As part of its ongoing electronic health records best practices series, Medical Economics examines the impact of EHRs on a rural medical practice.
With her personal approach, Donna Haney, MD, learns what makes patients tick, not just why they’re sick. She shakes unfamiliar hands with sincerity. She talks with people instead of at them. And she’s doing her best to learn the nuances of Pike Family Medicine’s electronic health record (EHR) system, but she’s leery of staring at her laptop too much. She’d rather look people in the eye.
In the city of Zebulon, Georgia, about 50 miles south of Atlanta, the 1,200 residents are within walking distance of Haney’s office. In this rural region, people are down-home and direct.
“To connect, you have to listen well and try to get to know each patient,” says Haney, owner of Pike Family Medicine, a small practice she began in Zebulon in 2000 after serving at a nearby hospital for four years.
“It takes longer than a few minutes to develop trust and a relationship during a patient visit,” Haney says. “My style will never be to herd as many people in and out as possible. If I ever feel the pressure to do that, I’ll have to find another line of work.”
Haney appreciates people more than pixels, and many of Pike County’s 320-plus families turn to her for a variety of health and wellness needs. In her mind, the only way to treat the local “salt of the earth” community is to remain grounded.
“I’m basically a solo practice-I don’t have a nurse,” Haney says. “It’s just me and one front-office employee, along with my mother who’s in her 70s. She’s our part-time biller.”
Like her big-city brethren, Haney is in charge of upgrading technology, boosting efficiency, and delivering customized patient care. She believes it’s possible to mix Pike Family Medicine’s small-town feel-she treats only about 10-15 patients a day-with innovation.
Pike Family Medicine is one of 29 participants in the 2-year Medical EconomicsEHR Best Practices Study, an ongoing project intended to draw out valuable, real-world insight for healthcare leaders. Haney says she figured that using an EHR system could lead to improved workflow and patient experiences. Like other healthcare leaders, Haney realizes her practice’s productivity level is contingent upon how quickly and accurately it can acquire, move, and share information.
In May 2012, Haney and her staff began using EHR technology from Aprima Medical Software Inc. The system is designed to help doctors gain more control over their time and their practice.
Aprima sent two on-site trainers to Zebulon to instruct Haney, her mother and the front-office employee-none of whom is “overly comfortable” with computers and software, Haney says.
“I had high hopes that the EHR would make life easier for us after an initial 6- or 8-month period,” Haney says. “I wanted to be able to go home at night without two sacks full of charts.” She figured the EHR system also might help Pike Family Medicine keep a more accurate record of when patients are due for checkups, labs, and follow-up appointments, she says.
“Ensuring proper patient care while also running a business is a big challenge,” Haney says. “Other people who aren’t in the medical field may laugh when I say this, but unless you’re a super-specialist or a doctor who [dwells on patient volume], it’s not simple to make money. To be honest, we barely make ends meet here. The office employee gets paid first, and there are literally times when my paycheck waits. When we started with EHR, I honestly wondered how much longer we could hold on. And I still have that same question today.”
The staff at Pike Family Medicine had problems learning the EHR system and new ways of handling patient data entry, coding, billing, scheduling, and more.
“We were pretty overwhelmed the first few days, but we’re getting more comfortable with it,” Haney says. “I must say, though, the trainers were excellent, and I’ve requested the same ones to come back and provide additional training. They were patient, and took time to show what the system was all about.”
Pike Family Medicine’s front-office employee welcomes patients and checks them in. She gives them a paper patient history form. Those who have not been to the
practice since May 2012 aren’t in the EHR system, and so Haney adds their information in Aprima after hours.
The front-office employee brings each patient to an exam room, where Haney takes vital signs, asks about the reason for the visit, forms a diagnosis, completes other patient note information in Aprima, and sends e-prescriptions through the system. She takes her laptop from room to room, so the EHR technology is at her fingertips.
“Actually, the computer is like a barrier between me and my patient. I feel like my back is to the patient too much. I try to turn around and give eye contact, but I’m furiously trying to get information in there so I don’t forget by the end of the day. I have to turn around and give them eye contact to make them know I’m listening in addition to typing. The whole thing can get impersonal,” she says.
The Aprima trainers assured Haney that it’s fine to not complete patient notes while in the exam room, but to at least try to get most of the diagnosis in so she can print out a plan by the time the patient leaves, or mail one in a few days. “In the winter during flu season, I’m not leaving the office until 8 or 9 o’clock, because I don’t have Internet access at home,” she says.
One EHR feature Haney was excited about, e-prescribing, has been moderately successful, she says. She uses Aprima’s handwriting feature on a tablet PC to write new prescriptions or quickly write refills. She can also download a patient’s medication history from the pharmacy to learn if any prescriptions may conflict with medications the patient already takes.
“It’s convenient, but I’ve made more mistakes with prescribing since going to e-prescribing. Most mistakes are when I didn’t have my cursor in the right spot, or I accidentally clicked on something and didn’t realize it,” Haney says. Recently, she was on the phone with a pharmacy regarding a patient who came in July for a wellness check. She sent all the patient’s prescriptions through the EHR system, and the system indicated they went through successfully, but the pharmacy didn’t get them. “I redo stuff like that every single day,” she says.
Haney quickly cites another EHR issue: LabCorp can automatically place lab results and other information into Aprima, but Pike Family Medicine doesn’t send enough labs to qualify for LabCorp’s bidirectional interface, she says. This means the practice is getting lab results, but can’t send new orders easily. “It takes a few extra steps, including printing the requisition,” she says.
Haney says her comfort level with the EHR has improved, but the system still isn’t as efficient as she needs. “I still have some hope that we’ll get there, and it’s a goal to use some features that we don’t yet know enough about. That’s why I’ve decided to get some further training. But I have to say, my general attitude toward EHRs is not good,” she says.
Health maintenance is a key feature of Aprima. The system enables practices to help patients comply with medical advice and best practices via automated alerts. The EHR system can alert Pike Family Medicine to a patient’s overdue tests and procedures. Also, Haney can tailor the system’s health maintenance feature to fit the needs of different groups of patients. For example, she can customize information by diagnosis or by payer to accommodate carrier guidelines.
Another underused benefit of Aprima, Haney says, is the ability to enter data in her terms. Aprima provides flexible data entry options that can help physicians eliminate busywork by pre-populating fields and providing recommended codes, diagnoses, and links. Doctors can choose the method that’s most familiar to them, and adapt to new methods at their own pace.
“The way Aprima enables us to enter data, we can customize the EHR to the way we operate,” Haney says. “I’ve been able to figure out some of that customization myself, and Aprima has Web site videos that can help. But realistically, I’m busy from the time I get here.”
That’s why she opted to invest in additional on-site training for her and the staff. She also plans to ask the trainers about how to receive customized reports, including a demographic breakdown of her patients. “I know that’s something we should be able to pull up right away, but we’re so busy every day trying to keep our head above water. The training is going to be a couple thousand dollars, and that hurts.”
Next May, when the 2-year study is over and Aprima will start charging Pike Family Medicine an additional monthly service fee for using the EHR system, Haney isn’t sure what she’ll choose to do. “I could foresee a time where we go to cash-only and say bye-bye to any EHRs, but the government may pass a law saying that’s not allowable,” she says. “I also still have hope that we’ll be able to keep plugging away and doing a little better because of health maintenance and other improvements. Time will tell.”