To view this online go to:
BlackBerry users please scroll down for story text.

Advanced Practitioner Conference
Designed to address clinical and business issues

Evaluating, Choosing and Implementing an EMR System
Daniel Strauch, MHA, CMPE

As Nephrology practices plan for the future, the conversations will almost always include a discussion about whether to implement an Electronic Medical Records (EMR) system, unless they already have one. With the upcoming federal incentives via the American Recovery and Reinvestment Act, medical groups are taking a very careful look about taking the plunge and pursuing an EMR system. Here is one group’s experience in evaluating, making a selection, and implementing an EMR system.

Our Nephrology practice, The Center for Kidney Care had discussed the merits and challenges of implementing an EMR system. Several of our nine physicians were in favor of pursuing an EMR system, a couple of the senior physicians were very leery, and the other members of the group were lukewarm. We knew that the practice was not as efficient as we could be, with wasted time looking for patient charts. Our physicians needed to have information at their fingertips, so an EMR system was identified as a solution. We needed to gain a consensus, and decide how to move forward. If we decided to evaluate EMR systems, we needed a process to evaluate the different vendors and make a selection. The next important step would be preparing our practice for implementation.

We evaluated the pros and cons of going to electronic charting. The pros included:

-The practice was spending thousands of dollars every month on transcription of dictated notes. Postponing EMR would retain those costs.
-Pulling, refilling, and searching for charts were inefficient and were hindrances to the staff’s productivity.
-The physicians who wanted EMR were interested in moving ahead and not waiting.
-There was an opportunity to improve the operational efficiency of the practice.
-By utilizing ePrescribing, there was a greater likelihood of fewer medication errors.
-EMR would facilitate a bi-directional interface with reference laboratory companies for faster (and theoretically easier) lab ordering and results.
-EMR would allow for faster claim creation (for office visits) and better cash flow from faster billing.
-EMR would provide greater access to clinical as well as management data and dynamic reporting capabilities.

The cons included:

-Major capital expense
-Time and effort to implement a new system
-Loss of productivity during the initial weeks of using an EMR system
-Difficulty in transitioning to a new way of creating and maintaining patient charts
-Concern that there may be consolidation in the market and we would not want to purchase a system from a vendor who goes out of business
-Risk of system crashes and potential loss of data

Procedure Used to Select the EMR System:

At a meeting of all the owners of the practice (physician shareholders), it was decided to form an IT (Information Technology) Committee and start the process to evaluate EMR systems and ultimately choose one. This was a pivotal point in our practice’s consideration of whether to proceed, and we have not looked back since that day. The following steps were undertaken by our group to evaluate and select an EMR system:

1.The IT Committee included two physicians (champions), the Front Office Manager, the Billing Supervisor, and the Administrator (me).
2.The IT Committee prepared a list of all the attributes that would be desired in an EMR system, including important features of a Practice Management (PM) system and the characteristics we wanted in an EMR company.
3.The IT Committee started collecting a list of all the possible vendors that we knew about, and researched recommended vendors from other local practices, from medical conference exhibitors, and from other resources such as the Renal Physicians Association and the Medical Group Management Association.
4.The Administrator developed a Request for Information (RFI) and the IT Committee reviewed and finalized the document that would be sent to the various EMR vendors.
5.The IT Committee narrowed the list of vendors to 16, by eliminating smaller companies and ones where we had heard negative comments.
6.The RFI was sent to all 16 EMR vendors and the responses were reviewed and evaluated by the IT Committee.
7.The IT Committee rated the responses and the top four were invited to provide a live onsite demonstration.
8.The top two systems were evaluated extensively, including reference checks, site visits, internet research, and negotiations of the companies’ proposals.
9.The top two systems were invited to give a final round demonstration to all of the physicians and managers.

All our staff who attended the demonstrations completed an evaluation form that ranked the system on several important measures. We discussed the strengths and weaknesses of the top two EMR systems and we identified a clear favorite.

The EMR vendor that we selected had a user-friendly application that the physicians could understand and navigate. The physicians felt more comfortable with the ease of documenting their office visits. The finalist was slightly less expensive than the number two vendor. The decision was made to implement eClinicalWorks in the Spring of 2009.

