Experiences of Physicians who have Implemented an EMR

If you are a physician who has made the jump to EMR, this posting provides an opportunity to share your experiences with others. The objective is to discuss challenges and opportunities that you have faced that will be applicable to all physicians who have implemented an EMR. Please do not discuss issues that are specific to the individual EMR system that you have chosen.

An example might be the challenges of managing paper documents that come into your office in non-electronic format or the change issues that your staff or colleagues faced as a result of the implementation of EMR.

To share your experiences, please click on the ' Comments' link below.

Comments

[Fred Freedman]

Just to start the ball rolling on this topic...
We implemented a new EMR (NetMedical by Healthcare Software) on March 28. Here are some preliminary comments.

First is that I think the desks that we chose have turned out to be an important part of the implementation. The new desks (which are shown on this site) are kidney or scallop shaped. This allows us to face our patients with the LCD (and I think that is important as well) screen essentially beside their head.
If you can touch type, this means that you can enter a clinical note without losing eye contact with the patient. I feel this is very important as I have always worried about computers interfering with the clinical 'mood'. So far no concerns here.
I would advise others to really consider the ergonomics and setup of their office.
We are using iMac G5s with 17" LCD screens and we each have HP 1015 laser printers on our desks. These printers are virtually silent and have a very small footprint...certainly the smallest of any printer I've seen. Being laser, I expect a long life and fairly inexpensive running costs. We bought them at Staples as refurbs for 1/2 price.

The software is very intuitive with a lot of keyboard shortcuts. I have always felt that mice can be over-rated. It is often much easier to use a keyboard shortcut than open endless menus using a mouse. Of course the shortcuts should be intuitive (on ours apple P --two keys--prints frommost screens).

I was interested in tablet and handwriting entry but I am now satisfied with the keyboard and desk setup I have.

We have had 4 training sessions with two more to go so we have still to implement lab downloads. I can say, however, that so far I am sold on EMRs.
Prescriptions is easy and will be much easier after we have collected the fax numbers for all the local pharmacies. As well we still don't have every consultant's fax number in the system but we are working on it and that should be a great benefit to us.

I thought hard about how hard to push our secretaries to put in the pharmacies and referral lists...the sooner they are in, the sooner we reap benefits. However, and I think this is a very important point, changing systems is a lot of work for a secretary and one has to be very supportive of them.
I have at every stage of training encouraged them, asked for their comments and suggestions. Last week I took them out to lunch and have told them that I understand the difficulty in adapting and assured them that I know what they must be going through.
I asked if they were interested in earning some overtime pay to come in early or stay late to put in the lists on the computer. To my surprise, they managed to do much of it during work time.
We plan to give them a little bonus soon.

No doubt about it, a new computer system is expensive. Aside from up front purchase costs, we have had to close our office for training and it has stimulated a whole re-assessment of how we practice that has resulted in some new purchases. While expensive, I have hope that it will all pay off.

The other big issue is getting charts into the EMR. We are just in the middle of figuring out how best to do that.
Currently, we have asked our secretaries to slow down appointments a little. All of us have put in some extra time at lunch and day's end to put in data.
I put in all the patients whose charts come across my desk. At the end of the day before I go home, I am inputing data for all the patients I will see tomorrow. I am not entering old progress notes but just the CPP like Rxs, FH, Meds, Vaccines, etc. This is aided by the page we have kept in all our charts documenting these things. If you haven't been doing this it will take longer. But I find it is going quicker than I would have anticipated.
When I take a phone call, I put in the patient's CPP while talking.

At this point, I am finding that I can see all my patients during a day without even opening a chart most times (although I keep their chart on my desk at present for possible reference).

We have hired by son's girlfriend, who is finishing 2nd year Life Sciences, to input patients' charts for 4 months this summer. The Ontario Ministry is paying a bonus of $2500 per doctor when 600 or 2/3 of our rostered patients (whichever is smaller) are entered in the computer. We are hoping that this pays for itself...I will report back.
There are different ways to approach putting in charts. We have started with patients as they come in. That has given us immediate feedback and some positive results in terms of benfitting from an EMR.

Another approach is simply to go through the alphabet A to Z. Another one would be to do the biggest and most complicated charts as that will offer the biggest return since they are the most frequent and difficult visitors. But it is more discouraging as progress is slower.

When our 'help' arrives in May to input data we will have to make a decision about inputing patients as she will have enough time to do all the patients for the next day and much more.

So far, as we are not doing labs electronically, the secretarial file saving has not yet been realized...that will be two weeks and they are very much looking forward to it. For we doctors, access to information has been great.

