Tapping into IT to Improve the Office-Based Practice



Information technology infrastructure, especially the electronic medical record (EMR), does deliver. Consider:

  • An EMR trims operating costs. According to Medical Group Management Association (MGMA), it costs $4.50 each time a patient calls and a staff member must pull a chart. Cardiology practices must multiply the $4.50 figure by upwards of 10 to 20 calls daily.
  • Say goodbye to transcription costs. That’s about $12,000 per year per physician. And the practice can reduce medical records FTEs.
  • Think revenue increase. The EMR facilitates better coding, which translates into a 5 to 12 percent increase in reimbursement for office visit. The primary reason? Many physicians are afraid to code an office visit as a level four, but an EMR contains the data to support the higher-paying code.
  • The EMR delivers improved risk control. Charts aren’t lost; they can be accessed from home or another office location. Plus, electronic records provide a more complete picture of the patient, helping cardiologists avoid patient safety errors like drug-drug interactions.
  • An EMR is a stepping stone to better relationships with patients and improved service. Patients don’t need to remain on hold for five to 15 minutes or longer to secure a prescription refill.
  • Electronic charts help physicians regain time. Cardiologists in EMR-equipped practices can end the work day sooner than colleagues chained to paper charts and transcription. They also can see more patients each day, and document patient encounters more completely. And of course, the data can be mined in easy to create reports to recognize trends in the practice.

The upshot? The EMR and other investments in IT infrastructure represent a winning scenario for office-based cardiology practices. As practices transition toward an EMR, they need to look beyond software and consider questions about hardware and staffing, too. Insiders can provide a wealth of information about the benefits and do’s and don’ts of IT infrastructure and steer their colleagues toward a smooth implementation.

Inside an IT pioneer

The Medical Group of Southern California (CVMG) is a health IT pioneer. Ten years ago, the Los Angeles-based practice was one of the first medical groups to launch its own website. The website paralleled another important IT development: NotesMD, a homegrown, web-based EMR. The premise behind the practice’s online efforts is simple. Physicians are the knowledge workers of the healthcare world, says Ronald Karlsberg, MD, clinical professor of medicine at David Geffen School of Medicine UCLA. “They need patient information and unlimited resources,” states Karlsberg.

At CVMG, NotesMD is the vehicle for transmitting knowledge to the physician. The server-based system has become an indispensable tool where cardiologists view lab results, general knowledge and patient charts. An integration with McKesson Corporation Horizon Cardiology allows physicians to view images in the patient record. The practice reduces the bandwidth stress associated with hefty file sizes of studies like cardiac CT angiography by creating summary images in a PDF format and compressing moving images beyond normal ranges. On the reporting and documentation sides, NotesMD minimizes note taking and typing and can generate all reports from dictation.

NotesMD allows CVMG to capture 95 percent of patient data, compared to 40 percent in most practices. Prescriptions are refilled with a single click, not only reducing errors, but also increasing efficiency. Other cost savings come on the staffing side. For example, the solution enabled the practice to transition from one transcriptionist for three to four physicians to one transcriptionist for 16 cardiologists.

On the hardware side, the web-based product can run on any device such as a PDA, iPhone or Tablet PC. CVMG opted for hardwired secure workstations in all exams rooms to provide a stable, dedicated workspace at the point of care.

EMR upgrade makes the grade

The first time is not always a charm when it comes to technology—particularly for early adopters. Take for example South Florida Cardiology in Pembroke Pines, Fla., an 18-cardiologist practice that first implemented the EMR in 1997. The impetus for the first project was improved documentation, not enhanced efficiency, says partner Perry Krichmar, MD. “Without proper documentation, it can become problematic to secure reimbursement for tests.”

The initial system performed as expected; however, as costs increased and reimbursement decreased over the last decade Krichmar and his partners realized that the practice needed to find new ways to increase efficiency, spend more time with patients and less time on paperwork and documentation. The paperwork burden in a conventional practice can be daunting. Krichmar sees 20 to 30 patients and reviews as many as 30 echocardiograms daily. The daily workload translates into 60 patient encounters, each with a stack of papers. In 2007, South Florida Cardiology reached the logical solution. “The only way to increase efficiency is to reduce manpower needed to push paper around,” sums Krichmar.