Once the decision was made, we let the two finalists know the results. Then we started the implementation phase. Here is the process we followed:

1.The Purchase Agreement was reviewed thoroughly by the Administrator and several items were revised and improved.
2.After signing the Agreement, a Project Manager was assigned by eClinicalWorks (eCW) and weekly telephone meetings were held with the Administrator.
3.The data from the existing practice management system (Medical Manager) was extracted and transferred to eCW.
4.The Front Office Manager, the Clinical Coordinator, and the Administrator attended a week-long “Super User” course in Massachusetts to learn all of the basics of the system and to prepare us to serve as resources for the rest of the staff.
5.The training was scheduled and the “Go Live” date was set. May 1 was selected for the PM system and June 1 for the EMR system. We normally would have opted for two months between “Go Live” dates, but the summer vacation schedules would have made July very difficult.
6.Once the PM system was implemented, we started scanning records for patient appointments starting as of June 1.
7.We worked with a hardware vendor to install three servers, replace five PCs that were too old and slow to handle the new system, and purchased tablet PCs for the physicians.
8.We added enough trainer time so that we would have one onsite for the week of EMR “Go Live.”
9.The number of appointment slots was reduced by 50% for the first five half-day office sessions for each of our physicians.
10.We added some temporary part-time staff to help with chart scanning and entering patient problem lists and medications into the EMR system.
11.Starting the week after “Go Live,” we held three “Users Meetings” for our physicians to share their questions, challenges, and solutions with each other.
12.We worked with the two major reference laboratories and have achieved effective bi-directional interfaces with both of them.

After one year using the EMR system here are a few of the lessons we learned:

-The transcription costs have been eliminated, saving slightly more than the costs of the EMR system.
-Having electronic access to charts is far superior to having to find and pull paper records.
-The tablet PCs are fine, but the physicians rarely use the stylus. Regular laptop computers would have been fine, and less expensive.
-We are pleased with the eCW system and the physicians are producing satisfactory clinical notes. The reporting functionality of the system is sometimes difficult, but we are learning to work with it.
-Take the time to make sure the physicians are ready to tackle the challenge of an EMR evaluation and implementation project.
-Include operational, clinical, and billing staff in the evaluation process.
-Invite all the physicians to the final demonstrations and encourage their questions. Make sure everyone completes an evaluation form after the demonstrations to facilitate an objective comparison.
-Anticipate the administrative demands of working with the EMR vendor’s Project Manager. It is more time that would normally be expected.
-Negotiate the fine points of the Purchase Agreement. There are some items that can be adjusted if requested.
-Be willing to add and pay for additional training time, particularly during the “Go Live” week(s).
-The scanning and data entry tasks take longer than most would anticipate, so plan ahead and bring in extra staff as available.
-Use outside resources to get information, find unbiased references, and share experiences, such as the Renal Physicians Association and the Medical Group Management Association.

Daniel Strauch is the Administrator for The Center for Kidney Care in Mt. Laurel, NJ. Mr. Strauch also serves as a member of the RPA Practice Managers Committee. If you would like to contact Dan, he can be reached at or 856-581-2951.


RPA News
CMS Distributes 2008 PQRI Payment Adjustments
Six-month Reporting Period for 2010 PQRI Begins July 1
FTC Delays Enforcement of Red Flags Rule Again; AMA Files Lawsuit

Practice Management
"The 12-Step Way to Reduce Practice Expenses: Part 2, Operational Efficiencies"
"Becoming Clock Wise: How to Get on Time and Stay on Time"
"How to Find Any Attorney Who's Right for You—and Your Practice"
"Data Breach Reports Now Posted Online"
"P4P May 'Divert' Healthcare From Those Who Need it the Most"
"AMA Says Health Plans Should Enforce Rules in New 10-Point 'Code of Conduct'"
"EHRs Improve Patient Contact, Distract Docs: Study"

