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Practice Administration

Electronic Medical Records: The Inevitable Path to Improved Quality of Life

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 In 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act (or “HITECH Act” for short). This act is a part of the American Recovery and Reinvestment Act of 2009 (ARRA). The act includes incentives related to information technology and health care, including very specific incentives meant to improve the rate of adoption of electronic health record (EHR) systems. It should also greatly expand the exchange of electronic protected health information (ePHI), widen the scope of privacy and security protections for patients, and increase the legal liability for non-compliance. These provisions apply to all healthcare providers, including dentists, and include mandatory penalties for “willful neglect” toward compliance which can exceed fines of $1,000,000 with repeated or uncorrected violations. This act should bring about a full shift to electronic health records for all service providers. Clearly, the HITECH Act is something that all future health service providers need to be aware of, and in full compliance with if they hope to run a successful business. 


The healthcare system has begun to undergo a tangible evolution in light of the growing adoption of electronic medical records (EMRs). Today’s practitioners witness daily the manner by which innovative medical technology improves the lives of their patients while simultaneously improving their efficiency and productivity.  Electronic medical records hold great promise, and achieving adoption on a national basis requires a high level of cooperation among all those working to implement and use these systems effectively. 


Keys to successful start-up include careful partner selection, patience, and clear communication among the numerous healthcare professionals (HCPs) in the chain of care: physicians, nurses, third-party payers, laboratories, administrators, and information technology (IT) specialists, just to mention a few.  The challenge is considerable, but the rewards look to be even greater. Many consider the efficiencies inherent in EMRs as critical to help control rising healthcare costs. As individual physicians and larger facilities alike begin to transition from paper and partial computer files to fully digital records, there may be resistance and hesitation--factors that accompany any major change.  Nevertheless, during the learning, implementation, training, and start-up phases, HCPs and IT professionals should consider that EMRs will help meet two of the most crucial tenets of healthcare today--controlling costs and improving the quality of patient care—and achieve other benefits as well: 

  • Automated Data Entry – Automated entry of data or charges significantly reduces the occurrence of overlooked or missed charges. 
  • Increased Staff Efficiency–Overtime charges can be reduced when the staff cuts back on time spent entering charges and searching for charts. 
  • Enhanced Coding–EMRs enable better documentation of data and include automated coding advisers. 

Automated Data Entry 

 Central to improved patient care is the avoidance of errors attributed to unclear and misinterpreted handwriting, which wastes time in verifying information and can result in serious drug interactions and treatment complications. Clarity of communications is more vital than ever, especially today when patients may require multiple medications or receive treatment from a variety of specialists, some even geographically dispersed. While handwritten paper records will exist for the foreseeable future, standardized forms and code sets help minimize errors, and handwritten documents can be easily scanned into a digital database. 


Electronic medical records are far more than just templates. As the industry progresses, and as high-speed, hand-held, laptop and workstation computers widely proliferate, the discipline of data entry into a digital format will further reduce errors and increase productivity for all involved in patient care and administration. New voice-recognition software designed for the needs of physicians and medical professionals now achieves speeds of 160 words per minute with exceptional accuracy. As this technology improves and as EMR usage grows, it will be faster and easier to enter information into the patient’s electronic record. 


Governmental Support 

A unified EMR technology infrastructure and universal formats offer advantages to the entire healthcare system.  In 2004, the President signed an executive order establishing the position of a National Health Information Technology Coordinator charged to lead nationwide implementation of an interoperable IT infrastructure aimed at improving the quality and efficiency of health care within ten years. According to the U.S. Department of Health and Human Services, a universal EMR is a digital collection of a patient’s medical history. It could potentially include items such as diagnosed medical conditions, prescribed medications, vital signs, immunizations, laboratory results, and family history.  In addition to data entry, an EMR can include digitized images of the individual’s physical information (eg, paper records, notes), photographs, radiographs, or similar scans. Today, because of the different sizes and shapes of physical items, this information presents a storage problem. It often resides in disparate places or with different HCPs, and such data can be onerous to access and consume costly facility space that could be repurposed more productively.  Centralized digital storage of EMRs will maximize facility efficiency and allow instantaneous, simultaneous access by several authorized users for telephone or video conferencing and for decision making.  


To help promote the adoption of EMR, the federal government is encouraging the development of Regional Health Information Organizations (RHIOs) and has awarded nearly $140 million in grants to advance the networking of healthcare services. The objective of this initiative is to connect providers with laboratories and insurers in order to share EMRs within designated geographic regions, and perhaps someday nationally, or even internationally. Today, there are hundreds of RHIOs across the U.S. in various stages of development. They provide an early opportunity for all to get involved with the future of EMRs, provide input, and, through a cooperative effort, develop procedures that will be instrumental in the success of EMR implementation.   


