 90 percent of the practice’s 230 employees who will use some component of the EHR system. Any “extra time” that is found during this process will be devoted to reviewing the workflow diagrams, he says.

The road to EMR and EHR implementation may be paved with profanity, sweat and dollars, but these physicians agree that the destination—better patient care—is worth the pain.