Over the past decade, EHR implementation and optimization have gained a foothold in cardiovascular practices, even in smaller practices. Some cardiologists find going paperless lightens their administrative burden. But to maximize benefits, practices must roll out implementation carefully and anticipate bumps in the road.
Slightly more than half of all U.S. cardiology practices have moved toward some form of electronic documentation, according to a survey by the Medical Group Management Association (MGMA). There are a number of factors driving this shift: the need to integrate with a hospital's record-keeping system; inefficiency of paper records and problems associated with secure storage; the wish to maintain a modern practice; and the Health IT for Economic and Clinical Health (HITECH) Act, which offers financial incentives for Meaningful Use of health IT, specifically EHRs.
According to MGMA’s 2011 “Electronic Health Records: Status, Needs and Lessons” report, 52.3 percent of the respondents used an EHR, while 35.8 percent maintained paper charts. The results for cardiology practices were similar, with EHRs implemented to varying degrees in 60.4 percent of responding cardiology practices and 34.6 percent reporting use of paper charts.
Cost and fear of lost productivity are two factors survey respondents cited most often when explaining their continued use of paper records. Private practices can expect EHR acquisition and installation costs of $40,000 to $50,000 per physician, and maintenance costs of up to $5,000 per physician, per year, says Jerry D. Kennett, MD, a cardiologist at Missouri Heart Center in Columbia, Mo., and chair of the American College of Cardiology's Advocacy Steering Committee. Even so, the MGMA report indicates that 62.9 percent of paper record keepers plan to seek the financial rewards the HITECH Act offers, which can be substantial. The Medicare EHR incentive program, for instance, provided up to $44,000 to eligible professionals over five years if they began participation by 2012.
“The reality of the future is that you will need an EHR to participate in the various payment models,” says Kennett. It may seem that the push to implement EHRs is yet another example of bureaucratic interference with the efficient, compassionate practice of medicine; however, the examples of practices that have successfully implemented and optimized EHR do not support that notion.
Practices that have fully implemented EHRs say that, if done properly, the EHR can lead to efficiencies and improved quality of life for physicians. A 2010 study found that physicians spent an average of four hours per week providing documentation and other information to third-party payers (Health Aff 2010;29:1248-1254). Reducing the amount of time that physicians need to spend on responsibilities not directly related to patient care can be a benefit of an EHR system.
Samir B. Pancholy, MD, an interventional cardiologist and director of the cardiac cath lab at Regional Hospital of Scranton in Scranton, Pa., is a big fan of his hospital’s EHR system, saying that it has reduced the time he has to spend on documentation. “There is much less duplication and redundancy, and I am able to engage with my patients. I can make eye contact and be present with them, and stop worrying so much about getting all the information down,” he says.
Pancholy had several cardiac nurses whose primary duty was documentation. “This was such a waste of highly trained, intelligent people who could have been contributing to patient care,” he says. “And highly inefficient, because often I also would have to document the same thing the nurses had already documented.”
When his hospital implemented its EHR system, staff from the cardiac unit was involved from the beginning. They had input into the template design, ensuring that the fields were appropriate and made sense in the context of practices.
Pancholy also appreciates the ease with which the cath lab's EHR interfaces with a quality improvement toolkit he uses. The two systems work together in a way that permits him to track performance, collect and collate data, as well as promote best practices. “[It is] a great help in getting the system to work most effectively for the patients and for the entire cardiology unit, physicians, nurses and everyone involved,” he says.
Transitioning is difficult
Although EHR adoption went well in Pancholy's practice environment, his experience is by no means universal. Kelli Nicholas, an administrator at Cardiovascular Consultants Medical Group in Mission Hills, Calif., offers a different perspective.
The practice, which has a dozen cardiologists and several satellite offices, began implementing its EHR in March 2012, after spending two years considering options. The process was challenging. Part of the motivation for adopting an EHR was a desire to participate in Meaningful Use incentives. In addition, one of the local hospitals began an initiative to forge closer relationships with physician practices, and urged the practice’s participation in its efforts to implement Meaningful Use, Nicholas says. As part of the hospital’s pilot program, the practice is working with a vendor and third-party administrator selected by the hospital.
That third-party administrator offers only one EHR system, and it is not cardiology specific. Nicholas and her staff had to customize the templates, and they were allowed only a limited amount of customizing before the practice had to pay for programming time.