Technology and Infrastructure 

The technology exists to create effective, user-friendly EMR systems. By digitizing records of all types and building the dedicated networks to share information quickly, critical information can be instantly available at any hour of the day. When paper records reside at a physician’s office, they are only accessible during office hours and must be faxed or conventionally forwarded during an emergency. When records reside on a computer database, authorized users have fingertip access at a moment’s notice.  The privacy and security issues of EMRs are presently addressed to the satisfaction of patients, providers, and regulatory agencies via secure intranets that allow only authorized access to files. Safeguards such as hard firewalls and encrypted access developed in the financial industry protect the privacy of medical information as well. Sophisticated data networking organizations such as AT&T have the infrastructure in place to provide secure connectivity at broadband speed over fiber optic cables. This ensures efficient transfer of digital files such as high-resolution MRI, radiographic images, and the like.  


Importantly, EMRs enable geographically remote facilities and different practices to confer on a patient’s record using a unified data platform. Electronic medical records also have the potential of allowing comprehensive analysis of administrative, financial, and clinical data, which will presumably lead to streamlined operations, greater personal productivity, and related savings on the healthcare system.  


The Rollout of EMRs 

Currently, there are two models for EMRs competing in the marketplace. One creates a centralized database where patient files are stored and allows the exchange of individual records among authorized participants. Regional Health Information Organizations are developing the other, called the “federated model.” Each RHIO has its own database to store EMRs and allows access to HCPs. While both approaches have advantages and disadvantages, it is feasible to anticipate that eventually the two systems will merge into a national database.   


With the implementation of robust and easily accessible EMR systems, the benefits are many. The use of EMR is expected to reduce adverse drug events, lower morbidity and mortality rates, and facilitate better monitoring of data and access for research and reporting. Most importantly, physicians treating a patient--no matter where they are located, no matter how many different referrals are involved in the patient’s life--can have the complete record of the patient’s history, treatments, tests, and the informational tools necessary to administer the highest level of  care. 


Physicians facing or entertaining the prospect of instituting EMRs should not regard them as a burden but rather an opportunity. The leading strategies towards successful implementation include: 1) participating in formative or established regional information networks; 2) working with other HCPs or healthcare organizations to share resources and costs; and 3) exploring possibilities and financing options with telecommunications network vendors. It is also highly advisable for one to consult with organizations that have transitioned, or are transitioning, to EMRs. In this manner, it is important to learn from their mistakes and benefit from their successes. Practitioners should also consider EMR applications that already interface with their existing practice management software, are marketed to practices of similar size, and are well-rated in independent surveys. 


Larger hospitals are further along in EMR adoption than mid-sized and small hospitals, and urban hospitals have generally progressed further than rural facilities.  When consulting with major network solution providers, it is appropriate for the decision maker to be particularly concerned with safeguards that ensure privacy, security, and reliable backup systems to protect the files.  Upgrades to computer workstations may be required to increase speed and storage capacity, and monitors improved to view higher-resolution images and better read handwritten documents.  Workflows should be reevaluated to maximize the operational efficiencies conveyed by the new technology and to avoid duplication of effort; staff training too will play a critical role in the transition to EMRs (see sidebar).  


Ultimately, EMRs will benefit the patient most of all: better care, better outcomes at lower costs because of increased overall productivity, and quality performance of healthcare operations. Insurers have already begun to guide patients to digital records in their own right, and this movement is still only in its infancy. As greater numbers of patients and providers are acclimated to the considerable benefits of EMRs, their outcome on the entire system appears highly promising indeed. 


Implementing and Training 

  • Set expectations: It is important to remember that the transition from paper charts to the EMR does not happen overnight. Implementing EMR protocols will take time, but their long-term benefits will outweigh the length of the learning curve. 
  • Vary the approach: There are different methods for staff training, including classroom-style, online training courses, and even one-on-one meetings. Employee training will depend on the type of EMR system purchased and the HCP’s implementation plan. 
  • Know the audience: Customize the training program for each type of employee you train. Training receptionists, for example, may be different than training for clinical providers.   
  • Use experienced trainers: Professionals experienced in EMRs should conduct training, and general orientations should begin early in the process--for all staff affected by the new technology--and continue with on-going support.   
  • Confirm compatibility: Consult with IT professionals to ensure that the EMR system you are considering is compatible with other programs you are already using. 
  • Prioritize practice needs: Consider how time is allocated when trying to contact patients, to decipher provider notes, or to enter lab reports into patient charts. Setting goals for what you hope to accomplish with EMR software will aid in the decision-making process. 

Learn to Love Your Numbers

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With today’s technology, one can walk into just about any dental office, press a few buttons on the computer, and get bar graphs, comparatives, and systems reports that reveal EVERYTHING about the practice and then some! Yet, the majority of dentists never bother to look at their statistics. If they do look, they don’t act. So why do so many dentists and their teams complain that they are not in control of their practice? The answer is, if the dentist doesn’t have a healthy relationship with the statistics of the business, he or she can never be in control.


