Taking
the Bite out of Medicine
Electronic
clinical information systems hold the promise of increasing efficiency
and decreasing the cost of health care.
By
Rodger P. Pinto, PhD
Taking
the Bite out of Medicine Electronic clinical information systems
hold the promise of increasing efficiency and decreasing the cost
of health care. By Rodger P. Pinto, PhD When Roche Pharmaceuticals
recently recalled one of its hypertension drugs, cardiovascular
practices throughout the country were faced with a dilemma: how
would they identify patients using the drug from among the thousands
of patients they treated and do so in a timely manner? There had
already been 24 deaths related to the drug.
For
the Indianapolis-based Nasser, Smith & Pinkerton (NSP) Cardiology
Group, it meant reviewing 65,000 patient records, says chief operating
officer Stephen A. McAdams, MD. Within 30 minutes, however, the
practice had a list of patients who used the prescription. An electronic
clinical information system (ECIS) enabled NSP to find the patients
quickly--and economically--McAdams says. Looking for patients "the
old way"--having employees scan medical records or doing a mass
mailing--could have cost $20,000 to $100,000 and taken up to 2 years
to complete, he notes.
"We
struggled with whether or not to convert to a clinical information
system. The fact that this system ... may have saved just one of
our patient's lives tells us we made the right decision," McAdams
says.
The
Computer Age
In
today's managed health care environment, there is an increasing
demand to reduce costs and increase efficiency. Electronic medical
record systems (EMRS) seem to hold the promise of helping clinicians
meet this dual goal.
There
is a wealth of information on EMRS. In fact, it is almost impossible
to pick up a journal on clinical medicine, health care informatics,
or practice management nowadays and not find at least one feature
story on the subject. This might lead one to believe the tools and
technologies for developing and implementing these record-management
systems are sophisticated and readily available, but such is far
from the case. Selecting the right system remains a complicated
matter, with numerous issues to consider, including the impact the
system will have on the clinic work flow, system costs, pre-EMRS
clinical preparation, and implementation requirements.1
Perspectives
On Information Systems
There
are basically three major perspectives to consider when choosing
an EMRS: clinical, administrative, and research.
In
the clinical perspective, benefits of implementing a computer
system include greater availability of data; access to more accurate
and timely clinical information; increased patient throughput; reduction
in the clerical duties of medicine (ie, documentation); and improvement
in the quality of patient care through decision support tools such
as alerts, reminders, protocol tracking, and the like.
In
the administrative perspective, EMRS provides better demographics
and insurance plan management, the ability to easily obtain clinical
information for authorization requirements, and claims processing
that improves billing and coding capabilities, leading to fewer
denied claims. Patient tracking, cost accounting, and maximized
reimbursement capabilities are also cited as benefits.
In
the research perspective, EMRS allows one to link outcomes
with actual treatment data. The ability to institute a protocol
for health care providers, track the protocol, and evaluate its
effectiveness is an important component in outcomes analysis. As
more institutions implement EMRS, reporting the quality of treatment
will increasingly become standard operational procedure.
When
considering implementing an EMRS, it is imperative to identify the
dominant perspective and allow it to drive the evaluation and implementation
strategy. Choosing A System There are hundreds of systems to choose
from, including EMRS, computer patient record systems (CPRS), and
ECIS. The following system descriptions are those presented by Mohr2:
-
An
EMRS is an information system that presents a graphical image
of the paper record. These systems deal largely with images
of documents, such as a physician's chart, with some lists that
serve navigational purposes and with basic lists of noncodified
information.
-
A
CPRS includes a clinical data dictionary, standard technology,
standardized codes and reports, and support for various means
of documentation ranging from dictation to self-entry templates,
making it more than an electronic version of the paper medical
record.
-
ECIS
is an enterprisewide application that facilitates system integration
of clinical information, provides access to information to improve
work-flow efficiencies, and allows for the documentation of
clinical encounters.
Any
system you choose must perform the majority of the tasks needed
to run a clinic in order to be fully integrated. For example,
there are several steps to process a simple office visit, including:
- patient scheduling
and registration;
- the office visit;
- data collection;
- messaging;
- ordering;
- diagnosis;
- treatment, planning,
and implementation;
- results reporting;
- documentation;
billing and collection.
A system that is
capable of handling all of the above functions would be most successfully
integrated. Because ECIS is the most comprehensive system (Figure 1),
it will be the focus of the remainder of this article.
