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EMRs boost efficiency, too


By eliminating charts and improving communication, note-taking, and charge capture, an enhanced electronic record can make the office hum.

EMRs boost efficiency, too

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Choose article section...Documenting on handhelds takes some getting used to Charge capture: more work for doctors, less for others

By eliminating charts and improving communication, note-taking, and charge capture, an enhanced electronic record can make the office hum.

By Ken Terry
Senior Editor

Before it introduced an electronic medical record a year and a half ago, the Primary Care Medical Center of Murray, KY, was a chaotic, inefficient place.

Patients frequently had long waits to see a doctor. Nurses, scurrying around in search of misplaced charts or pulling records for callbacks, didn't know who had arrived until they went up front. Doctors thumbed through charts, hoping that all of a patient's meds were listed. Billing clerks scratched their heads as they tried to figure out whether a doctor had billed for a test, and which diagnosis should have been recorded for it.

Today, while the six physicians at the main clinic are seeing as many patients as they did a year ago, the waiting room is nearly empty. Nurses aren't searching for misplaced charts, because they've been put in storage. Only two or three need to be pulled each day, usually because a patient hasn't been in for a year or more. Physicians know that all of a patient's meds that were prescribed by a group doctor are listed in the patient's electronic record. And billing clerks know a diagnosis will be attached to every charge, and that nearly everything the doctors did will be billed for.

The vast improvement in the office's efficiency is directly related to the implementation of an electronic medical record in October 2000, and a new billing system in February 2001 (see "EMRs cost too much? This group says No Way!"). Computer servers located in the clinic store the programs and their associated databases.

All 45 staffers have access to the PenChart EMR on desktop computers, and 21 clinicians, including nurses, midlevel providers, the six physicians in the Murray clinic, and a doctor in a satellite office 18 miles away, can obtain and enter data on portable computers known as pen tablets. They can also access the EMR from home and other remote locations.

The clinic has its own lab and X-ray facility, and doctors can order tests and receive lab results through an interface with the EMR. They're also in the final testing phase of an interface with Labcorp.

But they can't get any information online from their hospital, even though it's next door. On rounds, they make notes on paper and scribble charges on 3 x 5 cards that they bring back to the office. Discharge summaries and inpatient lab results are scanned into the EMR. This will change once the hospital's new clinical information system is fully implemented later this year.

A key feature of the PenChart EMR is that it incorporates scheduling. (Many other EMRs interface with the booking modules of practice management systems, but few have their own scheduling system.) This is important, says Sarah Lovett, the Murray group's office manager, because it enables the receptionist to inform doctors and nurses electronically that a patient has arrived and record that fact for billing purposes.

The patient's ID and insurance data on the registration screen are automatically duplicated in the EMR's charge capture module so that they can go into the billing system through an interface. This gives doctors the ability to capture charges without having to enter any administrative data other than CPT and ICD-9-CM codes.

When a patient arrives in the office, the appropriate nurse is informed via handheld computer. The receptionist checks the patient's insurance and asks for the requisite copay. (PenChart calls for copays to be made before the patient sees the doctor.) The physician, too, is alerted via his handheld when the nurse is taking the patient's vital signs and when the patient is ready for him. The system also tracks patients' waiting times from the time that they check in at the front window.

The nurses have more time to guide patients to exam rooms and do their intake because they no longer need to pull and file charts, notes Lovett. Nurse Janet Schecter says she's now able to do more patient education and handle callbacks more efficiently. Take refill requests, for example. "Instead of going up front and pulling the chart," Schecter says, "all I have to do is look in PenChart and see when the patient was here last, make sure she's taking her medications correctly, hit two buttons, and the refill is faxed to the drugstore. Or I can call the patient and say, 'It's time to come in for a checkup.' PenChart also is very good for keeping up with lab work. Everything you need to know is there."

The physicians, too, are glad to have patient data at their fingertips. Noting that medication lists weren't always kept up to date when they were in paper charts, FP Robert C. Hughes says, "For me, the biggest clinical advantage of the EMR is keeping medications straight." He adds that computer backup prevents him from prescribing drugs that might react adversely with other meds a patient is taking.

His wife, pediatrician Joyce F. Hughes, notes that if the EMR shows a child is allergic to a particular drug, the program won't let her prescribe it. She also likes the fact that each patient's record has a summary screen so she can absorb a history on the fly without browsing through every visit note.

