Jupiter Medical Center – Dr. Irma Lopez – EHR Experience (After the Implementation)

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Category: Reality
Date: April 6, 2010
Views:6,637 views
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Part 1 - The Interview

Dr. Eric Fishman: This is Dr. Eric Fishman for EHRtv and we're speaking with Dr. Irma Lopez, a board-certified internal medicine physician in Jupiter, Florida. Dr. Lopez has been using Practice Partner for approximately 15 months and we're going to learn about her experiences today. Irma, thank you for allowing us to share your office for a few minutes. Can you tell us why it is that you decided to start utilizing an electronic health record?

Dr. Irma Lopez: Since I first started practicing medicine, I always found it very difficult to keep up with the records. Whenever I would see that the medical record was developing, I said that would be ideal that I don't have to have charts all over my office and always looking for the next order, the report or have my staff walking through the office looking for charts and trying to accommodate reports with charts right before I can see the patient. Or worst than that, in front of the patients looking for that report that I know I saw but where was file. So it was always in my dreams to have electronic medical record.

Dr. Eric Fishman: And you were practicing about 10 or 11 years in Palm Beach County prior to even getting the EHR.

Dr. Irma Lopez: That's correct. Whenever I would look to acquire one, I would go to these conferences where they were selling all these systems. I would look to each of them and they all looked good but my fear is how am I going to be able to pay for this that was number one. Number two is once I go through the investment, am I going to be able to use it.

Dr. Eric Fishman: I see you're wearing the Jupiter Medical Center jacket. You're on staff at the medical center and the Stark exception allows them to pay a meaningful portion of the installation. Was that part of your decision process?

Dr. Irma Lopez: Yes, that was why we were able to do it and why I decided to go with Practice Partner. I knew they put a lot of research behind Practice Partner and the company. It was expensive software and they are willing to associate with us physicians. We paid a very modest fee for the software but best of all is the team that they put together to train us physicians how to use the system. These girls are very, very good.

Dr. Eric Fishman: And I understand approximately a three month period of time at the end of 2008 - maybe October, November, December - where the transition went from using only paper records to using almost exclusively Practice Partner?

Dr. Irma Lopez: I would say that we started October, September 2008 to train the staff. They would go from very little details to explain exactly how we'll integrate the front office to the whole office at work and then start training for the physicians.

Dr. Eric Fishman: How did the staff like it?

Dr. Irma Lopez: At first they were fearful because they have been working with me for several years using the same system, very methodical and all of a sudden they have to learn something new. Like every human we don't like changes.

Dr. Eric Fishman: How long did it take until they were sort of very happy with it because you're right, September, October, November of 2008 might have been a difficult point and time. When did the aha moment arise in your staff in general?

Dr. Irma Lopez: I would say we introduced slowly and the details were increasing on the daily basis. The Jupiter Hospital IT team would come to our office, sit next to them and go over the details over and over in a practical way. The patients were calling; it's time to set up the appointment.

Dr. Eric Fishman: And you were seeing patients during this time.

Dr. Irma Lopez: Correct. What are we doing now? And they love it.

Dr. Eric Fishman: Did you have to lower your patient volume during that period of time or did you stay later or did you just pack it all into the normal day?

Dr. Irma Lopez: There were at least three days that we tried to have minimal patients so we would all be able to go patients to the computer and write all the full note. It took like two, three days. After that, it was in the middle of the season so it was no time to waste.

Dr. Eric Fishman: Can't do it.

Dr. Irma Lopez: We would have to do the full schedule. I would say I was staying here in the office long hours trying to learn the system.

Dr. Eric Fishman: For how long? Was that days, weeks, more than a month?

Dr. Irma Lopez: I will say weeks, at least three to four months that I was more comfortable going inside the patient's room, writing my notes, writing what was then in front of me. I got to know the templates well that I didn't have to be looking to see where was everything and was able to recognize the different templates and just get to work with them while the patient was in front of me. I would say it was probably three to four months.

Dr. Eric Fishman: That would be January, February maybe March of 2009?

