Modest Alternatives To Costly Technology

At Tulsa Pain Consultants, paper is all but a thing of the past.
But the four-physician Oklahoma practice didn't rid itself of paper charts, faxes, and insurance cards by shelling out hundreds of thousands of dollars for an electronic medical record (EMR). Instead, Tulsa Pain took hold of its document management needs just as you should: by first gauging its most pressing demands, then seeking a system designed to meet them.

Along the way, two things became evident: first, most true, off-the-shelf EMRs have capabilities that go well beyond what the practice needed. And second, they cost a whole lot more than the group wanted to spend. Coming to that realization is hardly uncommon. Across the country, practices that once tingled with anticipation at the thought of high-tech automation have become disillusioned by the high costs and complexity of EMRs.

"There are a lot of products out there, and trying to nail the right one can be overwhelming," says Rosemarie Nelson, a consultant to medical practices on technology issues, and a market development manager with medical technology developer Welch Allyn in Syracuse, N.Y. "People wonder, 'Am I betting on the right horse? Am I picking a [company] that's going to be around long-term?' There's so much volatility in the market. ... And because the solutions have a lot of flexibility [in their capabilities], implementation can be very difficult. The implementation period alone can take nine to 18 months. So practices worry, 'Is every physician and every staff member going to be able to work with this?'"

Faced with such hurdles, Tulsa Pain eschewed a paradise-or-bust philosophy to document management and instead took a practical, go-slow approach. It rejected costly, all-in-one "solutions" that have more bells and whistles than Air Force One in favor of a custom-built, leaner system that accomplishes what the practice wanted -- and only that.

Efficient, cheaper

Matthew Griffin, the Tulsa Pain Consultants administrator who heads the practice's technology efforts, says cost was the motivating factor in its decision to create its own system. "A stand-alone EMR for the practice would have cost $300,000 or more," he explains. "If I had gone to the physicians and told them I needed $300,000, I would have failed."

So Griffin, along with Businet, the practice's local technology vendor, designed an all-digital system just for Tulsa Pain. The system -- which Businet has since developed and sells, in customized form, to other practices -- is not an EMR, but it still goes miles beyond the paper-based process Tulsa Pain was using before. Called EzChart, the new system is exquisitely simple: it is little more than a big electronic database containing scanned images of every patient's clinical and administrative information.

Intuitive and easily navigable, the system is tied to the practice's scheduling software, automatically creating charts for new patients and updating charts for existing ones. Notes are transcribed into Microsoft Word and go directly into the system.

"The entire platform is geared to make [the process] look, feel, and be managed just like it is on paper, except you're just using a computer and a mouse," says Griffin. "It populates your screen with something that looks very much like a paper chart. ... Down the right hand column, there are tabs [labeled as] clinical correspondence, diagnostic studies, insurance information, and so on."

There is space within each chart for doctors' and nurses' notes. Physicians are alerted via an electronic message when a nurse makes a note that calls for their attention, and vice versa. Charts are easily accessed from a PC, and the system is Internet-based, so users can access documents remotely.

"No more telling patients who call, 'Hey, let me call you back, I have to pull up your chart.' They can immediately pull up your chart and see what's there -- it's manageable in real time," Griffin says.

Paper mail continues to come in, but those items are scanned immediately into the system and attached to patient files when appropriate. Patients' insurance cards are scanned, too. An $800 desktop PC serves as a fax server, automatically converting faxes into digital form.

Sounds simple enough -- and it is. Simple, yet effective: EzChart solved Tulsa Pain Consultants' major document management problems at a fraction of the cost of an EMR.Griffin estimates the custom system cost the practice about $90,000.

"That's still a lot of money," he says. But it's worth it: "I was able to produce a cost-benefit analysis that looked at how our paper records were being managed, and how many people it took to manage them."

You can, too

Your practice can emulate Griffin's by taking, as consultant Nelson says, "a stepping stone approach across the river of automation." In fact, your first steps may be much less ambitious -- and far less expensive -- than those of Griffin and Businet. "There's a lot of interest among practices in fixing specific problems without biting off the whole enchilada," says Nelson.