Strategic vs
Component Methodology: Pros and Cons
Selecting and implementing
an ECIS requires technological, clinical, practice management, and legal
knowledge.
Practices that use
a strategic methodology usually want to develop standardized
protocols that must be monitored and managed at the point of service.
Being able to track patient flow allows these providers to develop cost
models that more accurately identify their true cost of business. The
ability to get the proper information to the medical personnel who need
it also allows for quicker and better medical decisions. If a strategic
approach is used, ECIS becomes, by default, the dominant enterprise
application.
A component strategy
seeks to solve a single problem--for example, eliminating transcription
to allow for the easy retrieval of archival documents and more efficient
handling of prescription calls or laboratory callbacks.
The chosen methodology--strategic
or component--will drive all decisions in implementing an ECIS. Be forewarned,
however, that the strategic approach is not for the faint of heart.
Cost is considerably greater since you are starting from scratch. Because
the integration of an ECIS can be very complex and costly, many institutions
have opted for the component approach. In the short term, this approach
is cheaper and easier to implement, and provides faster results. Ultimately,
however, it will not produce the same payoff in terms of efficiency
as a strategic approach will. This article approaches ECIS from a strategic
methodology and provides a process to integrate an ECIS into a practice.
Choosing An ECIS
The first step in
selecting an ECIS is assessing how much the conversion will cost and
how long it will take.
To make these determinations,
a baseline study of current computer capabilities and needs must be
conducted. This is usually done by the vendor. This is best accomplished
through a structured site visit. A structured questionnaire can be used
to streamline the process, but there are several goals that can be accomplished
only through a hands-on site visit.
During the site
visit, a technological assessment should be made. This would involve
charting local area networking capability, cabling readiness, availability
of outlets, and the like. The facility's physical layout, desktops,
and radio frequency access points are other issues that should be evaluated.
During the visit, the staff's computer literacy should also be evaluated
with questionnaires or personal interviews. In one site visit, it was
discovered that 76 percent of the clinical staff (physicians, nurses,
and technicians) did not have any personal computer experience. This
meant a basic computer-training strategy was vital to the success of
ECIS implementation.
The second area
to evaluate is the clinical functions performed at the facility. Patient
registration, scheduling, and check- in and checkout are all important
areas to evaluate. Learning about existing problems that compromise
efficiency is very important. During one site evaluation, it was discovered
that it took the staff eight to 12 steps to refill a prescription over
the phone. The average cost of personnel time to refill these prescriptions
was calculated at approximately $8.40 per call. This practice averaged
more than 260 calls a day, representing an average of $47,000 a month--a
huge expense. There are no mechanisms to recoup this cost either, as
prescription refilling is not considered a billable procedure. In this
case, the ECIS was designed to reduce this cost significantly. Instead
of eight to 12 steps, the refilling process has been reduced to two
to four steps. Once all the paper medical records have been converted,
the cost will be approximately $2 a call.
The third area to
evaluate is the medical records department. A thorough knowledge of
how this department functions is vital to the success of any ECIS. Some
typical questions would include:
- How Is Filing
Done?
- What problems
does the staff have in maintaining external paper flow?
- What method will
be chosen to convert the paper charts into an ECIS?
- Will there be
a complete conversion of all information and records? (Paper medical
records conversion, in terms of how much information there is to be
converted or when and if the paper chart can truly be eliminated,
is currently a highly debated issue, for which there does not seem
to be a universal answer.)
- Will an abstract
of the information be entered into the electronic version?
- What is the time
line for completing this project?
Answering these
questions is necessary to estimate the costs of conversion and time
frame for ECIS implementation. Other costs to consider include1:
- Software licenses,
typically sold on a per-workstation basis.
- Hardware, consisting
of individual personal computers for both the office and exam rooms,
central database servers, network hardware, and modems.
- Training and
implementation, which involves preinstallation planning and on-site
training of users.
- Software support,
usually an annual contract typically sold as a percentage of the total
sale.
- Hardware and
network support, which is primarily on-site, or telephone support
for hardware-specific issues and problems.
Typically, costs
of implementing a system range from $15,000 to $30,000 per practitioner.1
The fourth area
to review is the current business office functions. A thorough knowledge
of the strengths and weaknesses of the business office is imperative
as the ECIS will provide all of the billing information (demographics,
insurance, and encounter level of service). Questions to ask might include:
- What problems
is the business office having in getting the proper ICD (International
Classification of Diseases) or CPT (Current Procedural Terminology)
codes?
- What items are
they consistently not capturing properly?