In the News
"Major Depression Linked to Poor Outcomes in Chronic Kidney Disease"
"Renal Outcomes Linked to LVMI"
"Scientists Find Clues to Kidney Transplant Success"
"Molecular Imaging May Be Best for Capturing Renal Transplant Complications"
"CODHy: Mixed Findings on Vitamin D and Metabolic Syndrome"
"Risk of Cancer Following Hospitalization for Type 2 Diabetes"
"New-Onset Diabetes Linked to Post-Transplant Hypomagnesemia"

RPA News

CMS Distributes 2008 PQRI Payment Adjustments

As a result of AMA advocacy, the Centers for Medicare & Medicaid Services (CMS) created an inquiry process for physicians who believe mistakes were made in calculating their payments under the Physician Quality Reporting Initiative (PQRI). For 2008, CMS received a number of inquiries that identified apparent discrepancies between the estimated physician payment schedule allowed charges reported in the CMS feedback reports and the physician’s own records. Following a careful review, CMS identified inaccuracies in its calculations of total estimated allowed charges that were used to determine the 2008 incentive payments. These inaccuracies involved eligible professionals who submitted claims for reconsideration or claims for which Medicare was a secondary payer, and affected a large portion of program participants who satisfactorily reported in 2008. CMS is in the process of distributing the additional payment adjustments.
Six-month Reporting Period for 2010 PQRI Begins July 1

It is not too late to start participating in the 2010 PQRI program and potentially qualify for incentive payments. The new six-month reporting period begins on July 1 and extends through December 31, 2010. Eligible professionals who satisfactorily report PQRI measures for the 6-month reporting period will become eligible to receive a PQRI incentive payment equal to 2.0 percent of their total Medicare Part B allowed charges for services performed during that time. Those who have not participated in the PQRI program can begin by reporting data using: claims-based reporting of individual measures; claims-based reporting of one measures group; registry-based reporting for individual PQRI measures; or registry-based reporting for a measures group (with a minimum of eight patients). Although there is no requirement to register prior to submitting data, there are some preparatory steps that physicians should take prior to undertaking PQRI reporting. To access the 2010 PQRI Implementation Guide go to

FTC Delays Enforcement of Red Flags Rule Again; AMA Files Lawsuit

On May 28, the Federal Trade Commission (FTC) announced that, for the fifth time, it will again delay enforcement date of the Red Flags Rule—this time through December 31, 2010. The AMA strongly disagrees with the FTC’s view that any physician who does not require payment at the time patients receive medical services is bound to comply with the Red Flags Rule, which requires creditors to develop and implement written identify theft programs. On May 21, the AMA, along with the American Osteopathic Association (AOA) and the Medical Society of the District of Columbia (MSDC) filed a lawsuit in federal court seeking to prevent the FTC from applying the Red Flags Rule to physicians. While we welcome the FTC’s decision to delay enforcement, we urge the Commission to agree with us that physicians are not creditors, and that the Red Flags Rule does not apply to them.

Practice Management

The 12-Step Way to Reduce Practice Expenses: Part 2, Operational Efficiencies
Family Practice Management (06/10) Vol. 17, No. 3, P. 30; Tinsley, Reed

Medical practices can save a lot of money even with small reductions in their operational costs, first by reviewing their office lease and other lease agreements, including maintenance contracts and repair costs. Office supply costs are another area of potential expense reduction, and group purchasing can yield volume-discount prices. The practice should optimize the ordering and handling of supplies, while further operational efficiencies can be realized by scrutinizing the cost-effectiveness of outside services. In addition, the practice should seek ways to economize on postage and telephone costs. The final three steps for lowering practice expenses include assessing the practice's advertising for waste and ineffectiveness; tracking down and removing causes of patient refunds; and tightening controls on petty cash and eliminating problems that incur extra bank charges. The 12-Step Way To Reduce Practice Expenses: Part 1, Staffing Efficiencies can be viewed here.
Web Link - May Require Paid Subscription | Return to Headlines

Becoming Clock Wise: How to Get on Time and Stay on Time
American Medical News (05/17/10) Cook, Bob

