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Small Town, Big EMR

When William E. Davis, M.D., broke into medicine in the late 1970s, computerized options for storing clinical information were scarce. But Davis believes in technology at his small group family practice in Winona, Minn., a hamlet of 27,000 residents on the Mississippi River. After tinkering with a punch-card system during his residency years, Davis adopted COSTAR, an early version of the electronic medical record developed by Massachusetts General Hospital. Eager to advance his practice, he then convinced his physician colleagues to take a quantum leap into Web-enabled technology. In 2002, Family Medicine of Winona bid farewell to its legacy system, opting to lease a more sophisticated EMR from adjoining 99-bed Community Memorial Hospital, where Davis serves as part-time chief medical information officer.

Due to better documentation, Davis’ three-physician group promptly saw annual revenue increase by some $250,000—without an increase in the number of patient visits. The COSTAR system could not adequately track the work performed by the practice, he explains. “We were getting underpaid for many years.”

Using EMR technology from Kansas City, Mo.-based Cerner Corp., the new arrangement supports Winona Health Online, a data-sharing and patient portal project. Davis’ group shares the hospital EMR—and all patient records—with another multi-specialty physician clinic. Now expanded to five physicians, Family Medicine of Winona also enjoys the streamlined data exchange just getting under way elsewhere in the nation. Clinic physicians can view both patient records and provider schedules at the hospital or the other group practice. Such data sharing boosts clinical decision-making and office operations, Davis says.

After three decades in medicine, Davis is beginning to cut back somewhat. A glimpse at Davis’ next three IT projects, however, suggests the veteran physician faces plenty of challenges during the next phase of his career. The 15 hours a month he logs as CMIO may soon grow.

1. Cerner upgrade

Early next year, the Cerner system will undergo a major upgrade that includes physician order entry, automated discharge summaries and medication reconciliation for patients moving in and out of the hospital. Instead of having distinct screens for the office and hospital environments, the new system will offer everyone the same user interface. For Davis, the new system represents a major training challenge. As CMIO at Community Memorial, he served as a “super-user” who helped physicians and nurses learn the original Cerner system. Training physicians, he says, requires some insight into their psyche. “It is better to train physicians one at a time,” he observes. “Group settings don’t work. It is a competitive thing held over from medical school. Physicians don’t like to admit they don’t know something.”

One key difference in the new version will be prescription writing. Under the current set-up, a physician ordering medications gets the online equivalent of a blank prescription pad, Davis says. That tool will give way to a more powerful ordering screen that makes it easier to write multiple prescriptions, he adds. The built-in medication reconciliation process will replace a cumbersome workflow that is documented on paper. As patients are registered for inpatient stays or move from the intensive care unit to a regular bed, the EMR will bring up a list of meds, enabling caregivers to document what must be continued or dropped. The technology should enhance compliance with Joint Commission requirements, Davis says.

Physicians at his five-member family practice already enjoy some of the benefits of electronic prescribing. Prescriptions are sent via auto-fax to local pharmacies, thus sidestepping legibility issues and helping to uphold patient compliance. Davis’ group alone writes about 2,000 weekly prescriptions, he estimates.

2. CPOE

Training physicians on the upgraded Cerner system’s screens may be a snap compared to Davis’ second undertaking: computerized physician order entry for inpatient tests, procedures and medications.

Davis is well aware of CPOE’s checkered reputation among many physicians. That’s one reason Community Memorial is going to install two precursor applications—an electronic medication administration record and an emergency department documentation system—before attempting CPOE. Currently, nurses document medication administration on paper, a step that Davis thinks should be automated first. Likewise, the ED documentation system would be a first step in capturing critical clinical information that physicians would later use in writing orders electronically. At a rural hospital, IT projects must move at a deliberate pace. “We have limited resources,” Davis acknowledges.

Nonetheless, he has begun sketching a game plan for CPOE adoption. The hard part, Davis figures, will be writing the order sets needed to make the system function smoothly. The order sets—collections of common orders arranged by diagnosis—must not only reflect best medical practices, but be accepted by the medical staff.

Using order set creation software from Los Angeles-based Zynx Health, Davis has convened a small group of nurses and physicians to begin building. In addition, Cerner may be able to offer some sets from other hospital customers. “We have not decided how intensely we want to do this,” Davis says. “The average hospital needs 300 order sets. That means writing one a day for a year. That’s a real challenge.”

3. Virtual office visits

Davis’ colleagues appreciate the efficiency of many EMR functions, such as importing test results directly from the hospital lab. But when it comes to “e-visits,” they are wary. In this set-up, patients with minor problems would forego traditional office visits, opting instead for secure communication with their caregiver through Winona’s health online portal. After patients type in a problem, the system recognizes key words, then leads patients through a series of related questions. The answers are dispatched in a bullet point summary to their physician, who could order a prescription, recommend a follow-up test or require an in-person visit. With the blessing of two Minnesota health plans, Winona Family Medicine began its e-visit pilot last January, with Davis as the physician guinea pig.

Thus far, demand for the online service is limited, and Davis has only conducted about one e-visit per week, for which he is reimbursed about $25. To be eligible for the service, patients must be registered users of the portal, which also grants them online access to their medical records and enables them to request appointments. About 4,000 patients have registered as portal users, and Davis says participation can only grow. “Patients may not want to take time off from work to see a doctor,” he says.

Online visits are well-suited for many common minor complaints, Davis says. By embracing the technology, physicians can reclaim much of the revenue they have ceded to free telephone consultations, he adds. But in the long haul, Davis says patients will gravitate to physicians who offer the same sort of technological access that banks and airlines do. “Patients will vote with their feet,” he says.

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.