The third-party administrator has been a helpful source of information and advice, and the product is certified for Meaningful Use, she says. In the practice's assessment of various EHR products, the one that the hospital chose was one of the practice’s top three choices. While the product is good, according to Nicholas, the limited ability to customize has been a problem.
It took most of the doctors at Cardiovascular Consultants months to learn to use the EHR efficiently; but after a difficult initial few months, Nicholas says that “it gets exponentially better every week we use the system.” Retrospectively, she says that the transition was "manageable” and definitely worthwhile. “You can't possibly work efficiently on paper anymore.”
At the end of 2012, despite the challenges inherent in implementing and using a new system, 10 of the 12 physicians in Nicholas' practice met Meaningful Use. She grades the system a success, adding that the transition “is not something I would ever look forward to going through again, but now that we are electronic, I can't imagine going back.”
Bronson Advanced Cardiac Healthcare in Kalamazoo, Mich., has one main office and six satellites. The provider introduced an EHR into the practice almost eight years ago. According to Practice Administrator Kurt Kuppler, the EHR has been a great success. Since implementing the system in 2005, the practice has grown from seven cardiologists to nine. “We couldn't see the number of patients we see per day without the EHR; a paper infrastructure couldn't support that kind of growth. And it's not just a matter of dollars, but also balance,” he says.
On the subject of balance, Kuppler explains that the doctors in his practice now work a shorter workday. The day's final appointments are at 4:30 p.m. “Now they go home at 5:30, not 7:30 or 8. Instead of dictating the entire visit, they can just dictate the relevant history and plan.”
The EHR allows Bronson’s physicians to call up a patient’s chart using an iPhone app. They can access the data they need from home or anywhere remotely.
Mark Spetsios, manager at Florida Cardiac Consultants in Sarasota, Fla., helped the group implement its EHR in 2007. The practice has seven cardiologists, two full-service offices and a satellite, which cover two hospitals. The inefficiencies of trying to maintain paper records at multiple hospitals and offices led the practice to adopt an electronic system.
The physicians in Spetsios’ practice were not particularly comfortable with computers, so he recommended an interface more like a document imaging system than a “point-and-click” EHR. “I wanted to provide [physicians] with something that looks like what they used to hold in their hands and keep their day-to-day activities the same as much as possible.”
Spetsios’ strategy worked. He reports that his physicians adjusted to the system quickly and with minimal effect on productivity.
Since implementing a paperless system, Florida Cardiac Consultants has been able to double the number of office appointments and eliminate two medical records staff. The practice is now more profitable and able to grow, Spetsios says.
He says physicians embrace the system, because it makes their lives easier. The two most computer-savvy physicians in the practice began using the system, “and after a few months, all the docs wanted it,” he says. The cardiologists can call up patient records from their offices, exam rooms and PCs at home, allowing them to carry out administrative duties more conveniently.
Kuppler agrees that the Meaningful Use program has changed the dynamics of decision-making on whether to implement a paperless system, especially for smaller practices. Yet, he urges practices to consider the potential benefits beyond the Meaningful Use incentives.
“What used to be a conversation about how we can improve patient care is now a conversation about how we can comply with Meaningful Use and other regulations,” says Kuppler. But optimizing an EHR “offers a way to do all that and make it easier for the doctor to spend more time caring for more patients.”3 keys to successful EHR implementation
Several common themes emerged among practices that implemented EHRs.
Find a physician champion within the practice who can show others how the system can work in a way that they can appreciate, respect and understand.
Devote as much time and money to training as possible. Have a professional trainer work one-on-one with physicians, not in a group. And have the physician champion back up the trainer by being available to answer questions, trouble-shoot and demonstrate. Some practices have implemented shadowing programs where the physicians observe how the physician champion works with the system. Regular meetings to discuss questions and glitches also may be necessary. "Don't be afraid to go over budget on training; do whatever it takes to get one-on-one training for the doctors," says Mark Spetsios, manager at Florida Cardiac Consultants in Sarasota, Fla. "It shortens the learning curve tremendously and they'll be productive again sooner."
Design a workable system to transfer paper records into the new system and devote adequate time and resources to this process. Begin abstracting the data to be transferred before implementing the new system, so the record transfer can begin immediately. Recognize that it may be necessary to hire temporary staff or reassign some employees to full-time scanning duties.