Teleradiology practice Virtual Radiologic Consultants (VRC) makes its home in Eden Prairie, Minn, but only its business office and information technology (IT) department are in the Twin Cities area. The company employs or contracts with dozens of radiologists worldwide, giving its clients round-the-clock access to expert opinions. “They live wherever in the world they want to,” says CTO Brent Backhaus.

From remote points all over the globe, VRC radiologists provide 24-hour coverage to emergency departments and other critical-care areas. “A lot of our customers are asking us to provide final reads,” he says.

The premise behind the service, according to Backhaus, is that the workload of other practices has increased but physicians are not willing to take calls every night. Practices use the promise of not having to be on call as a tool to recruit and retain physicians and to gain new business. “At least [clients] can have their nights and weekends available to them,” he says.

None of this would be possible without electronic medical records (EMRs), state-of-the-art digital imaging, secure infrastructure, and other high-tech information systems. “It’s as electronic as you’re going to get right now,” Backhaus says.

Because it is a “virtual” operation, VRC is an atypical example of an electronic practice. However, more and more traditional physician groups are realizing that paper records, transcribed documentation, and film-based imaging are inefficient and old-fashioned.

Sure, EMRs can be expensive. They require not only a financial investment, but also a retooling of long-established processes. Sure, payors—including Medicare—have been slow to move to standardized electronic transactions under the Health Insurance Portability and Accountability Act (HIPAA).

Practices remain under unprecedented financial pressure, with increased demand for clinician time, declining reimbursements, and spiraling malpractice insurance premiums. To this point, only a smattering of health plans have offered to pay bonuses for technology that promotes patient safety and improved outcomes. Even fewer malpractice carriers have provided incentives for putting in safeguards against medical errors. But even the most basic technologies can save a practice money.

A Quick Scan
John Dulcey, MD, is chief medical officer of NextGen Healthcare Information Systems (Horsham, Pa), an ambulatory EMR vendor. He estimates that each chart pull costs $4–$9 in both staff time and lost productivity as physicians, nurses, and billing clerks wait for patient records. “Not having to move charts from place to place is a big advantage,” he says.

A simple means of sharing information is through the scanning of paper documents to make records available from multiple locations simultaneously. “When things are scanned, there can be ubiquitous access,” Dulcey says.

However, he considers scanning to be an “interim solution,” because scanned documents are merely electronic representations of paper forms. Users can view and send the images over a network, but they cannot do anything with the data itself, such as populate patient history forms, create referral letters, or mine the information for benchmarking and quality-improvement purposes.

“It is a way to get physicians to use electronic devices. You’re moving them along the continuum of usage,” Dulcey says. “Scanning helps a great deal in the implementation process.” Even software like Microsoft Excel can be a “basic format of patient documentation,” according to Dulcey, but certainly, it is not an EMR. “I would consider scanning a little above [Excel] in terms of functionality.” However, until there are true EMRs, “offices will still be exchanging paper,” he says.

Graves-Gilbert Clinic (Bowling Green, Ky) originally looked at scanning as a low-cost alternative to an EMR, but decided that it would not do much to reduce errors or provide better patient care. “It was not a searchable database. It’s just an image,” says Steve Sinclair, associate administrator and CFO at the clinic.

Southeast Texas Medical Associates (SETMA of Beaumont, Tex) turned to scanning last year as a more efficient means of storing and retrieving the old records that have lined dusty shelves of file rooms for years. Since January 1999, SETMA practitioners have been documenting patient encounters electronically.

“When we started, I felt like we could be paperless within 5 years,” says James L. Holly, MD, CEO of the multi-specialty practice. “We beat that by 2 months.” However, Holly says that the main goal wasn’t to simply eliminate paper. “We wanted to do a better job treating patients,” he explains.

Today, SETMA has full electronic integration of all three of its clinical locations and three ancillary centers, offering a hospice, home healthcare, physical therapy, and a mobile X-ray facility. Any of the 40 providers—including 21 physicians, plus nurses, physician assistants, and physical therapists—can access patient records, check laboratory results, view images, and enter orders from any computer within the practice. The doctors and other providers are supported by more than 250 additional staffers, including a complete IT department to manage the network.

SETMA has hardwired its system to a local hospital so that physicians can view and update records while caring for patients there. Plus, all practitioners have direct access to the database from their home computers.

Case Studies
Holly defines an EMR as an “electronic means for electronic documentation of a patient encounter.” While scanning essentially is the management of documents, EMRs involve true data management. Holly says that SETMA has gone beyond document management, all the way to “electronic patient management,” proof that a physician actually is doing a better job. That will be important as Medicare and private health insurers start paying physicians for quality, he says.

The practice has adopted clinical benchmarks for various chronic diseases, including congestive heart failure, diabetes, asthma, hypertension, and depression. Physicians and other providers can choose between point-and-click data entry from templates, typing, voice-activated dictation directly into the computer system, and scanning to capture patient information and document encounters. Some practitioners use speech recognition technology, but the general consensus among industry experts is that speech recognition is not yet accurate enough to replace medical transcription completely.

Elizabeth Herrell, an analyst with Forrester Research’s telecom research group (Cambridge, Mass), says that there is not a single product currently available that can produce medical transcripts from spoken dictation without the need for editing, largely because of the complex vocabulary in medicine. “All of them still require some manual reading,” Herrell claims.

The SETMA system—NextGen’s EMR—keeps a record of all incoming telephone calls and the practice’s response to each call, which is helpful for compliance with HIPAA privacy rules and for defending against malpractice claims. It also includes the capability to fax electronically generated prescriptions directly to pharmacies; to produce referral letters in an instant; and to send lab results and other information to patients through a secure, password-protected email gateway.