Dr. Irma Lopez: By January 1, just because the year was about to start, we decided since today we will not open any new charts. So all new patients, we have no paper charts. The old patients we started scanning the day before the most important records that we wanted to have available at the time we were seeing the patients. We had probably 30 percent of patients were scanned, the rest were charts. Slowly, we progressed to more and more charts were already scanned in the computer so less and less charts I have to bring inside the room. Today, after 13 months, I probably have one or two records a day, sometimes every three days that I have bring inside the room.

Dr. Eric Fishman: So it's February 2010 now and I've looked at your chart rack and you do have some charts in 2009 but I see no charts that have a 2010 sticker. So you're completely avoiding bringing the charts into the examining room at this point and time?


Dr. Irma Lopez: That's correct. We created a system that they will take the list of patients for tomorrow, they will look through the charts and the ones that were scanned they stamp them so they know which ones they don’t have to pull out because it's all scanned in the computer. It also took another member of my staff filling out the past medical history and the medications. All the old data was built into the computer so all this data is ready for me when I'm typing or bringing it up to the different templates. Sometimes when they come for physicals especially, I try to upgrade all that data to make sure we're keeping track of all the details.

Dr. Eric Fishman: Perfect. Now let's compare today with 18 months before you had ever used Practice Partner in any way shape or form. Do you have more staff or less staff, or you spending more time in the office or less time, do you see more patients than you used to? Can you make that comparison so that we can make a determination what Practice Partner has actually done for your practice?

Dr. Irma Lopez: I'm happy to report that we have less staff. At first, we had a young fellow that was just doing filing. He was very young and very good with computers so he helped us to remember the details that they were teaching us and we would always ask him. So there's no more filing and after six months or so, he didn't have to come any more. Then we used to have two girls for the phone because whenever you make a phone call, they have to stand up and look for this chart that wasn't always in the right place. Sometimes you have to run through the whole office finding that chart to document or to find the medications. Now, it's available right when the patient calls. We are able just to pull the patient's chart and make a decision. So we went down to one person on the phone.

Dr. Eric Fishman: Must be quite a savings.

Dr. Irma Lopez: It is quite a saving and all the savings helped to pay for the software and the hardware, all the investment we went through to get ready for Practice Partner. We still have to scan a lot of the reports that come through the mail from other doctors and other services but we have also been able to track all the faxes that comes through a computer. Then we match the faxes with the patient so we don't have to print.

Dr. Eric Fishman: You don't have any physical paper when there's an incoming fax?

Dr. Irma Lopez: Correct.

Dr. Eric Fishman: And tell me what type of connections you make with the outside world whether it be the hospital, your patients, other physicians, what type of data comes in and out of the office electronically?

Dr. Irma Lopez: Jupiter Hospital is able to send us almost every record directly to the patient's chart.

Dr. Eric Fishman: So it never shows up on a physical piece of paper?

Dr. Irma Lopez: No.

Dr. Eric Fishman: And it doesn't require your staff to put it in the chart, it just shows up in the proper chart.

Dr. Irma Lopez: Right in the proper chart.

Dr. Eric Fishman: Let me stop there for just a moment. How do you get notified as to whether or not there is something of interest that is in the chart? How do you get told that there's low potassium for instance?

Dr. Irma Lopez: There's two boxes on my desktop. One is for labs and it comes with the red line, very bright red when there's a normal value. You can quickly go and double click on that even between patients. I can come, double click there and see if there's really something that we have to take action or something that I was expecting.

Dr. Eric Fishman: So do you think that you're getting access to that data sooner than you used to?

Dr. Irma Lopez: Absolutely. Before, I had to wait from them to fax it to the office and then going from the fax to the chart. The lady has to match the chart with that fax and then it will come to my office and they will pile one on top of the other. So we have the stat piles and the ones that can wait piles. Now, I just come and I see this red line and I know I can just quickly go (unintelligible)

Dr. Eric Fishman: And so not to put words in your mouth, but do you think that you're able to provide better medical care because of Practice Partner?

Dr. Irma Lopez: Absolutely.

Dr. Eric Fishman: So we discussed the rapidity with which you get lab data. Are there other issues where is helps provide actually better care for your patients?

