Achieving Tangible IT Benefits in Small Physician Practices Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: First Consulting Group Authors: Keith MacDonald and Jane Metzger with contributions from Michele Mann September 2002 Acknowledgments First Consulting Group is a leading provider of consulting, technology and outsourcing services for health care, pharmaceutical, and other life sciences organizations in North America and Europe. More informa- tion about FCG is available at www.fcg.com. This report was compiled from interviews with over two-dozen physi- cians and their staff in small practices who are using information tech- nology at the point-of-care today. While these early adopters are not necessarily typical of their thousands of practicing colleagues who are yet to use technology, the benefits they have been able to achieve show that IT tools for the small practice have moved from concept to reality. Many thanks to these physicians for sharing their stories and lessons learned in the hopes of inspiring others (see Appendix B). Several colleagues contributed their time in reviewing this document throughout its development. Bruce Bagley, M.D., Past President of the American Academy of Family Practice, and Michele Mann, Director at First Consulting Group, specializing in ambulatory physician prac- tices and physician networks, both provided their valuable perspectives on the real implementation experiences of physicians using technology at the point of care. We are grateful for their insights. The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. CHCF’s work focuses on informing health policy deci- sions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems. The iHealth Reports series focuses on emerging technology trends and developments and related policy and regulatory issues. Additional copies of this report and other publications can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-CHCF (2423) or visiting us online at www.chcf.org. ISBN 1-932064-07-9 Copyright © 2002 California HealthCare Foundation Contents 5 Executive Summary 7 I. Overview The New Technology Landscape The Time Is Right: Meeting the Challenge 10 II. A Case Study Perspective on IT Use in Small Physician Practices Confirming Patient Appointments Using a Handheld Application to Find Drug Information Using a Web-based Prescription-writing Product Note-writing as a Step on the Road to an EMR Implementing an EMR in a Solo Practice 16 III. Lessons Learned: What the Case Studies Reveal A Specific Problem Was Targeted Some Technologies Can Address Multiple Problems The Physician Was the Principal Catalyst for Change Real Benefits Were Achieved How to Begin Using IT 22 IV. Guide to Finding, Selecting, and Implementing the Right Products A Quick Review of IT Tools Key Considerations Finding a Product Implementation Factors 28 Appendix A: IT Tools and Sample of Vendors 32 Appendix B: Contributors 34 Appendix C: Resources 36 Endnotes Executive Summary UNTIL RECENTLY, THE SUCCESS STORIES OF SMALL physician practices implementing information technology (IT) beyond billing functions have been few and far between. IT products available in the marketplace were mostly designed with larger physician groups in mind, with an associated cost and technological complexity generally not within the reach of the small practice. Those conditions are now beginning to change for a variety of reasons: I Web-based technology and widespread access to the Internet allow vendors to offer remotely hosted applications that simplify the task of managing the technology. I Many vendors now offer IT via the Application Service Provider (ASP) model, which spreads the system costs over time. I The advent of mobile computing devices enables a better fit with the work style of the physician, without huge costs for equipment and wiring. I Some vendors now offer modular, tool-based products, pro- viding more options for adding functionality incrementally. I Many vendors are designing products that make interoper- ability (ability to integrate different systems) and data trans- ferability (from one system to another) less problematic. I Vendors are reconfiguring their products and pricing models to meet the needs and budgets of small practice. How are small physician practices taking advantage of this new IT environment? The research conducted for this report sought to identify the spectrum of IT approaches in use in small practices today and to demonstrate through case studies that physician use of IT can and does produce qualitative and quantitative benefits. Physicians and staff at more than two- dozen small physician practices were interviewed along with vendors and leaders from several national professional organi- zations. These interviews attest to the successes that small physician practices are enjoying with a wide variety of IT tools. Achieving Tangible IT Benefits in Small Physician Practices | 5 A look across these IT success stories reveals common elements: I A specific operational problem that is the tar- get of the IT initiative; I A motivated physician interested in IT leading the charge; and I A vendor product that represents a good fit for addressing the identified problem. The interviewed practices offer lessons from their experiences finding, selecting, implement- ing, and evaluating their IT solutions. Issues of product integration, long-term practice planning, workflow, and budgeting are considered as well. Though few of the interviewed practices under- took a formal return-on-investment analysis before, during, or after IT implementation, physicians and practice staff all shared abundant evidence of the benefits they achieved for the practice and their patients. Some evidence was anecdotal, some was quantified, but every story articulated some measure of success in addressing the problem the practice set out to solve. The case study lessons are augmented in this report by an overview of available products and their general characteristics. Taken together, this report can serve as a mini-guide for the small physician practice eager to find IT solutions for the challenges in their practices. 6 | CALIFORNIA HEALTHCARE FOUNDATION I. Overview “Physicians can’t effectively UNTIL RECENTLY, SMALL PHYSICIAN PRACTICES care for patients nowadays have not been in a position to benefit from the use of informa- tion technology (IT) other than through billing functions. without the help of computers. Cost, workflow, and technology, among other issues, had com- We don’t expect travel agents to bined to create barriers that small practices simply could not memorize hundreds of airline surmount. Vendors concentrated on serving the needs of larger practices, where financial and other resources to support IT flight schedules, and we cer- implementation were more likely to be found. But a number tainly can’t expect physicians of factors have recently changed. to memorize all the available drug options.” The New Technology Landscape —Bruce Bagley, M.D., The technology and product landscape has changed in ways Past President of the American that are creating strong appeal for small practices. Some of the Academy of Family Physicians more significant changes are listed below. I Web-based technology and widespread access to the Internet allow vendors to offer remotely hosted applications that simplify the task of managing the technology. Applications no longer require expensive mainframe computers or high- end PCs. I Many vendors now offer IT to physician practices via the application service provider (ASP) model, which spreads the system costs over time rather than requiring significant up-front investment. I Mobile computing devices fit the work style of the physician, bringing tools to the point of care without necessitating the hardwiring and equipping of every exam room and office with PCs. I Some vendors now offer modular, tool-based products, providing more options for adding functionality incremen- tally. This provides the flexibility for individual practices to work on pressing problems first, then tackle additional challenges later with the same vendor and product suite. Achieving Tangible IT Benefits in Small Physician Practices | 7 I Technological advances in computer network- A New Range of Technical Possibilities ing enable computers in a small practice to With increased use of the Internet, develop- be linked using a wireless network, alleviating ment of wireless technology, and advances in the need for disruptive computer cabling. end-user computing devices, small physician practices have new options for deploying I A new breed of computing devices such as technology in their practices. wireless laptops, flat screen monitors, and handheld devices make physician computing Application Hosting more easily possible in crowded exam rooms • At the physician office and on the run. • At the vendor via the Internet (using an application service provider hosting model) I Many vendors have also been employing generally accepted technology standards in Network Infrastructure their product design, making interoperability • On a fixed Local Area Network (LAN), (the ability to integrate different systems) and using traditional wiring to each computing point data transferability (the ability to move data from one system to another) less of a concern • On a mobile wireless network, using than in earlier days, when systems could rarely radio frequency to transmit data through a centrally located wireless server communicate with each other and a vendor’s demise could leave clients with no way to End-user Devices access or easily transfer their vital information. • Office- and exam-room-based PCs with True industry standards will further help flat panel monitors, touch screens, and improve the situation, but vendors are still CPU (central processing unit) devices that better aligned now than they were five to ten can be hidden or stored centrally years ago. • Wireless laptops and handheld tablet devices With the ability now to deliver more affordable • Handheld Personal Digital Assistants tools to small physician practices, many IT (PDAs) using either Palm- or Windows- vendors who originally targeted large providers based technology are now eager to serve the 35 percent of active physicians in the United States who work in solo or small physician practices. Many have reconfigured their products and pricing models, and new vendors have emerged specifically targeting this practice setting. As a result, the IT options for the small physician practice have markedly expanded in the past few years. Not only have several more affordable multi-function EMR products come onto the market, but there are numerous single-function products available that are relatively inexpensive. 