Interview of Dr. Peter Muir of Springfield Center for Family Medicine
How long have you been using EMR? Which EMR do you use?
We have been on NextGen Ambulatory EHR since 2003 and NextGen Practice Management since 2006 for billing and scheduling.
Did you have to upgrade your EMR to meet the certified EHR and meaningful use requirements? How much did it cost for you to do that if you had to?
Upgrades are provided as part of NextGen maintenance fees.
What criteria did you find most important in your selection of an EHR?
We selected NextGen EHR in 2002 because the company was focused on clinical offices. It was not a product purchased from another company. NextGen invests heavily in improving the product, which was important to us. I have even attended a development think tank at the company’s headquarters in Horsham. I also wanted the capability to self customize templates and gain full access to data with tools such as Crystal Reports. In addition, the EHR handles routine activities (time, date, etc.) which lets you focus on tracking health maintenance and prevention.
Having demographics, scheduling, clinical and billing in one database makes reporting much easier and more comprehensive than those EHRs with separate databases or separate vendors. Kudos to NextGen for addressing this. It was done so long ago that I take it for granted now, but it has had a huge impact on operability.
It really can take up to a year to migrate information from paper charts into structured data. We were not under a time pressure since we had a self-imposed timetable in 2003. This allowed our docs to progress at their own pace. I changed to doing all my documentation in the EHR approximately 3 months after startup. The first year was stressful but after that you would not go back to paper charts. Because we started the process so long ago, we were really on the ‘bleeding edge.’
How many hours of extra effort do you estimate it took for you and your staff to meet the meaningful use criteria?
It is really difficult to estimate since we have been constantly evolving since 2003. In fact our motto is that the only constant is change. Our work flows are constantly being fine tuned.
What were some of the changes you had to make to your practice style or documentation methods to meet meaningful use?
Cindy Brewer (our business office manager) focuses on office/clerical and I focus on clinical. For Meaningful Use, we had to capture some information as structured data that is not necessarily the most useful for our clinical purposes. For example, race/ethnicity groupings have more in common with government categories than the genetic risk grouping I use clinically. (eg. I differentiate between Northern and Southern Europe descent, and between India and Asia, due to differences in genetic risk.) As a result, we capture that MU-required info in the registration process rather than the clinical process.
I go after smoking cessation aggressively, but in the past would not always document it if it was not the main purpose of the visit. Often, we would document it in the plan as text rather than in the social history smoking cessation check box. Only the later can be easily tabulated for Meaningful Use, so a minor change in our work flow was required to meet that requirement.
There was no real change in our practice style from the patient perspective.
Who helped you through the process (your vendor, a consultant, your REC, etc)?
CMS web site for requirements and advice, attestation process, etc.
NextGen Healthcare for upgrades to software, pathway documents and webinars – very helpful
GBS of Youngstown, Ohio is our NextGen vendor for hardware and software – very helpful
GBS also did our server and security upgrades in 2010 in anticipation of the process
In 2006 I also helped start CCHIE (Collaborating Communities HIE) connecting to and using HealthBridge as our data engine. Southern Indiana HeathLINC (Bloomington) was also connecting to HealthBridge around the same time.
Subsequently, they have added two regions in northern Kentucky and GDAHIN of Dayton OH. Marty Larson is Executive Director of CCHIE and GHADIN. CCHIE board includes: Jim Gravell (Catholic Health Partners), Mark Weiner (Community Mercy Health Partners), two Health Commissioners (Charles Patterson and Shelia Hiddleson), and others.
HealthBridge also spawned the TriState REC. CCHIE is part of the TriState REC. Ron Mayse of CDI Springfield (CCHIE & REC) was of great help for technical support and advice on Meaningful Use. Charles Baumgardner of Far North Computers was helpful for network and security.
I continue to assist CCHIE and the REC as a physician informaticist. I feel it’s important to keep learning by doing.
What would you have done different in your efforts to show meaningful use?
Initially I thought that PQRI (now PQRS) would fulfill the clinical Quality Measures menu component, so I left it towards the end. Fortunately, the required information was already being captured by the time I made the discovery. (BTW, these may be difficult for specialty offices.)
What benefits did you receive from being part of the ONC Meaningful Use Vanguard Program?
I have been using computers to assist medical practices since 1980. The Vanguard Program provides recognition which may allow a greater input in system design and operation, which interested me. The flow of information between systems is critical and has not received enough attention (multiple database silos still exist within and between different vendors). Problems that face healthcare include ICD-10 implementation, variations in LOINC classification, and a lack of standardization.
Meaningful use Stage 1 has a relatively low bar. Are you concerned that stage 2 and 3 might be a much harder challenge?
I think the set points of some items do not jive with real practice. For example, patient portals that are tethered to a vendor would require a patient with three doctors on three different systems to have three different portals. A regional solution would provide for improved flow between offices.
The signal-to-noise ratio is critical, as important information can be buried within a lot of routine data. In other words, a paragraph of pertinent positives can be more helpful for diagnosis that pages of negatives.
What do you say to your fellow doctors who are concerned about implementing an EHR in their practice?
Unless you are planning to retire in the next couple of years, the longer you delay the process, the more compressed the time you’ll have to implement an EHR and the more financial and staffing impact it will have. Those who have waited will know specifically what targets they have to meet for meaningful use, but the activities of daily practice are much broader and more demanding.
The reason for using computers in practice should be to improve patient care, safety and outcomes rather than just meeting meaningful use. Do not select a system that just meets the meaningful use requirements; select a system that assists you in providing better medical care.