Internist Hollis J. Clark feels the EMR has improved his efficiency in reviewing lab results, which are sent to him electronically. "Instead of ignoring a stack of paper, I can review one or two of the 10 sets of lab results and know what I have left at the end of the day."

Documenting on handhelds takes some getting used to

Bob and Joyce Hughes usually make electronic notes in their exam rooms. Does the presence of the handheld computer bother patients? "I don't think so," says Bob Hughes. "If the doctor were too focused on the computer, it could, but it's no different than if you're writing with the patient there. You have to maintain some eye contact, and you have to pause at the same times you would if you were writing."

Clark still handwrites notes in more complicated cases, documenting the visits afterward with the pen tablet on a recharging stand attached to a keyboard. Citing the need to maintain eye contact and do hands-on evaluation, he says, "You must be very careful not to let the computer detract from the physician-patient relationship."

EMRs pose some other problems. You might not like having to follow a preprogrammed list of questions when you do evaluations, and navigating a maze of check boxes can be time-consuming. There are three reasons why the Murray doctors haven't had these problems with PenChart:

• The doctors can dictate to the handheld when they have something special to say about a patient.

• They've discovered how to summarize normal findings with a single "click" of a pen.

• They're able to customize templates to their specialties and practice styles.

The EMR program is permanently maintained on the server, and only three people in the practice can change its templates. But physicians and nurses can alter templates on their own handhelds. Joyce Hughes did this with the cold and flu template. "PenChart had 60 symptoms on its list. A lot of them were things I never check, like whether the patient is sneezing. I deleted the symptoms I didn't need so the list would fit on one page."

She also customized the template for well-child checkups so that she's clicking one time instead of clicking on "normal" 20 times. "If they have one abnormal, I click it off, then go to that page and indicate what's abnormal. For example, if a patient has an umbilical hernia, I'll click off the abdominal 'normal,' go to the abdomen section, then check the box next to 'hernia.'"

Modifying a system can have its drawbacks, though. When Bob Hughes created a normal-exam template to reduce the amount of data entry, the EMR recognized it as documentation for only one body system rather than a full exam. So, Hughes and his colleagues have decided not to use the E&M coder function.

Charge capture: more work for doctors, less for others

Physicians can't finalize their notes in the EMR until they choose visit codes. Nor can they order tests from their in-house lab without a charge or without that order going into the clinical note. Moreover, every charge must have an accompanying diagnosis.

While this might seem similar to what you do on paper encounter forms, the Murray physicians, like most busy doctors, left out some data when they were recording charges on paper. If something was missing—like, say, a diagnosis—the billing clerk would either pull the chart or guess. So a lot of claims were submitted with missing or wrong information and got bounced back.

Billing clerks must still check to make sure physicians have put in charges if they're not E&M-related. But now, instead of having to pull charts if they have questions about billing, the clerks can glance at a split screen containing electronic notes and corresponding charges. At the same time, they make sure that the diagnosis on the claim matches the service. For instance, if a doctor orders a thyroid test for a patient with an asthma diagnosis, they'll flag that in the EMR so that the doctor can correct it, if necessary.

As a result, says insurance manager Julie Stone, far more charges are being captured and far fewer claims are being denied. Equally important, the doctors can defend their charges—and they can't blame billing clerks for errors.

"With PenChart, the documentation is right there in the computer and the doctor is responsible for his own coding," Stone observes. "We don't have to interpret anything he puts down. Should there be an audit, it all goes back to the doctor."

How do the physicians feel about that? Well, it's taking them a bit more time to capture their charges than when they depended on staff to help them. But even though this can be frustrating, the physicians realize that it will help maximize their earnings. Besides, notes Bob Hughes, liberating the insurance manager from the bulk of her charge-checking duties has enabled her to chase down more claims from slow-paying insurers.

The Murray practice has only begun exploiting the potential of its EMR. Much more can be done in the areas of clinical trials, disease management, and online connectivity with the hospital and other providers. When the practice's Web site is up, patients will be able to request appointments and refills via PenChart, and eventually they might even be able to see portions of their record.

For now, the group is happy with what has been accomplished, and no one is more pleased than the staff. Says Janet Schecter, "It's made a big difference in my life as a nurse."

Ken Terry. EMRs boost efficiency, too. Medical Economics 2002;7:38.

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