- What is the denial
rate of claims?
Finally, the clinical
encounter process must be reviewed. If a strategic approach is going
to be successful, physicians must use the computer in their assessment
and treatment process. If the provider does not use the computer but,
rather, relegates this task to a nurse or a medical assistant, the ability
to implement and manage protocols becomes relegated to reporting after
the fact whether or not the protocol was followed, making specific cost-analysis
impossible to perform. Again, the administration would be left with
analyzing costs by using some estimated rate such as relative value
units. If an ECIS is to be successful, it is imperative to identify
ways that it can make physicians more efficient in performing their
duties.
Implementing
An ECIS
If an ECIS is going
to be implemented, all future choices must be based on this decision.
Whether an institution will be able to keep the current practice management,
scheduling, or patient registration system will be determined by whether
they are compatible with the ECIS. Providers often have significant
investments in existing systems and, wherever possible, want to preserve
these investments. Doing so, however, presents its own set of costs
as upgrading these systems frequently requires custom-built interfaces.
To ensure the entire system will work properly when the upgrade is implemented,
the interfaces have to be evaluated, usually in a test lab, resulting
in higher maintenance and support costs.
The second level
of integration involves the clinical process. Installing an ECIS allows
a practice to reinvent how it does business. Allowing access to clinical
information and clinical tools to anyone who needs them opens up a wealth
of opportunities. A physician who has access to his/her scheduling book
can instantly schedule a patient's next appointment. Nurses who have
information on a patient's prescription and have refills authorized
can refill prescriptions on the spot following the accepted protocols
of the practice. Pathways or protocols could be inserted that allow
physician assistants or nurse practitioners to be more involved in patient
care, and the physician could have access to evaluate and oversee their
work in "real time." Intranet or Internet browsers could also be attached
to the system, allowing instant access to medical references and patient
information materials. The physician's diagnosis, treatment, documentation,
and billing could all be integrated in a way that is not possible with
existing systems.
Return On Investment
Significant cash
outlay must be evaluated in terms of what the return on investment (ROI)
will be. ROI means, at a minimum, that the system pay for itself over
a predetermined time. It is easy to determine the ROI when you are deciding
whether to sign up for a support maintenance agreement if you have a
history of repairs, breaks, and fixes on the equipment. When entering
an area in its infancy, such as ECIS, however, it is much more difficult.
In addition, there have been only limited attempts to develop a model
based on existing paper records to apply to an ECIS. This is a dangerous
approach as an ECIS is more than just a paper medical record.
One method that
has been offered to develop ROI for an ECIS is the manufacturing model.
Identifying steps in a process, such as those involved in refilling
a prescription, allows the specific tasks and the personnel assigned
to do the tasks to be listed. This, in turn, allows costs-per-job to
be developed.
Selecting A Vendor
Because the ECIS
field is new, many companies are still testing the waters, and many
clinics find that they unwittingly have become the testing ground for
new ECIS software.1 When implementing an ECIS, it is therefore important
to try to find a company with a proven track record. This can be done
by contacting other institutions that have integrated an ECIS, visiting
these institutions, and basically asking a lot of questions.
Also important to
remember is that an ECIS consists of hardware, data communications,
local and wide area networks, and software applications. Finding one
vendor who handles all of these components may be difficult. For small
groups, the application vendor may recommend other vendors to use. Larger
groups may require a consultant to help integrate an ECIS into the existing
information system. One invaluable vendor source is the HCP Directory
(see box, below). When comparing prices among vendors, one must make
sure each vendor is offering comparable features.1
Conclusion
We are at the beginning
of the information age of medicine, and ECIS are of intense interest.
Over the next several years, there will be a wealth of component and
strategic approaches to ECIS development. When choosing a system, it
is important to take a global approach and consider the needs of clinicians,
administrators, and researchers. It is also important to remember when
you purchase an ECIS, you are not only buying the system, but you are
also buying the company that backs it.1 Keeping these factors in mind
will ensure a selection that meets the dual goals of increasing efficiency
and reducing costs.
Rodger P. Pinto,
PhD, is chief executive officer of Gateway Electronic Medical Management
Systems, LLC, in Indianapolis, and a member of Healthcare Information
and Management Systems Society.
References
1. Ury A. Choosing
the right electronic medical records system. Cost & Quality.
March 1998;4-6.
2. Mohr D. Benefits
of an electronic clinical information system. Healthcare Informatics.
1997;11:49-58.
--
October 1, 1998
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