The EHR project: An interview with Melissa Lucarelli, MD

Editor’s note: As part of our continuing coverage of Medical Economics EHR Best Practices Study, we spoke with Melissa Lucarelli, MD of Randolph Community Clinic. A graduate of the Massachusetts Institute of Technology with an MD from the University of Illinois, she operates a rural solo practice in Randolph, Wisconsin. She is working with McKesson to implement an EHR system.

Medical Economics: Tell me about your practice?Lucarelli: We are the only medical practice in the town of Randolph, Wisconsin and Randolph is a town of under 2,000 residents. I am a solo practice family doctor. I have a lot of staff members who are part of our team including a physician assistant and a nurse practitioner. Randolph, Wisconsin is sort of in the middle of everything but near nothing, and we are about an hour from both Milwaukee and Madison.

Medical Economics: How many staff members do you have in total?Lucarelli: Virtually no one on the support staff is full-time. The three providers are full-time, but we are using a kind of 0.5 to 0.8 model for the other staff members. We have 12 employees.

Medical Economics: Is it a management challenge?Lucarelli: It’s really important, when you are in a solo practice, to have a lot of flexibility. So when you have folks who are part-time, then you have the flexibility of expanding them temporarily in order to meet a need. So, if somebody is on a medical leave or somebody is on prolonged vacation, we have a deep pool of temps we can utilize. I think it actually works better for us, and it’s a good fit for our employees. Right now, not by design, the staff is comprised of all females and most of us are also parents. It gives us the ability to be able to focus on our families and contribute to the clinic.

Medical Economics: Tell us about your involvement with the Medical Economics EHR Best Practices Study. Is this your first electronic health record system?Lucarelli: Yes.

Medical Economics: How did you and your staff approach this project?Lucarelli: The process started back in about 2004, actually. We had a couple of vendors come in and do presentations then, and we even had one come back a second time so that we could kind of test drive the system. At the time, I didn’t feel like I could financially afford an EHR. The price tag then was higher than it is now -- just the start-up costs. I am so glad I waited. The company I would have been jumping in with is now defunct. It’s now out of business. The product that we would have been with is no longer supported, and for sure it is of no meaningful use. I put implementation on the back burner. Then, we started to do some government programs like the Physician Quality Reporting System (PQRS) through a dashboard. We were manually entering data in order to qualify.
We qualified for PQRS the first year it was available, but it seemed awkward. Meaningful use came along and opened up incentives to financially make it possible for us to adopt an EHR system. That was right about the time the study opened.

Medical Economics: Could you talk about how your practice organized internally when you started talking to McKesson to implement this system?Lucarelli: First, we wanted to decide what workflow we were going to change when we moved to an EHR. Before we went live, we tried to look at the transition and tried to figure out how we could do it without cutting back on the numbers of patient visits.
That strategy doesn’t work for everybody, and it doesn’t work for every practice. We operate on such a narrow margin in this practice that we are really hand-to-mouth for our paychecks. We are in the black, and we always have been, but I don’t have the ability to just cut our visits in half. So, we had to figure out a transition to maintain our same production. It wasn’t 100% percent successful, but it was the goal.
We also had a regional extension center in our area, and we decided to sign up early on to have them assist us with our EHR implementation. They helped us with not only workflow analysis and bringing in vendors, but to understand where the priorities are during an implementation. They are still helping us with Health Insurance Portability and Accountability Act risk analysis assessments as part of our annual meaningful use attestation.
After that we organized as a group and split into small teams. We did a lot of whole clinic meetings too. We have been doing more staff meetings than we have ever done before to talk about all the details of retiring charts, for example. To make the transition, we decided that each of our three providers would be responsible for two new EHR patients a day. That’s how we rolled it out when we went live. Over time all of our patients were entered into the system.
We were running two back-end systems too. We were running our old billing system, and we were running the new billing system. That way when we were having difficulty testing certain claims and certain payers with the EHR, we still had our back-end system running for the majority of our charts. Because of it, we didn’t see a huge drop in our collections because we were catching things as we were going. It really worked well, because you have to transition your old medical management system over at least 90 days because there are collections in various states of payment. So you can’t just shut off your old system and switch to the new anyway.
We actually continued generating claims on the old system at the same time as we were generating 6, 8, or 10 new claims a day on the new system. I had my clinic manager pick which patients were be going to be arrived in the EHR, so that we had a mix of payers as well. We would actually track the time to collections and see where the system was hanging up.