8 | CALIFORNIA HEALTHCARE FOUNDATION The Time Is Right: I Complexities of clinical care. The need for Meeting the Challenge physicians to have comprehensive, up-to-date The opportunities for IT solutions for small information about treatment options and practices could hardly come at a better time. pharmaceuticals as well as immediate access The challenges that face physician practices are to relevant patient information is increasing not trivial and, in fact, may be worsening. Recent due to a number of trends. These include the reports of physicians leaving practice altogether proliferation of medical technologies and treat- and shortages of specialists in some regions of ment options, direct promotion of pharma- the country may represent the disillusionment ceuticals to the public, widespread access to of physicians with the practice environment.1 the Internet, and newly heightened concerns Physicians face a number of marketplace challenges: about patient safety. Yet most small physician practices are disadvantaged by their reliance I Declining revenue. Physician practice revenue on paper-based medical records. has continued to shrink, due largely to declin- I Increased patient expectations. Patients are ing reimbursement by insurers and stricter rules for payment.2 According to an American not sitting quietly on the sidelines: As their College of Physicians-American Society of share of health care costs has increased and Internal Medicine analysis, the average solo the Internet has made access to information general physician practice will lose nearly easier, patients have become more involved in $8,000 in revenue in 2002 from declining the care process, and their expectations for reimbursement—in particular from Medicare.3 shared decision making and better service and results have grown as well. I Administrative burdens. The ever-escalating complexity of documenting care in a largely The information technology implications of paper-based setting creates a huge burden for these marketplace factors are obvious. But to what the small practice. With increased scrutiny extent have small physician practices actually used by the federal government for health care IT to address the challenges they face? Which fraud and abuse and the pressures that man- applications are suited to the small physician aged care continues to apply, physicians must practice in terms of workflow, cost, and techno- provide accurate, detailed documentation of logical factors? How much effort and process care or risk denial of payment and allegations change is required to implement and use these of fraud. A majority of surveyed physicians systems? And, most important, can measurable report dissatisfaction with the amount of time benefits actually be achieved? they spend on administrative duties compared Addressing these questions, this report illustrates with patient care, and 95 percent believe that why and how numerous small practices are turn- managed care has increased the amount of ing to more advanced IT solutions to address administrative paperwork required.4, 5 their practice needs. The physicians and practices featured in this report are necessarily early adopters, but their success in integrating afford- able tools demonstrates what is possible today and may inspire others to follow. Achieving Tangible IT Benefits in Small Physician Practices | 9 II. A Case Study Perspective on IT Use in Small Physician Practices The processes they undertook NEARLY TWO-DOZEN SMALL PHYSICIAN PRACTICES highlight valuable lessons using information technology were interviewed as part of this research report. While there were similarities among the for other physicians considering challenges they were trying to address, each achieved different the use of technology in their results in doing so. The processes they undertook highlight practices. valuable lessons for other physicians considering the use of technology in their practices. The following case studies reflect the range of product types available and the spectrum of results they were able to achieve; they are presented here in their entirety. While the vendor marketplace is evolving rapidly, with new vendors offering products for the small physician practice and others folding, these case studies are indicative of the types of products currently available in the marketplace. Chapter III will discuss what these case studies reveal. Confirming Patient Appointments Case Study 1 Jonathan Nissanoff, M.D. San Diego Advanced Orthopedic Center San Diego, CA Challenge: Save time confirming patient appointments Solution: Automated appointment reminder system from TeleVox Results: Receptionist spends less time confirming appointments, more time helping patients Dr. Jonathan Nissanoff, one of three physicians in an ortho- pedic surgery practice, wanted to find a way to save time and money confirming patient appointments. His practice’s receptionist was spending at least an hour every day placing calls to patients—time that otherwise might have been spent supporting patient care activities. He was introduced to a tele- phone messaging vendor at a professional academy meeting several years ago and decided to purchase their application. The system-generated reminder calls are automatically placed to patients each evening. 10 | CALIFORNIA HEALTHCARE FOUNDATION The initial purchase cost him about $5,500 product included: portability, reliability of infor- (which he paid in a lump sum) and took less mation, and cost. He discovered this particular than a day to install. The vendor created a product through a drug representative. Because “bridge” or interface from the practice’s appoint- the purchase cost for the application was so ment system so that upcoming appointments reasonable, he had no need to develop a formal could be queued up for calling. The vendor’s on business case or undertake a return-on-investment site support person spent time training staff and analysis to justify its purchase. reviewing the initial message quality. Now, once the current appointment information is copied over to the reminder system each day (a 5- to 10- The cost was so reasonable, he had no need minute exercise), the system-generated reminder to develop a return-on-investment analysis. calls are automatically placed to patients each evening. When the practice recently moved, they Implementation was easy: He simply logged even included their new address and directions in onto the Web to purchase the product, register their reminder messages. They’re also considering as a new user, and download the application implementing a feature that allows them to to the Handspring device that he already owned. remind patients to call and schedule their follow- Because the application is designed as a simple, up appointments. intuitive reference tool for physicians to use In Dr. Nissanoff’s opinion, the time he has saved during a patient visit, he could begin using it in staff costs has quickly paid for the system. immediately with no advance planning or train- ing and didn’t need to involve any of his office support staff. Using a Handheld Application to Find Drug Information While the benefits of his using the application were not huge or necessarily quantitative6, Case Study 2 Dr. Murphy believes that his use of the tool Andrew Murphy, M.D. improved his work in at least two ways: Asthma Allergy & Immunology of Chester County, West Chester, PA I Patient visits became more streamlined and “probably quicker in the long run” because he Challenge: Improve access to up-to-date drug was able to access more focused drug dosing information and cost information; and Solution: Handheld electronic drug reference from ePocrates I The quality of the care he delivers has Results: More streamlined patient visits improved through the drug interaction infor- mation he can now more easily access. Dr. Andrew Murphy is one of two physicians in And while he couldn’t say that he saved money an allergy and immunology practice. He began or increased his productivity, Dr. Murphy did using a handheld electronic drug reference recommend that other physicians try such an application, ePocrates, a year or so ago because application as an easy way to improve their the hard-copy PDR “was a pain to use” and he work lives. needed quick and easy access to current drug information. His key criteria for selecting a Achieving Tangible IT Benefits in Small Physician Practices | 11 Using a Web-based Dr. Rice’s biggest hurdle in implementing the Prescription-writing Product product did not involve the product itself but rather installation of the PC hardware and Case Study 3 high-speed (“DSL”) network connection. He Reginald Rice, M.D. identified a local PC consultant to complete this Placerville, CA installation; the process took six weeks, due large- Challenge: Improve prescription-writing process ly to installing the network connection. Using Solution: Electronic prescription writer from the application itself simply required his having Axolotl access to the Internet and signing up for the Results: Improved quality of care and legi- product through the vendor’s Web site. He also bility of prescriptions chose to electronically download his patients’ demographic information from his practice man- A solo family practitioner since 1992, Dr. Reginald agement system into the new product, which Rice has always been interested in electronic cost an additional several hundred dollars. His medical records (EMRs). In off-site meetings and total costs were under $3,000. retreats with his hospital colleagues as a senior The result: Dr. Rice was easily able to incorpo- staff physician, Dr. Rice would discuss the rate use of the product into his practice workflow possibility of implementing an EMR but “there from day one with little training and preparation. were no really good products” out there. And While writing prescriptions now takes him a bit when he was ready to buy a product, the price longer than it did by hand, he touts the drug tag was too high. alerts, prompts, and dosing information as very helpful—especially as an older physician. He can Prescriptions are now faxed directly to the access the application on a Palm device in the exam room with the patient or from a PC at his pharmacy, which patients appreciate. nursing station. Multiple medication refills are handled more easily and prescriptions are now As an alternative to the EMR, Dr. Rice began faxed directly to the pharmacy, which patients to consider addressing one critical element of his appreciate. And because the product “takes office visits—the pharmacy component. Drug prescription legibility out of the equation” he has information was “growing in leaps and bounds,” no doubt that he’s improving the quality of his he said, and it was becoming more difficult to patient care as well. While there were no tangible keep track of medication management issues. benefits to his use of the product, Dr. Rice He had met a physician involved in early devel- reports, “I’m using it for the value it provides” in opment work at Axolotl, liked their prescription accessing drug information and refilling medi- writer product, and decided to use it. cations more easily. 