Experts say physicians and all members of a practice should be on time and ready to go by the day's first appointment. This includes ensuring that exam rooms are ready, sharps containers are empty, charts are ready, and everyone is aware of who is doing what that day. There should be a discussion about the types of appointments that are scheduled in order to eliminate confusion later in the day. Experts also recommend the pairing of opposite types, such as a fast nurse or assistant with a slow physician. Other ways to eliminate bottlenecks include having patients fill out necessary paperwork prior to coming in for their appointments. Forms can be made available online or mailed to patients. It may also be worthwhile to create one or more full-time-equivalent (FTE) positions solely for check-in; such FTEs should not take phone calls. Another strategy is sending referral requests by fax after a patient has left the office rather than when they wait in an exam room. It may also be useful to schedule appointments for similar types of patients at the same part of the day, use longer group visits for chronic disease care, and use open-access scheduling for part of the day. For instance, the first few hours on Mondays can be reserved for patients who call and come in for problems developed over the weekend on a first-come, first-serve basis.

How to Find Any Attorney Who's Right for You—and Your Practice
Modern Medicine (05/07/10) Krizner, Tricia

There are various issues that physicians may have to contend with when managing their medical practice, and practice management experts recommend cultivating relationships with specialized legal professionals to help navigate these issues. Health Law Center President Neil B. Caesar says that "it's very important to view [the attorney] as a business adviser—perhaps one who filters advice through a legal prism—but an adviser nonetheless." Consultant Michael D. Brown stresses the value of looking for an attorney who is solely focused on healthcare law. Among the resources that healthcare providers can use to find healthcare attorneys are referrals from colleagues, the Internet, speaker lists, bar associations and specialty associations, state attorney's offices, and county and state medical societies. Caesar notes that specific types of issues call for specific specialists. Furthermore, the degree of legal service the practice owner may require may vary according to the size of the practice.

Data Breach Reports Now Posted Online
American Medical News (05/04/10) Dolan, Pamela Lewis

The Department of Health and Human Services (HHS) is now listing healthcare-related breaches on its Web site. Since the organization started this practice in February, there have been 64 incidents reported, affecting more than 1 million people. Theft was the most common cause of a breach and others categories included loss, unauthorized access, hacking, or other causes. Of the 64 breaches, seven involved laptops, 12 involved paper records, eight involved desktop computers, eight involved either hard drives or network servers, and seven involved portable electronic devices. The current report lists by name hospitals and large medical centers that experienced breaches. Private practices are listed as "private practice," with the city and state, but soon will be named.
Web Link - May Require Free Registration | Return to Headlines

P4P May 'Divert' Healthcare From Those Who Need it the Most
Healthcare IT News (05/05/10) Merrill, Molly

A new RAND Corporation study published in "Health Affairs" finds that pay-for-performance programs may increase medical disparities for racial and ethnic minorities and people of low socioeconomic status. The study simulated how a typical pay-for-performance program used in the Medicare demonstration projects that begin in 2007, would affect primary care physician practices in Massachusetts that treated patients enrolled in any of the five largest commercial health plans in the state. The study found that average-sized practices serving the highest proportion of vulnerable populations would receive about $7,100 less annually than other practices. "Paying for performance may have the unintended effect of diverting medical resources away from the communities that need these resources the most," says RAND's Mark Friedberg, the study's lead author. "If you don't watch where the money goes, pay-for-performance programs have the potential to make disparities worse."

AMA Says Health Plans Should Enforce Rules in New 10-Point 'Code of Conduct'
HealthLeaders Media (05/25/10) Clark, Cheryl

The American Medical Association (AMA) released its new Code of Conduct on May 24 that it says all health insurers should enforce. In a few years, the AMA said it intends to publish a scorecard showing which plans follow these rules. With the release of this new code, the physician group has also sent letters to eight specific health insurance companies that it says have not had good track records in the past, including Aetna, Cigna, Coventry Health Care, Health Net, Humana, Health Care Service Corp., UnitedHealth Group Inc, and WellPoint. The AMA developed the code with support from 43 state medical associations and physician groups representing 19 types of specialized care, including the Renal Physicians Association. Provisions in the code include one for Rescission and Cancellation, which says that health plans should not cancel plans for unintended application mistakes, after a "significant delay," or for patients who become injured or severely ill after a policy is issued. The new provisions also say that health plans must cover all emergency treatment services "without regard to prior authorization or the treating physician's or other healthcare provider's contractual relationship with the payer," and that systems must be focused on improving quality rather than reducing cost and must use good relevant data.