Dr. Irma Lopez: Well, I have access to this program and all my patients' data wherever I am. So at home it could be any day, any time and I just have to open the program at home. It comes through the Internet so it's very simple, very fast. If a patient needs a refill, I know when it was the last time it was refilled and with one click I can refill.

Dr. Eric Fishman: Certainly saves a lot of time. Can the patients request a refill online or schedule their patient appointment online?

Dr. Irma Lopez: We are about to install that part of it.

Dr. Eric Fishman: The patient portal?

Dr. Irma Lopez: Yes, the patient portal.

Dr. Eric Fishman: Looking forward to it?

Dr. Irma Lopez: Looking forward to it, correct. It will reduce the amount of phone calls and we're looking forward to see how it will work.

Dr. Eric Fishman: So that brings me back to a question I'd asked earlier about the change in staff and the change in efficiency. You've said there's less staff at this point and time. How about your own efficiency? Are you able to see the same or possibly even more patients now in the same amount of time than before implementing the software or do you think you have the same amount of patients?

Dr. Irma Lopez: I think I'm able to see more patients. I know that it's a fact because when I first started with Practice Partner in October 2008, I used to have a physician assistant and she moved away right at that time. And my concern was am I going to be able to see all the patients by myself, her patients, and my patients. And nothing has changed.

Dr. Eric Fishman: So you're seeing two health care provider's patients by yourself?

Dr. Irma Lopez: On the same amount of time.

Dr. Eric Fishman: Great.

Dr. Irma Lopez: In the same amount of time. So I can say that yes, I can see more patients and I don't have to have a lot files waiting for me to finish my documentations. So I really experienced that.

Dr. Eric Fishman: Are there any bad experiences that you've had or any warnings you would give to another physician who is looking to purchase an EHR such as this?

Dr. Irma Lopez: I think try to schedule the very beginning of the process on a time that you know you're going to be less busy. We tried to do that but it was the very beginning for the hospital and for us, so we couldn't schedule that at the right time. So that would be very beneficial because around summertime, for example here in town, it would be very convenient. We have less patients so you have more time to concentrate on the learning curve. And then the same way we're investing money on the software and the hardware, we have to invest money in seeing less patients for that period of time.

Dr. Eric Fishman: How long a period of time was that?

Dr. Irma Lopez: At least eight to ten weeks.

Dr. Eric Fishman: Pretty typical.

Dr. Irma Lopez: It takes time just to change your habits because it's a habit that you're changing. You're documenting in somewhat different ways, you're finding data on the different spaces and your staff is learning, you're learning. You're trying to create for your own taste how you're going to do things, how you're going to scan, where these people are going to go so it takes time to modify the system enough that okay, this is the way I like it.

Dr. Eric Fishman: And you've done that. Do you make many modifications at this point and time now a year after being completely live with the software?

Dr. Irma Lopez: No. Minimal, if any.

Dr. Eric Fishman: I see you have a computer screen and a computer here in your personal office where we're sitting. I also notice that you have screens and computers in each of your exam rooms and we'll go over to one of the exam rooms in a few moments but do you find that you do most of your charting in the exam room itself or in your office?

Dr. Irma Lopez: Most in the exam room itself.

Dr. Eric Fishman: If a patient were seen and you were doing the charting, would it be possible for them to leave with a completed report that you could print up if they needed it and walk out of your office with it?

Dr. Irma Lopez: Absolutely, yes. It is very much possible. Most of the time, by the time we finish seeing the patients, the note is signed. If we wanted to print it, the system doesn't let you print it unless you have signed the report.

Dr. Eric Fishman: Do you find that you do that often or is there just not much need for it because it's a great functionality.

Dr. Irma Lopez: Patients don't ask for it much but there are times that the surgeons are waiting for that report.

Dr. Eric Fishman: They can be impatient.

Dr. Irma Lopez: They can be impatient and their offices are calling and not always the scheduling for the patient works with enough time so as soon as we finish seeing that patient, we can print it and send it to them.

Dr. Eric Fishman: Wonderful.


Part II - The Exam Room "Hands On"

Dr. Eric Fishman: So Dr. Lopez, we're now in a exam room and if I were a patient for instance and my throat hurt, my neck hurt, I understand that you have a monitor on a swivel so that both you and the patient can see the screen, you have a wireless keyboard. Show us the workflow; show us how you actually document a patient encounter in your exam room.