I understand that there are good reasons why dentists’ relationship with statistics continues to range from ambivalent to hostile. Numbers by themselves—when not tied to the bigger picture of vision, values, and goals—can feel empty and solely production-driven. If you tend towards pessimism, you might feel the numbers are just a stark reminder of your failures. But when done well, the numbers can create a self-motivated, optimistic dentist and team that are engaged in the mission of the practice because they feel informed about the business and are proactive about their future.


Entrepreneurial Rules

As a dental student, your school experience was focused mostly on the clinical with very little (if any) business training. To be successful as an associate or owner in this challenging environment, you need to break the cycle and learn to love the numbers! The first step in creating a positive relationship with your statistics is to willingly and fully commit to some basic entrepreneurial rules. These rules will put you and your team on the path to controlling what can often seem “uncontrollable”—the practice.


Rule 1: No One Number Means Anything by Itself.
With the myriad systems of operation and outcomes in a dental practice, it is easy to develop tunnel vision and focus on just one indicator of success.  This, however, can lead to “false positives” that belie the truth.  For example, a down month in productivity could be attributed to working fewer days as a result of vacation rather than a decrease in production or patients.  Or, collections may be down for the month because production has skyrocketed due to major implant case starts and not because the financial coordinator is falling behind on processing insurance.  Or, the number of new patients is off the charts so production should be strong over that period--but most are adolescents and require little dentistry.  Dr. Pride used to say, “Numbers tell a story but if you don’t read all the chapters you’ll miss the message.”  I agree wholeheartedly.


Rule 2: Every Number Means Something.

You may think that this rule contradicts the first rule, but it doesn’t. While no one number means anything by itself, every statistic means something. Statistics are situational flags that will point to strengths and challenges in your operating systems and the changes required of your team to manage those systems. By not paying attention to one indicator, you may skew perception and you will miss a great opportunity to successfully analyze the health of your practice. If you try to analyze why your collection percent is lower than last year without looking at everything from adjusted production to credit adjustments, productivity indicators, and accounts receivable, there’s a strong chance you’ll come up with the wrong solution.


Rule 3: Numbers Cannot be a “Hidden Secret”.

Open book management is a management technique that gives all employees all relevant financial information about their company so that they can make better decisions as employees. This information includes, but has never been limited to, revenue, productivity, profit, cost of goods, cash flow, and expenses. You may be concerned about practicing the fine art of open book management, and you wouldn’t be alone. Poor implementation of this technique can create competitiveness, misinformation, distrust, and discord. Open book management, however, is perfect for the dental world because a dental practice is often composed of a maximum work team of 5 to 15 people who all have key responsibilities that will drive the practice forward. A big business, on the other hand, employs people who may file charts for 25 years and never need to understand the valuable final products of the organization.


When a key staff member in a dental office gets a cold, the practice gets pneumonia. For this reason, the dentist--often stuck in the operatory--must depend on nothing less than excellent execution from every team member. If you desire self direction, you will need to keep your team informed and statistically interpreting progress. It’s not enough to say to an appointment coordinator: “I need you to work hard, fill the books, and be excellent with patients.” She will need to be aware of why that’s needed, have benchmarks for success as a result of her job description, and understand how her outcomes and results affect the other positions within the practice. All in all, practicing the art of open-book management is well worth the potential risks because it will allow your team to become Olympic athletes (who know their score) in representing your vision and values.


Rule 4: Numbers’ Analysis Only = Inertia: Do Something!

While being willing to look at your numbers is a baby step in the right direction, looking without acting is a waste of time! There are many reasons why no action can occur in a dental practice:


• Complacency: Realizing there may be problems but not feeling enough pain or not thinking that the problems have anything to do with you or the practice.


• Fear: Seeing the problems, but thinking the solutions may cause even more pain or damage.


• Perfectionism: Knowing there is a problem but waiting for the one and only perfect solution.


• Denial: If you don’t really look, it can’t be that big of a problem!


• Isolation: Being the only one aware of the problem and keeping it a secret from the team.


If you begin to see any of the above symptoms in your practice, STOP! Imagine what would happen if you and your team were willing to take the risk and pick just one number (one situational flag) that pointed to an opportunity to upgrade a system and did it. The results would likely be real increases in productivity and profitability, with a fair amount of decrease in stress and worry.


Do I expect you to automatically love your numbers? No. I am hoping for a mild interest and a first date. I suggest that upon entering your first practice; take a look at the spreadsheets and reports. You might discover you’ve got a few challenges to address with the potential for a lot of success to celebrate. Future dentists — start your calculators!


*International speaker and expert in practice management; CEO of Pride Institute, Novato, CA.