Smart planning helps practice succeed with EHR

Daniel S. Goodman, MD

Daniel S. Goodman, MD’s favorite depiction of electronic health records (EHRs) is a pediatric patient who sits on an exam table, using crayons to draw a picture of the room. In the girl’s drawing, her physician is seated with his back toward her, his head buried in a computer.

That scene, described in a column written by Elizabeth Toll, MD, and published in the Journal of the American Medical Association, describes the main fear Goodman and many of his peers have about adopting EHRs-the loss of patient interaction.

Now that his Atlanta, Georgia-based practice has been using EHRs for 16 months, Goodman often reflects on the column’s three points:

• The connection between a physician and his or her patient is established best by face-to-face interaction.

• “Picking and clicking” on tablets and computers has replaced internalized learning.

• Written notes are easily corrected after the patient leaves, but documenting notes in a computer seems more unforgiving, so physicians often focus on preventing an incorrect keystroke than on patient interaction.

“EHR has some intrinsic value, but also a lot of downsides,” says Goodman. “It’s being foisted upon us, and I understand why. There are things that can improve for practices that become comfortable with the technology and how to best use it. But there’s danger in treating computers more than we treat patients.”

Goodman, a general internist and solo practitioner with 25 years of experience, says he views EHRs as a work in progress, and that the best strategy is to stay true to the mission of providing high-quality care while also voicing ideas and opinions about how to improve EHR systems. In his mind, if providers, administrators, analysts, and policymakers collaborate effectively, EHRs will be more meaningful and powerful.

Small-Business Mentality Pays Off

“Take the best EHR system available on the market, and even it would fail if your practice doesn’t have a smart business structure already in place,” says Goodman. “I’ve looked at different systems, and I don’t think there’s a golden nugget out there. No matter what system you’re using, it’s far more important to have smart, efficient processes and operations in place.”

Goodman says having small-business acumen-understanding the value of having a good product (medical care), establishing a flexible strategy for managing overhead expenses, realizing the importance of fast access to accurate data -provided the organizational foundation necessary to adopt EHRs with the proper mindset. “It’s possible to stay true to my mission and run a small business at the same time,” he says. “Those pursuits aren’t diametrically opposed. Rather, they support each other.”

Goodman is one of 29 participants in the 2-year Medical Economics EHR Best Practices Study, an ongoing project intended to draw out valuable, real-world insight for healthcare leaders. As part of a clinically integrated network, he must be able to connect to its health information exchange and thus needs to understand and use EHRs.

“It’s a good time to do so, because the government is giving us a carrot [through Meaningful Use incentives] before there will be a stick,” he says. “We all might as well take advantage of EHRs and learn how it can help us.”

At his practice, that meant turning off the phones for two hours in the afternoon, on seven occasions, so that he and his four full-time employees could participate in a webinar training series led by MedNet Medical. The company’s web-based EHR product, emr4MD, is geared for solo and small medical practices like the one Goodman runs.

“We forwarded all phone calls on those days to someone who works outside the office-we just completely shut ourselves off during those times so we could focus on EHRs,” Goodman says. During that time, before the practice’s launch date of April 16, 2012, his staff members also preloaded medication lists, diagnosis lists and patient demographics into the MedNet system.

“We tried to stay ahead before we were even live, so patients who would come into the office after our launch date didn’t have to do those tasks,” Goodman says. “We wanted to be 100% live from day one.” He says he doesn’t plan to “backload” information from previous charts: “There’s still about a foot of paper charts sitting on the desk. It would just take too long to get that information into the system.”

Productivity is High

“The first couple of months were brutal, and much of that was just extra hours spent getting up to speed on the nuances of the system,” he says. “But we’re used to it now, and things are running smoothly. The entire staff is onboard with the EHR, and productivity is high.”

Goodman treats about 25 to 30 patients a day, four and a half days a week. Now, when a new patient arrives, he or she fills out a paper-based demographic sheet, presents insurance information and proof of identification, and gets a picture taken. A nurse then takes the patient into an exam room and records height, weight, and vital signs into the MedNet system.

Goodman then sees the patient, but waits until later in the day-usually either before lunch or before he leaves at around 6 p.m.-to enter chart information. Because he’s a slow typist, he says, he uses Dragon voice recognition software to speed up the charting process. “It’s pretty accurate, but sometimes I look back at my notes and think, ‘What in the world did I dictate there?’ I have to self-edit before I complete a chart.”

When he agreed to participate in the 2-year EHR study, “I just wanted the technology to not make me crazy,” he says. “Practically, I figured it could help us improve documentation.”

The MedNet software aims to integrate a practice’s administrative and clinical processes in a single system for streamlined, consistent patient care. The EHR provider customized Goodman’s templates to meet his clinical needs and to promote quick, efficient documentation. Encounter data is captured in the MedNet software easily by clicking, typing, or dictating directly into the patient’s chart. Goodman and his staff members can quickly view each patient’s medical summary, including prescriptions, tests, procedures, and diagnosis history since April 16, 2012.

He and his employees also use the EHR system to review and sign off on lab results and referrals completed since the patient’s last visit, create consultation letters and patient instructions, schedule follow-up appointments, assign internal tasks in a workflow management tool, manage the patient’s health maintenance plan (or specific care plan for a patient with a clinical diagnosis), and more.

Suggesting Future Changes

MedNet is promoted and founded by practicing physicians who have first-hand experience in building and running a successful medical practice, and Goodman says he communicates with them frequently about pain points and possible upgrades.

One such issue involves SureScripts and the EHR’s e-prescribing functionality. “I’m the only one who can release a script, and I just had a conference call [with MedNet] about how certain drug lists interact with SureScripts. I need to keep drug lists clean without duplications, and that has been a challenge.”

But all in all, Goodman says, he values the system and his vendor. His practice attested to meaningful use last year, and expects to again this year. “Also, I can get someone to listen to me,” he says. “Sometimes it takes awhile for things to get fixed-it’s a little like turning around a ship because changes involve engineers and beta testing and so on-but they listen to ideas.”

In September, Goodman turned to MedNet for practice management software. “Cohesion between the systems is going to be critical, especially as we move into ICD-10,” he says. “The diagnoses codes are going to be so specific. I don’t know how that will best work because I’m not sure how anyone besides me is going to be able to do it from the notes. I’m going to need to keep communicating [with MedNet]. The good news is that we’re on the right track with technology.” 

More on the Way

The Medical Economics EHR Best Practices Study allows physicians time to gain experience and knowledge by working with an EHR system over 2 years. As the study moves into its second year, all of the participating physicians have implemented systems, and many already have attested to meaningful use.ore than a year ago, Medical Economics connected 29 primary care physicians (PCPs) with nine electronic health record (EHR) system vendors to document best practices related to implementation.

Study participants are asked to report on everything from vendor selection, data migration, connectivity, and assessing a practice’s integration capabilities to developing a workflow and preparing for the unanticipated costs. Participants are reporting key benchmarks to help other physicians gain a realistic understanding of the process and identify creative ways to ease implementation in their practices.