For subjective-objective-assessment-plan (SOAP)-based patient care, the first generation of electronic medical records (EMR) systems worked well. Medical specialties which are primarily text-oriented tended to fare better, as compared to graphic-oriented specialties such as ophthalmology. At our practice we have used an EPM since 1983. But although this software met our needs for billing and scheduling, we were still accumulating stacks of paper records which required an increasing expense just to store the paper.

As we considered a change to an electronic medical records system, our practice compared the expected costs for paper records storage to the costs of converting to a new system. We fully understood that we’d have to become more efficient to make the transition cost-effective.

System Implementation Costs include:

* Infrastructure
* Consulting
* Software
* Hardware
* Tech Support

We also included the cost of additional work-hours which will be spent training people on the new system, along with data entry. In most cases a practice uses both the old and new systems concurrently until the entire conversion is complete. In the meantime, there could be some redundant tasks.

The primary factor in our decision to switch to EMR was based on the need to reduce the growing mass of paper we were storing. And it didn’t hurt to hopefully ride the wave of financial incentives from the government for EMR implementation. Meanwhile, there was the opportunity to proactively implement new HIPAA privacy and security guidelines in a way that would work best in our practice.

System Benefits Include:

* Improved Communication
* Better Efficiency
* Improved Compliance
* Enhanced Documentation
* Justifiable Coding
* Improved Integration

At our practice, the business choice came down to the belief that we could recoup our investment in approximately five years. This calculation was based on the savings of projected storage space costs, along with reduced needs for printing expenses and services. The journal Health Affairs found that the average primary-care practice recovered its costs in 30 months.

It is more difficult to measure the value of change to job efficiency and changes in staffing patterns, but we are monitoring these factors to accurately measure returns on our investment. Some studies have shown reductions in medical records staffing of 0.25 - 0.5 full-time equivalents (FTEs) as well as significant savings in dictation costs.

The overall trend seems to be toward a world where EMR is the norm. Insurance companies and government are placing more pressure on health-care providers to standardize medical records, and EMR could soon become obligatory. Costs are dropping as more businesses adopt the technology; soon even the smallest practices may find it cost-effective to ‘go paperless’.

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First, understand that a wireless network isn’t actually totally wireless. Something must be plugged in to something else somewhere. Also consider that a wireless system has several layers of associated expense.

You should work with a wireless consultant - preferably someone with experience installing wireless networks properly. A system that is implemented incorrectly will yield poor performance. Our practice chose to go with a Cisco-certified wireless network engineer. If you aren’t able to find someone with these rare qualifications, at least go with a consultant who specializes in network installation.

An expert consultant will use special equipment to map radio frequencies within the building. This will help to determine where to put the antennas. Our consultant’s team took several days to spread the antennas out on tripods, finally producing a map which illustrated the radio frequency overlay and a list of recommended placements.

If you plan to use cordless computers, you’ll have to use long-lasting batteries with plenty of back-ups available. Unless you’re using a special battery charger dock, this can’t be managed on the laptops. You may need to carefully plan your clinics, keeping in mind that the typical battery only holds a charge for about three hours.

Have a clear understanding of what is in your building. Is there lead in the walls? How about metal in the ceiling? These sorts of factors can either improve the signal through reflection, or degrade it overall. Are other wireless signals being broadcast in the area? Even microwaves and phones can have an effect on the signal, and most wireless networks are operating on a frequency which is on a spectrum in widespread use by other devices. The object is to prevent interference.

Be sure to keep a budget. One medical practice decided to use laptop computers connected to 24-inch monitors. This let both the patient and doctor see the monitor at the same time. However, this turned out to be costly - laptops are typically the priciest devices. Usually regular desktops are the most cost-effective solution.

Are you thinking about installing the wireless network yourself? Some network solutions on the market work well for e-mail and Internet, but might not quite cut it for operating your electronic medical records (EMR) system. There are two main reasons for this:

* Consumer wireless access points generally use a signal fixed on a higher strength than a usual laptop wireless card. This may sound good, but actually means that a laptop could detect a signal which is more powerful than it can actually return, resulting in a broken connection.