12 | CALIFORNIA HEALTHCARE FOUNDATION Note-writing as a Step on the Dr. Howard Landa was familiar with such Road to an EMR problems. Over the course of his career, he had witnessed practices using handwritten notes, Case Study 4 typewriters, and transcriptionists to document Irene McAleer, M.D. patient visits. He set out with a goal to improve Pediatric Urological Associates his own visit notes—making patient information San Diego, CA clearer and easier to access—and to save money Challenge: Reduce transcription costs for his seven-physician practice. He became Solution: Web-based notes writer from acquainted with the MedicaLogic Encounter MedicaLogic product through his work at a neighboring Results: Nearly eliminated reliance on medical center. transcription along with the associated costs He downloaded the product and trained Case Study 5 himself to use it over the course of a weekend. Howard Landa, M.D. Loma Linda Urology Implementation was relatively easy for both Loma Linda, CA physicians. Because this product was affordable Challenge: Improve access to patient data and and “we didn’t have to re-do the whole office,” cost savings Dr. McAleer says the practice was readily able to Solution: Web-based notes writer from implement it in less than a month after register- MedicaLogic ing it, downloading it off the Web, and getting it Results: Improved legibility of record, better set up. Similarly, Dr. Landa downloaded the access to patient information, and product and trained himself to use it over the minimal use of transcription course of a weekend, then started using it within a day. After moving his current visit templates Not all practices have the resources to implement into the product, he started using it first with an EMR; some have found value in taking incre- simple patient cases, then migrated to those that mental steps. were more complicated. It ultimately took Dr. McAleer about a month to get “up to speed,” Dr. Irene McAleer found that using transcription comfortably using the product and its encounter was expensive for her—plus there were errors, templates to create her patient notes electroni- rework, and delays. She had a colleague who was cally between patient visits. “really into IT,” and this inspired her to inquire about solutions while attending an annual profes- sional meeting several years ago. She found the MedicaLogic Encounter product. Achieving Tangible IT Benefits in Small Physician Practices | 13 Each physician cited a number of qualitative Implementing an EMR in a benefits they achieved in using the product: Solo Practice I Referring physicians get clearer consultation Case Study 6 notes much sooner than they did before; Lee Hamilton, M.D. I Encounter notes provide better information Yreka, CA for billing, with more accurate coding; and Challenge: Eliminate paper Solution: Logician EMR from GE Medical I The ability to search aggregate patient data Systems (formerly MedicaLogic) and the overall chart quality for audits has Results: Lower per-visit costs and better improved. patient management Both Dr. McAleer and Dr. Landa achieved measurable results as well: She eliminated $600 Case Study 7 a month in transcription expenses, more than Armand Gonzales, M.D. covering the monthly cost of the product. Riverpoint Pediatrics Likewise, he was able to gradually decrease his Chicago, IL transcription costs from $1,000-$1,200 per month to just $50 per month over a six-month Challenge: Track essential patient information period. In both cases, their practice partners and complete charts have yet to sign on to using IT, but they each Solution: EncounterPRO EMR from JMJ acknowledge that using such a focused product Technologies can make a measurable difference. “Especially for Results: Higher income from improved pro- a small practice,” says Dr. McAleer, “this is a ductivity and office efficiency good program to get started with. Changing the practice routine is difficult, but in the long run, Even solo practicing physicians are now turning my charting is better.” to EMR systems to manage the complex clinical information associated with their patient panels. These physicians have been able to minimize their overhead costs while maintaining or even improving the care and service they provide to their patients. The hardware side of the equation was not a bitter pill to swallow and I recouped that cost in six months. 14 | CALIFORNIA HEALTHCARE FOUNDATION Dr. Lee Hamilton is a solo physician who recent- I’d advise an absolute commitment to an ly restarted his practice in Northern California. EMR as the only way to go to provide good He had worked for five years in clinics, urgent care, and emergency departments, and witnessed care. I don’t think you can justify keeping the complicated paper flow that took place in paper records anymore. these settings. “I wanted to look at a better way to practice medicine,” he stated, “without the While implementation of these systems was not burdens associated with paper charts.” Not only complicated, both physicians had to uncover the could it take up to an hour to find a patient’s resources to make it happen. A self-described medical record in these prior situations, but the computer literate, Dr. Hamilton completed the financial burden associated with maintaining local installation of the computer hardware paper records seemed too great for him. He himself. He chose Dell because of its quality learned that the average family practice physician and customer support. “The hardware side of spends at least $20,000 per year dealing with the the equation was not a bitter pill to swallow,” paper associated with medical records. “I wanted he said, “and I’ve already recouped that part of to provide the best quality care I could while the cost in six months.” With the support reducing the financial burden” of paper records, of his software vendor, the entire implementation he said. After looking at about six products in the was completed within four weeks of signing marketplace and preparing a business plan and the contract. financial model, he selected MedicaLogic’s Logician product. Dr. Gonzales hired a local technician to wire his office with computers before the vendor came Dr. Armand Gonzales had similar challenges. in to complete the software installation and He had taken his practice back from the hospital conduct three to four days of training for himself in 1999 and, as a solo practitioner, did not have and his three full-time employees. Both physi- the resources to effectively keep track of all the cians currently pay a monthly license fee to their clinical details for every patient and complete the vendors for maintenance and support. necessary documentation. He’d had some experi- ence with a computerized billing system dating What have they achieved for their investment? back to 1980, but that system “was complicated Dr. Hamilton realizes practice expenses that are and had lots of glitches.” Then, in early 2001, 20 to 30 percent less per visit than he would he selected an EMR product (JMJ Technologies’ have experienced otherwise were it not for his EncounterPRO) at a trade show. With the help EMR. Dr. Gonzales has a different perspective: of his wife (an MBA) and a financial consultant, With his EMR, he is able to see personally the Dr. Gonzales prepared a budget that projected 600 patients per month (and up to 40 per day) his practice income against his expenses—includ- that he and his part-time practice partner were ing three years of monthly payments for the previously seeing together—and his income is up bank loan he would use to purchase the system. over 50 percent. “In this era,” he said, “it’s a mis- He realized that implementing this technology take not to have some kind of EMR and billing could work. system in your practice.” Dr. Hamilton feels similarly: “For new starting practices, I’d advise an absolute commitment to an EMR as the only way to go to provide good care. I don’t think you can justify keeping paper records anymore.” Achieving Tangible IT Benefits in Small Physician Practices | 15 III. Lessons Learned: What the Case Studies Reveal A few physicians saw IT as the WHAT DO THE CASE STUDIES COLLECTED FOR panacea for a whole range of this report and described in the previous chapter reveal about the use of technology in small physician practices? In begin- problems they were experiencing. ning the analysis, it became clear that all the case study experi- ences share four common themes: 1. A specific problem was targeted. Practices interviewed for this report were usually focused on a specific problem when they selected their IT product. While not every practice chose the same challenges to address, they all chose some- thing—and the scope, complexity, and type of problem the practice tackled shaped the characteristics of their solution. 2. Some technologies can address multiple problems. The case study interviews revealed that some products can be used to tackle different problems. Even the easier-to-imple- ment, single-function products demonstrated success in addressing different types of problems that small physician practices face. 3. The physician was the principal catalyst for change. In several cases, a highly motivated, technology-savvy physician drove a definitive process for introducing IT to the practice to solve challenges. In other instances—often where the challenges were less pressing and the staff’s pain less severe— more casual, inquisitive exploration of technology by a prac- tice physician led to the gradual introduction of a new product. 