Medical Economics: Did it work?Lucarelli: Yes, and then we got to a point where we ended up closing the back-end billing system and that didn’t really impact the practice.
After we attested for meaningful use, and we had enough of our patients populated in the EHR, we just made the decision to convert everyone into the digital format.
We learned that you have to be organized; otherwise it really slows you down.
As a team, we talk all the time about how we are going to do things differently. We still have little pieces of the puzzle that aren’t functioning yet, like our lab interface. We actually were part of another research study sponsored by the Wisconsin Research Education Network. They accepted us in a study having to do with workflow analysis. It gave us an opportunity to look at our workflow around labs. We were having problems because some people were populated in the EHR, some people were in the paper charts, some lab reports were coming by fax, and some were coming electronically.
So, now we have a staged plan for the labs too that we are rolling out.

Medical Economics: When you first started implementing, did you really take a look at the current workflow and did you adapt it all?Lucarelli: We did. Actually a full year before I even selected a vendor, we switched our paper charts to a different system. We started with templated notes. Before that we were straight dictation. We dictated SOAP notes for almost everything. Transcription gradually was fading away before switching to the EHR. Otherwise our charts were really handwritten, which is plus and minus.
Before the EHR, the practice created paper forms or templates. In other words, if a patient was coming in with an upper respiratory problem, we made a form just for upper respiratory. It was filled out and went into the paper chart. It was sort of a baby step towards using templates in an EHR. We wanted an EHR that had templates, because we were already used to using them. We already knew what we wanted included in our templates.

Medical Economics: Was it easy to create templates within the EHR?Lucarelli: I would say no.

Medical Economics: But it is important, right?Lucarelli: It’s important. Because we don’t have a designated information technology department, we had champions for different projects. My physician assistant is our expert template writer. She actually took a couple of paper templates and made them into EHR templates. Then, we tweaked them as we used them. It’s not hard to do; it’s just takes extra training and time. In a way, I think it’s nice to have a designated person who works on templates. We made the decision that all of us would use the same basic templates, and that’s what we were doing when using paper templates. You could do it the other way where each provider does their own templates and tweak them themselves, but I feel like the model works better if we all are used to looking in the same place for the same thing.

Medical Economics: As far as using the EHR, have you seen benefits or efficiency?Lucarelli: The obvious one that really has made a difference is e-prescribing. We were faxing the majority of our prescriptions. Our refills are so much easier now, and I think safer. There is less interpretation, and there are no handwriting problems.
If a patient is taking  five medications, I can click five boxes, and boom, it gets refilled. The patients are amazed too. We used to have piles of charts. At the end of the day, the nurses would get to those refill requests. Now that comes up automatically during the day, and it’s just so much smoother.
Another thing, although I didn’t think about until it started happening, is we spent a lot of time looking for charts. With the paper chart, that’s the medical record, and it moves around the office. I can’t even estimate how much of my lead receptionist’s time was spent looking for charts. In fact, I am looking at my desk right now, and while it’s not a pretty sight, there are no charts on it. That means my front desk staff is spending more time doing EHR-related activities and a lot less time chasing charts.

Medical Economics: How did your practice track other problems?Lucarelli: When we started implementing, we found that our EHR wasn’t able to consistently do all the things that we were expecting it to do.
When we started doing this, we started logging the problems, status, date and who was responsible for the fix. All of those things, from the minute to the really big project-oriented issues were on this master spreadsheet. As we addressed the issues, they would be crossed off. We shared the spreadsheet with our vendor and that’s when I learned there is actually a process for this in business, they call it creating tickets. We had over 100 open tickets for a while, and now I think we are in the 20s. So we are on our way.