Financial gain with reduction of medical records staff
Ease of incentive program reporting
Improved quality and ability to proactively monitor patient care
Dr. David Gorelick realized very early in his career that the complexity of patient care and all the associated data required an organized, efficient means of record keeping. During residency in 1991, he designed his own computer database to address many of the inefficiencies associated with paper charting. In 2003, as a member of the Rhode Island Quality Institute (RIQI) Clinical IT Leadership Committee, Dr. Gorelick developed a better working knowledge of EHRs. Ultimately his group, Aquidneck Medical Associates, implemented an EMR and Practice Management solution from eClinicalWorks in 2005. They were the first in Rhode Island to use eClinicalWorks, and the first in Rhode Island to create electronic lab and imaging interfaces and to e-prescribe using eClinicalWorks.
Computerizing a medical group practice was an extraordinary but rewarding undertaking. With a dedicated physician champion, reliable IT support, diligent research, and full commitment from everyone involved, the effort proved to be very successful.
"Using an EHR has resulted in a more satisfying professional environment."
EHR implementation involved analyzing and organizing each and every aspect of the process. The key to success for the physicians was adapting the EHR to their workflow rather than vice versa. "For several months before go-live, we dedicated time to learning and customizing the EHR to our needs," says Dr. Gorelick. "It was important to envision the doctor evaluating the patient in the exam room to allow logical, intuitive flow of questions/answers."
Dr. Gorelick trained himself to be a "super-user," developing an intricate knowledge the system. That expertise, along with a dedicated IT specialist, allowed him to successfully train his group. They utilized training videos, CD tutorials that could be viewed at home and they set up in-house demos and training sessions. Simulating evaluations provided an important perspective beyond simply watching demos. "We would have one doctor be the patient complaining of a headache, then halfway through the evaluation throw in other complaints. The physicians need to train and get comfortable with real situations—the more facile they are navigating around the EHR, the less risk there is of having the computer distract them from the patient."
Template creation and management is another key to successful implementation. Dr. Gorelick developed group templates for basic evaluations, physical examinations, diabetes, hypertension, and other common visits. Physicians should also learn to make their own templates to suit their needs. "Physician groups should create a nomenclature system for templates and lists; otherwise finding what you need will be time consuming and frustrating. For example, headache can be 'filed' under headache, tension headache or migraine." Dr. Gorelick structured templates into disease categories, such as "neuro – headache."
Policies and procedures must also be analyzed before changing office workflow. Dr. Gorelick's group envisioned possible scenarios and policies during the implementation process. They asked questions like who will take phone messages, how much will be documented, and which messages need to go to the physicians? "Phone messages prior to the EHR were not as complete; the tools were not reasonably available." They asked questions on coverage and security – who reviews labs, refills, and messages while a physician is off? How long should a progress note remain unfinished and unlocked? Physicians must determine which staff members have access, editing, and customization rights in each section of the system.
Another key to successful implementation is technical and administrative support. Administrative staff are needed in order to monitor the system throughout the day. Someone needs to track and recognize when systems fail, faxes stop coming or going, lab interfaces stop working, or electronic prescriptions fail. That way these problems can be solved as they occur.
Realizing all the benefits of an EHR requires time commitment for exploration. "You can make the technology work for you—push every button, open every screen, learn all of the features and take advantage of them. Don't just sit back and wait for the vendor training class."
Dr. Gorelick is seeing a significant bottom-line return on investment from a few factors. His income increased 30 percent year one, and 50 percent in years two and three from the pre-implementation baseline in 2005. The adjusted workflow has improved staff efficiency, allowing more work to be done in less time, and reducing the need for several staff members pulling records and filing paperwork. Improved documentation has justified more appropriate billing and reimbursement. Malpractice premium discounts were negotiated in relation to use of the EHR and other quality measures. Pay for performance and quality improvement programs have also been an integral part of the EHR’s financial reward achieved with use of the EMR.
Improved efficiency impacts most aspects of Dr. Gorelick’s office practice. "Using an EHR has resulted in a more satisfying professional environment. I can see many patients with the typical multitude of complex problems, find information within seconds, document progress notes, order labs, transmit prescriptions electronically, and review documents and telephone messages more efficiently than would ever be possible using paper charts."
Electronic prescribing has resulted in both time savings and improved quality of care. Dr. Gorelick and his staff used to spend an estimated ten hours per week managing prescription refills, e-Prescribing has reduced that to 30 minutes. "Now, a pharmacist can send an electronic refill request, you can see the patient’s chart, labs, history, and then authorize what is appropriate. The process is reduced to 15 seconds and it decreases the chance of errors related to handwriting recognition."
Using an EHR has also allowed improved quality of care. Populations of patients can be identified and tracked through EHR reporting and patient notification. Outstanding ordered tests can be identified within seconds and acted upon accordingly. "Several patients with cancer that would not have been detected, or whose diagnosis could have taken much longer, were identified within the first several years of using the EHR outstanding lab feature."
An EHR offers the power of external reporting and the potential for increased revenue through pay for performance and quality improvement initiatives. Dr. Gorelick's group will continue to participate in programs that financially support primary care physicians. "Knowing that you provide quality care is one thing, being able to prove it through computerized reporting is another."
His practice also plans to implement a patient portal and link to the Rhode Island Health Information Exchange, currentcare.