4. Real benefits were achieved. Substantive benefits were achieved using IT to address the challenges facing small physician practices. However, the level of benefit realized was contingent on the complexity of the problem they chose to target and the sophistication of the IT tool they used. Single-function, standalone tools did address some of the focused challenges of some practices, but the benefits were less measurable. This chapter describes these four common characteristics in further detail and how to begin using IT. 16 | CALIFORNIA HEALTHCARE FOUNDATION A Specific Problem Was Targeted “If I had to do it all over again, I’d first The types of problems addressed varied by prac- identify the problems I wanted to solve, tice; some were narrowly focused while others then undertake the analysis to determine were expressed more broadly. The complexity of the problem that each practice chose to tackle the potential benefits.” depended on the level of frustration experienced —A urologist in a seven-physician specialty practice and the practice’s tolerance for managing change. Dr. Nissanoff, in Case Study 1, wanted to make Several practices instead chose an EMR product appointment confirmations easier. In Case Study to address the challenges of paperwork. That was 2, Dr. Murphy needed easier access to drug partly Dr. Hamilton’s goal (Case Study 6). In information. Effectively managing paperwork at least one other small physician practice inter- was a bigger problem that led many small physi- viewed for this report, an EMR product accepts cian practices to select and install an IT product. external documents directly via fax, scans patient documents at the practice site, and transmits Many small practices cited the negatives of documents and prescriptions via fax to other paperwork and paper-based charts as their prin- physicians and pharmacies—all while delivering ciple reason for turning to IT. Typical comments other functionality typically found in an EMR. among the doctors interviewed included: “I This physician was willing to invest additional could never get ahead of the paper”; “There was up-front resources to convert his paper records no way for me to keep track of everything and and to adjust his mode of practice to incorporate write my charts…I couldn’t afford to stay in the new technology (see sidebar). paper”; and “We ran out of chart storage space in the office.” In addition, while most physicians cited a spe- cific, focused problem they sought to address, a Practices didn’t necessarily address their challenges few saw IT as the panacea for a whole range of in the same way, however. Differing approaches problems they were experiencing. The physician to the paperwork burden provide examples. restarting his practice in Case Study 6 “wanted One specialty practice used a document imaging to look at the right way to practice medicine” product to convert all its incoming paper-based and saw IT as the way to do that. Another information to electronic form. Another practice physician actually set out to “uncover the ideal employed a Web-based electronic messaging IT solution,” implying that one product might product that delivers clinical information such as solve all of his problems. As the case studies laboratory results, radiology reports, and tran- show, a physician’s interest in technology and the scribed notes that are already in electronic form practice’s tolerance for change are factors in the from outside sources to the physicians’ desktop decision about which IT solution to pursue. for review. The information is stored in the prod- uct’s repository for future access, thereby creating a virtual medical record. While the practice lacks some of the additional capabilities that an EMR product might provide, their current solution measurably reduced the incoming paperwork. Achieving Tangible IT Benefits in Small Physician Practices | 17 Similarly, EMR products are now being used Using an EMR to Tame Paperwork by an increasing number of small physician In an effort to get out from under the mountain practices, though the reasons each practice selects of paperwork he experienced for 22 years in such a product vary widely. Typical challenges practice—and to make laboratory results and that interviewees were attempting to address charts easier to find—Dr. Shashida Acharya, who describes himself as “not very computer- through EMR use included: savvy,” selected the AlteerOffice EMR product I Locating medical record charts; after attending a few conferences and visiting I Quickly accessing relevant patient information; with another physician user. Though he admits that no small effort was required to convert his I Reducing paperwork; and paper records, in doing so he eliminated the I Improving and maximizing visit coding administrative hassles of finding patient charts, (often to address managed care requirements). refilling prescriptions, and following up on test results. The doctor personally saves 1 to 1.5 In Case Study 6, Dr. Hamilton chose an EMR hours at the end of each day, which he uses to to improve access to patient information and complete paperwork. In addition, he no longer pays his staff overtime to stay late. He figures reduce his reliance on paper-based records. that the product (with associated hardware) In Case Study 7, Dr. Gonzales needed to manage paid for itself in two years—one year ahead the increasing number of clinical details in his of schedule. practice and make documentation easier. A phy- sician practice in New Jersey implemented an EMR because the documentation in its patient records was inconsistent—which made finding Some Technologies Can Address relevant clinical information difficult. They also Multiple Problems realized their physicians were not coding patient While nearly all the practices interviewed for visits properly—and that an EMR would give this report applied IT to solve specific challenges, their physicians better real-time tools for coding it became clear that some IT products can solve support than any amount of classroom education multiple problems. For example, one product in how to properly code a visit. Said one solo allows physicians to create structured patient notes physician, “Ninety percent of why I implement- electronically, then subsequently retrieve them ed an EMR was due to managed care coding via the Internet. Two different practices used this requirements and potential fines for over-coding.” same product to address different challenges they Each of these physicians used an EMR to tackle a faced. Case Study 4 describes how Dr. McAleer different problem and achieved different results. was motivated to use IT to reduce her transcrip- tion costs. In Case Study 5, Dr. Landa chose the same product to improve his visit notes—making patient information clearer and easier to access— and to code the encounter more accurately. In the end, like Dr. McAleer, he saved money, too, by gradually reducing his transcription costs over a six-month period. 18 | CALIFORNIA HEALTHCARE FOUNDATION The Physician Was the Principal The selection of an IT product can often be Catalyst for Change driven by the practice’s willingness or ability to It is typically the physician in a small practice— absorb the associated changes. One practice rather than administrator—who is most involved implemented a document imaging solution that in the decision to introduce IT systems into gave them easy access to patient information but the practice7, so it is nearly always those practices didn’t require physicians to type at a keyboard with at least one technology-inclined physician during patient visits and allowed the practice to that are adopting IT. Not surprisingly, the electronically capture and store all the outside level of interest in and experience with IT varies paper it receives each day. In this instance, the among physicians, as does their appetite for need was identified as easy, reliable access to introducing technology that might change the patient information; an important attribute of practice. the solution was minimal involvement of physi- cians in data entry. “I wanted to be able to sleep at night.” If the practice’s appetite for IT is more significant, a mutually beneficial relationship can develop —Physician concerned with potential fines for over-coding, who now uses an EMR between the practice and its vendor. Several physicians commented that their early adoption of a certain product helped the vendor improve In many cases, small practices reached an intoler- that product’s capabilities. In some cases these able level of frustration from a challenge they physicians not only became supportive spokes- faced, then sought out IT to help relieve the people for the product but they enjoyed privi- pain. For other physicians, it didn’t even matter leges such as reduced pricing and a bigger role in that the practice wasn’t explicitly looking to solve product enhancements for being early adopters a particular problem; simply being exposed to or providing pilot sites. Still, it was the physician technology was what got them interested in it. in nearly all cases who was the agent of change Exposure to technology occurs in a number for introducing technology to the practice. of ways. In several cases, the IT product a prac- tice selected was based on the sponsorship or endorsement of an umbrella organization such as an independent physician association (IPA), an affiliated medical center, or a community-based initiative. One urologist interviewed for this report discovered the electronic notes-writing product he uses through the hospital to which he admits patients. Another physician uses a Web- based messaging product that was prevalent in his community. Not uncommonly, physicians in one practice are introduced to a certain product because they know a neighboring physician who uses it. Achieving Tangible IT Benefits in Small Physician Practices | 19 Real Benefits Were Achieved Dr. Murphy (Case Study 2), who uses a hand- All of the small physician practices interviewed held product to improve his access to drug for this report were able to achieve some benefit information, suspects he’s improved the quality by implementing IT. The level of benefit and the of care he delivers. Dr. Rice (Case Study 