How To Evaluate EMR Systems For Your Practice

By Bruce Werber, DPM

   The prospect of converting medical records from paper to an electronic system can be quite a daunting challenge. Not only does it require learning new technology, it will likely require changes in existing processes and a collective mindset that is open and willing to embrace changes that can lead to improved efficiency for you and your staff. The difficulty is finding the correct system for your practice.    Electronic medical record (EMR) systems store and produce significant quantities of information. EMR technology has grown into a tremendous platform for managing clinical and financial information. The technology enables you to combine text, color photos, medical images, full motion video and voice into one very powerful platform that can precisely and accurately retrieve information.    When weighing the decision to make the switch to an EMR system, one should start with thorough planning. A master project plan should describe both a strategic focus (the long-term goals and their measurements) as well as the tactical focus (all the details of implementing the first phases). To accomplish this planning phase, you (and the other doctors if you are in a group practice setting) should write down what basic attributes you would like to see from the system. This includes how you want to interact with the system whether it is by talking, pointing and clicking or typing.

Taking A Closer Look At Your Office Processes And Procedures

   Then review how patients move through the office. Start with the initial phone call for an appointment, proceed to check-in and move through the patient’s visit to the treatment room and the subsequent evaluation and diagnosis. Review the procedures for: ordering diagnostic tests (such as X-rays or laboratory testing); reporting and reviewing laboratory and imaging studies; arriving at a treatment plan; writing prescriptions and giving patients instructions; scheduling follow-up appointments and responding to patient phone calls. Then one should review how the procedures, office visits and time are coded and how to record this in the patient’s record.    It is important to review the mundane repetitive processes that we often take for granted. Take a hard look at office processes or procedures that fall into the “we always do it that way” category. Don’t be afraid to alter the sequence of the procedure/process, make other changes or automate the process entirely. For example, instead of having patients complete their demographics, history and review of medications in the reception area, they could do this ahead of time over the Internet. This is called work process automation.    Another example of automation is the surgery booking process when a DPM performs a surgical consult and the patient wants the doctor to book the surgery. Normally one might tell the secretary and fill out a form. However, a computer could book a surgery by generating a booking form with the details of the proposed procedure, materials needed and equipment required. The program also can generate the consent, the equipment and materials list for the specific facility, the prescriptions, home instructions, follow-up appointment and whatever else is desired. One can do this just by clicking on the procedure while completing the visit note for the day. It is also possible to avoid writing out prescriptions. One click of the mouse can generate a printout of the prescription as well as faxing or e-mailing of that prescription to the pharmacy.    The biggest challenge at the work-process level is accurately reproducing a real business process. The major tasks are often the easy part. What can be difficult is automating those pesky exception items and rules. The key to continuous improvement is to measure the amount of change accurately. This can improve work in ways never before imagined.

What Questions Should You Ask In Your Request For A Proposal?

   After completing this analysis, it is time to put these requirements down on paper in the form of a spreadsheet so one can compare the different software products and their capabilities. I recommend putting this in the form of a request for proposal (RFP) and sending it out to several vendors. Collecting responses allows one to compare product features easily and relate the features to the practice’s needs.    There are a number of questions you should ask these vendors about their EMR systems. For starters, you should ask the following questions.    • Is the EMR system compatible with voice recognition software?    • What type of input system does it have (i.e., point/click, type, etc.)?    • Does it assist with E/M coding?    • Does the EMR system interface with the practice management (billing) software program?    • Does it assist with prescription writing?    • Does the EMR system have prescription assistance? This feature should include drug allergy and interaction checking.    • Does the system allow for data mining such as for research and/or recall purposes?    • Does it allow patients to have access to their medical records over the Internet?    Additionally, while most EMR software should be compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, it certainly cannot hurt to ask about HIPAA compliance.    Obviously, one may want to ask more questions, perhaps questions that are more specific to one’s practice. It may be worthwhile to employ a consultant. Preferably, the consultant should only represent you and not one particular software company.

Why Seeking Other Opinions Is Essential To Knowing The Vendor

   Knowing the vendor is very important. This is a large investment of money and time. It is important to know the company’s track record with this product. Find out how many practices and physicians are using the company’s EMR software. Ensure that the practice will have training support, and that the company will be around for the next five to 10 years.    Talk and visit with doctors who are using the company’s EMR software. Ask them about their experience, especially how the company handled the transition and how supportive the company was. Did the company make the training process easy or difficult? Is the practice using all of the features of the system? If not, what is the practice using and why is it not using certain features? Make sure you look at practices that are similar to your own office.

