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June 12, 2006
For 25 years, the Victoria Allergy & Asthma Clinic in Victoria, Tex., located two hours equidistant from Houston, Austin, San Antonio, and Corpus Christi, has been the only such clinic within 100 miles. People in Victoria just don’t have an asthma attack unless they can build in a full day of travel to and from a major city. That is, unless they know about the two-doc practice in Victoria. To help service its patients, the doctors established outlying clinics in Beeville, Weimar, and El Campo, each 50 to 60 miles from the Victoria home office. To ramp up for their new patient load, the staff grew to five nurses, one lab technician, and a six-person administrative staff. Five years ago, the Victoria-based doctors purchased digiChart to manage scheduling, check-in, treatment, and check-out. They also purchased Medical Manager (now Emdeon Practice Services) to manage the back office insurance and billing. But digiChart developed only a handful of asthma and allergy clinics nationwide, choosing instead to focus on OB/GYN practices. “When digiChart made the decision to stop supporting our clinic, they told us we had six months to find another vendor,” says Bryan Nelson, the clinic’s practice manager. A retired manager from Union Carbide, Nelson had 31 years of experience with change management. He dusted off his notes and stood ready to apply “root cause analysis methodology”—business jargon for “where are the problems, and how are we going to fix them?” “Our staff and one of the doctors grew up on computers with the utilization of digiChart and Medical Manager, so they were comfortable with the computer systems change. With just six months to make the switch, we had our work cut out for us,” Nelson says. The doctors and Nelson decided to change practice management systems and also implement an electronic health record (EHR) system to complete the move to a fully digital practice. The doctors and staff reviewed several systems and selected Misys’ EHR and Tiger computer software systems for several reasons, but primarily because it was an integrated system, meaning the right hand would talk to the left hand. “We didn’t want one vendor pointing to another in the event of technical problems,” Nelson says. EHR Software Postproject Implementation Evaluation Avoid Importing Inefficient
Workflow Nelson searched for symptoms of inefficiencies by watching daily routines, observing frustration, and logging communication procedures. Not only did the nurses and administrative staff identify wasted time, the move to technology allowed them to get rid of old and inefficient habits. Low Work Value That Can Be Automated • Constantly copying forms, such as instructions on how to give allergy shots, and other patient education materials. Originals lost; new originals needed to be created as copies became unreadable. • Following the nurse’s intake, the nurse and doctors exchanged paper medical records an average of six times (three complete hand-offs) before the patient signed out through the billing office. • When visiting outlying locations, clinicians used cell phones to call into the Victoria office and schedule patient visits. • Letter dictation to a referring physician submitted on disk to a transcriptionist, returned for edits, then reviewed again and approved for signature. • Slow payment from paper claims. Automated Work • Partnered with a printing company and put all forms into a central file. Ran off 500 to 1,000 copies of one form at a time, reduced the need to re-create and copy forms. • The Misys EHR system allows doctors and nurses to log in and make entries without losing, exchanging, or refiling paper record. • Through the wireless network, clinicians can log on to the Internet to access the practice management scheduling system through the main server. They can also access billing and collections and process payment while on site, plus have full, online access to patients’ electronic medical records. • Referral letter samples were included in the system. A physician can pull content from the electronic record into the letter, print, and send it to a referring physician. A future enhancement will be to send referral letters via e-mail to referring doctors. • Payments are posted directly to patients’ claims billing accounts without manual entry or errors. As a result, 98% of the billings are paid within 60 days. After identifying workflow inefficiencies during the initial project scoping and contractual review stage, Nelson built a case for moving to technology, assigned a value for each automated activity, and presented the potential savings from a computerized practice to the physicians. Below is his savings analysis. Nelson initially estimated the total savings to be roughly the equivalent of one administrative staff person, or approximately $40,000 to $50,000 per year, including benefits. Within six months of implementation, one administrative person quit when her husband was transferred. By that time, the staff was so confident in its automation process that it did not refill her position. But when another staff member left to pursue a pharmacy degree, it did fill the vacancy with a part-time employee. Two years after the new computer system implementation, the medical practice had achieved a staff reduction of 1.5 people (25%), along with numerous work process improvements for the doctors and employees. Process improvement now also includes sharing quarterly expense information with employees. Without disclosing physician salaries and revenue, Nelson shares the remaining costs with staff so together they can better determine areas for future improvement. Now, when the four-person traveling clinical team goes into the outlying clinics, rather than bringing boxes of medical records, they bring four laptop computers. — Carolyn P. Hartley is president and CEO
of Physicians EHR and coauthor of EHR Implementation: A Step-by-Step
Guide for the Medical Practice.
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