3) way they measured it varied significantly. Some uses a slightly more advanced IT tool to actually expressed benefits in anecdotal terms; typically, create prescriptions electronically; he appreciates these included: the automated drug warnings and multi-lingual educational printouts he can now provide I Less time was being invested in locating and to patients—but can’t cite tangible cost savings. assembling patient information and producing Other physicians using electronic prescribing clearer documentation; tools have also touted their benefits—even if they I Important details about patients were being are not readily measurable (see sidebar). attended to more reliably and patients were receiving better service and care as a result; I Up-to-date drug information was easier “I’m not sure that it saves me time but to obtain; it does make my notes much better—and I Patient prescriptions were generated more I can treat patients more effectively because efficiently; and I have access to better record-keeping.” I Workflow improved overall. —Physician using EMR product Many practices revealed qualitative results that convinced physicians and managers the invest- On the other hand, a number of small physician ment had been worthwhile. Whether or not they practices were able to describe quantitative results have been able to invest the time to measure they had achieved through implementing IT. the benefits they’ve achieved, they know their Even if they had not initially set out to evaluate practice is better for it. their success, several were able to cite quantifiable benefits. Typically, these included: I A measurable reduction in the amount of “Even though electronic prescribing takes paper received; me longer than writing paper prescriptions, I Recovery of previously lost revenue and/or an we no longer have to pull charts and the increase in the practice’s revenue; prescription is electronically routed so we’re I Increased physician productivity (measured in ultimately saving up to two hours per patients seen per day); physician per day in medical assistant time.” I Reduction of staff FTEs or increased product- ivity and capacity of current staff; and —Physician I Reduced per-visit costs. 20 | CALIFORNIA HEALTHCARE FOUNDATION How to Begin Using IT E-Prescribing As a Solution As the case studies have illustrated, many effec- In his quest to find an IT solution for his solo OB/GYN practice, Dr. Edward Zabrek, the for- tive IT solutions exist for small practices seeking mer IT chairman at a large not-for-profit health to address both specific and broader challenges. system, turned to Allscripts. He knew the The new range of IT products and tools available potential benefits of using a handheld prescrip- and recent advances in Internet-based capabilities tion-writing product, having used a now- have increased the options for these practices, but defunct one in the past, and hasn’t yet found have also made the choices more difficult. How an EMR product he likes. He now has better do physician practices decide where to start? electronic access to information with this more focused product and a better handle on drug allergies, interactions, and formulary decisions. Plus, “patients want physicians who are “I wanted to get rid of the paper chart keeping up with [the latest information],” he but didn’t want to wait ten years for an maintains, “and they feel more confident with the legibility of my prescriptions and my use EMR product that could do that.” of technology.” Although Dr. Zabrek hasn’t —Physician in a specialty physician practice using observed time savings, he says the prescrip- a document scanning and imaging product tion writing tool is time neutral. In considering solutions to existing problems, small physician practices need to consider not In one specialty practice, the director shifted his just the initial level of change they can sustain medical records staff to accomplish other tasks but the practice’s likely long-term level of invest- and was able to increase the number of physi- ment in information technology and the benefits cians in the practice without adding more staff. it may desire at some later time. The practice’s Dr. Hamilton (Case Study 6) lowered his per- vision and future plans do become important. visit expenses using an EMR. In Case Study 7, In cases where physicians’ appetite for investing Dr. Gonzales can see more patients and has in IT and tackling the associated change is initially increased his practice revenue using an EMR. high, practices often pursue robust products like an EMR right from the start. In other cases Sometimes the benefits from using IT represent where the level of pain experienced by the prac- trade-offs among different staff. An EMR might tice is not sufficient to drive the practice to invest make the overall practice more efficient and in robust tools requiring widespread change, ultimately save money, for example, but imple- practices may opt for simpler and seemingly less menting the product might mean physicians disruptive tools—at least to start. Anticipating spend more time completing tasks themselves— future IT needs up-front can be beneficial, how- even though they do so more efficiently than ever, as practices set out to make their initial they did in their previously paper-based practice. investment. “Our practice realized a 15 to 20% increase in overall bottom line revenue after six to nine months.” —COO of a physician practice using EMR product Achieving Tangible IT Benefits in Small Physician Practices | 21 IV. Guide to Finding, Selecting, and Implementing the Right Products “I wanted to use a computer USING THE EXPERIENCES OF PRACTICES INTER- at the point of care without viewed for this report, this chapter reviews the types of tools that are currently available in the vendor marketplace and offers changing my practice style— advice on how to locate, choose, and install them. and [this product] was a wonderful bridge to more A Quick Review of IT Tools advanced capabilities.” A good starting point for understanding the marketplace is —Solo physician using a handheld looking at the tools that are packaged in different ways, since prescription writing product the benefits that can be achieved are related to the type of prod- uct or tools employed. Many of the IT tools for small physician practices are available as either standalone functionality or in combination with others. Some functionality previously available only through the use of an EMR or practice management product can now be purchased separately, giving the small physician practice a num- ber of easier-to-implement options. For example, some of the newer “EMR-lite” products are largely focused on documenting the clinical encounter; similarly, new handheld products focus solely on helping the physician select the right medication or visit code. In addition, some of the more comprehensive multi- tool products like EMRs are now modular, allowing practices to “pick and choose” which capabilities they wish to implement first and adding more functionality as the practice’s level of com- fort with technology grows and additional benefits are desired. The IT tools and products now available can be categorized as financially focused, clinically focused, and patient focused. Financially Focused Tools While many practices already have some form of IT to support their financial practice management functions, new options have emerged. Charge capture and coding assistance have been brought closer to the physician through the use of handheld devices that increase the accurate and complete capture of visit information. New practice management systems offer Web- hosted solutions that decrease the up-front purchase costs and minimize ongoing IT management issues. Though not reviewed for this report, a number of vendors now offer online capabilities for conducting key payer-based transactions such as member eligibility, referral/authorization, and claims submission. 22 | CALIFORNIA HEALTHCARE FOUNDATION Clinically Focused Tools Patient Focused Tools Traditional EMR products in the marketplace— As patients increase their involvement in their typically offering a wide range of integrated care, small physician practices may want to clinical and decision support tools—have been employ tools that help manage patient flow and joined by simpler, more affordable EMR prod- meet their patients’ expectations. Telephone man- ucts that provide basic functions such as prescrip- agement systems for small businesses—including tion writing, problem list management, and physician practices—can more efficiently triage notes writing. Some are also available in a Web- and direct incoming telephone calls. Some hosted environment, bringing them more into vendors are offering new ways to telephonically reach for smaller practices. Capabilities previously remind patients of upcoming visits or care they found only in EMRs (such as drug reference and might need, as well as mechanisms to facilitate prescription writing) can now be purchased as communication via the Internet between patients standalone functionality for handheld devices at a and their physician practices. Newer Web-based lower cost. While these products may not achieve capabilities for patients requesting appointments the breadth of measurable benefits that a full and prescription refills are just now appearing EMR can, some small physician practices have in the vendor marketplace. Surprisingly, these still found benefits in their use. patient-focused products actually reap financial savings for the small physician practice when they perform routine administrative tasks that “I saw this product as the stepping-stone to would otherwise require support staff time. a more complete EMR.” Table A-1 in Appendix A describes these IT tools —Solo physician using a Web-based product in greater detail. that delivers test results and clinical messages to an electronic in-basket for his review “Patients have commented on how easy it Some Web-based vendors are now offering tran- now is to get their test results, even after- scription and visit documentation capabilities hours or when they’re traveling.” that can replace, or at least support transition to, —Manager of a two-physician practice using a tele- the use of an EMR. Document scanning, for phone messaging and reminder system example, has been shown to achieve some of the benefits of a full EMR without the requirement