October 1997 Bulletin

First steps to buying EMR software

Have realistic objectives, solid business case

by Helen Larkin and D. Michael Williams

Helen Larkin is administrator for Watauga Orthopaedics, PLC, an orthopaedic clinic in Johnson City, Tenn. D. Michael Williams, president of Williams Information Engineering, Johnson City, Tenn., has more than 16 years of experience in the development and deployment of business applications. In the spring of 1995, Watauga Orthopaedics and Williams Information Engineering began to develop an electronic medical record (EMR). They have successfully implemented several EMR system components, and are continuing with the development of an EMR, Samaritan™, which is a multiuser client-server application designed to work in a networked environment using wireless pen-pad computers as the primary physician interface.

Are you thinking about purchasing electronic medical record software? Do you expect the electronic medical record to make you more productive and your office staff more efficient? While it's true that it may help, there's no guarantee, especially if you are unclear about your objectives and the benefits you expect to reap. Automating for automation's sake won't always yield a positive return on investment. Before you take a giant leap of faith with your favorite salesperson, develop a solid business case and a clear set of objectives for an electronic medical record.

Here are the first four steps to take to establish a clear set of realistic objectives and develop a solid business case for an electronic medical record.

1. Review and document the current business and clinical processes. This can be accomplished by having your staff list all of the activities they perform, and describe the steps involved in each. Follow this with a few short review sessions during which each activity is discussed and suggestions for improvement are voiced. You will be surprised at what you will learn. You and your staff will find that many tasks are being performed for no real reason at all and many others can be avoided by a simple change in procedure. Remain open-minded about changes in procedure, and you will begin to see opportunities for improvement that previously were hidden.
2. Estimate the current costs of each of the activities being performed, and do your best to aggregate costs to the reasons for the activity as opposed to the activity itself. For example, estimating the cost of chart-pulls is insufficient. You need to examine why charts are being pulled and estimate the cost associated with each reason. This will require a little elbow grease and creative thinking, but will help you focus on those "hidden" business and clinical processes that are costing you the most.
3. Estimate the benefits that can be realized from increases in your productivity and efficiency. Up to this point we have focused on the back-office activities that are being performed to support your practice and how they might be improved. Now it's time to focus on how your individual productivity can be increased. The reality is, in most cases, the greatest benefits that can be realized from an electronic medical record are not due to reductions in operating costs, but to increases in the physician's productivity and efficiency. You should answer the following about your practice.

   What is my average revenue per office visit? This can be calculated by simply dividing your gross revenue by the total number of office visits for the past six months. Assuming that the number of office visits has a reasonable correlation to the number of surgeries you perform, an increase in the number of office visits will result in a proportional increase in revenue.

   With this figure in hand, examine what activities you perform day in and day out, and question how an electronic medical record, or an increase in office staff or a shift in clinical responsibilities might make you more productive, i.e., allow you to see more patients per day. You can quickly calculate the net annual return on investment that you can expect to receive from an increase in productivity by using this simple formula: (additional office visits per day) X (number of clinic days per year) - (annual cost of change) = (annual return on investment).

4. While the preceding three steps focus on decreases in cost or increases in revenue, you also should consider and document what benefits you might expect from improvements in service and improvements in quality of life. While these areas aren't as easily quantified, they are just as important.

   Once you have completed the preceding steps, you are ready to "talk turkey" with the sales people. Ask each potential vendor to visit your site, review your current business and clinical process descriptions and cost estimates, and your ideas on how physician and office productivity and efficiency might be increased. Ask each vendor to respond to your documented results in the form of a proposal which shows how their system might improve each of the business or clinical processes noted. Also, ask them to document other benefits that your practice might expect to accrue by using their system.

   Once the vendors have responded, review their responses and ask those that appear to be contenders to arrange for a demonstration of their system at your site and a visit to one of their installed sites. These steps should provide you with sufficient information to make an informed decision. But here's a few keys points to remember:

   • Be sure to focus on the benefits that each system can provide, not on the bells and whistles. A frequently repeated question at system demonstrations should be, "How will this help our practice be more productive and efficient?"
   • Don't be too concerned about the cost of the system, but instead focus on the net cost, i.e., the annual benefit less the expected cost. While some systems can be "pricey," they can net you much more income than their inexpensive counterparts, thus, cost-benefit is the key.
   • Be sure to consider installation, implementation and ongoing vendor support, including, of course, vendor training. While some good systems are available from some large vendors, without proper implementation and ongoing vendor support, you may just be throwing your money away. Some regional vendors can provide much better ongoing training and support than their national competitors.

Once you have selected the system that best fits your needs it's time to buckle down and learn a few new tricks. Implementation is the process of getting the installed software and hardware up and running and integrated into your current and new business and clinical processes. While training is key, it still requires significant effort on the part of you and your staff to maximize your return on investment. The following few pointers might help.

Implementation must be a planned process that should be taken one step at a time. As you plan for the installation of each segment, think about all the business processes that will be affected. This is the perfect time to eliminate unnecessary processes and to shift responsibilities to more appropriate staff. Solicit the input of those who actually do the work.

Training cannot be emphasized enough. Most physicians' practices employ staff (both clerical and clinical) with a wide variety of educational backgrounds and experiences. Some will be quite knowledgeable about computers. Others may not be so comfortable and will be extremely reluctant to use them. A conversion to electronic medical records means that everyone in the practice must be knowledgeable about using computers.

What is the best way to train? It is best to use a variety of methods. You might purchase training manuals and videos for your staff and physicians to use at scheduled times, or you may want to have training sessions where you close your office and have the lunch catered while the staff listens to project updates and related lectures. Sometimes, it is necessary to hold one-on-one training sessions and other times it is best to send some staff to more intensive, outside training classes. Training should be made mandatory for all staff and physicians. It is important to remember that training is not a one-time task, but an ongoing process. The staff becomes more like the physicians in that regard. They can no longer just "graduate and practice" forever, but must continue to train and learn better ways to do what they do. Attention to training is what makes everyone an expert.

As you work through the implementation process, you will encounter some problems along the way. Obviously, you will have technical and business issues to work out, but you also will encounter other issues. They fall into three related categories: resistance to change, fear of new technology and morale.