Dr. Irma Lopez: At first, when we decided to start working with EMRs, one of my fears was that the patient would feel uncomfortable because I was concentrated on the computer and my attention wouldn't be exactly to what they were saying or consultations. And I heard some of those complaints before from my patients.

Dr. Eric Fishman: It's a very rational fear and it can be done poorly and you've done it very well so it seems.

Dr. Irma Lopez: So I decided to get the monitors and the keyboard on a place that I will be able to keep eye contact with the patient. Now, that I'm very comfortable getting to the templates and how to write these notes, I can easily click exactly where I want to be and keep listening and change my eyes from what I'm trying to do and looking at the patient and the story and keep up with the story with the patients trying to follow with the follow-up questions so they know we are both on the same page. Many times they're talking and I'm looking back to the reports that they're referring to. If they're saying they were in the emergency room last week-end well, I already have the report from the emergency room on my records. I can immediately go and see, yes, they say this is the condition that they treated you for and this is the treatment that is started. Sometimes the patients said I was afraid to do this and that and I can refer to that report. When they see that this is complimenting our visit, they really like it. And I send the prescriptions right from the computer to their pharmacy. Before I would get the request from the patients, "Can you call my pharmacy so I don't have to wait in line when I get there?" Now, I tell the patients do you want me to send the prescriptions to your pharmacy and they go, oh whatever is easier for you. I say well, it only will take me a click to send it to your pharmacy. They're all so impressed, they really like that. So it's convenient for them and for me. I don't have to print the prescription; I don't have to sign a prescription. It's already there. Same for refills. If they need any refills it only takes two clicks and the medication is refilled either to the local pharmacy or to a (unintelligible) away pharmacy.

Dr. Eric Fishman: The Meaningful Use criteria require 80 percent of prescriptions to be done electronically. What percentage of your prescriptions do you do electronically at this point and time?

Dr. Irma Lopez: I think we are close to 90 percent just because the system works very, very well. At first, patients would go to the pharmacy and it wasn't there but now it is 100 percent. I don't get any more phone calls back "the prescription isn't here or "the pharmacy couldn't find it."

Dr. Eric Fishman: Now, let's make believe that I were that patient that went to the emergency room and I'm now telling you that my throat is hurting even worse than it was last week. Could you actually document using a template, pull down a template and show us how you would get this very brief history information?

Dr. Irma Lopez: The patient has to be on the schedule. So I can quickly open the chart. Here comes the chart with the patient picture, name, the day of birth just like a regular chart. You have the progress notes and the past medical history and the medications and consults and the chart summary. So I can immediately go to the chart summary, open up and see what happened or I will get ready to write my notes. I have to say that before the patients comes in, my assistant already did the vital signs and put the vital signs right on the patient's record. So when I enter, and she leaves me these on a blank page, so I'm ready to click the templates that I'm going to use for this visit. In your case, it will be a follow-up visit so I have the follow-up visit templates right here.

Dr. Eric Fishman: Are they organized by diagnosis or by condition?

Dr. Irma Lopez: You can organize it by diagnosis. Since my patients have multiple diagnoses most of them, I kept my old system of new patients, physical exam, follow-ups and some illness. So those were the templates that I created.

Dr. Eric Fishman: Let's go back 14 or 15 months ago when you were first implementing the software. Did the hospital then give you options as to how you would like to organize your templates?

Dr. Irma Lopez: Absolutely. They came, looked at the way I was doing things and tried to accommodate it as much as they could to what I was doing. Then, I myself also made suggestions - I like this way or that other way - and the girls from the hospital and the whole team helped me to create these templates. I was doing it on a piece of paper; I like to do this like that or I like to bring this and this. Then slowly we worked, eliminated things and added things until it ended to what I want it. So with just one click I have my formal note. With one click, I can bring past medical history, social history just one click is already bringing right to my note.

Dr. Eric Fishman: Does that help with the billing? I would anticipate that certainly with this much sophistication, you may feel more comfortable in doing the coding that you're doing that you'd be able to withstand an audit if it would come.