It should be noted, of course, that online physician-patient communication is poised to grow. As of July 1, the American Medical Association (Chicago) began implementing a new CPT (current procedural terminology) code, 0074T, that allows practices to bill for this service as long as they keep an electronic or paper record of the exchange.¹ Few insurers, however, have announced plans to accept this Category III “experimental” code to reimburse for electronic communications.

The SETMA electronic infrastructure provides clinical decision support and computerized physician order entry (CPOE), including automatic warnings of possible drug interactions, right at the point of care.

On the administrative side, staff members can view the master patient index, schedule appointments, and verify insurance eligibility from their desktop computers. The system captures charges and generates billing codes at the moment practitioners enter orders and document procedures; then it generates HIPAA-compliant transactions.

According to a 2002 study of SETMA’s return on investment, “Because we now bill automatically from the patient’s examination room, our overall average charge per patient visit has increased from $171 to $206 (a 20% increase), and the average collection increased from $80 to $104 (a 30% increase)” between 2000 and 2001.

“From a financial perspective, the return on investment has been enormous,” Holly says. But it did involve a large initial outlay of capital—a deal-breaker for many cash-strapped practices.

“The reality is that systems will reduce costs after an initial lag time of 12 to 18 months,” Holly says. However, he concedes, “Surviving until you get there can be tough. There was some belt-tightening along the way.”

Admittedly, SETMA went for a more comprehensive infrastructure than it knew it needed in the short term. Back in 1999, the practice had just seven physicians, but Holly had intentions of growth. “We built a system that was scalable to 100 physicians,” he says.

Practice officials also built multiple redundancies into the system and back up all data 5–10 times a day. In case of a catastrophe, like a flood or fire that destroys the entire infrastructure, SETMA has a plan for restoring everything from the backups within 3 hours. Holly happily reports, “We have had 6 hours of downtime in 5 years.”

Few physician groups have such capabilities or contingencies. More typical of electronic practices is the incremental approach adopted by the Graves-Gilbert Clinic.

The multi-specialty practice has 53 physicians in two locations just one block apart from each other. The clinic also staffs a freestanding, walk-in urgent care center about 5 miles from the main clinic.

Graves-Gilbert has had a laboratory information system for 2 years and recently completed installation of a PACS. “It took 4 to 5 months to get [the PACS] fully implemented to work with all radiology modalities,” says Tom Babik, practice administrator. The one thing the medical group does not have, however, is an EMR.

Graves-Gilbert currently is evaluating vendors and is perhaps 18 months away from having a true working EMR, one that would aid in continuity of care and in improving patient satisfaction. So far, the clinic has not been able to find a suitable product, according to Sinclair, the associate administrator. “At some point, it’s going to replace the old way,” he says.

Clinic staff actually made a conscious decision to move slowly, in part because clinic officials have determined that they would need 11 different interfaces to an EMR from existing lab, PACS, billing, and affiliated hospital systems to create full integration. “Fully integrated would mean that our physicians would be able to look at records from any facility,” Babik says, referring to any Graves-Gilbert facility and affiliated hospitals where its own doctors practice.

Working Toward Unity
Integration is fast becoming a buzz word across the entire US health system. Earlier this year, President Bush called for nearly all Americans to have complete electronic health records by 2014 and appointed medical informaticist David Brailer, MD, PhD, as the first-ever national health IT coordinator.² Last year, the Department of Veterans Affairs and the Military Health System joined with the Department of Health and Human Services (HHS) to promote electronic connectivity and interoperability between federal healthcare providers.

Meanwhile, the private sector, with some prodding from HHS Secretary Tommy Thompson, has been busy developing working standards for electronic health records and for a minimum set of data that patients should have to ensure proper continuity when they move between care settings.

Although vendors of healthcare software and medical devices continue to sell and develop proprietary technology, many are building their products with integration in mind.

“One innovation has been the integration of medical imaging devices into the [Web] browser,” says NextGen’s Dulcey. Newer iterations of NextGen software lets users view reference-quality images—as primary care physicians generally do not need the bandwidth-hogging full fidelity required by diagnostic radiologists—directly through a browser window in the EMR so they do not have to sign on to multiple systems.

In the near future, Dulcey says there will be a “continuing evolution of video-type displays” so that referring physicians will be able to display full-motion video of procedures like coronary angiography right in a Web browser.

As a radiology practice, VRC needs to send uncompressed digital images to its far-flung practitioners. Its physicians read images from high-resolution monitors, then dictate reports into digital recorders.

In producing electronic documentation, “they make very efficient use of macros and speech recognition,” VRC’s Backhaus says. But rather than zapping data across the Internet at light speed, VRC radiologists usually end up sending their reports by a decidedly 20th century means.

VRC has no near-term plans to force its clients to interface their systems. “We’re big believers in evolution rather than revolution,” Backhaus says. “We have not found an emergency department yet that wants anything other than a fax.”

The same is true at Graves-Gilbert. “Every day, we get closer to making that [EMR] decision,” Babik says. “Think of it as a bumpy plane ride to the Bahamas.” The journey may be harrowing, but “it’s well worth the trip.”

Neil Versel is a contributing writer for Medical Imaging.

References
1. American Medical Association. Category III CPT Codes. Available at: http://www.ama-assn.org/ama/pub/article/3885-4897.html.   Accessed July 1, 2004.
2. Government to Business. Consolidated Health Informatics. Available at: http://www.whitehouse.gov/omb/egov/gtob/health_informatics.htm.   Accessed July 10, 2004.