The second time around: a California practice learns lessons from their first EMR and integrates their PM with a new, on-demand EMR for an improved bottom line and clinical workflow.

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In 2000, I founded Pediatric Partners, which at the time was a single-site practice with three physicians located 60 miles northeast of San Diego. Like most small practices, Pediatric Partners found itself experiencing massive inefficiencies in our front and back office operations. At the time, we were using an outside billing company and our legacy practice management (PM) system was presenting constant staff issues dealing with insurance verification, accurate patient demographics and patient scheduling.

These process breakdowns resulted in the practice experiencing growing denial rates and DAR of more than 90 days. In order to execute our practice's vision of not only growing our current location but also expanding, we needed to find a solution that would deliver consistent administrative outcomes. In 2001, we began leveraging an on-demand PM and billing service.

By 2005, after one previous attempt to install an electronic medical record (EMR), the group revisited choosing and installing a new EMR solution. One that if done correctly, would allow us to deliver better patient care along with achieving consistent financial results. The decision to install a new EMR did not come lightly for the group based on our past experience. If this new system was going to work for the group, I felt we would need complete buy-in from all of our locations and staff, making for one of the most challenging decision-making processes our group had ever experienced.

Selection

We began the process by forming a selection committee that was represented by physicians from all locations as well as administrators and staff. Our goal was to bring together key stakeholders from all facets of the group, including some that were against implementing a second EMR. We spent a good deal of time discussing our concerns related to cost, our current PM system and impact on workflow. As part of this process, we gathered industry research from third-party resources on EMR vendors and critical factors to take into consideration when selecting one.

The whole process took several months but was well worth it. We eventually narrowed the number of vendors down to three, including our current PM vendor. We agreed that a completely Web-based system was a core requirement due to the natural cost savings and flexibility of that model in conjunction with our growth strategy. Training and workflow were also concerns due to the previous system's lack of functionality in terms of data entry and retrieval.

Regardless of the vendor selected, our goal was to streamline office workflows and then create a detailed training, implementation and support plan prior to implementation.

With those requirements and goals in mind, we selected an EMR system from our current PM and billing vendor, athenahealth. They had just launched a new on-demand EMR service known as athenaClinicals, which could be integrated with our current PM and billing platform. An additional benefit to the company's centrally hosted EMR system was a new back-end service operation we did not have with our software-based EMR. Our hope was that this clinical service and additional document management functionality would be more scalable and help with our current clinical workflow issues.

Installation and Training

Soon after the selection process, we put together a "super group" of users that consisted of preselected physicians throughout our nine locations. This would act as phase one of the implementation, allowing us to work through any implementation concerns or issues. This group included physicians with negative impressions of the former EMR in hopes of their acting as core advocates and trainers for the new EMR during the remaining implementation cycle.

After implementation, training and two months of system use by the super group, we moved on to other locations. The vendor worked with us to create a detailed implementation and training schedule along with having their staff on site. Additionally, we requested that physicians work with the system during off hours to get a better sense of the functionality and how they would incorporate the EMR into their normal patient workflow, which proved extremely helpful in the weeks to come.

The second and main phase of implementation started with three of our largest locations with the greatest patient volume, despite the vendor's suggestion that we begin with our smaller sites. We reasoned that going live at the larger sites would augment our super group efforts and act as a training guide for the remaining practices. Primarily due to the Web-based nature of the system and our training process, all nine of our locations went live in less than 12 weeks, making for a far better experience than our previous implementation. Most importantly, we had gained tremendous buy-in from providers and staff throughout the group, which we attributed to our weekly training sessions and formation of our super group.

Network Power and the New "Paperless"

By late 2005, all of Pediatric Partners' locations were live on athenaClinicals and soon experienced something beyond improved clinical workflow. At the time of installation we had determined that, enterprisewide, our physicians were receiving anywhere from 70 to 110 inbound faxes a day per physician. With our EMR and PM system now on the same network-based platform, we leveraged the clinical document management service to integrate all the moving parts of our practices--scheduling and billing, automated coding, and clinical task management--into a single clinical workflow system. This functionality proved critical for a few of our smaller locations that did not have the same staff levels as our larger sites.

Our group was now able to address any new workflow issues and eliminate administrative errors via a new "Virtual Clinical Back-Office" managed by the vendor's network. This back-end service began intercepting all inbound faxes and reports coming into all office locations as each one went live, converting them into electronic documents and then categorizing them into clinical work buckets that were built directly into each physician's workflow. By indexing inbound faxes to the correct patient and, if applicable, the original order, our new clinical service provided us the basis to address closed-loop, order-cycle integrity.

However, even with all of our lab results now coming in electronically, there was still a massive amount of paper coming into our medical offices. While this had been a pain point with our first clinical system, our new EMR service was able to scan and categorize every incoming fax, then match specific clinical documents to existing patients and patient orders. This gave our group an incredible amount of process control on both the clinical and operational fronts. Not to mention that the EMR service now managed the connectivity to our labs and pharmacies, which significantly reduced the number of calls into our practices.

Along with eliminating our group's paper congestion, we were now part of a network-based EMR that provides all of our locations with continually updated payer-specific coding rules, and evaluation and management coding reviews at the point of care. This helps our providers optimize reimbursement and begin dealing with new practice-specific, pay-for-performance (P4P) payer contracts. This was why one of our core objectives was to select a fully Web-based system.

Gaining Control for the Future

In 2007, the group began to see the results of our hard work in going live with this new clinical system. That year, saw the implementation of a major new P4P program from the Centers for Medicare & Medicaid Services known as the Physician Quality Reporting Initiative (PQRI). Under the new initiative, medical professionals that report on certain quality-of-care measures given to Medicare patients can earn incentives of up to 1.5 percent of their total allowed charges.

With our EMR and PM service being part of a larger national network, all 74 of the 2007 PQRI reporting measures were automatically built into our operating system's rules engine and alerted our staff to which PQRI measures applied to them. This was a tremendous help in our ability to participate in the program as well as helping to maximize participation and reimbursement under the program. In 2008, PQRI expanded to incorporate 119 performance measures. Our system is now live with these measures in addition to two structural measures with staff working to incorporate them into our patient workflow.

Today, we still maintain a core super group that looks to stay present with emerging industry trends like P4P initiatives and determine any technology needs. We have found that the over arching benefit of our on-demand EMR service is that it enables our group to leverage a utility that researches and qualifies, and is updated daily with new rules and measures, allowing our group to optimize both our administrative and clinical outcomes.

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Thomas Mohr, M.D., is president and

CEO of Pediatric Partners Medical

Group MPC, Temecula, Calif. Contact

him at pediatricpartners@msn.com.