Mr. Viellieu says practices might run into difficulty from staff members who feel a change is making their jobs more difficult. An EHR, for example, provides a formidable obstacle during implementation, when physicians and nurses are trying to treat patients and learn a new software system simultaneously. "They might say, 'This is keeping us from doing what we need to do,' " he says. He recommends acknowledging the difficulties your staff is having and then pointing out the eventual benefits. "Implementation is always the most difficult time," he says. "You have to stress the benefits that you won't get if you allow them to talk you out of it."
2. Implementation can happen in stages. Installing an EHR may have to be done in stages, says William R. Pupkis, CEO of Capital Region Orthopaedics in Albany, N.Y.. For example, physicians are used to dictating the chart, while some EHR systems require the doctor to point and click on a computer to build the chart. Doctors may prefer to continue dictating into voice records, which would only be transcribed into text if needed. Alternatively, the practice might hire clerks to enter information into the computer during and after the doctor examines the patient.
If some physicians or nurses in the practice are resistant to the change, implementing the technology over a longer period of time may help them warm up to the system. Many people worry about fast change, but a slow change process could help people become more comfortable with the systems.
3. The interface can look like a paper chart. The digital chart that the doctors see on the screen looks much like the paper chart they used to have, so using it is very intuitive. The EHR can also include extra features that the paper chart did not have, such as clinical summary that lists allergies and a prescription history. The messaging feature digitizes all of the incoming reports, dictation and messages that used to be on paper, so that everything needed is already attached to the patient's chart. No one has to go find the chart anymore; it's all there.
4. Collect the needed data with a few key workflow changes. Many orthopedic surgeons have expressed concern about the scope of the data collection requirements in the program, says Brad Melis, Founder and Executive Vice President, ChartLogic. Most primary care facilities see 15-20 patients per day, many of which are follow-up visits. Many specialty practices, however, may see 40-60 patients per day, a large percentage of which are new patients.
In terms of EHR data collection, follow-up visits are relatively simple since the patient data has already been entered into the system. New patients, on the other hand, require a new record to be created in the EHR system. Under the meaningful use program, physicians will be required to select from a "menu" of patient data reporting measures. This allows a choice of some options in data entry. All physicians, however, must report three "core" measures of quality: blood pressure management, tobacco use screening and adult weight screening and follow-up.
Since orthopedic practices have generally not collected this information, this will mean a workflow change. While these three core data points can be collected by nurses or physician assistants, the orthopedist will need to document his or her evaluation of the patient. Thus orthopedists should look for EHR systems that focus on speeding up the data entry process through dictation or click minimization. In addition, physicians who are selecting a EHR system for purchase should "test drive" features such as chart review, e-prescribing, order creation and tracking to make sure they are comfortable with the data entry and retrieval process.
5. Automated transcription saves the practice money. Implementing EHR and automated transcription can save practices money, says Michael Rauh, MD, an orthopedic surgeon at UB Orthopaedics & Sports Medicine in Orchard Park, N.Y. "From a cost standpoint, we have more than 30 physicians in our group and we measure the cost of transcription per patient across the board," he says. "We found that those who are non voice recognition users cost about $6.52 per patient. Those who continue to use the technology are reporting an average of $2.34 per patient. One of the partners found it costs him $1.06 per patient, and another reports an average of $0.63 per patient. It's a huge cost savings on the front end transcription. Those who are using this technology are also billing at a higher level because the claims are documented appropriately. When there is a lower cost per patient and a higher rate of reimbursement, it ends up doubly benefiting us."
6. Your EHR vendor should help you with compliance. Your EHR vendor should be an effective technology partner for your practice as you seek to meet the meaningful use requirements, says Mr. Melis. Your vendor should be able to counsel you and your staff on the needed workflow changes and suggest new procedures to handle the new data reporting requirements. Ideally, the vendor can work with you on test runs to make sure all the necessary data fields are being populated correctly.
In addition, your vendor should be able to suggest techniques to meet the other requirements of the incentive program. For example, one rule requires physicians to "provide patients with timely electronic access to their health information (including lab results, problem list, medication lists and allergies)."
Many orthopedic practices find that the best way to comply with the "timely access" requirement is to create an Internet-based patient portal, where the patient information can be quickly uploaded and read by the patient. Your EHR vendor should be able to advise you how to create and maintain patient portals to meet this requirement.
7. It promotes efficiency and communication with other providers. Every orthopedic practice is looking for ways to become more efficient, and implementing EHR with automation can streamline many daily processes. "I think the biggest benefit of this is that my notes are generated the same day that I see the patient and the primary care physician can get information on their patients the same day," says Dr. Rauh. "The technology also promotes communication between myself and physical therapists as well as other specialists. With traditional transcription, it may be two or three days before you get the report written, and then it takes longer to receive approval. With the automated program, the report can be generated and approved in the same day. In a lot of cases, primary care physicians who refer their patient to me get the notes even before the patient leaves the office. This convenience has really increased my referrals because the primary care physicians feel comfortable that something is going to happen and they know what the plan is for their patient."
8. Patients can self-report demographic data. The meaningful use requirements state that practices must collect demographics as structured data, including preferred language, gender, race, ethnicity and date of birth. Again, this is likely to be a new data collection task for many orthopedic practices.
Patients are used to self-reporting this information in many business situations; it makes sense to have them do this in the waiting room, says Mr. Melis. Many medical offices are finding it makes sense to provide check-in kiosks or tablets to patients. At least one company will provide customized "check-in" laptops free to most physicians (the devices display health product ads).
Some practices fear that their patients may not use an online or waiting room option if it is computerized. For example, many elderly patients may not be familiar with laptops. If you want to stay with a paper solution for this demographic and clinical intake data, you can provide "bubble-in" or Scantron forms that can be fed into optical mark readers which will feed the data to your EHR system. This is less efficient than collecting information digitally via tablet, but still an improvement over making staff keyboard in the data.
If you provide bubble sheet forms in addition to a patient portal or kiosk solution, you will be giving your patients several options. The key is to get the patients to enter the data in a usable form, so that your staff can reduce their data entry burden. Again, you should validate your options with your EHR vendor prior to implementing the new solution.
9. Records are easy to use for data-mining. One of the biggest challenges private practice surgeons face when practicing evidence-based medicine is data collection and organization. Surgeons don't have time to input patient information multiple times into different databases and most practices don't have the resources necessary to hire another employee for this type of data management. However, implementing electronic medical record systems takes data input from the surgeon and organizes it in several different ways simultaneously. "We record the data like we would in the ordinary, every day process of seeing the patient," says Scott Trenhaile, MD, an orthopedic surgeon with Rockford (Ill.) Orthopedic Associates. "We collect the data on the front end so it can be extracted later electronically. That's how private practice practitioners can contribute on a grand scale."
10. Merging with others might be necessary to afford the technology. For small groups, implementation of this new technology could put a great financial burden on the practice. One solution some small practices have found to meet these needs is merging with other groups. "What we're hearing is a lot of confusion about what healthcare reform means in terms of how to adopt EMR, which EMR system providers should get and what it's going to mean for patient care in general," says David Shrier, CEO of HCPlexus, the company that produces the Little Blue Book database of physicians. "The orthopedic surgeons need to see more patients to keep up with the declining reimbursements and invest in EMR technologies at the same time." He says one of the solutions many spine surgeons are finding to combat these higher costs is to join a specialty practice or merge their practice with another to form a larger multispecialty practice. "The healthcare reform act requires a lot of technology and that is difficult for small practices to grapple with," he says.