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May 2006 — Volume 1, No. 4 
Samuel Goldstein, MD Sports Medicine & Orthopedic Specialists, PC When to go digital? How do you know when your practice is ready to take the plunge into Electronic Records? In 2003, Sports Medicine & Orthopedic Specialists was experiencing rapid growth. A practice that was started as a solo venture had already added a Primary Care Sports MD to a well established Orthopedic Sports specialist. There were two locations, and very busy doctors.
Charts were being transported from one office to another and our space for charts was dwindling. After research and several vendor demonstrations, our decision was made. In July of 2003 we signed our contract and by September of 2003 we had our “go live” day. We now have four physicians and our practice saves several thousand dollars a month with EMR, PACS and an integrated billing system. There have been some difficulties along the way, but these were just temporary set-backs. Once integration was complete, problems have been non-existent. Today practices can learn from the experiences of early adopters like us. There is the EMR selector from HIMSS that allows practices to narrow the number of programs that would fit individual needs. HIMSS also sponsors EMR meetings to help physicians with planning, selection, contracting and implementation. If only we had this available in the “dark ages” just a few years ago. Physicians are facing scrutiny for increased medical errors, decreasing reimbursements and pay-4-performance. EMR helps to address all of these issues. When is the time to take the plunge, now! An Interview with Mark Leavitt, MD, PhD, FHIMSS
Q. How will the certification process help physicians who are ready to implement the EMR in their medical practice? A. Certification of ambulatory EMR products will simplify the decision-making process. Physicians will be able to visit the CCHIT Web site in mid-July to find the list of certified products. It is also very educational to look at these criteria to see what functionality is being acquired. For physicians starting from scratch, this will be a tremendous help because they know that those products (on the Web site) meet the certification standards. In addition, the physicians' work with the vendors can be much more focused. If they have a special need that is not in the criteria for a certified EMR product, they can focus on that application with the vendor. And the vendor doesn't have to demonstrate the product basics across the country. Q. Now that the certification effort has begun, what will happen to the market in terms of the cost for EMR systems? A. Our goal at CCHIT is to see the market, and the value of the EMR, accelerate with certification in place. When this happens, vendors can sell at a lower price and invest more in research and development or attract more capital. For physicians, the lower price will lead to increased implementation of the EMR. These same clinicians will also be more satisfied because their EMR functionality needs have been met and they have an interoperable system that connects to other sources of data at a lab or hospital. Q. Can you go into more detail on the actual certification test? I know there has been some pushback on the number of criteria. A. With 250 criteria that must be met by vendors, our testing is considerably more rigorous than that done by other organizations. We need to do that to satisfy the purchasers and deliver value in this process. The test is actually a demonstration of the products in a patient care situation, which is called a scenario demo. The scenario includes a physician, nurse and patient; the vendor must show how the product works in specified settings. The actual test is conducted over the Web in a simultaneous audio conference. The vendor doesn't have to travel but, instead, works in his/her own setting with familiar staff. Three jurors, including one practicing physician, make up the jury that reviews the scenario for certification of the product. With this design, the process offers a good blend of practicality and technical review. Q. How long does it take to become certified? Some vendors believe it takes a year to receive their certification? A. We will start announcing certified products on a quarterly basis in mid-July. But “up to a year” is not accurate. Vendors that applied in May will have results in less than three months. However, certification for inpatient EMR systems is a year away. Q. Can international EMR products be certified through CCHIT? A. Any vendor can make a business decision that they want to be certified. However, the product must be marketed for sale in the United States. The company itself can be based anywhere. Q. What has been the biggest challenge in putting together the certification criteria? A. Balancing opposing forces has been a challenge, but it is natural to have such opposition surface. Clearly, providers will rely on the certification recommendations for buying assistance. Vendors don't want the process to add a lot of expense, take a lot of time, or interfere with products already selling well. Physicians want, and expect, the testing to be quite rigorous to satisfy the research standards they are used to working with. Q. What is the most pleasant surprise you experienced during this certification process? A. I have been pleasantly surprised by the industry's response…it must have been time for this. CCHIT received generous support from hundreds of people who gave their time and commitment to us. We have a small staff and we have 80 work group members. A lot of people across the industry gave up a lot of time to participate. Q. How can interested vendors find out more information for the next certification process? A. Applicants will be able to access the final certification criteria, test scripts, handbook and sample contract on the CCHIT Web site. Drafts of the criteria and test scripts have been available for review since Nov. 30, 2005. We will publish the first list of certified ambulatory EMR products in mid-July. Certification testing occurs quarterly so the next round of certification applications will be accepted in early August. The Digital Office will have an update on the first group products certified by CCHIT in the July or August issue. FDA Bar Code Regulation Helps Improve Patient Safety A new U.S. Food and Drug Administration (FDA) regulation will help nurses and other clinicians ensure that patients receive the correct blood product during a transfusion or other medical procedure. As of April 26, 2006, certain human drug and biological product labels must contain a bar code that is machine readable. At minimum, the label must carry the National Drug Code (NDC) number, defined by the FDA as a “universal product identifier for human drugs.” Why is this important to patient safety? It means a safer blood supply and improved patient care. Consider these statistics:
With such ongoing and necessary clinician/patient interaction, blood transfusion and medication administration errors can – and do - result in serious adverse drug events. In fact, the FDA estimates that the implementation of the bar code regulation will result in 500,000 fewer medical errors and a savings of $93 billion in healthcare costs during the next 20 years. Of course, happy and healthy patients also mean a reduction in hospital litigation and better diagnosis documentation. Bar codes and radio frequency identification (RFID) labels on these products now give nurses a technological backup when managing transfusions. Typically, two nurses administer blood to the patient by checking the patient's name and other information on the label. Instead, technology will manage the first data review followed by the human clinical component to ensure the technology does not fail. Will the technology really work? The new standard reduced the medical error rate by as much as 70 percent, according to a pilot study conducted in 1999 by the Veterans Administration Healthcare System study conducted in Topeka, Kansas. More information on bar code regulation. Read the FDA regulation.
