EMR Primer: Work Better, EMR or Not

December 15, 2007

Examining your practice’s processes is the first step toward solving office inefficiencies. You may discover that low-cost, low-tech tools can help you more than a pricey EMR.


In 1994, Richard Wasserman selected and implemented an EMR for his Dallas-based practice, Pediatric Allergy/Immunology Associates. Today he fully attributes his practice’s low overhead to the productivity and work-flow enhancements the new technology compelled his staff to adopt.

“I began with the EMR in 1994 primarily because I was paranoid about documentation and audits,” says Wasserman. “Expanding the automation to patient-created histories, integrated spirometry results, interfaced practice management and lab results, [and] faxing and e-mail from within the EMR all created operational efficiencies that derived directly from the EMR.”

EMR proponents often point to the power of the technology alone as the reason for its efficacy, but the enhanced operational efficiency required for effective EMR implementation can be just as crucial to optimizing your office’s work flow.

Evaluate your processes

Knowing what you hope to gain by implementing an EMR is the first step toward determining whether you are prepared to adapt the technology’s capabilities to your individual practice. Ask yourself: What objectives do you want to achieve by implementing an EMR? What problems are you trying to solve? Are your current day-to-day administrative and clinical operations optimized with the tools you already possess?

Before you invest in an EMR, identify your practice’s current needs regarding paper and patient flow.

Your operational EMR readiness assessment should focus on your current processes and procedures, your staff’s ability to adapt to new technologies, and your physicians’ receptivity to the standardization an EMR makes possible.

Spend a day observing your practice’s work flow. Identify each step required for routine tasks such as processing prescription refill requests, receiving and managing patient test results, and fulfilling requests for immunization records or back-to-work forms. Count the number of handoffs each process requires, and assess potential opportunities to eliminate unnecessary or redundant steps that have evolved simply because “that’s the way we’ve always done it.”

One example: An imaging report for a patient arrives via fax. This triggers a chart pull so the physician can review the report in the context of the patient’s record. The report is then added to the patient’s chart, and the chart is filed. Two or three days later, another copy of that same report arrives via snail mail. Unaware that the task has already been completed, another staffer pulls the same chart to file the same report, and the process continues until someone detects the redundancy.

Operational assessments are most successful when you involve your entire staff. Ask your receptionist, your medical records clerks, your nurses, and your billing staff to help you conduct a comprehensive evaluation of each of their commonly performed procedures. Chances are you’ll detect a lot of time-wasters you can easily eliminate with improved work flow. Other inefficiencies may require new technologies to remedy them.

But do the inefficiencies you detect automatically mean you should purchase an EMR? Not necessarily. You may want to consider some easier-to-learn and less-expensive “piecemeal” technologies that can deliver operational benefits while also enabling your staff to adapt to change.

Implementing new technology is not so much an IT issue as it is a “change management” issue. A stepping-stone approach to larger technologies can help you build a culture of change within your office that may help you more easily transition to an EMR when and if you ultimately decide to do so.

Low-cost solutions that work

A document image management system (DIMS) is one example of a lower-cost solution that can help your staff access information more efficiently. These systems easily support staff who handle routine phone requests. For example, Jerry Schlund, information systems director at The Heart Center in Fort Wayne, Ind., reports that his practice’s “time for a nurse to process a request for a drug refill went from 30 minutes to one minute” after he implemented a DIMS. His group reduced its number of chart pulls, improved direct patient services, and increased employee satisfaction. Can a system this simple always be this effective? “We couldn’t live without it,” says David Cannom of LA Cardiology in Los Angeles of his DIMS.

Perhaps your operational assessment indicates a much-needed improvement in your telephone message management. Irene Heinemeier, practice administrator for Cardiovascular and Thoracic Surgery Associates in Annandale, Va., implemented a call documentation and management system to address her practice’s inefficiencies in this area. Her group can now track messages by assigned nurse/physician and readily identify in real time the messages that have not been addressed within the group’s expected time frame. “The ability to manage staffing levels based on actual call data rather than guesses provides our nursing staff the right level of support to meet our patients’ needs,” says Heinemeier.


Effective, efficient patient communications is a key driver of patient satisfaction. A portal that allows patients to self-serve consistently rates highly with users. Susan Dicosola, chief operating officer in the Murray Hill Medical Group in New York City, gave her practice’s patients the ability to schedule their own appointments via the Internet in late 2001. “Ninety-five percent of Internet users do not go back to the phone, and our no-show rate with Internet appointments is less than 1 percent,” affirms Jeffrey Friedman, a partner in the group. Based on the average 35 hours per week put in by medical secretaries, services like these delivered via the Web can increase your virtual office hours an average of 380 percent.

Piecemeal or whole hog?

Of course, many practices are concerned that a stepping-stone approach will ultimately be pricier than just going ahead and purchasing an EMR with structured data capture for visit documentation, electronic prescribing, lab interfaces, and document management. That concern may not be valid, as many first-step applications will remain a component of the comprehensive solution you ultimately adopt.

For example, physician practices have implemented DIMS that have later become embedded within their EMRs. A document image management system gives an EMR access to historical patient records; in fact, some EMR vendors have developed interfaces to DIMS applications specifically to accommodate the electronic conversion of paper records.

Does that mean every technology investment you make can be a permanent one? Of course not. In fact, one prudent policy is to plan to replace one-third of all your PC workstations each year. The PC life cycle dictates a planned replacement strategy to ensure you don’t adversely affect your staff’s productivity with outdated, inefficient technology.

Consider your technology investments the way you would your child’s college tuition costs. To succeed, your practice must acquire a level of expertise with technology, and that requires an investment - an investment in hardware, software, and training.

Giving your billing office basic scanning tools will teach your staff about the hardware required to support large-scale projects such as scanning entire patient charts. Investing in PCs for your nurse stations will teach your nursing staff how to access patient education materials via the Internet and how to retrieve lab results without using the phone. As your staff’s technology prowess grows, you’ll be better positioned to tackle each new implementation as you proceed down the path of comprehensive digital information integration.

Rosemarie Nelson is a well-known healthcare technology guru and principal with the Medical Group Management Association’s Health Care Consulting Group. She can be reached via editor@physicianspractice.com.