Clarity from Chaos

Incremental changes are key to making EHR adoption wireless–and painless–for a Tennessee clinic.

Incremental changes are key to making EHR adoption wireless–and painless–for a Tennessee clinic.

Get Less, Do More
Murfreesboro, Tenn., has relied on Murfreesboro Medical Clinic and SurgiCenter (MMC) for innovative, quality care for more than 50 years. Sixty physicians treat more than 21,000 patients and 400 surgical cases each month, averaging 250 new patients per week. MMC’s campus is 35 miles from Nashville and covers eight acres. Its 120,000 sq. foot building comprises a surgery center with one GI room and two ORs, two to three exam rooms per doctor, and represents a quarter of the medical community in the area.

However, even with such prominence in and loyalty from the community, MMC suffered from shrinking yearly physician profit margins and a corresponding decline in reimbursement. Joey Peay, MMC’s chief executive officer, says Medicare’s annual decrease in payment rates to physicians was the primary culprit, which, he says, is predicated on a formula that incorrectly calculates doctors’ abilities to lower costs.

Regardless, the corresponding reductions in yearly reimbursements continued, while patient visits increased and operating costs rose. “We were facing a proposed 4.5 percent cut in fees,” says Peay. “But at the same time, our staff wanted raises. It’s a fact that if doctors can’t do more with less, their income will get squeezed.” Doctors at MMC were seeing up to 1,200 patients per day and had 30 to 40 FTEs just pulling charts and getting them to the correct locations. According to Peay, 10 to 15 percent of MMC’s staff did nothing but move paper from one place to another. The clinic’s nine-physician leadership board searched for a technology solution that would reduce costs without compromising patient care.

The Learning Process
MMC made the jump to an EHR in 2002. Unfortunately, they implemented a system from a Canadian company that was totally wrong for the group’s culture. MMC physicians enjoy a great deal of autonomy and control over their time and practice. That EHR’s rigidity conflicted with their workflow. It also was not modular and did not support a ramp-up to full usage. It was all or nothing, and required full-template understanding from the outset. This was unacceptable to MMC’s physicians who refused to work with the software. “Just as abruptly as we went into the new technology, we backed out,” admitted Peay. “We had created chaos.”

Out of chaos, however, came clarity. What MMC learned it needed was a more advanced EHR, one that would emulate their current workflow. It also had to be modular, so it could be incrementally rolled out to their 60 physicians.

For example, in the first year, MMC had more than 600,000 lab results come back electronically that previously would have been filed on paper. Radiology reports now go straight to the ordering physician after the radiologist electronically signs it. Before electronic dictation, the process involved “strippers,” whose job it was to take the dictation, which had been manually typed by a transcriptionist onto sticky paper, cut it into strips and paste it into the patient’s chart. The chart would then go to the doctor for review and sign off. This process would take up to two weeks to complete, consume huge quantities of paper and require vast storage.

“When we first went live, one of my older physicians stopped me and said [the EHR] was an inefficient process,” says Peay. “What he was talking about was how many times he had to click on the computer to acknowledge a radiology report coming back. What he didn’t realize was the effort and cost involved with the prior process of getting a paper report generated, getting it to him, getting the chart to him matched up with that particular report and filed and back on the shelf.”

Now, after an MMC radiologist dictates a report into his PDA, he taps the screen and it automatically transmits the file to the transcriptionist, who types it up and electronically returns it to the radiologist for review. Once it’s signed by the radiologist, it goes electronically straight back to the ordering doctor, who acknowledges receipt, reviews it and takes any necessary action. The report is then filed electronically in the patient’s chart. No paper, no hard storage, much less time.

In addition, scripts are electronically transmitted from the point of care to fax servers that automatically fax them to the proper pharmacies. The patient’s prescriptions are already filled and waiting when they arrive. The end result for MMC is a staff reduction of eight FTEs, and fewer nurse hours spent filing and on the phones calling pharmacies.

The health professionals also employ the mobile devices for patient education, using the EHR to help patients better understand their condition. “The tablet PC feels like a patient chart,” said Peay, “so, doctors and nurses use it like a chart, flipping it up, and keeping the keyboard close and accessible. It’s becoming part of their daily routine without the voluminous cost of putting a computer in every exam room.”

Even the most senior physician on staff took to the tablet PC, a doctor who first used a computer only six months earlier. “He went through the training, he carries his tablet around, he dictates into the iPAQ, he’s done just fine,” says Peay. Even technology-savvy doctors learned how convenient having patient records so transportable could be. Peay cited one doctor who recently took his tablet PC with him on vacation. He found a wireless hot spot, completed his reporting tasks at night when the kids went to bed, and returned from vacation caught up and ready to see patients.

Accessibility and Portability Are Key
Instant access to patient information is what MMC doctors appreciate most from their EHR and mobility solutions. “Patient charts are in-hand, dictation time is faster and patient notes come back almost immediately,” states Peay. “Test results are reported electronically, which speeds up physicians’ contact with patients for follow up. It’s a whole new world.” In addition to the EHR application, most physicians use the handhelds as mobile workstations with other applications. They also provide Internet access and e-mail communications.

In the first year since implementation, MMC saved $250,000 by eliminating paper supplies for patient charting and not filling open positions. Less quantifiable savings are equally significant, including the practice’s ability to deploy staff that used to work in paper-based charting to more productive tasks.

MMC also feels real-time access to safety information is critical in providing the best patient care. When the FDA requested that Pfizer suspend sales of a drug (Valdecoxib tablets) in the United States, just weeks after MMC’s EHR went live, MMC electronically examined their entire database and within minutes had a report identifying all their patients on the drug.

“We instantly had access to a report of all patients who were on the drug and were able to quickly notify them about the recall,” said Peay. “In the past, we would never have had any possibility of doing something like that. None whatsoever.” MMC’s health professionals now load the latest medication lists on their tablet PCs or PDAs, keeping their drug information always up-to-date.

Access to real-time patient information, e-prescribing at the point of care and mobile electronic notes dictation are key tools now in use at MMC, made possible by the EHR and mobile solutions. The ability to pull up patient information and answer insurance companies’ questions during patient billing also accelerated reimbursements.

Most importantly, profitability has enjoyed a tremendous boost. MMC’s gross charges are up 7.5 percent (more than $3 million) in just one year, which Peay attributes primarily to the efficiencies gained through the new EHR and the mobility tools.

For more information on HP Tablet PCs and iPAQ Pocket PCs,
www.rsleads.com/602ht-224

For more information on Allscript’s TouchWorks,
www.rsleads.com/602ht-223