Emotionally it has been a real roller coaster. I think every office needs a 'champion' of the conversion. In our office I have played that role. It means holding the hands of the other doctors and employees as they meet the inevitable frustrations. It can be trying and adds to an otherwise hectic day.

But, we are only 2-3weeks into the process and already I am doing very little hand holding. I am definitely doing more work right now with inputting data. But I must say I often enjoy it. I can type quite well and I think that really helps compared to my partners. I am doing all my referral letters by computer while my partners say they haven't found the time to do that yet. I can type about as fast as I can write so why wouldn't I type it. Once done, it's in the chart and one keyboard shortcut and the letter is printed (and isn't that the sad fact...why should I have to print a letter when everyone has a computer...but that is the next training session....hold tight for a report!).
If you can't type well, learn how!!

In summary, it has been more work but less than I anticipated. And the rewards are definitely there. And some of the work has been fun.

I know we aren't supposed to talk about individual software packages, but I think it very important to find one that most closely resembles what you want to do.
Number of keystrokes is crucial.

It isn't good enough for a software system to be able to do everything. Ask yourself how many keystrokes is it to get to that function. If it is a seldom used but vital function how easy is it to find and execute?
I have so far found my software to be rather intuitive. Don't buy from a vendor (like one we met for a very popular software system)that says 'you're going to be computerised so you will be doing things completely differently'.

No you won't. You want your computer to aid you to do things better but you shouldn't have to change substantially the way you work to fit any computer system.

Another update as I go along. We have two more training sessions and then we will be fully computerized!

[Fred Freedman]

Here's a short 2nd instalment of 'tales of instalation':

We have had our 2nd last training session. Interestingly, we have left electronic lab results to the last. It is, presumably, the most immediately rewarding application of an EMR as it dramatically reduces filing. More on that in two weeks after our session on that topic.

We have just finished training on scanning in reports and intra office 'messaging', really intraoffice email.

We have done very little scanning yet and it promises to be the biggest obstacle to th implementation of a fully paperless office.

It is very important for any office to properly plan for scanning. The location of the scanner and the computer to which it is attached is important. Scanners requires extra computer memory so make sure your hardware is appropriate. Scanning also occupies the computer to which it is attached (at least OmniPage X does)exclusively. No multitasking here. You cannot use that computer to access your EMR while it is scanning. And scanning takes about 30 seconds per printed page. So budget computer (and personnel) time appropriately.

What to scan and how much is also important. Do you want to scan EVERY diagnostic result (x-ray, U/S) in it's entirety or perhaps simply enter them as normal, if that is the result? Do you need a 'written' copy of an entire CXR that is normal? You must decide. If you just enter 'normal' do you feel comfortable then throwing out the paper copy or will you want to file it away for possible future reference?

Of course, if you file it then you have missed the opportunity to have less paper and it mean entering the data AND filing which is, of course, more work than the pre-EMR setup.

These are difficult questions that our office is grappling with. We are still in transition so I think we will change our minds several times before hitting on the solution that we can feel comfortable with.

For now, I am entering 'normal' for such results and then filing the hard copy. I can see, however, that soon I will feel comfortable trashing the hard copy.

Of course, things would be much simpler if we could simply get diagnostic facilities to email results to us. More on this in a later update as I intend to go on a campaign among my local specialists and diagnostic facilities to see if I can get them to do just that.

For consult notes the task can be more difficult. A good consultant's note is a great summary of the patient's condition as well as an education on how to approach treatment as well as the suggestions for treatment. I often want the entire note kept in the chart....time consuming to scan and visually it takes a lot of space in the chart. One can simply highlight the items one is interested in and have your secretary type them in, or alternatively, scan the consult and then remove the non highlighted data.

Again, decisions about this to come. And much time to be saved by having specialists email consults.

Internal messaging has been a great addition. Before implementing our EMR, we visited a couple of other offices with EMRs. None of them were fully utilizing an internal messaging system...they were still leaving notes on charts, etc.

We finally, just two days ago, left paper notes aside. All telephone messages and prescription renewals are now posted electronically. I can okay a renewal and post the reply to my secretary without stepping up from my desk or touching a piece of paper...well almost. Until all my patients' information is entered, I still need a chart to review when it was last renewed etc.

As an aside, one secretary has voiced concerns that she will gain weight because she won't have to get up from her desk as often to track down charts and results!