* If you require more than one wireless access point, there could be a conflict. Just walking from one side of the office to the other with the laptop could cause your session to drop, requiring another login after a possible loss of data.

Regardless of your final choice for wireless EMR implementation, make sure your team is on-board. And try to justify all purchases and keep an eye on costs. Refrain from indulging on the latest gizmos when you can - instead, stay focused on serving your patients in an efficient but cost-effective way.

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3 months? 6 months? A year?

Of course, this is a trick question. First, you have to define when the actual project starts. Is it as soon as you make the decision to go paperless? Is it as soon as you have purchased the software? The hardware?

If you aren’t already using EMR, you are no doubt feeling some pressure from Washington to get with the program. After all, there is some serious money coming in the form of incentives in the next couple of years. Although, you can most certainly spend some serious money on the endeavor, especially if you don’t plan properly. With a reported failure rate of 30-50%, EMR implementation will be one of the biggest jobs your practice will tackle.

In our case, the timeline was more like three years. Granted, we could have pushed to meet the original goal of eighteen months. But, the arrival of two new partners - and two hurricanes - pushed this back. In subsequent articles, we will discuss the mechanics of the actual rollout. But for now, we will stick with the planning process. That’s the part that most practices fail to do, and which ultimately is the main cause of failure.

Some of these things may have been mentioned before, but I will summarize all the steps of a proper implementation of your EMR project:

1. Perform a needs/wants assessment. What exactly are you looking for in an EMR system?
2. Set up an EMR committee. This should include key players from different aspects of the practice: doctors, nurses, medical assistants, administration, billing, and of course information technology (IT).
3. The EMR committee should come up with a check list for an ideal EMR system based on #1. What are ‘must-haves’, ‘would-like-to-haves’, and ‘neato-cool-wish-list’ features?
4. Based on #3, come up with a short list of EMR systems, interview and demo them, check references, perform due diligence, and then make your choice.
5. Consult with a certified project manager. Check out the Project Management Institute . You may think you can’t afford one, but the truth is you probably can’t afford not to. Alternatively, ask your EMR vendor for some recommendations. The last option is to have your IT person or consultant to run the project - but this person should have some experience with project implementation, not just IT.

The project manager, or your staff member who has been trained to be one, will set up your project in a dynamic timeline known as a Work Breakdown Structure (WBS). This tool has the ability to adapt to changes in your schedule which will undoubtedly occur. By contrast, a schedule set up on a traditionally rigid calendar can easily be scuttled by a minor setback - this is a perfect opportunity for the naysayers to voice their “I told you so’s”.

For the do-it-yourselfers, use the tool the professionals use for producing your own WBS, mind-mapping software. The gold standard is MindJet’s MindManager. Although there are some less expensive or even free products out there, this is the most robust and the files are ubiquitous.

However you do it, don’t do it alone. And take the time up front to plan properly. This way, your project can roll with the punches instead of rolling over dead.

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But, anyway, this is supposed to be about EMR.

Although as an ophthalmologist I try to spend as little time as possible in a real hospital, other medical practitioners do actually spend a lot of time tending to truly sick patients. For those docs, wouldn’t it be nice to be able to document patient visits on a handheld device?

In iPhone Magazine, there is an article on some cool apps for the iPhone for the physician on the go (and yes, I know, he is not holding an iPhone in the picture).

iChart EMR for the iPhone comes bundled with a web application for syncing and, in addition to managing patient care, also handles coding and billing. At $139 it is considered ‘expensive’ for an iPhone app, but that is pretty cheap as EMR systems go.

Some technology writers will debate the merits of convergence, where one device becomes the do-all, end-all: phone, pda, pager, computer, reader, etc. For physicians at least, it would be nice to have a phone which can truly run an EMR solution. I have not personally tested the iChart EMR system but it looks like it might be worth checking out.

Also mentioned in the article is the Epocrates Rx free drug and formulary reference. I downloaded it one morning and ended up using it a couple of times that day. The Premium version, which I passed on,  includes such things as infectious disease treatment, diagnostic and lab tests, and pictures of pills at $149 per year.