that physicians themselves enter fully structured documentation. Furthermore, document scan- ning and faxing capabilities built into EMR products can increase office efficiency and reduce the practice’s reliance on paper. And with Web- based capabilities for ordering laboratory tests and managing the results, some physicians have been able to more effectively address many of their paperwork and information-tracking needs. Achieving Tangible IT Benefits in Small Physician Practices | 23 Key Considerations The research also showed that complete integration In the case studies collected for this research, of a practice’s different IT tools is not essential practices choosing between single-function and to start; standalone IT tools can provide benefits more comprehensive IT solutions had to consid- to the small physician practice. For example, the er their capacity for investing in IT and the case studies showed that a physician using an associated workflow change or disruption, as well electronic drug reference application on a hand- as their anticipated needs for the future. Their held device can readily implement the product experiences suggested: with very little planning and minimal impact on support staff; however the benefits achieved I Standalone IT tools can produce value to the will markedly improve when the physician uses small physician practice. more sophisticated e-prescribing capabilities— I Implementing a greater number of IT tools— especially when they are integrated with electronic especially those supporting documentation patient records. and physician workflow—requires more plan- When more tools or products are employed, ning and causes more disruption during integration of them becomes essential because implementation than does tackling fewer IT stand-alone tools can’t otherwise take advantage tools or only those that primarily affect sup- of patient information captured and stored port staff and patients. elsewhere, thus requiring duplicate data entry. I However, the more IT tools a small physician The significance of technology integration is that practice implements, the greater the achieved without proper planning, a small physician benefits are likely to be. practice could potentially employ a number of discrete, un-integrated IT tools that don’t com- This last point highlights the importance of municate with each other or with outside entities. considering where the practice would like to be Beyond the inefficiencies and workflow challenges relative to technology and practice improvements this places on the physician, the use of multiple at a point in the future. Even when a practice’s un-integrated IT tools can mean that practice tolerance for change is initially low, selecting a staff must enter basic patient information into product that offers a wider range of capabilities multiple systems, introducing potential errors in will better support its interest in achieving greater the process, causing staff rework, and decreasing benefits later—even if only small modules of overall efficiency in the practice. In addition, that product are implemented at the start. vendor support, training, and system upgrades all become more complex with multiple vendor relationships. When a single electronic source for “Free [technology] may not be worth it if patient information is employed throughout the it takes me more time to use.” practice, rework is diminished and the benefits —Physician achieved increase measurably (see Figure 1). Standalone products offer more capabilities; more advanced IT capabilities are available only with a higher level of product integration—and typically, at higher cost. 24 | CALIFORNIA HEALTHCARE FOUNDATION Figure 1. Continuum of Products and Range of Possibilities Basic Capabilities Moderate Capabilities Advanced Capabilities Standalone Product Moderate Level of Integration High Level of Integration Electronic charge capture: Charge Capture Electronic Electronic charge capture With electronic transmission and Coding coding assistance to payers and/or integration with EMR documentation e-prescribing: Prescription Electronic Standalone e-prescribing With electronic transmission Writing drug reference with alerts to pharmacy and/or integrated with an EMR Documentation Document Voice recognition and Structured documentation scanning transcription as part of an EMR Structured documentation In addition, several of these tools require a higher I Talk to local and national colleagues who may level of integration (with other systems, within have positive experience with a specific vendor. the practice, or with external entities) in order to I Contact national professional organizations. be effective. Electronic transmission of prescrip- The American Academy of Family Physicians tion information, for example, requires the use (AAFP) and the Medical Group Management of a vendor with electronic connections to the Association (MGMA) both offer good key pharmacies that a practice’s patients use. resources on selecting a vendor. (See Appendix While this essential capability is available from C for more details on these organizations.) a few e-prescribing vendors, the integration required to seamlessly transmit and receive I See Table A-2 in Appendix A of this report for laboratory and diagnostic orders and test results a starter listing of vendor products. is available in even fewer IT vendors. I The practices cited two key factors in making their product selection: price and the perceived Finding a Product ease-of-use by physicians. The practices interviewed for this report dis- In several cases, the ultimate decision came closed a number of means by which they found down to the cost of the product. “This particular or selected a vendor partner. product was affordable,” said one solo practice I Check with a larger umbrella organization physician user. Small physician practices may to which the practice may belong (such as an have to select a more narrowly focused vendor Independent Physician Association, or IPA, product over one with richer capabilities— an affiliated hospital or a neighboring medical despite the challenges they wish to address— center). Its sponsorship of an IT product because the price tag for the richer product is may provide a ready-made decision—plus too high. Most vendors with modular products, use of the same product by a larger community however, offer modular pricing. of physicians can be helpful for exchanging information. Achieving Tangible IT Benefits in Small Physician Practices | 25 How each product fits into the practice’s work- Most small practices do not have the resources to flow and its impact on physician users is the undertake a complex financial analysis on their other crucial consideration in selecting a product own. One interviewee did prepare an initial for many practices. How a physician uses a budget with his wife (an MBA) and then hired a particular product to document a patient visit, consultant to compare his projected income with select an appropriate billing code, or obtain the anticipated lease payments. Another physician patient information, can vary considerably in prepared a business plan with a financial model terms of screen layout and flow—and physician at the start of his practice to confirm that he users are generally the best judges of which tools could afford his new EMR system. In any case, they can realistically use. Spending more time an abbreviated financial comparison of the antici- using technology may not pay off for busy physi- pated costs and benefits is probably warranted. cians—even if there are measurable benefits to Below are some key questions to consider in doing so—if a product is difficult for them to use making a quick or preliminary financial analysis. or if the benefits accrue to someone else (such as I Costs. What is the initial cost of the vendor’s support staff or patients). A product’s ability to software product? What will the necessary effectively address the practice’s problems without hardware components cost? What will the detrimentally affecting the physician’s workday ongoing costs be—for both the software vendor is essential. and for any anticipated maintenance or sup- port for the hardware? Implementation Factors I Savings. Are there any anticipated savings that The implementation challenges that the case the product will deliver? studies revealed can be categorized as follows: I Bottom line. Can the practice afford the costs budget planning, financing, and hardware purchase/installation. (see also the next section on Financing) minus the savings in its monthly operating budget? Budget Planning Purchasing and Financing The fact that many of the products available have both lower costs and purchasing options In many of the case studies, the up-front costs for that avoid a big up-front investment makes hardware and software were small enough that it easier to justify investments. In fact most prac- the practice was able to complete the purchase tices interviewed for this report did not under- outright. In other instances, the purchase price take a formal return-on-investment analysis was partially or fully funded by a third party such before buying their product. as a pharmaceutical company, a hospital or deliv- ery network, or the vendor itself. Practices should also investigate funding through grants (such as the Tides Foundation) or health plans (who may sponsor products for disease management). 