As I mentioned in instalment one, I use these items as an 'excuse' to electronically enter patient data. When I have a renewal or a phone call, I am asking my secretary to pull the chart (if she sees there is no electronic record) so I can enter the data as I talk to the patient on the phone. As a capitated practice, we do a lot of phone work so this works well.

Again, having short cuts (instead of searching menus) in your software is a great enabler.

I can see the day quite soon when I will no longer routinely need a chart during the day. We will keep the charts in the office likely for a couple of years for reference to old data that we haven't entered but that should be their only use.

Still outstanding:
1. we'll see how the lab result entry goes. At this point, since only one lab can be chosen for electronic entry, we have requested our lab give us a single page with all their locations listed and we give this sheet to every patient who goes for a lab test. We are telling them that they can only go to an 'approved' lab to ensure that we receive the results electronically.

2. scanning: we still have to decide how much paper to keep after data entry. Obviously if we scan the entire document, we will throw out the original...otherwise..?
Another scanning issue is release signatures and other non standard paperwork. If I get a request for an insurance form with a signature on it am I not obliged to keep the original with the signature? I am looking into that as well. Again, if we have to keep a chart to store such forms it obviates some of the advantage of EMRs.

I would welcome any advice on this (or any other) matter.

3. I need to start contacting diagnostic facilities and specialists to see how receptive they are to emailing results.

The biggest issue is still the one I have complained about before in CanadianEMR...communication with the outside word.

More later.

[david vincent]

I have used an internet based emr for 2 years, we scan all incoming mail and test results; our labs are downloaded to the software from CML. You review the result and it is linked to a follow up function which allows you to send a message to a staff member to rebook the patient or preform any other request you may have, it is all logged. It has taken me more than 2 years of working everyday to do my CPP's, I write all my script electronically and repeats are very fast. Once we are sure we have a second copy of all scanned information we are shredding the originals.
We are using a $700 Snap Scaner which instantly turns the scanned document to a pdf file which is then attached to the chart. This works very well and is fast.
We would love to have all information emailed but due to security concerns this is not happening yet, I recently read about an inexpensive program that will encrpyt email and hopefully this will encourage this avenue of communication in the future as now a lot of our incoming reports come by fax, are printed then scanned and shredded, a great waste of time and paper. Our software has the ability to send scripts by email to the pharmacy but the Ontario College of Pharmacy will not allow this at present so again we have to print them and either fax copy or give the script to patient.
The snap scanner scans about one page per second.
Our EMR software is internet based so it is quite easy to access your charts from any place you can get on the internet and working from home is just as fast as in the office.
The quality and organization of my notes and charts has improved immensely since going to EMR and finding information is much quicker, I can now type and talk to patients at the same time without having to continuously look at the screen. This has just naturally happened by using the system everyday for the last 2 years.
My biggest pet peeve is that we would like to become even more electronically connected with other health care providers but we are waiting for funding and regulatory changes to catch up with the technology, at least here in Ontario.

[Fred Freedman]

It's been a while since my last instalment.
We have finished all our training and implementation. It has been an itneresting experience and there will be another instalment, I suspect, after this one.

We have had some real technical difficulties. We are using Apple iMac G5s and of the 11 we purchased, two have required repair...and dealing with Apple has not been a pleasure! As well, we have had difficulties with the faxing software.

As I write this today, all systems seem a 'go' from a technical point of view.

Some of the issues I listed previously are still of concern.

We are faxing all our Rxs when possible, but it is time consuming for our secretaries to input all pharmacies and their fax numbers. It would be wonderful if the Shoppers and Pharmaplus's in Toronto send out a CD with all their fax #s listed (this is a project someone should undertake).

We have had no problems with pharmacies accepting fax Rxs.

The real issue is scanning all the consutl notes. We use OCR (not PDG like David Vincent referred to) as it allows us to manipulate the scan...we can erase and reformat reports so they are more useful in the patients' chart. So far all this scanning is being done by our summer student....it will be a real burden when our secretary has to do it. Scanning is very slow and ties up a computer while it's happening making booking for that staff member difficult.

I have contacted several specialists asking for emailed consults but so far very little postive response. Something MUST be done about this or EMRs are never going to prove their worth.

And, while I thought we could ellimate the need for new charts, I find we still need a paper chart to file release forms etc. Is anyone out there aware of alternate approaches to this?

Messaging between my staff and myself takes some getting used to. I find it much easier to have a chart in paper on my desk to look at when reviewing a message but I think this is just a matter of getting used to. When I check my screen and see I have 4 messages I find it more 'onerous' then to find some charts stacked on my pile.

