I have been working with electronic medical records (EMR) for many years, having first become interested in 1996, when I was looking for a tool to collect data for pediatric sinusitis. As we designed a product to collect this data, our scope expanded into developing a subspecialty-specific EMR. I have since learned a great deal about developing and codifying information and am currently participating in my third and largest implementation of an EMR at Boys Town National Research Hospital in Omaha, Neb. In this column, I would like to discuss what to look for in an EMR and give some initial thoughts on implementation.
EMR vs. EHR
There is often confusion regarding the nomenclature of electronic-based records. In general, EMRs are designed for smaller practices. They may or may not be integrated or interfaced with a billing system. The system is integrated if both the EMR and the billing system operate from the same database. It is interfaced if the system has separate databases for the EMR and billing systems and the two databases "talk" to one another. Electronic health records (EHR), on the other hand, are generally designed for much larger health care systems and usually incorporate multiple specialties and settings. EMRs are more practice centric while EHRs are more patient centric. Ideally, information in a health record database would be available for all facilities and caregivers at the time of the patient encounter. This is a tall order for both systems; however, the EHR is designed more for this type of process.
It is important to understand that implementation begins with the selection process.Most otolaryngologists practice in two to three-person groups. They are usually independent from hospitals and, therefore, have autonomy in selecting the programs they use. If you practice at a larger system, academic or multispecialty, you will likely have little to no input into the selection of the EHR you will use. These larger systems are driven by the needs of primary care physicians, which are quite different than the needs of a surgical subspecialty. You will have to adapt that system and perhaps even create your own knowledge base. The likely advantage, however, is a large IT staff that will help with support and implementation. For these reasons, I am going to focus primarily on the EMR needs of independent otolaryngology groups.
It is important to understand that implementation begins with the selection process.Transitioning Your Practice
The first step is to seriously assess the practice’s physician commitment towards the implementation of an EMR. Unfortunately, implementation of an EMR often leads to dissatisfaction. I have seen several practices split because staff and physicians could not commit to full adoption of the EMR. It is crucial that all physicians in a small practice be completely engaged in the selection and implementation process.
Virtually all practices now utilize an electronic billing system. If the practice is satisfied with its billing system, it may be very difficult to change. One of your first decisions will be to determine if you should keep your current billing system or replace it with an EMR that is integrated with a new billing system. This decision should not be taken lightly. If the EMR already has an interface built to your existing billing system, implementation will be much easier and is a viable option. Interfaced systems can and do work very well. If you work with a beta site, however, there will be many challenges to this implementation. Integrated billing and EMR systems usually perform much better, but the entire staff must be retrained.
The next phase, a very important one, is to examine the otolaryngology knowledge base. Many systems are designed for primary care and lack content for the surgical subspecialties, particularly otolaryngology. Salesmen will spin this as a great opportunity for you to build your own customized knowledge base. Don’t believe it! You will dramatically underestimate the time commitment necessary to create the knowledge base items and then program them into the EMR. Many companies will offer programming services, but they are quite expensive, usually $150-$200 an hour, with no control over efficiency, costs or deadlines. You are much better off selecting an EMR with a more mature otolaryngology knowledge base. Where are you most likely to find these systems? Start looking at EMR companies that are investing their money and time in coming to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) annual meeting. We are a small surgical specialty, and you will find a handful of companies that are committed to our specialty. Regardless of your choice, you will most likely be dissatisfied with the knowledge base; however, you will be able to adjust a system with an existing otolaryngology knowledge base much more easily than a system designed for primary care.
Next, take the time to understand the philosophies regarding how the system is designed. Does it fit your "flow" of thinking? Does it minimize the work of entering data? You will have to take the time to dig into the system in more depth than you can get in a 30-minute demonstration at the AAO-HNS annual meeting exhibit hall. Consider webinars with the company, for example.
Having been on both sides of these discussions, let me make a few suggestions. Let the company’s representative show you how they document information. Look for systems structured around some type of an extended disease-specific SOAP (subjective, objective, assessment, and plan) note. Let them walk you through a typical simple encounter without interruption. On your initial pass, don’t focus so much on the system’s knowledge base, but instead focus on understanding the design and flow of the system, asking yourself questions such as, can you understand it and does it make sense?
In my next column, I will discuss what to look for in documentation tools and how to make the system work for you. Please take the time to contact me with your feedback and suggestions for these columns at rodney.lusk@boystown.org. ENT TODAY
Rodney Lusk, MD, is director of the Boys Town Ear, Nose & Throat Clinic and Cochlear Implant Center at Boys Town National Research Hospital in Omaha, Neb. He has been working with EMRs since 1996.