26 | CALIFORNIA HEALTHCARE FOUNDATION In several cases (particularly for EMR products), The installation process has its own challenges. practices interviewed for this report needed to While the most IT-savvy physicians interviewed undertake alternative means for financing the up- for this report were able to complete the installa- front purchase of either the software, the com- tion on their own, this is not always the case. puter hardware, or both. They used a number of The practice representatives interviewed for this financing methods: report suggested several resources for help in I A lease buy-back program with the vendor installing computer hardware and network con- (typically of three years’ duration); nections: I A bank loan with the practice as collateral I A few IT vendors will assist their clients (also typically over three years); or with some of the basic hardware installation I Tapping into the practice’s revolving line of (though most will not). credit at their bank. I Most local computer retailers have their own These practices simply incorporated the regular IT contractors who can assist customers with lease or loan payments into their monthly hardware and network installations. operating expenses. In at least one case, savings I Some practices have ready access to a local from the use of the product helped pay off “computer guru” who may have installed their the loan earlier than projected. original hardware and/or network and is avail- able for ongoing maintenance and support. Hardware Procurement and Installation Ask about local resources at nearby practices With continued competition among PC manu- that already have IT. facturers and decreasing costs of computing power, small physician practices have a number Finally, several of the IT products for the small of options for purchasing or leasing hardware. physician practice require high-speed access to The IT software vendor typically makes the Internet. If that is the case—as it was for recommendations for the computer equipment several of the case study settings—practices can that will be required. Small physician practices look to a local Internet service provider (ISP) can then turn to several sources to purchase or their local telephone or cable operator; many the hardware: of these are now offering DSL or broadband access to the Internet, particularly in urban and I A local computer retailer (like CompUSA); high-population suburban areas. I An online or catalog computer distributor (like MicroCenter); or I PC manufacturers themselves (like Compaq, Installing an EMR “is not painless. It Dell, or Gateway—all of which have online requires extra time; you need to plan the sales). project and then lighten your schedule.” PC equipment—like the software itself—can —Physician in a four-provider practice using PMSI’s also be leased rather than purchased outright. Practice Partner product AMEX Financing, City Capital, and GM Leasing were cited by one practice administrator as leasing organizations that finance health care equipment purchases. Achieving Tangible IT Benefits in Small Physician Practices | 27 Appendix A: IT Tools and Sample of Vendors IT Tools Available Axolotl: Elysium, Private Patient Portal Table A-1 reviews the array of IT tools currently www.axolotl.com, (800) 461-7724 available in the marketplace to the small physi- Berdy Medical Systems: SmartClinic® cian practice. They have been categorized as www.berdymedical.com, (800) 66-BERDY financially focused (related to reimbursement), clinically focused (related to patient care), or ePhysician: ePhysician Practice patient focused (related to patient communica- www.ephysician.com, (650) 314-2000 tion or support). The table also describes ePocrates: ePocratesRx, ePocratesRx Formulary how these tools can be used by small physician www.epocrates.com, (650) 592-7900 practices to address the challenges they face. GE Medical Systems Information Technology (formerly MedicaLogic): Logician Sample of IT Vendors www.gemedicalsystems.com, (800) 322-5538 Table A-2 displays specific IT products available Healinx: Healinx from some vendors. The list below is not an www.healinx.com, (510) 654-6181 attempt to identify all of the vendors offering IT products for the small physician practice market InfoMedx: iRetrieve or to endorse any particular vendor products www.infomedx.com, (206) 528-2003 (though the listing only includes vendors who JMJ Technologies: EncounterPRO have implemented their products in small physi- www.jmjtech.com, (800) 677-5653 cian practices). Instead, this represents a sample of the vendors uncovered and contacted for this MDEverywhere: ClearCoder report, and can serve as a useful starting point in www.MDEverywhere.com, (919) 484-9002 thinking about available products. Information MediNotes: Charting Plus was obtained directly from vendors and was www.medinotes.com, (877) 633-6683 believed to be accurate as of early spring 2002, but purchasers should undertake their own thor- Perfect Practice: Practice Manager MD ough investigation of each company and its www.perfectpractice.md, (800) 825-0224 products’ capabilities, affordability, and fit with Physician Micro Systems Inc.: Practice Partner practice goals and resources. Keep in mind www.pmsi.com, (800) 770-PMSI that the vendor marketplace is evolving rapidly. Each vendor has a different history, business SmartTalk: SmartReminder, LabTalk, model, and track record in the small physician SmartHealth, SmartSurvey marketplace, and vendors often introduce and www.smarttalk.com, (888) 415-9001 discontinue products with little notice. TeleVox: HouseCalls, LabCalls Allscripts Healthcare Solutions: TouchWorks ™ www.televox.com, (800) 644-4266 www.allscripts.com, (800) 654-0889 Webley Systems: Alteer: Alteer Office CommuniKate Virtual Assistant www.alteer.com, (949) 789-0500 www.Webley.com, (888) 444-6400 Amicore: Amicore Clinical Management www.amicore.com 28 | CALIFORNIA HEALTHCARE FOUNDATION Declining Revenue Increased Patient of Clinical Care Complexities Involvement Challenges Paperwork Table A-1. Types of IT Tools Currently Available in the Vendor Marketplace for Small Physician Practices IT Tool Brief Description Use Challenges Addressed Financially Focused Coding assistance Reference or advice for accurately Used by physician as reference x coding the patient visit while coding patient visit, or tool actively guides physician towards appropriate visit code Electronic charge Electronic means for recording the Used by physician/clinician x x capture appropriate level of service (E&M code) during or at the completion and other activities performed during of the patient visit the patient visit (CPT codes); can be standalone capability or integrated with the process for documenting the clinical visit itself Electronic payer Electronic capabilities for transmitting Behind-the-scenes capability x x connectivity claims-level information from patient often provided by the Practice visits directly to insurers Management System Clinically Focused Electronic documentation Transcription Employed by a growing number of off- Used behind-the-scenes by x and voice recognition site IT vendors to translate large bodies vendors supporting physician of spoken dictation about the patient documentation visit into unstructured, printable text Document scanning Electronic scanning and cataloging Used by medical records/ x and imaging of a written or printed image for future clerical staff to scan paper- viewing on a PC; can be information based information for the internal or external to the practice patient record Electronic Tools for capturing discrete, structured Used by physician while x x x documentation data elements from the patient visit documenting patient for easy future research encounter Electronic Electronic means for securely communi- Used by physician office x team messaging cating between physician office staff personnel about patients and related tasks; usually only included in an EMR Test results and reporting: Electronic lab Electronic means for ordering laboratory Used by physicians ordering x order entry and other tests; can include prompts laboratory and other diag- and reminders that guide physician nostic tests ordering decisions; usually only included in an EMR Electronic routing Electronic transmission of laboratory Retrieved by physicians who x of test results tests and other results back to the have ordered laboratory and ordering physician other diagnostic tests Achieving Tangible IT Benefits in Small Physician Practices | 29 Declining Revenue Increased Patient of Clinical Care Complexities Involvement Challenges Paperwork Table A-1. Types of IT Tools Currently Available in the Vendor Marketplace for Small Physician Practices (continued) IT Tool Brief Description Use Challenges Addressed Clinically Focused E-Prescribing: Drug reference Electronic access to drug information Used by prescribing physicians x Drug alerts and Electronic messages that warn physi- Used by prescribing physicians x formulary checking cians of potential drug interactions, side effects, and non-formulary medications Electronic Easy means for electronically generat- Used by prescribing physi- x x prescription refills ing a refill for a patient with a past cians; often initiated by office prescription support staff Electronic Electronic transmission of prescription Behind-the-scenes capability x x transmission information directly from the applica- provided by e-prescribing tion to a pharmacy, oftentimes by fax and EMR applications Clinical decision support: Point-of-care Electronic messages that guide physi- Used by physicians at the x decision support tools cians in making decisions about patient point of care treatment Patient Registry and Tools for tracking patients in certain Used by physicians either x outreach reports disease categories and monitoring their at the point of care or retro- treatment spectively Practice analysis and Tools for analyzing and understand- Used by physicians and x x reporting tools ing how clinical services are used by a practice managers practice’s patient panel Electronic Medical Can be a combination of any of the Used by physicians and office x x x Record (EMR) above clinically focused IT tools staff at the point of care Patient Focused Incoming call routing Electronic triage of incoming telephone Installed and managed by x and management calls that directs patient to best options; practice manager or lead can be personalized by practice staff person Telephone-based Telephonic means to automatically Installed and managed by x x patient appointment notify patients of upcoming appoint- practice manager or lead staff reminders ments; can also be used for announce- person ments such as a practice’s new location Automated delivery Notification to patients of test results Managed by practice manager x x x of test results via secure telephone message box or lead staff person under direction of physician(s) Telephone-based Telephonic means to automatically Managed by practice manager x x x patient reminders for notify patients of the need for required or lead staff person under health maintenance follow-up (such as pap smears, mam- direction of physician(s) mograms, or immunizations) Electronic patient Secure electronic means for physicians Used by physicians and x x messaging and patients to communicate asyn- office staff chronously; also provides documented record of communication Source: First Consulting