EHR User Series: Part I

Over the next several months, the Technology Connection department will house a series of Q&As with EHR users. Each contributor uses a different system and can distill unique insights both about their own EHR as well as the changing field of EHR technology in medicine and dermatology.

Can you describe your experience with purchasing your system and how you settled on it?

We purchased our EMR system—Electronic Medical Assistant (EMA) by Modernizing Medicine—in late 2010 and were only the third customer with the system. Because our system does not have a practice management system, there had to be an HL7 interface built between EMA and our practice management system, which took much longer than anticipated. One advantage of the delay was that we were able to practice with the system for a few months before going live. We decided rather than ease into using it that we would just jump into the deep end, and on June 1, 2011 we switched from templated paper notes to 100 percent use of EMA. Even though we ran a bit behind with our patient schedule in the first week or two, the staff adjusted quickly and we have never looked back! We had a previous EMR system about six years ago that we spent the better part of a year trying to customize to our needs and never could. We abandoned it for paper notes and spent the next few years in search of a better system. Along the way we demoed several EMR systems and were on the verge of being a Beta site for a new dermatology-specific system under development when we had the good fortune to come across an article about Dr. Michael Sherling and Modernizing Medicine. We set up a demo for the next day that blew us away compared to any other system we had demoed in the past. We cancelled our plan to be a Beta site and shortly after signed with Modernizing Medicine to use EMA.

Has your EHR changed how you approach daily tasks or your view of medicine? what are some of the challenges of adjusting to this technology?

For the office as a whole, having an EMR has been great regarding intra-office communication as well as eliminating the daily chart hunt that we had with paper charts. Everything is available wherever you have computer access, which has been nice when you are on call and need to review what another provider may have done for a patient. Our notes are much more legible and professional looking compared to our old paper template notes, which worked well for internal documentation but sometimes weren’t as meaningful to an outside clinic because of abbreviated notation that was often used.

I think our biggest ongoing challenge is ensuring that our medical assistants, who act as scribes for us in the exam room, put in the correct information. As with any computer-driven system, you can fall victim to “garbage in, garbage out.” Another challenge is to remember that the patient is the most important focus in the room, not the computer or the iPad. With an EMR, you do run the risk of the focus being on the computer screen and not the patient. However, with EMA being an iPad platform, it does allow the MA or physician to interact more directly with the patient and move around them during the exam documentation rather than being tied to a computer station.

Can you provide an overview of what it’s like to use your system in real-time, or a patient scenario?

Our front desk uses the iPad for the patient to verify their demographic information and insurance information at check-in. A medical assistant will room the patient, review past medical history information, and obtain the patient’s chief complaint/history of present illness (HPI) information. The assistant can also take the patient’s picture with the iPad to help ensure we have the correct patient. The photos are also very helpful to remember a patient if, like me, a person is better with faces than names. The iPad is then placed outside the door like a chart would be. Then when the provider is ready to see the patient, the assistant gives a brief summary of the CC/ HPI before entering the room. While in the room, the provider is able to focus on the patient while the medical assistant acts as a scribe on the iPad. At the end of the visit, the medical assistant hands the iPad to the provider who can then review the note, send any e-prescriptions, and finalize the note if it is complete and requires no editing. EMA captures all of the appropriate billing codes with modifiers, which has significantly been helpful with ensuring we are billing visits appropriately without fear of overcoding or under-coding.

Has working with your EHR affected how you interact with patients or staff, and what are some of the lessons you have learned along the way with EHRs in general?

It has made communication with the staff and patients better in the sense that we aren’t relying on “sticky notes” on charts to convey information. Everything is much more accurately documented. One concern we had was becoming too focused on the EMR and having the patient feel ignored. However, our experience has been that patients seem to be getting used to the role technology is playing in medicine and are even impressed with our use of technology and may even enhance their feeling that our practice is “cutting edge.”

We found it very helpful to have regular classes for the staff during our implementation and continue to have periodic classes or post “quick tips” on how to use the EHR in a meaningful way.

How would you sum up the current environment of EHRs and what do you think is on the horizon?

I’m skeptical that EMRs will help reduce health care costs in a meaningful way, though there is no doubt it helps organize data and gives us great access to our patients’ records from any computer or iPad. It has also virtually eliminated errors of misinterpreting chart notes and has cut down on the workload of having to fill out paperwork by hand. A great example of this is with pathology requests. In the past, our medical assistant would fill out a pathology request by hand, as well as the labels that would go on the specimen bottle. Now the pathology request form and labels are printed from EMA, eliminating errors in labeling. Another great feature is electronic prescribing, which we’ve been doing for about six years; the eRx system in EMA is outstanding. Patients love that they can go to the pharmacy and their prescription is ready for them when they get there. And of course the pharmacist isn’t trying to decipher the doctor’s handwriting!

One feature that is coming with EMA is a “Grand Rounds” button, which will allow you to see how other doctors have treated a condition you may see only once in a great while. Not only that, but you will be able to see how all 2,000+ users of EMA have treated that particular condition, giving you ideas for possible third- or fourth-line treatment options. Another feature will allow a user to track patient responses to treatments and their outcomes. I think these features have the potential to improve patient care and outcomes.

If you could offer a bit of advice for those considering the investment in an EHR, what would it be?

I’d recommend visiting a practice that is using the system you are interested in rather than just relying on a demo by a sales rep. Seeing the system in action and talking to actual users is a great way to know if it’s a system that will work in your practice. I know we’ve had a few practices visit us to see EMA in use and they all felt it was invaluable.

Mark D. Gaughan, MD, FAAD is in private practice in Durango, CO.