Pertinent Tips On Negotiating A Contract

   Make sure you define your expectations in detail, including timelines for training as well as the “go live” date for installation of the EMR system. Detail the practice’s responsibilities and the vendor’s responsibilities. Spell out who will buy and install the hardware, who will install the operating system and program software, and who is responsible for making sure all the hardware and software integrates correctly. Detail the costs, possible areas for cost overruns, payment due dates and cancellation provisions.    If your office is using an ASP (application service provider), make sure your practice is entitled to access the data in a usable form at anytime at no additional cost. This will help protect you in case the EMR software company goes out of business or if the product is or becomes unusable. This way, your practice will still have its records.    If you are expecting full integration with the present practice management system, make this clear in your written expectations of the EMR vendor. I would recommend including performance goals. If they are not achieved within a certain timeframe, consider the option of a refund, discount and/or returning the product for a full refund should the EMR system not perform as demonstrated.

How The Right EMR System Can Reduce Overhead, Save Time And Improve Efficiency

   In addition to the overhead reductions resulting from the time-saving advantages described above, EMR systems can open up more slots for patients. These systems can also help one code for the maximum reimbursement possible as these systems can prompt doctors and/or staff for information they need to document for particular E&M codes. EMRs can reduce staff inefficiencies, materials and space from a practice’s operating costs.    Some estimates indicate that each time a staffer pulls a paper chart, it costs a practice 75 cents. Now one can eliminate that action and probably one or more staff members because the charts are available anytime and anywhere from the network.    One can also eliminate chart materials. This can be a significant savings ($1.50 to $2 per new chart or more) depending on the type of chart folders, tab dividers, paper, paper punching and labels. Multiply the pulling of charts by the number of patient visits and the number of charts by material cost per chart, and you can see the large savings.    For example, 10,000 annual patient visits amount to about $7,500 saved each year in pulling charts. If 30 percent of those patients are new, that amounts to 3,000 patients times $2 per new chart materials. In other words, you save an additional $6,000. Add maybe another $1 in materials for each of the remaining patients and the total savings exceed $20,000 a year. Depending on additional staff reduction and patient volume, the savings can be even more significant.    Finally, one can dramatically reduce chart space and save space on storage in the office because there are far fewer charts to store.    I would recommend developing a spreadsheet so you can easily visualize the cost of an EMR system and the potential cost savings. In summary, one can eliminate several costs including: transcription costs, costs for paper charts, the cost of paper itself, the cost of employees pulling and filing charts, the cost and liabilities of looking for and the transfer of lost charts, and the cost of storing paper charts.    In terms of improved efficiency, the practice will save time telephoning patients with their lab/radiology reports since they can view them online. Patients can also make and modify their appointment schedules online. Accordingly, this minimizes the staff expense of scheduling. This can also minimize the number of telephone lines required in the office because much of the office/patient interaction will occur via the Internet.    In terms of reimbursement and coding, having an EMR system can increase reimbursement for the services you perform. It can help ensure not only proper coding but the ability to code to the highest level that the EMR will permit without fear of an audit. Medical Economics magazine has estimated that physicians who routinely down-code one E&M level to avoid audits lose up to $40,000 annually.    Having an EMR system will also help minimize the performance of medical services without billing for them; avoid lost superbills; and avoid the failure to code for ancillary services that you perform. These systems also help facilitate electronic billing as the medical records are already in an electronic and easily transmittable format

In Conclusion

   It is easy to see how a well-chosen EMR system saves time, reduces cost and eliminates extraneous overhead. However, keep in mind that EMRs can also consume vast amounts of time if one does not carefully plan for implementation, training and maintenance of these systems.    In general, an EMR system takes at least nine months to one year to fully integrate to the point where its use is second nature to the practice’s staff. Usually, for six months, the practice runs EMRs with paper charts as a backup. This transition affects patient wait times, processing and staff time, and more importantly, revenue. It can create enormous frustration and stress on everyone in your practice as well.    Therefore, it is wise to transition the practice into EMRs either per doctor, per clinic or per location so the experience does not feel like everyone is bogged down. Allowing for an adequate transition time also allows the practice to fine tune its use of EMRs so if you need to make changes, you can do so before the entire system is in place. It helps if one doctor implements it first so when the rest of the group begins, the experienced user can quickly guide his or her peers and reduce problem-solving redundancy. Dr. Werber is a Fellow and Past President of the American College of Foot and Ankle Surgeons. Editor’s Note: For a related article, see “HIPAA Compliance: Do You Make The Grade?” in the August 2004 issue or check out the archives at

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