EHRs Improve Patient Contact, Distract Docs: Study
Modern Physician (04/10) Conn, Joseph

A new report from the Center for Studying Health System Change and the Commonwealth Fund concludes that electronic health records (EHRs) can have both positive and negative impacts on physician-patient communications. The study - "Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?" - found that an EHR provides quicker access to patient information, giving physicians time to spend with patients that they might otherwise lose searching for information through paper records. However, using an EHR can pose a distraction and possibly lead physicians to rely on them for information gathering “at the expense of real-time communication with patients and other clinicians,” according to the study. Center for Studying Health System Change researcher Ann O'Malley says vendors also need to keep refining their systems to make them less distracting to physicians, and calls on policymakers to "consider incorporating communication-skills training for medical trainees and clinicians" using EHRs.
Web Link - May Require Free Registration | Return to Headlines

In the News

Major Depression Linked to Poor Outcomes in Chronic Kidney Disease
Medscape (06/09/10) Barclay, Laurie

A study seeking to determine whether the presence of a current major depressive episode could be linked with worse outcomes in patients with chronic kidney disease (CKD) who were not receiving dialysis could not definitively say that depression contributed to the poor outcome but did conclude, "Patients with... CKD experience increased rates of hospitalization and death... Depressive disorders are associate with morbidity and mortality." Two hundred and sixty-seven patients were followed for a year and examined for a major depressive episode under the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. A major depressive episode was present in 21 percent of the patients and absent in 79 percent, with 127 composite events, 116 hospitalizations, 38 dialysis initiations and 18 deaths. Patients who had a major depressive episode were more likely to have an event. The study's authors noted, "The presence of an MDE [major depressive episode] was associated with an increased risk of poor outcomes in CKD patients who were not receiving dialysis, independent of comorbidities and kidney disease severity." The findings support the need for further investigation into the safety and efficacy of antidepressant treatments within in the vulnerable population of people living with CKD.

Renal Outcomes Linked to LVMI
Renal and Urology News (06/10/10) Schieszer, John

Researchers at the American Society of Hypertension 25th Annual Scientific Meeting and Exposition report that in men at high risk of cardiovascular events, left ventricular mass index (LVMI) may help better predict renal outcomes, including the need for hemodialysis (HD). Left ventricular hypertrophy is becoming common in patients with renal dysfunction, and a strong association between impaired renal function and adverse cardiovascular events has been documented. The researchers conducted a study conducted at the VA Medical Center in Washington, D.C., retrospectively studying 6,163 men (mean age 68 years) for 14 years. The investigators assessed subjects' left ventricular mass index (LVMI) at baseline and measured kidney function and BP levels at baseline and at the end of the 14-year follow-up period. The study found that each 42 g/m2 increase in LVMI was associated with a 45.7 percent increased risk of a doubling of serum creatinine, a 51.9 percent increased risk of having an estimated glomerular filtration rate below 30 mL/min/1.73 m2, and a 58.3 percent increased risk for needing HD.

Scientists Find Clues to Kidney Transplant Success
Reuters (05/25/10)

A team of European scientists have found a full range of markers in the blood of kidney transplant patients that may predict the success of their new organs and whether it will require large amounts of immunosuppressant medication. This may help doctors provide more personalized care for kidney transplant patients in the future. Led by Maria Hernandez-Fuentes at King's College London, the researchers studied various groups of kidney transplant patients, including 11 who had stopped taking immunosuppressant drugs after the transplant but did not reject the donor organ. Blood tests showed that these 11 patients had unique characteristics to their immune systems that helped them develop a natural "tolerance" for the donor organ. The researchers compared the 11 patients to those who were still taking various amounts of immunosuppressants, including those who were taking the medications but still showed signs of rejecting the donor organ, and a group of healthy controls. Results showed what the team described as a "full set" of markers which made a "tolerance fingerprint" in some patients. Another study corroborated the findings, and both were published in the Journal of Clinical Investigation. Investigators stress that these findings do not indicate that transplant patients should stop taking their medication without consulting their physician.

