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Making sense of EMR systems

November 1, 2010
by David T. Smith, PhD, LICSW
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A Minnesota treatment agency navigates numerous variables in the planning process

Speculation regarding behavioral healthcare compliance and implementation requirements for electronic medical records (EMRs) has escalated as IT vendors offer decision-makers a bedazzling array of software options, and federal incentives come on line before the 2015 federal EMR deadline. Providentially, the basic government requirement is that healthcare organizations billing Medicare need only an “element” of an EMR in place by 2015, which can easily be met by planning.

During 2010, New Beginnings at Waverly, LLC, one of Minnesota's largest addiction treatment providers, purchased a flexible-design EMR system. The system has customizable evidence-based treatment planning features capable of accommodating high patient record volumes across multiple sites and levels of care. Presented here for organizations at the outset of their EMR decision-making process are the variables encountered in the planning, selection, purchase and design of an EMR system.

Simply, “An EMR (electronic medical record) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision making. The EMR can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EMR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.”1

One staff chorus chants, “We spend all our time looking at computers, not clients.” Others reply, “We cut our paperwork by 50 percent, spending more time with clients.” Both of these statements accentuate a new behavioral healthcare axiom: Technology is clinical, and technology has clinical implications. Each human contact within a treatment environment results in the production of data, and building a database capable of capturing the essence of these data communications requires analyses of conceivable clinical interactions to produce meaningful data for entry and storage in any EMR system.

EMRs are simply sophisticated data collection mechanisms with the advantages and limitations of any research tool involving collection, analysis and generation of findings or actions to be taken in response to data collected. Exactly how EMR data are collected determines the quality of clinical patient information and patient care. Vendor selection, price, bandwidth, hardware configurations, system capability, expectations, regulatory standards, and maintenance are the elements of successful EMR planning. They overlap like variables in any major initiative and are not easily disentangled.

New Beginnings’ experiences

We found that vendor presentations vary widely. We attended trade shows, which provided the advantage of examining operational displays and opportunities to interview knowledgeable staff and identify preliminary planning issues. Internet sites were helpful resources, as vendors offer video or screen shots as well as customer testimonials. We conducted vendor phone conferences that enabled our CEO and CFO to ask questions relevant to operational and financial planning.

The process lasted several months, before we chose Celerity's Clinical Addiction Manager (CAM) system. It offered us the requisite flexibility of accommodating our custom evidence-based treatment planning model, and it had been recommended by another provider.

Prices of EMRs varied considerably. Programs ranged from under $50,000 to well over $400,000. Celerity was on the low end of the above range, as the system required our contributing to the design and operationalizing of the system architecture from in-house resources, which requires some employee technical competence.

A word of caution: Under- or over-purchasing EMRs can lead to big problems. One example of under-purchasing might arise in the case of CEOs who are reluctant to allocate adequately for an EMR system because exponentially increasing technology costs may not be seen as improving the bottom line as measurably as more tangible capital expenses.

Over-purchasing can occur with expensive “modular” or “heavyweight” programs that offer accounting, human resources and scheduling functions, which smaller organizations might not need. Be wary of vendors selling you four out of 10 modules in a software program. Some high-end programs offer little design flexibility and might come with hidden costs related to software changes, the addition of new forms, annual fees, maintenance, and system upgrades. Overall annual program fees could range from $7,500 to more than $20,000, a significant expense for smaller programs.

Got bandwidth? Downloading information from the Internet takes less bandwidth than uploading. Consequently we will still have a hard copy chart, as one of the few ways to add external data to a clinical record is via scanning and/or uploading, which is bandwidth intensive. A T1 (heavy data) line might cost $300 to $1,000 per month for service, multiplied by number of sites. Add the scanning technology or personnel and/or the scanning service, and numbers get big fast. Know your bandwidth capacity before you purchase your software system. You will have difficulty driving a Ferrari software program on country road bandwidth.

Now, for the most tangible variable in the planning process: Will your server(s) be located on-site or Web-based? Do you have reliable data backup and power systems? At New Beginnings we chose a “cloud” or Web-based server. It handles bigger files, and the off-site server is free of on-site power dependence or risk related to the half-life of an on-site server (and they do have half-lives).