Dr. Irma Lopez: Absolutely. It's a lot easier now to document so you don't have to fear if your records ever get reviewed that you billed for a higher code than they expected because the notes are all full and you can make it as full as you need it for that day.


Part III - The Staff

Dr. Irma Lopez: I'd like to introduce to you Darlene and Rae (unintelligible). Darlene has been my assistant for the last 12 years when I first opened my practice there she was with me with the first charts and we built all the way to here. Rae has also been here for five years and they were the backbone of the success of Practice Partner. They were the first ones to go to training and the first ones to learn the details. But yes, they were fearful at first.

Darlene: Dr. Lopez was strong enough to get us moving faster and every day was a challenge. I love it now.

Dr. Eric Fishman: How long did that challenge last?

Darlene: For me, maybe four or five months that I felt so comfortable where I didn't have to constantly ask questions. I could just go in the computer, click and do my work where I was really comfortable.


Dr. Eric Fishman: And how about now? How do you compare your work today as compared to a year and a half ago?

Darlene: Oh, my gosh, I'd say like 100 percent.

Dr. Eric Fishman: Is it easier in many ways?

Darlene: Much easier.

Dr. Eric Fishman: Can you give us some examples of what changes have occurred that you're happy with?

Darlene: All the transactions, all the medical records, all scanned in the charts. If a patient calls on the phone or a doctor's office and need information, we can just click and just get right to the screen to that test and everything's pulled up right in the computer.

Dr. Eric Fishman: Any problems with it at this point and time?

Darlene: No, not at all. It's been perfect.

Dr. Irma Lopez: Darlene, tell them about how to create orders to send patients to the labs or to different tests. Before, Darlene will have five, six, ten different forms for each different labs or radiology center. Or even consultants, we have to keep the little business cards. So how has that changed?

Darlene: Now, all I do is I click in. I can click in which laboratory the patient's going to, click the diagnosis, click all the tests that need to be performed and then just print it and give it to the patient.

Dr. Eric Fishman: Tell us about the interaction you have with the outside offices. As an internal medicine physician, I'm sure you get referrals from a large variety of folks. What do they think of your use of the software?

Darlene: They think it's great. They're more reluctant; they're asking us if we really like the program and all which we do.

Dr. Eric Fishman: Now I guess you say yes.

Darlene: Right, because a lot of them are on paper. They have charts and I tell them it's a lot easier once you get used to doing it.

Dr. Eric Fishman: Do you have any offices that you deal with that do use Practice Partner or another EHR where you're actually sending information back and forth?

Darlene: No, not at this time. In the near future, we are which we're really looking forward to being able to just send to the other doctor's office. Now we do some faxing.

Dr. Eric Fishman: Now, tell us about the templates. You spent quite a lot of time I bet learning them. It's not an easy task.

Rae: No, it's not.

Dr. Eric Fishman: Tell us how you learned it.

Rae: From Kelly and Karen, the group from Jupiter.

Dr. Eric Fishman: So Jupiter Medical Center came down, sat with you?

Rae: Yes, that had one on one.

Dr. Eric Fishman: They knew how to make templates and you used the templates to talk to load those one or two that had been on paper and you implemented them. Are you still spending any time making new templates?

Rae: As of right now, no

Dr. Eric Fishman: How long did the process take until you were done making all of the templates that were necessary?

Rae: Probably a couple months.

Dr. Eric Fishman: Either of you interested in going back to paper?

Darlene: No.

Rae: No.

Dr. Irma Lopez: Rae, explain to them when patients call asking for prescriptions for refills or to set up an appointment.

Rae: It's much easier. If they're calling we can just click on to the schedule and then just look for their name and put them in and put what they're coming in for. Then for the medication part, we can one click "renew" and then we can just send it right back to the pharmacy.

Dr. Eric Fishman: We know that Dr. Lopez uses the system when she's outside of the office. Do either of you interact with the system at all when you're not in the office?

Darlene: No.

Rae: No.

Dr. Irma Lopez: We're looking forward to add that to the present program.

Darlene: We’re ready for the next step.

Dr. Eric Fishman: Anything else either of you want to add?

Darlene: I don't think so. Just generally overall, we're very happy.


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