It can be argued that patient satisfaction goes hand in hand with physician and staff satisfaction, so when health documentation gets in the way, no one can attain satisfactory results. However, the implementation of electronic medical records (EMRs) is far from
an automatic panacea. Just like a tailored suit or custom dress, EMR systems are often expected to fit the practice rather than the practice changing to fit the EMR. Yet, the best solutions should change the practice, when the change is for the better. For a Colorado-based practice, building an EMR system from the ground up meant a custom fit that all small and medium practices can tailor to their specific needs.

Alpenglow Medical, LLC is a Fort Collins-based primary care clinic providing outpatient medical services to adults. The clinic serves 70 percent Medicare beneficiaries, 28 percent privately insured, 2 percent private pay or uninsured, and less than 1 percent Medicaid. Begun as a solo practice in 1999 by Dan Griffin, M.D., Alpenglow has grown to include a second physician and one medical assistant, who collectively provided care in about 10,000 patient encounters. Today, the single practice has expanded to four as Griffin brings existing practices under the Alpenglow umbrella.

Like most small to medium practices, Alpenglow is a reflection of the ethics, compassion and outlook of the founding physician. However, unlike most practices seeking to tip the scales toward patient care rather than paperwork, Alpenglow chose to design the practice from the ground up around an EMR rather than converting after establishing the practice. "Our goal at Alpenglow is to deliver efficient, quality healthcare with no patient waiting time and 100 percent patient satisfaction," said Griffin. "The EMR is an important component to achieving that goal."

Early Experiences, Early Thoughts
Griffin’s interest in creating a different type of clinical practice was shaped early in his career as he saw how poor documentation adversely affected the pursuit of high quality medical care. "Coursework done for a certificate program through the Johns Hopkins School of Medicine convinced me that solving the problem of documentation was critical for a clinic to succeed as a business while maximizing customer satisfaction, quality and staff efficiency," explains Griffin.

The early concept for the eventual practice centered on an EMR from the beginning, allowing Alpenglow to start out moving in the right direction to higher quality care, a streamlined practice and a happy staff. At the time, conversations with peers on the subject were less than encouraging. Some physicians believed that EMRs should allow them to keep known, but inefficient workflows, while others felt that anything electronic is good. "You have these people walking around with their Palm Pilots and even if it slows them down and decreases their efficiency, they feel that the technology needs to be embraced at all costs," said Griffin.

For Griffin, it was uncommon to find physicians willing to find out how the technology could be helpful, how it needed to change, and how the workflow needed to evolve to create a happy medium. As EMRs have further developed in the last several years, a new category of users with EMR system experience arose. The challenge then became sorting through the converts who felt that the system operations were the best they could be and finding the few who recognized things could be better.

Objectives
The physician’s top priorities for an EMR system were to capture clinical encounter documentation in real time to increase the quality of documentation, include the patient in the accuracy of documentation, and to reduce malpractice risk through improved accuracy and completeness. Additionally, he wanted a system that could serve as a database for knowledge management of ideal clinical care.

Griffin intentionally avoided a template-driven EMR in favor of a system that would allow him to build care management plans for individual patients based on his own knowledge, training, ongoing review of the literature, and Web-based clinical decision-support services, and then store them for future application. "In the mid-90s, you had to force the issue for any of the available products to be a true health record so it was a partial solution at best that you had to make work against its design," says Griffin.

As Griffin began to focus on the specifics of the EMR in conjunction with the eventual practice goals, a clear picture of the staff criteria began to emerge. The physician knew that it was imperative to hire staff that shared his vision for service delivery, patient care and full utilization of an effective EMR system. "One of my main challenges with staff was that they often had worked elsewhere and therefore had to be retrained to the new approach of mutual buy-in to continuing education, both within their fields of study as well as with updates to the eventual EMR system," says Griffin.

System Selection
Once deciding on the EMR system criteria and the type of staff he needed for success, Griffin spent a month reviewing available systems. He ultimately chose Praxis EMR by Infor-Med primarily due to its Concept Processing rather than structured templates. A Concept Processor is an artificial intelligence software program that learns from its user, and in turn, documents faster and better with each patient encounter. The Praxis UpToDate decision support system contains thousands of disease-specific templates referred to as concepts. "We could build patient concepts based on our needs and preferences, or import them directly from decision support software," explains Griffin.

Additionally, the Praxis system met his criteria for charting and real-time documentation as well as task automation for prescription writing, test ordering, generating bill information and scheduling of return visits. This laid the groundwork for clinical encounters that fit typical physician workflow and thought processes.

Once he selected a system, Griffin hired a local IT consultant familiar with the healthcare sector to assist with hardware purchase and installation. The IT consultant worked through a reseller and Praxis to obtain recommendations for the purchase of hardware. Griffin purchased Dell hardware via the Dell Website and was part of the installation team. "Just because you’re going to EMRs it is unrealistic to think that you are going to master the whole field, so you not only need IT consults that understand the technology, but also the needs of healthcare and HIPAA compliance," says Griffin.

Implementation
The team consisted of Griffin, the reseller, a Praxis representative and the local IT consultant. They collectively set a goal to complete training and testing in the week prior to opening the practice to patients. Once completed, Griffin hired a nurse and office manager and scheduled a week for the training. Users were responsible for looking critically at the areas of the EMR that they would be using and bringing questions, suggestions, and feedback on the EMR system back to Griffin and the trainers.

