A 'do it yourself' approach to EMR implementation


My decision to transition Town & Country Pediatrics to a digital practice was influenced by the desire to increase patient safety, chart more efficiently, automate prescribing and billing processes, and enhance profitability. My practice is ineligible for meaningful use, therefore any increase in value would have to be realized from productivity enhancements, improved revenues and reduced costs rather than incentive funds.

I sought an EMR that met my exact specifications because EHR Incentive Program certification was not a consideration. Topping this wish list was the ability to design my own intuitive templates. I soon discovered limited options. While evaluating systems from top EMR vendors, I found none fit my practice workflows. In particular, they required use of pre-defined templates, forcing me to fill in multiple data fields that were irrelevant to my practice.

A do-it-yourself approach
After a lot of investigation, I opted to go with an EMR that let me configure nearly everything. I knew this approach would require more of my time up front, but I was confident that custom-designed templates would eliminate productivity declines and provide quicker returns on time and costs invested.

I selected BuildYourEMR, a MU 2011 (now 2014) Certified cloud-based system that provides a framework enabling me to evolve EMR functionality as my needs changed. With the help of my practice manager and staff, I easily followed a 10-step process to precisely define the features and functionality I needed.

1. Determine data collection points. Identify most frequently used items from standard terminologies. Then define templates for various sections such as History of Present Illness, Review of Systems, Physical Examination, Family History and Past History.  Review any interface requirements for exchanging data with laboratory, practice management and other systems, as well as health information exchanges.

2. Create order sets. Compile a list of the most common plan items and use them to define order sets. Use free-text plan templates when appropriate.

3. Define clinical decision support rules. Map plan items to frequently used items in Step 1, using standardized codes and requirements for Clinical Quality Measures (CQM) reporting and meaningful use whenever possible.

4. Build encounter/progress form. Select between Subjective, Objective, Assessment and Plan (SOAP) note and CMS-recommended formats, then define the layout and link it to sections defined in Step 1.

5. Design workflows. Define user roles and privileges. Then define workflow for each step of the patient encounter.

6. Establish navigation links. Define patient quick lists, a patient dashboard screen and preferred methods for searching patients.

7. Define document management processes. Determine which document tabs in your paper records will be carried over to the electronic forms and review processes to manage any remaining paper forms.

8. Design internal communication processes. Define management of patient phone calls and task assignments.

9. Design ancillary communication processes. Define management of referrals and patient-physician communications.

10. Create reports. Design patient, provider and practice-level reports, as well as CQM, meaningful use and any other custom reports.

Rapid ROI
My experience with BuildYourEMR was unlike most practices. Instead of struggling for months to regain pre-implementation productivity levels and realize a return on my EMR investment, my experience was exactly opposite. There was no increase in time-per-patient because I designed the templates to look and act like automated versions of my paper charts. In addition, documentation to support appropriate reimbursement levels was streamlined. For example, encounter templates are now designed to record all the components needed to justify 99214 or 99215 charges when appropriate.

My custom templates enhanced patient safety.  One example is the diagnosis of concussion that requires detailed advice, which was difficult to capture on written charts. I was able to design templates that document extensive detail and add it to the patient’s chart with a single click.

The EMR saves time previously spent searching for and transporting paper charts, which also enhances privacy by limiting opportunities for improper access. The improved productivity created by the system’s electronic Task Management function is also noteworthy. Using Tasks, I communicate instantly with my triage nurse and medical assistant, reducing verbal interruptions and creating a more organized workflow.

Using a customized EMR has increased patient satisfaction, in particular with e-prescribing, enabling me to use tablet computer in the exam room.  Patients have stated they get much better eye contact when I use the tablet than the clipboard.

Opportunistically scanning archived documentation into the EMR has freed up resources previously dedicated to managing more than 250,000 pages across 15,000 paper files in less than a year. This includes the elimination of approximately $500 a month for offsite archiving and reclaiming two exam rooms that previously served as onsite storage. 

None of these benefits would have been realized so quickly if I had picked a legacy system. By configuring this myself, I created exactly the EMR my practice needed.

Joel S. Koenig, MD, founded Town & Country Pediatrics and is chief of pediatrics at Missouri Baptist Medical Center in Town & Country, Mo.