Group 30 | CALIFORNIA HEALTHCARE FOUNDATION Practice EMR and “EMR-Lite” Management (including those with practice management/coding Telephone & & Coding and e-prescribing functionality) E-Prescribing Patient Messaging Berdy Medical Systems Table A-2. Representative GE Medical Systems Sample of IT Vendors for the JMJ Technologies Webley Systems Perfect Practice Small Physician Practice MDEverywhere MediNotes ePhysician SmartTalk ePocrates InfoMedX Allscripts Amicore TeleVox Healinx Axolotl Alteer PMSI Web-based ASP x x x x x x x x x x x x x x x Handheld devices x x x x x x * x x x x Financially Focused Coding assistance x x x x x x x x Electronic charge capture x x x x x x x x x x Electronic payer connectivity x x x x x x Clinically Focused Electronic documentation: Transcription and voice recognition x x x x x x x x x Document scanning and imaging x x x x * x x x x Electronic documentation x x x x x x x x x x x Electronic team messaging x x x x x x x x x x Test results and reporting: Electronic lab order entry x x x x † x x x Electronic routing of test results x x x x x x x x x E-Prescribing: Drug reference x x x x x x x x x x Drug alerts and formulary checking x x x x x x x x x Electronic prescription refills x x x x x x x x x Electronic transmission x x x x x x x x Clinical decision support: Point-of-care decision support tools x x x x x x x x Patient Registry and outreach reports x x † x x Practice analysis and reporting tools x x x x x x x x x x Electronic Medical Record (EMR) x x x x x x x x x Patient Focused Incoming call routing and management x x Telephone-based patient appointment reminders x x Automated telephonic delivery of test results x x Telephone-based patient reminders for health maintenance x x Electronic patient messaging x x x x Source: Information compiled by First Consulting Group as provided by vendors. * Via solution partner. † Scheduled for release June 2002. Achieving Tangible IT Benefits in Small Physician Practices | 31 Appendix B: Contributors A large number of individuals graciously con- L.Gordon Moore, M.D. tributed their time to share with us their experi- Ideal Health of Brighton ences using information technology in the small Robert Morrow, M.D. physician practice. We appreciate their insight and wisdom. Andrew Murphy, M.D. Asthma Allergy and Clinical Immunology Small Physician Practices Jonathan Nissanoff, M.D. San Diego Advanced Orthopedic Center Shashidhar Acharya, M.D. Acharya & Sharma Medical Group Ralph Pasqualy, M.D., Director Swedish Sleep Medicine Institute Roy L. Bishop, M.D., CEO Argyll Medical Gregory Pecchia, M.D. Family Practice Physicians Inc. Tom Carli, Clinic Administrator Spokane Internal Medicine Reginald Rice, M.D. Dan Diamond, M.D. Stephen Sherer, M.D. The Doctor’s Clinic Karen Soderstrom Jeff Diliddo Valley Associated Urology Hart Associates Eric Sohn, M.D. Cindy Dixon Indian Trail Family Medicine San Diego Advanced Orthopedic Center Karen Thompson Armand Gonzales, M.D. Gordon Binder Vision Institute Riverpoint Pediatrics Robert Weber, M.D. Lee Hamilton, M.D. Family Doctors Robert Keet, M.D. Sylvia Wessinger, Medical Technologist Western Medical Associates Office of Dr. Markowitz Howard Landa, M.D. Edward Zabrek, M.D., FACOG Loma Linda Urology Medical Editor, Pocket PC Magazine John Masiello, COO Bergen Medical Alliance Irene McAleer, M.D. Pediatric Urological Associates 32 | CALIFORNIA HEALTHCARE FOUNDATION Industry Professionals Bruce Kleaveland, Sr. VP Sales & Marketing Bruce Bagley, M.D., Past President PMSI American Academy of Family Physicians Dan Michelson, VP of Marketing Scott Jauch, Practice Management Associate Allscripts Healthcare Solutions American College of Physicians-American Nicole Miller, Director of Post Sales Support Society of Internal Medicine (ACP-ASIM) Healinx Robert H. Miller, Ph.D. Heather Monast Associate Professor of Health Economics in M.D.Everywhere Residence, Institute for Health & Aging, Mark Nass, CEO University of California San Francisco SmartTalk Tom Sullivan, Vice President Catherine Pompei, Business Manager Massachusetts Medical Society GE Medical Systems Information Technology Lori Poston, Director of Marketing Vendors M.D.Everywhere Jack Berdy, M.D., Founder and CEO Berdy Medical Systems Cyndee Privitt, Marketing Director Perfect Practice Carolyn Copenhaver, VP Marketing JMJ Technologies Monte Regier, CEO InfoMedx Malcolm Costello, VP Marketing GE Medical Systems Information Technology Frank Rhie, M.D., CMO Alteer Jon D’Angelica, Director, Marketing ePhysician Scott Riedel, Marketing Manager MediNotes Reese Gomez, VP Marketing/ Product Management Nicole Roth, Marketing Manager Amicore Axolotl Chad Greer, Director of Medical Sales Walter Sujansky, Director, TeleVox Clinical Products Division ePocrates Bob Katter, Sr. VP, Sales and Business Development Christine H. Williams, President Healinx Harland Communications Karen Kelly, Marketing Manager Palm Inc. Achieving Tangible IT Benefits in Small Physician Practices | 33 Appendix C: Resources A number of organizations, societies, and trade Magazines and Trade Journals journals provide good resources for physicians in Advance for Health Information Executives— small practices seeking help with information monthly trade magazine that produces annual technology. survey of computer-based patient record system vendors (www.advanceforhie.com). IT-Focused Organizations Healthcare Informatics—monthly journal American Medical Informatics Association with frequent software comparison guides (AMIA) publishes monthly informatics journal (www.healthcare-informatics.com). with frequent articles on computer-based patient Health Data Management—monthly trade records (www.amia.org). magazine that includes end-of-year resource Computer-based Patient Record Institute guide on information technology vendors (CPRI-HOST) produced a number of early (www.healthdatamanagement.com). resources on computer-based patient records and M.D. Computing—monthly publication sponsors annual award for excellence in imple- endorsed by AMIA, includes annual Directory mentation of a computer-based patient record of Medical Hardware and Software Companies system (www.cpri-host.org). (www.mdcomputing.com). Health Information and Management Systems Society (HIMSS) provides IT professionals a Physician Practice quarterly journal on IT (Journal of Healthcare Management Organizations Information Management) and an annual conference with a large vendor exhibition Medical Group Management Association (www.himss.org). (MGMA)—professional organization for physi- cian practice leaders offering reference books Toward an Electronic Patient Record (TEPR) (including Computerizing Healthcare Information: produces survey of trends and usage of Developing Electronic Patient Information Systems electronic health records plus sponsors an by M. Davis and Information Technology: Tools for annual conference showcasing IT vendors the Medical Practice by E. Magnis) and an annual (www.medrecinst.com). conference with a vendor exhibition focused on physician practices (www.mgma.com). PhysiciansPractice.com—reference articles on IT for the physician practice plus resource listing of selected vendors by product type (www.PhysiciansPractice.com). 34 | CALIFORNIA HEALTHCARE FOUNDATION Professional Organizations Smith, David and Lucy Mancini Newell. “A and Societies Physician’s Perspective: Deploying the EMR,” American Academy of Family Physicians Journal of Healthcare Information Management, (AAFP)—various resources including: vendor Vol. 16, No. 2, spring 2002. survey, vendor requirements, FP Net (online Spitz, Jerold. “Redefining the Internet as a computer information source) and Fam-Med Communication Portal,” Group Practice Journal, listserv (www.aafp.org). January 2002. American Academy of Pediatrics (AAP)— Stevens, Larry. “Doctors Tap the Web to Cure “Special Requirements for Electronic Medical Back-Office Woes,” Internet Week, CMP Media, Record Systems in Pediatrics” (www.aap.org). January 24, 2000. American Medical Association (AMA)—various Terry, Ken. “How the Device in Your Hand Can resources (www.ama-assn.org). Put Money in Your Pocket,” Medical Economics, December 17, 2001. Additional Reading Tetrault, Joanne. “Charting the Progress of Andrew, William F. “A New Dawn for the CPR,” EMRs,” Physicians Practice Digest, November/ Advance for Health Information Executives, December 2001. April 2002. Reece, Richard L. “EMRs Help to Boost Pro- Bazzoli, Fred. “Physicians Pressed to Adopt ductivity” and “Technology Improves Efficiency,” Online Records,” Internet Healthcare Magazine, Urology Practice Options, January 15, 2002. July/August 2001. Cross, MargaretAnn. “Room to Roam,” Tech- nology in Practice, November/December 2001. Janas, John J. and The Coker Group. “Electronic Medical Records: Optimizing Use in the Medical Practice,” 2000. May, Stacy. “A CPR System Can Grow a Practice,” Healthcare Informatics, January 2002. Simmons, Janice. “Handheld Technologies Are Changing the Way Physicians Practice,” Phy- sicians Practice Digest, January/February 2001. Achieving Tangible IT Benefits in Small Physician Practices | 35 Endnotes 1. Kowalczyk, Liz. “Mass. Hit by Shortage 6. In a recent study published in the Journal of of Medical Specialists,” Boston Globe, the American Medical Informatics Association May 24, 2002. (May/June 2002), about 63 percent of sur- veyed physicians and medical students using 2. Medical Economics Continuing Survey, the ePocrates RX handheld drug reference tool September 17, 2001, and the U.S. Bureau of could find drug information in less than Labor Statistics. 10 seconds, while nearly 54 percent of users 3. From the American Medical Association reported that it took more than one minute to Web page (http://www.ama-assn.org/ama/pub/ find drug information using more traditional article/3216-5979.html), April 19, 2002. non-electronic sources. Eighty-three percent of respondents credited the application with 4. “National Survey of Physicians: Doctors’ improving patient care, and nearly half said Opinions About their Profession,” the application had helped prevent at least Kaiser Family Foundation, March 2002. one adverse drug event per week, on average. 5. Ibid. (From iHealthBeat, April 25, 2002) 7. “Technology Usage in Physician Practice Management,” a study by the American Medical Association, 2001, as highlighted in Advance for Health Information Executives, February 2002. 36 | CALIFORNIA HEALTHCARE FOUNDATION