Source: John Halamka, MD, in a column titled "Early Experiences with E-prescribing," in the Spring 2006 Journal of Healthcare Information Management. Dr. Halamka is the CIO of Harvard Medical School and Beth Israel Deaconess Medical Center as well as an early adopter of RFID, including having a passive chip implanted in his triceps.
Resources for the Digital Office
EHRVA - Electronic Health Records Vendors' Association HIMSS EHRVA is a trade association of electronic health record (EHR) vendors that addresses national efforts to create interoperable EHRs in hospital and ambulatory care settings. The association is a partner of the Healthcare Information and Management Systems Society (HIMSS) and operates as an organizational unit within HIMSS for vendors who are EHR software solution providers. HIMSS EHRVA helps HIMSS establish its strategic direction and official positions on issues related to the EHR. The EHRVA Interoperability Roadmap supports the national goal of interoperable electronic health records and provides a pragmatic, logical plan that will succeed when adopted and implemented by key stakeholders. The EHRVA provides this Roadmap to mobilize the leadership of healthcare organizations, information technology vendors and other relevant stakeholders to collectively deliver on the vision by incorporating this Roadmap into their plans. Download the EHRVA Interoperability Roadmap (The roadmap is 46 pages.)
Develop a Costing Model for Total Cost of Ownership When considering costs of implementing an electronic medical record, it is extremely valuable for the physician practice to develop a costing model that identifies the Total Cost of Ownership (TCO) across the entire life cycle of the project: from pre-implementation planning through ongoing support and sustainability. Essentially, TCO is not only about identifying and understanding those one-time costs that are incurred to implement and bring a project to a production environment, but it is also about understanding both the recurring and variable costs of a project over its life. When developing a costing model, it is helpful to consider capital and operating costs, as well as vendor direct, indirect, fixed, and variable costs from the various perspectives or phases of a project. These include:
Indirect costs usually are not directly associated to the project, such as unplanned downtime, overtime, etc. Operating expenses are typically those costs that are planned for over time and can include rolling replacement of hardware, hardware and software maintenance. There may also be variable operating expenses, such as re-training of existing staff, staff and replacement. Other factors may also influence TCO, such as initial declines in provider productivity, which is an indirect cost of the implementation that affects revenue. The more time that is spent understanding all costs associated with a project, the more informed the physician practice will be from a TCO perspective.
CHARTCARE's EMR Eden Park Pediatric Associates, a five-physician group practice in Lancaster, Penn., began an evaluation process in 2004 to replace its paper-based medical records system with an EMR. The practice wanted to provide clinicians with faster, more streamlined access to patient records and ready access to patient information concurrently at the two clinical sites. After a thorough evaluation process, the practice selected CHARTCARE EMR by CHARTCARE, Inc. of Lakewood, Wash. This EMR not only integrates seamlessly with the group's pediatric-specific practice management system by Physicians Computer Company, but it also is one of the few EMRs to offer pediatric-specific functionality including integrated growth charts, immunization reports and categories that can mirror the standard Denver Developmental Flow Sheet. Now, two years later, clinicians rely on instant access to patient notes instead of waiting four days for transcription. The EMR also has streamlined and improved the everyday processes that support and uphold Eden Park 's delivery of quality care. ROI: Eden Park saved an annualized $114,000 – more than 10 percent of its operating budget – by implementing an EMR that eliminated transcription fees and reduced administrative staff by 25 percent. The practice used the savings to fund a new position designed to boost patient adherence to treatment plans. Source: "Financial Savings From an Electronic Medical Record in a Small Group Practice," by Colleen Cook-Moine, MD, and Lynn Cramer, RNC, 2006. 
Kathlene Walters and Howard T. Harcke, MD, of the Alfred I. DuPont Hospital for Children in Wilmington, Del., understand the benefits of technology, specifically the electronic work list visible on the screen and voice recognition technology, a contrast to the single piece of paper on the desk. Don't Miss the PACT Conference in Your Area Electronic Medical Records – A challenge or an opportunity? It's both. The EMR is becoming an effective and beneficial component of doing business in today's U.S. healthcare environment… Mark these dates above for upcoming Physician Adopting Computer Technology (PACT) conferences. * June 24 – Boston, MA The one-day meeting offers physicians, practice managers and others an opportunity to address the challenges and successes of EMR implementation. Register now for PACT and meet the early adopters of this new technology to understand what it takes to successfully convert from paper to electronic records. Physicians Adopting Computer Technology (PACT) is jointly sponsored between the Massachusetts Medical Society and HIMSS. The Massachusetts Medical Society designates this educational activity for a maximum of 7 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity.
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The Digital Office talked with Mark Leavitt, MD, PhD, chair of the Certification Commission for Health Information Technology (CCHIT), about the application process for the first certification announcement of ambulatory care EMR products scheduled for release in mid-July. Vendors could apply for certification of their products from May 3-12. Following is an excerpt from this interview. 
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