Molecular Imaging May Be Best for Capturing Renal Transplant Complications (06/07/10)

A recent study suggests that using both physiological and structural images from a single photon emission computed tomography and X-ray computed tomography (SPECT/CT) hybrid imaging can allow clinicians to better diagnose and treat patients with renal-transplant associated complications. Shashi Khandekar, administrator of the nuclear medicine department at Cleveland Clinic, explained, "SPECT and CT fused images provide both functional and anatomical information about the kidney, which provides better diagnostic capability and greater confidence to our physicians." The combined imaging techniques provide a detailed portrait of the biological processes of renal function that can help answer clinical questions previously requiring further imaging, invasive biopsies and delayed treatment. The study involved 10 renal transplant cases, and the high-tech imagining helped clinicians positively identify urinary leaks as well as kidney failure and an infection.

CODHy: Mixed Findings on Vitamin D and Metabolic Syndrome
MedPage Today (05/18/10) Gever, John

A small study has found that vitamin D insufficiency could account for some causes of metabolic syndrome, but a larger study has refuted these findings. In a 92-patient study, researchers found that individuals with relatively severe vitamin D deficiency were at significantly increased risk of metabolic syndrome, while a study of 405 patients found no such relationship. The condition of metabolic syndrome is characterized by a variety of risk factors for both type 2 diabetes and heart disease, including obesity, impaired glucose tolerance, and high blood pressure. The smaller study found that men and women were at higher risk of diabetes, hypertension, ischemic heart disease, and renal insufficiency with serum 25-hydroxyvitamin D (25-OH-D) levels below 16 ng/mL. In the larger study, 46 percent of the 405 subjects were diagnosed with metabolic syndrome, but their mean 25-OH-D level was 24.4 ng/mL, compared with a mean of 21.2 ng/mL in those without the full syndrome. These researchers, however, did not report on the possible relationships between vitamin D and individual components of metabolic syndrome. Both studies were reported at the World Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension.

Risk of Cancer Following Hospitalization for Type 2 Diabetes
The Oncologist (05/17/2010) Hemminki, Kari; Li, Xinjun; Sundquist, Jan; et al.

Patients who are hospitalized for type 2 diabetes are at greater risk of certain cancers, according to a study of more than 125,000 individuals hospitalized with type 2 diabetes in Sweden between 1964 and 2007. Of these patients, 26,641 had an affected family member. A total of 24 cancers showed an elevated risk during follow-up after the last hospitalization, and the greatest risks were found with pancreatic and liver cancers. Other cancers included upper aerodigestive tract, esophageal, colon, rectal, pancreatic, lung, cervical, endometrial, ovarian, and kidney cancers, with a lower risk for prostate cancer. The researchers note that the findings "showed an elevated risk for several cancers after hospitalization for [type 2 diabetes], probably indicating the profound metabolic disturbances of the underlying disease."
Web Link - May Require Paid Subscription | Return to Headlines

New-Onset Diabetes Linked to Post-Transplant Hypomagnesemia
Renal and Urology News (05/02/10)

Hypomagnesemia in the first three months after renal transplant may be a risk factor for rapid new-onset type 2 diabetes (NODAT), researchers suggest. Their study involved 16 renal transplant recipients who were on a triple-drug protocol of mycophenolate sodium, tacrolimus, and prednisone. Three of these patients developed NODAT within the first three months after the transplant. These patients had a mean HbA1c level of 8.1, while the 13 who did not develop NODAT had an HbA1c of 5.1. At three months, the blood magnesium levels were 1.3 mg/dL in the NODAT group, compared to 2.1 mg/dL in the others. The researchers noted that hypomagnesemia is a frequent complication in the early post-transplant period, and it is particularly associated with the use of calcineurin inhibitors. The researchers reported their results at the 2010 American Transplant Congress.

Abstract News © Copyright 2010 INFORMATION, INC.
Powered by Information, Inc.
June 2010
Advertise Here
Save the Data
One 1 week left. Surveys due June 22.
Find or advertise your next job here