Although the practice remained skeptical about its ability to go paperless, it decided to deploy the gMED EMR to boost efficiency. Since deploying the software in August 2007, South Florida Cardiology has replaced the paper chart process with electronic charting, sending messages via computer rather than paper. In terms of monetary savings, it no longer costs more than $4 to pull a chart with each patient phone call, says Krichmar. The software improves patient service in other ways as well. A Healthcare Insurance Portability and Accountability Act (HIPAA)-compliant patient portal provides a means for online scheduling and distribution of variety of test results. In the near future, patients will be able to log in online to review radiology reports and lab tests.Integration with the practice’s billing solution enables automated billing and appointment verification, which increases efficiency and cuts costs.

South Florida Cardiology continues to refine gMed. For example, the IT department expects to complete an interface to allow physicians to view echocardiograms, lab, CT and nuclear stress tests results in gMed. In addition, cardiologists will be able to generate reports within gMed, which represents an upgrade of the current scanning process. “We will be able to review and file reports with a single button. Currently, it takes two to three hours to review this paperwork with a nurse. That time should drop to about 10 minutes with this development,” states Krichmar.

To optimize its investment, South Florida Cardiology invested in complementary hardware and IT resources, outfitting each exam room and echocardiography station with a workstation. “We decided against Tablet PCs because they aren’t as fast as hardwired systems, and access can be spotty,” says Krichmar. The upgrade also required an additional server. Finally, a full-time IT staffer manages the system and updates. “Outsourcing is an option,” indicates Krichmar, “but it can cost more.”

The 0-to-60 approach

In 2003, Cardiac Specialists, PC in Fairfield, Conn., was residing in the dark ages of IT. The 15-physician, three-office practice had very few computers and no network or central server. The decision to deploy SRS Clinical Manager electronic charting solution proved to be a springboard into the information age and propelled the practice into the leading edge of IT infrastructure.

The first step on the journey was installing a high-speed broadband network and a Windows-based server with backup. The original plan called for a workstation in every exam room, physician office and nursing station. “We were surprised to find out every clinical staff person, not only cardiologists, needs a computer, so we needed more computers and printers than we purchased,” recalls Practice Administrator Robert Hendler. Today, each nursing station is equipped with a pair of computers, printers and scanners to provide chart access to multiple nurses and medical assistants.

Migrating to an electronic chart is a process, cautions Hendler. “It’s very laborious; it took a year to transfer all of our records to the electronic chart, but by doing so, we’ve achieved new levels of efficiency and service to our patients.”

The practice did stumble a bit during the implementation. For example, the user interface presented a conundrum. With an electronic chart, the practice can define the look of the chart. Initially, physicians decided to replicate the look of a paper chart, but after realizing that they could add extra categories, they went overboard and created 35 new categories in the chart. “It’s a good idea to have a committee composed of nurses, physicians and billing staff who can balance competing issues and logically determine about 15 categories,” recommends Hendler. Categories that should make the final cut include preliminary and final lab results, says Hendler.

After Cardiac Specialists realized the benefits of its new system, the practice decided to optimize it, upgrading to faster workstations and installing cache servers in all locations. Every server has the same data, which provides rapid retrieval. What’s more, with duplicates of all data in each office, the business can continue to operate if one server goes down. Other updates include interfaces with various laboratory information systems and transcription services to import information into the EMR. Electronic results are fed into the chart to eliminate the inefficiencies and costs of faxing results.

The benefits of the electronic approach are significant. With instant availability of information patient service is faster. Cardiac Specialists also trimmed clerical staff from five to two, an annual savings of more than $100,000.

Optimizing IT via outsourcing

Like many office-based cardiology practices, Cardiac Solutions in Peoria, Ariz., has seen tremendous growth in the last five years. The practice exploded from a four-physician, single-site office to an eight-cardiologist practice with two offices, providing a full range of services and four nurse-directed clinics. “Our most valuable resource is physicians’ time. As we started growing, we realized we needed to tap into IT solutions like the EMR, scheduling software and BlackBerry devices to help physicians maximize productivity,” recalls Laurie Duvall, RN, director of clinical/business operations.

Initially, the practice contracted with a small local IT provider to handle its IT needs; however, the company lacked the health IT know-how to deliver expected results. When Cardiac Solutions decided to implement GE Healthcare Centricity EMR and practice management software and Dragon voice recognition software, it also contracted with DirectPointe to outsource its IT services.