This isn't a terrible issue as I am already getting used to it and it is very simple to type a note while talking to a patient on the phone.

Also easier is when a mother brings in two children to see when only one is booked! At least I have all the charts at hand on the computer.

Labs is sometimes problematic. We give every patient a list of labs sites they can go to (we use CML and give tnem a list of all CML sites in the GTA) so results can be downloaded automatically. We state clearly that they can go ONLY to those locations. Well...about 1/4 of our patients go to other labs in spite of all this and so we have to manually enter their results!

As for chart entry....as I stated before, we hired Melissa (University student) to enter charts for us. She has been working for 4 weeks today and has entered perhaps 75% of our patients! This has proven to me to be the only way to go. It is a great thing to open a chart electronically and find data already there.

One problem, however, is that no matter how bright someone is, really only the patient's own physician knows what they need in the chart and we are finding that we send charts back to Meilissa to enter new data.
However, she will be here until the end of August and I am sure we will have all our charts appropriately entered by then.

The biggest issue is the same one I worried about before...communication of data with the 'outside'. Scanning correspondence is a difficutlt time comsuming process and there has to be a way around this.

More later

[Dr. Jan McCaffrey]

We are one year into our EMR, MedAccess, and there are orchids and onions to be awarded.
So far I am only using a wireless lap top with a printer outside the examining room(helps to conclude some appointments). Waiting to upgrade, but want to do the right thing.
Docs meet every 2 weeks and I meet with my MOA for a few minutes everyday as the task mangement and work flow is ever evolving.
We have just recently had the labs coming in, it is easier to deal with abnormals as you can go straight to the chart, you don't have to wait for your staff to pull it, and you can instruct the staff or pt. immediately.
I have been populating my problem lists when the patient is in for their physical. this has resulted in steady data entry over the year and it is starting to look great. We didn't want to spend the time and money up front to have someone who couldn't appropriately triage the information going into the chart. We are not scanning. I am enriching the problem list and recall list as much as possible when I go through the mail. This is easy to do and takes care of most documentation necessary.
The practical wins are with Rx renewals and consults. Instead of saving the chart to work on the referral later (drag the chart home), write a letter and pull relevant info, i use the visit note as the body of the letter, the program attatches the summary and any data I need, and I do it with the patient right there. Now I want a FAX server to fax Rxs and consults directly to my pharmacies and consultants...but easier said than done. I don't think our system is quite prepared for that, but until everyone out there is doing the same thing, we are printing on lots of paper only to fax it to its destination.
Patients, love that we are 'progressive'. I give them copies of their chart summaries at their physicals, I copy them on their lab results. It is moving them to better self management.
We are in a predicament in that in the last few months, 2 partners have declined involvement...so now we are pioneering a mixed system. 2 of us don't want to give it up, and 2 do. Yikes! Anyone out there doing a hybrid office??

[Norman Yee]

Alan invited me to wade into some your postings. Congratulations on your implementations and the persisting through the experiences as a result. We've been live for 3 years now in Calgary and have been very happy with our current situation (painful to get here though).

I note that the most common complaint, aside from external connectivity, is the lack of preloaded phone/faxes from para-health professionals. Good suggestion that Shopper's etc should send us all a CD with their info. In fact, has anyone checked? I have all of our pharmacies, physios, x-ray, specialists uploaded, and it was done long before we had an emr. Just call the local regional hospital, college of physicians and surgeons, college of physio, college of pharm, etc and they have computerized lists already. Simple matter to make a request (+/- fee) and have them email you the CSV delimited file for uploading. Should be a matter of 10-15 min work to get it uploaded once you get the file. And if you can't figure out how to do it, you could convince the vendor to load up the files for you and all benefitting clients to enjoy...or get your kids to do it!

Norm

[Norman Yee]

Just noted Jan's wish for a fax server and it's potential difficulty. Unless you're looking for something specific, it shouldn't be too tough to set up.

Although we have local printers in each exam room, we also have 2 central work horse printers, one of which is a Canon imageRunner 3300. This 33 ppm work group printer also serves as a central fax send/recieve hub, recirculating copier, scanner and e-document filing cabinet with a 20 GB hard drive. Sure it's worth $14K, but it paid itself off in < 3 years in a 6 doc office (check out the business case for improved document handling including e-documents, staff productivity and much much lower consumables costs). Anyway, it is not only a fax server, but is a copier server and print server. You can load up to 20 GB of documents to do what you like with. I frequently send letters out via the fax server. I compose at which ever workstation, including from remote laptop, and send the print job or fax job via the clinic network to the Canon and the job gets processed. In fact, I often check the job logs remotely to ensure that certain documents are either printed or faxed.