That's because "most practices tend to do the same things over and over again, so maybe 90 percent of the features available in an EMR go unused," says Monte Regier, CEO of InfoMedx, a Seattle firm that offers an Internet-based document management system on a subscription basis.

The key to building what some call a do-it-yourself EMR -- but what in reality is usually far less elaborate -- applies across the board to all types of technology undertakings. Start by getting a handle on your practice's top priorities for document management.

"When I meet with clients," Nelson says, "I ask them, 'What are your biggest pains in the neck? What's causing all the hullabaloo? Where are the most painful areas where, if you could just fix those things, it would make all the difference?'"

According to Nelson, the answers typically depend on the specialty of the practice. In primary-care and internal medicine offices, doctors dream of a medication database that could help them track patients' prescriptions and manage refill requests. At walk-in clinics and practices with a lot of last-minute appointments, staff members have visions of automated systems for telephone triage notes dancing in their heads.

Pediatric practices, meanwhile, are struggling with immunization tracking. As more states and localities are demanding paperwork to prove kids are immunized as a condition of school enrollment, pediatricians are having trouble keeping up.

"There's an awful lot of paperwork involved in filling out all the forms and getting them to parents," Nelson says.

For one pediatric group in Georgia that needed such help, Nelson recommended the purchase of three desktop computers, on which nurses could create Excel spreadsheets containing each patient's latest immunization information. Nurses now simply add new information in real time. Total cost: a few thousand dollars.

"Now they don't have to pull a chart every time a parent calls and says, 'My kid needs a shot,'" Nelson says. "If they had purchased an EMR, it would have cost them $400,000 and they would have had to implement it -- they would have had to go through the planning, the training, the psychological barriers of change."

Once you know what you're looking for, you can figure out what sort of help you'll need, if any. It's possible you can do everything yourself, especially if yours is a modest plan and you have some technical know-how.

Otherwise, consider hiring a technical consultant or a local technology company -- a firm that specializes in building customized information systems for business -- especially one that's worked for medical practices before. This is vital if your plan, like Tulsa Pain's, calls for someone to write computer code just for you.
Not an EMR

The Tulsa practice isn't finished building its system. The introduction of a wireless component via so-called tablet computers is the next phase; the step will allow physicians to easily carry the practice's document management system into the exam room. Tablets are hybrids between laptops and personal digital assistants; they are easily portable yet bigger and more powerful than PDAs. Of course, there are important differences between true EMRs and scaled-back approaches.

Griffin acknowledges that his group's system -- which he first helped implement for a previous employer, a nearby surgical practice -- is not an EMR. The main difference? Most EMRs have data-mining capabilities that EzChart does not.

"Our system doesn't allow us to say, for example, 'I want a list of all 35-year-old white females who were prescribed Xanax,'" Griffin says. "What goes into EzChart are mainly scanned, graphical images of documents."

Like most similar systems that other practices have built, EzChart is merely a sophisticated file cabinet. For the most part, it can't distinguish between the types of documents being entered into it, nor can it analyze the information contained within them. Staff must be careful to place files into the correct tabs on the correct patients' chart.

Still, the system is an effective way to control the flow of information and reduce paperwork. And for Tulsa Pain Consultants, nothing more is needed. The doctors there, says Griffin, are in the healthcare business; they're not statisticians.

"We don't have time to run those kind of data-intensive studies," he says. "I've been [employed] in a big surgical practice and I work in a pretty big practice now, and what everybody's interested in is taking care of the patient and getting paid."

If those are the primary concerns at your practice, and you don't have the money for a true EMR or the stomach to look for one, consider something simple that won't bust your budget but will solve your biggest problems. After all, you have to learn to walk before you can run.

Bob Keaveney, associate editor for Physicians Practice, can be reached at

This article originally appeared in the November/December 2002 issue of Physicians Practice.