Prior to the EMR implementation, DirectPointe completed a thorough needs assessment to determine the practice’s hardware, network and server needs. Cardiac Solutions added three Citrix servers, a fax server and a Microsoft Exchange server to facilitate a paperless, wireless environment. Office staff no longer call cardiologists; instead they communicate via email and Blackberry to update schedules and procedures. In addition, BlackBerry devices are equipped with mobility software, which allows physicians to submit charges through the handheld. Consequently, all charges are submitted electronically at the end of the day—leading to faster turnaround time on charges. Other cost-savings are expected, too. Duvall predicts that the practice can reduce office staff as the new approach enhances productivity. Finally, the combination of voice recognition and Tablet PCs lead to enhanced continuity and communication as notes can be shared with referring physicians before the patient leaves the building. And because physicians always have access to the patient record, Cardiac Solutions reports fewer duplicated services.

Advice from the trenches

  • IT should accommodate a wide variety of physicians.
  • Make sure the EMR can handle transcription, scanning and file uploads.
  • Be sure to thoroughly evaluate various solutions, and remember a mistake can be costly, says Krichmar. A user-friendly interface is critical to the success of the deployment.
  • Aim for a gradual adoption. IT should amplify, not change, work style, says Karlsberg. CVMG built its EMR gradually as cardiologists accumulated medications and problems.
  • The key to success is planning. Form a planning committee that represents the interests of all stakeholders in
  • the practice.
  • Set a realistic budget and realize it will probably cost more, says Hendler.
  • Recognize that internal ROI can be elusive and not immediately apparent. On the upside, Medicare is evaluating programs to partially mitigate IT costs. But don’t spare a dime on workstations. Investing in a fast central server, beefy workstations and hefty storage devices sets the stage for a successful implementation, says Joe Rubinsztain, CEO of gMed Inc.
  • Tap into lead staff to acquire IT knowledge, particularly if the practice uses external support only. At Cardiac Specialists, multiple staff members have acquired IT know-how to troubleshoot basic issues. Other practices, like South Florida Cardiology hire a dedicated IT staff person to manage IT infrastructure.

Benefits and beyond

An investment in an EMR is an ongoing process. Practices should realize key benefits such as reduced costs, improved efficiency and better patient care with the move to electronic patient records. At the same time, systems can be viewed as a work in progress. Practices that continue to tweak their investment, interfacing and integrating it with other systems often report additional gains such as computerized billing and a one-stop-shop for all patient data. The upshot? The EMR is a must-have for office-based cardiology practices.


Maintaining a Physician-centric Approach
The key consideration with IT investment is not which infrastructure the practice needs, says Joe Rubinsztain, CEO of gMed Inc. Instead, the practice should ask which EMR solution supports the efficient practice of cardiology. Cardiologists work at a faster pace than most other specialties and many see more than four patients per hour. They also complete many procedures, and revenue is divided equally among the two activities. “A solid EMR operates at the speed of cardiology, and it allows multiple inputs so auxiliary personnel can contribute to the office notes,” explains Rubinsztain. At the same time, the EMR should support richness of data with minimal manual effort as cardiac data originates from multiple inputs: electrocardiograms, diagnostic devices and imaging modalities.

Practices that make a wise choice will realize significant dividends as the EMR offers passage into 21st century healthcare and improves patient care and relations, reduces the paperwork burden and enables maximum efficiency, and patient care.

Choosing The Right Hardware
An EMR is not a standalone solution. Optimization requires the right mix of hardware. Evan Steele, CEO of SRSsoft, provides some guidance for cardiology providers.

Most EMRs are client-server solutions. A “plain vanilla” Windows server offers a sufficient base, says Steele. Practices with multiple offices should consider outfitting each site with a server and replicating data at each office. The multi-server configuration allows the practice to retain access to critical information if the internet goes down. On the connectivity side, point-to-point T1 lines offer a solid pipe for transmission of EMR data. Some practices choose fiber optic transmission.

The primary electronic chart enabler is the exam room workstation, says Steele. “Right now, the fixed workstation is the gold standard. Everyone seems to want Tablet PCs, but physicians are often dissatisfied. Tablets are higher maintenance than fixed workstations. They’re plagued by speed and connectivity issues, can be lost or broken and require frequent recharges.” On the other hand, fixed workstations are economical and lower maintenance. As far as numbers and siting of workstations, Steele says practices should plan for access to the EMR anywhere clinical staff view charts—that means exam and consult rooms and central nursing areas.

The end results are well worth the time and investment as the EMR delivers improved efficiency, reduced costs and enhanced patient care.