Less costly investments are available, including a smaller but still work group capable machine, or a fax app on your server may serve the same purpose.

Check it out.

Norm

[Dr. Mark Dermer]

Our group of 10 family physicians working as an Ontario Family Health Network (blended payment, the majority of which is capitation) in Ottawa has used Healthcare Software's EMR system since 2002. Our system has 28 stations, laser printers in each exam room and one dedicated scanning system in our former file room.

I have written and presented extensively on the implementation and optimization of EMRs, so my views are widely known. However, a few pointers for the questions being asked here:

- Having a hybrid office is inefficient and potentially unsafe, since all processes are done in two different ways. We were hybridized in the early going and the staff hated it. Either find an EMR that everyone likes or break the group into two.

- The "EMR island" phenomenon is the most upsetting part of being in an EMR office. We receive pages and pages of data that was printed from computers at our consultants' offices, diagnostic imaging, labs etc., for which paper seems to be the transmission medium of choice. However, this problem is not going to go away soon.

- Email sounds like a nice idea, but it has two problems: privacy and suitability for the EMR. The former makes it a virtual non-starter unless you have arranged for good encryption. The latter means that although an email will save you the scanning step, it won't save the more significant part of the work, which is identifying the correct electronic chart to which to add the report. Without unique patient identifier codes that can automate the matching of an incoming report to the correct patient, email is not the solution that it first seems.

- We do not fax our prescriptions to pharmacies because we have found that if we fax to them, they fax to us. Faxes must be scanned or moved as paper, which is more onerous than answering the phone and typing a message within the internal system. Furthermore, fax software often has trouble interfacing with EMR programs.

- We scan virtually everything, then shred the incoming paper. We use OCR whenever possible, both to reduce the size and permit searching the text, though we will image scan anything that we cannot OCR (primarily graphic and handwritten reports, but sometimes blurry or weirdly formatted text). We have "sealed" our former paper charts two years aog, which means that we do not add anything further to their contents. For documents that are too long to be worth scanning (psychometric reports etc.) or for consents, we put in a brief entry that notes the date that we received the item, then file BY DATE in an envelope. The result is that we create a 9" x 12" envelope each day that normally has 10-30 pages in it, which means about 500 pages per month of new material tor retain.

- We stopped pulling paper charts for visits about 9 months after converting and now only look at them for insurance or legal reports. We plan to move the "sealed" charts off site this summer and pass on any retrieval fee for getting a paper chart out of storage to the lawyer, insurance company etc.

- We have interfaces for two of the three private labs in our region and have created a handout that directs patients to these sites with a clear explanation of why we want to use them (efficiency, speed and accuracy), and we have found that we have nearly 100% compliance.

- We have a VPN setup that permits us to access our systems from home or on the road, which is a godsend for us as we all work part-time and yet like to manage our own practices.

- Even with the significant cost of labour for scanning, and even with the significant cost of hardware, software and support, we think that the system has been an excellent investment given how much time it has saved the physicians. In addition, our quality of care is enormously increased, primarily due to our rich array of automated reminders that help keep us on top of screening, immunization and disease management.

None of us can imagine ever practicing with paper again.

[John Fernandes]

Installation of an EMR was the biggest mistake of my life. I was savvy enough to simultaneously run a paper office in case things didn't go well. The first vendor's software was simply too slow and cumbersome....the second vendor went out of business...and the third vendor's support was exceedingly poor. Also, the hardware was unreliable and MUCH slower than paper.

The end analysis was that, in my opinion, EMR software is simply too unsophisticated and simplistic to use to in any way increase the efficiency of an office. I have proven exhaustively (with the assistance of a formal business audit) that current EMR's are inefficient and actually decrease office income.

I have gone back to paper with a sigh of relief. Funny thing, considering that I am a retired software programmer and systems analyst. The standards that Docs appear to accept for EMR's are shockingly low....

I believe that this EMR bandwagon is probably for Docs who have their overheads supplemented and so are never bothered by the inherent ineffeciency that EMR's will force them to accept.

The technology is simply not up to the task yet. I believe that things will improve - but this will perhaps require the power of the upcoming "quantum computers"....to make an EMR really work.

[Chin Chung]

I have been on EMR with Healthscreen for the last 14 months. It still involves a lot of work to put in all the data. It's up and running well and I have started to scan in the old files. Hopefully my office will be paperless in another 1 1/2 yrs.