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160 pts.
 Top recommendations for an integrated approach to EHR/EMR when cash is strapped?
The adoption of EHR/EMR is more often than not a gradual, piecemeal endeavor. First billing systems are considered, then clinical values and nursing notes from med-surg, followed by the lab and moving into CPOE and the like. In this process, there tends to be a lack consistency in systems which hinders real interoperability, making it difficult to interface different components, etc. If you are a small to mid sized facility trying to make the journey as smooth as possible (who most likely does not have the funds or resources to transition in one pass), what are some top recommendations and tips to making adoption as smooth, and integrated, as possible? 
ASKED: April 29, 2010  7:20 PM
UPDATED: June 22, 2010  3:50 pm

Answer Wiki:
Succesfully implementing EMR/EHR at minimal cost requires extensive preparation. Here are some tips to make sure the transition as smooth as possible. Each of these can be expanded if you want more detail. 1. Evaluate and chart your current processes. Be as detailed as you can. Draw up work flow charts for each activity. 2. Try to find any holes in your process -- are charts or other data sinking into "black holes". Do you have camouflaged work processes that are not adding value? 3. Once you have completed the above, change your current work flows and procedures to be as efficient as possible. 4. You MUST eliminate silo thinking and practices. An EMR/EHR system works best and is most easily applied when the whole system, from patient aquisition to final receipt of payment is regarded as one process. e.g. billing is NOT a separate process from clinical work. Properly entered notes and clinical values must support billing. Whatever training needs to be done to get clinical staff (particularly providers) to move toward proper ICD coding will save a TON of money in billing and in reduction of rejections. Weekly peer reviews are great for improving practices. 5. When comparing different EMR systems for cost -- do not review just the intial costs, but the cost over the first twelve months. This eliminates the difficulties of trying to compare the different systems since they all have different pricing structures. There is much more to the process, but this will get you thinking about it. Please resist the piecemeal approach. It will cost much more in the long run and create much misery for everyone. There are integrated systems available that would actually cost less than trying to integrate separate systems. Remember, a lousy process automated is still a lousy process. However, it will be faster at producing bad results. Your efforts at streamlining and integrating your current system should, if done properly and objectively, save you the cost of a new EMR/EHR system. And the Doctors will love you. The keys to actual implementation in the smoothest and fastest way are another discussion.
Last Wiki Answer Submitted:  June 4, 2010  11:29 pm  by  Dyson12   35 pts.
All Answer Wiki Contributors:  Dyson12   35 pts.
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Two men (or women, or a man and a woman), analyze the issues concerning the sunrise. One says, it is light outside therefore the sun will come up. The other concludes that it is light outside because the sun is rising! Neither will ever convince or disprove the other.

This the same logic applied by most of us trying to discuss why or why not health care information systems are successful and cost effective – or not. What are we really talking about when we say ELECTRONIC Health Care systems? We are talking about computer technology (files, records and fields oh my!) as applied to the health care industry.

I am involved in one of the largest electronic health care implementations to date. The intent of this venture is to provide services to affiliates in the out lying community who cannot afford to go it alone. I was asked what should we be doing to improve our EMR offering. My response was immediate – create an engineering environment separate from the production and non-production environments (Q/A, Test, Training). This will create the proper atmosphere to support this kind of venture and the engineering neighborhood to raise your engineering support work force. This will eventually happen anyway, after great suffering, high costs, missed deliverable dates and gnashing of teeth. My audience was surprised at my response, but I was not surprised by theirs.

The answer to the sunrise question – the sun never rises.

 280 pts.


The only thing I will add, since you mention CPOE and interoperability in your question, is when considering the cost, do not forget about the possible cost of all the interfaces, needed for meaningful use. The most immediate interface, sending e-requisitions to your labs, can cost between $3000 – $5000. There are instances whereas, the Lab will pay the vendor for this interface to keep your business. However, this usually requires you to meet an Average Monthly Lab volume for the lab. Note: Typically Labcorp has less stringent requirements than Quest. Additionally you would want to identify the type of interfaces each EHR vendor has with each of your labs (i.e. bi-directional, uni-directional, demographic bridges). These considerations must be paramount in your EHR vendor decisions!

 410 pts.


With regard to solo and small independent practices, the step-by-step approach is necessary. I strongly agree with Dyson12. One needs to begin with a thorough understanding of the entire process and a complete vision of how the practice will operate after the EMR/EHR is fully operational. It is far better to have a single system solution that spans the entire process and shares a single data model than to have a lashup of separate products that require interfaces to resolve their incompatibilities. However, with respect to implementation, the approach needs to be step-by-step in order to allow for the practice to learn how to use the functions of the system effectively and, most important, to mitigate the impact of the loss in revenue which will occur during the transition. The implementation should be planned in such a way that each step delivers operational benefits that become the foundation for the next step.

 385 pts.


The interoperability problem is out of hand and too late, due to various reasons, but not out of control. I’m little apprehensive about the way the problem is approached for reaching at a solution.

First of all the size of a EMR is huge with so many sub-systems in it. I see lots of similarity in an EMR and ERP software. There are lots of small vendors providing service to just one or two sub-systems. A physician’s office sometimes ends of having at least 2 products, if the office wanted to be cost-effective. To solve the problem, in my personal opinion we follow below strategies –
1. The users should start buying products from a vendor who gives the whole product and not just 2 or 3 subsystems. This is like a company just deploying HR module of SAP or “supply chain” module of Oracle and wants to integrate both of them. Once the smaller players, who can’t contribute to the interoperability process are removed, the job is half done.
2. The standard bodies who are trying to control the interoperability problem, should focus on “interface points” and should strongly enforce the “entry criteria” and “exit criteria” at each “interface points” and certify this.
3. The standard bodies should either focus less or should not enforce the business process of a physician or hospital. Rather it should be upto the physician how he / she wants to do his business, rather than being dictated by someone else. This will create a opportunity for customization and the EMR implementor will have to customize and get certified with all interface points as defined by IHE or HITSP.

 200 pts.

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