Bring workflow into the 21st century

Practices that move to an electronic medical record (EMR) have a problem. Office practicesand systems that work on paper will not work well on computer.

"You can't do the same things the same ways you did them on paper in the digital world," saidJohn Bachman, MD, department of family medicine at the Mayo Clinic. "If we do nothing about ourworkflow, the problems we have on paper will become even bigger problems on computer."

Practices contemplating the move to EMR may also not realize that efficiency will drop andcosts will rise before they begin to see improvement, Dr Bachman said during the American Academy ofFamily Physicians 2007 Scientific Assembly in Chicago on Friday. The problem is that paper andelectronic records must coexist for a time, driving costs and time use higher. As more work istransferred to the EMR, the use and expense associated with paper records will fall.

How long that transition takes depends on how devoted the practice is to implementing change.Harvard is still using paper records 10 years after introducing its EMR, Dr Bachman noted. The MayoClinic took three years to eliminate paper charts. Solo and small practices can make the change in ayear, he said.

EMR users typically move through several stages, Dr Bachman explained. They start outconfused, frustrated, angry, and inefficient. As they learn basics like templates over the first yearor so, they become more efficient, but still spend too much time at the computer.

Somewhere after the first year, most master the basics and begin to use more advancedfunctions. The countless hours already invested begin to pay off in significant productivitygains.

Some users not only learn the functions built into the EMR, they find add-ons and workaroundsto make the system perform useful tasks it was never meant to do. That is the point at whichproductivity and satisfaction take off.

"Most doctors who deal with EMRs feel like victims," he said. "You need to add the add-onsand the workarounds. You need to bend that EMR and every other piece of information technology toyour will. The computer may be fast, but you're smart, and when it comes to IT, smart wins everytime."

Smart means matching the user to the EMR need. Every step of the patient care process shouldbe handled by the most appropriate person. And that is rarely the physician until the actual exam, DrBachman said.

In many offices, physicians still take histories and vital signs, which is a waste of avaluable resource, he said. Staffers, or patients themselves, should be doing the routine work. Linkthe EMR to a patient portal and patients can fill out their own history online before they even comeinto the office. Some practices use portable computers or PDAs for patient data entry in theoffice.

Either way, he said, the patient becomes a key part of the care team. Data is more completeand more accurate because the patient has time to reflect on entries. Entering their own data alsohelps patients organize their thoughts and makes for a more valuable office visit.

How valuable? The typical office visit generates $7 in net revenue if the physician isentering patient data, Dr Bachman reported. Having a staffer enter data boosts the revenue to $17. Ifthe patient enters data in the office, net revenue jumps to $26. If the patient completes data entryfrom home, revenue per visit soars to $46.

That is only the beginning, he continued. The smartest physicians complete the entire chartentry and interview report while the patient is still in the room. The time that patients spendundressing and dressing is usually wasted time. With a computer station in every exam room, thephysician can be entering notes instead of waiting for the patient.

Once the exam is finished, it takes just seconds to print out a copy of the interview report and handit to the patient. That gives the patient a complete account of the encounter and writteninstructions for medications or other treatments.

The patient is more directly involved in care and there can be no doubt or confusion as to whathappened during the encounter. That makes for better adherence to whatever recommendations were made.Giving the patient a copy of the report also reduces malpractice liability. With a copy of the reportin hand, it becomes difficult to file a credible claim about what did or did not happen during theencounter.

"The EMR transition will be painful, but the only way to succeed is to jump in and do it," DrBachman said. "You can't try to change the way you work, you have to do it and accept the pain aspart of the price you pay for delivering better care at lower cost. You will have happier patients, ahappier practice, and when the last patient leaves at the end of the day, you walk out the door a fewminutes later."