According to Griffin, staff suggestions were integral to the system’s success. Based on these suggestions, patient photos were added to ensure correct patient identification without opening the chart. New printers and a software upgrade were added so that clinical information such as procedures, prescriptions and lab results could be printed at the back nursing station, while administrative information was available at the reception desk with ergonomic and easy access for staff.

Griffin and staff spent a great deal of time identifying what information should be transferred from the paper chart to the EMR. Alpenglow scheduled 30-minute visits with each new patient where relevant information from their paper chart was entered into the EMR system. All additional relevant information was given to staff for scanning, with the full paper chart placed in off-site or attic storage. "We held a meeting to review what was actually in an ‘old chart’ and discuss what information was relevant to an internal medicine practice and what information providers and staff would access and use," explained Griffin.

In order to speed scanning of consults and other documentation into the system, Griffin consulted with the vendor, who developed a process for batch scanning and sorting information into each patient chart via high-speed batch scanners. This improvement eliminated hours of staff time per day. Additionally, Griffin worked with the vendor to reduce current medication updates in the system from two clicks per medication to just two clicks to activate the entire medication list.

Staged Patient Implementation
To avoid creating a chaotic environment resulting in poor system use habits by staff, Alpenglow initiated a staged patient implementation that allowed the practice to focus on full utilization of the system. "I was convinced that the success of this model heavily depended on staff participation, which I was able to achieve through my hiring criteria, the pursuit of individual buy-in, and making sure the staff felt a real sense of open dialogue," said Griffin.

The goal of never having patients wait also was integral to the rollout as well as the workflow of the resultant EMR system. To accomplish this goal, Griffin and staff set up system test dry runs of complete patient encounters in order to set reasonable patient volume goals for the first week of actual patient care following implementation. Alpenglow saw only six patients per day in the week following training. The next week saw an increase to 12 patients per day and 23 by the third week. "I wanted to eliminate patient perception of the EMR as an inconvenience and felt that a short period of decreased visits would ease the transition," said Griffin.

Ultimately, the staged implementation was a success for staff and patients, with no downside and more than one unexpected bonus. While some physicians might feel that implementing new technology could cause concerns for patients, Griffin found just the opposite. "What I mainly get is this perception that if you have this computer and you’re making notations and entering notations into an EMR, then they presume it reflects that you’re at the cutting edge with your medical care," explains Griffin. "Consequently, the patients seem very excited."

EMR in Practice
With the EMR in place, a typical office visit begins with physician and patient entering the exam room together, and then accessing the electronic system. The opening screen shows a picture of the patient, all demographic and insurance information, current lab and X-ray reports, prompts from the disease-specific concept, and current problem and medication lists.

The patient is able to view the screen during the interview as the physician enters relevant notes and reconciles medication data. Following the examination, the patient and physician return to the computer to enter any additional resulting information. Griffin verbalizes all entries into the system while typing to ensure accuracy, allow for corrections or additional patient input, and to serve as an educational intervention. "I place a high priority on fully answering patient questions, and we schedule appointments with that goal in mind," said Griffin.

Alpenglow uses UpToDate, an evidence-based clinical decision support tool, to access clinical information at the point of care. Praxis is linked to First Data Bank, National Drug Data File Plus, a national medication and clinical information database that allows providers to select medications and obtain detailed information including drug-drug and drug-disease interactions. Medications entered into the medications section of the patient encounter form print automatically to the front desk along with referrals ordered within the patient encounter. The EMR imports, stores and displays laboratory, radiology, and referral reports and stores media files.

After completing all documentation, physician and patient leave the examination room together and go to the front desk where prescriptions, test and referral orders as well as billing information are printed. The front office staff has access to the follow-up recommendations section of the clinical encounter and, whenever possible, schedules the next appointment before the patient leaves. At the conclusion of the visit, all documentation is completed, with no pending data entry.

The medical assistant (MA) enters vitals, updates the current medication list, and enters the primary and any secondary complaints into the EMR system. The EMR interfaces with Quest, LabCorp and PVH (the local hospital), and has a manual interface for entering and converting to electronic format any results from smaller local labs in Fort Collins, or reference labs that are not interfaced.

The MA also manages an electronic tickler system that sends messages alerting when to check for lab results. The latest upgrade of the EMR system at Alpenglow is being used to run disease-specific reports on specific patient populations to identify patients missing recommended services, or responding inadequately to treatment.

Achieved Practice Goals
Since the implementation of the EMR system, Alpenglow has met or exceeded the goals set by Griffin long before the first patient entered the practice. Today, the practice only needs a single MA for its two clinicians, saving the practice $30,000 annually. Additionally, the practice has no need for a medical records staff or transcriptionist, saving an additional $20,000. Also, gross revenues for the practice have increased some 21.5 percent since 2002, with a collection rate exceeding the goal of 90 percent.

Expansion and the Future
Alpenglow closes several days per year to allow full staff participation in update training via live Praxis Web training. Every employee is responsible for making notes about bothersome aspects of the electronic system, and/or suggestions for improvement. Improvements are made as identified, while pervasive or difficult issues are discussed at monthly meetings with vendor assistance utilized for those issues that cannot be rectified in-house. As icing on the cake to these results, Griffin and Alpenglow Medical have been recognized with a 2006 Davies Award in the ambulatory care category from the Healthcare Information and Management Systems Society.