Charlie Immordino, RN, CASC, principal and president/CEO of Ambulatory Surgery Center Consultants, LLC, and an Accreditation Association for Ambulatory Health Care surveyor, sat down with Joe Macies, president and CEO of AmkaiSolutions, to discuss why an increasing number of ASCs are making the switch to electronic medical records, what they should do before selecting an EMR, and what surgery centers should look for in an EMR solution.
Joe Macies: What do you see as the primary reasons more surgery centers are switching to an electronic medical records system?
Charlie Immordino: The biggest reason is accuracy — accuracy for accreditation, licensure and compliance areas. It's becoming more and more imperative that the accuracy of the information be assured in the chart.
The next reason would be portability, the ability for the patient to go to a different provider, and a different area of care within a facility, and always have access to the information in their medical record.
The third reason is one of economy. It takes more people and more time to put together a handwritten healthcare medical record than an electronic version. An electronic version essentially takes you through the record-creation process and helps you accurately document all necessary information without having to continuously write the information in the record
The fourth reason would be the potential government mandate for every healthcare entity to use an EMR. Physician offices and hospitals have already been mandated to do this, so we can be sure ASCs aren't far behind.
JM: Do you think it is important for an ASC to invest in a system developed specifically for surgery centers, or can systems designed for practices and hospitals still work effectively?
CI: I think it's very important that the system physicians choose best fits the type of facility they're working in. Traditionally, using office practice software or hospital software has not been the most efficient or economical way for a physician to create an EMR for their surgery center.
There are minimal requirements and standards for a practice visit. But in an ASC, before patients are put through the process, physicians have to make sure there's a history and physical on the chart. They have to make sure the patient has been appropriately assessed, not only for the procedure but also for the anesthesia plan. There has to be a discharge order. There are many requirements for the ASC that are not required in office practices, and these are built into an ASC-specific software program.
On the other hand, hospital-based systems are too much for the ASC, with everything from radiology to radiation oncology included in the software. There are many areas that simply don't apply to the ASC record, and the ASC will have to navigate through and pay for all of that unnecessary software.
JM: Is it important for the system to be designed to meet the specific intricacies and needs of different physicians and specialties in multispecialty facilities?
CI: Definitely, and one of the advantages of a good electronic record is that you can sculpt and focus it to meet the individual needs of your particular type of center and its related specialties. For example, the system can be programmed with all relevant diagnosis codes, procedure codes, and can streamline all the intricacies that go into a center's specific billing processes.
It's also important that the ASC's system creates a medical record that can interface with office- and hospital-based software systems. This is, again, for economic reasons. It is highly advantageous to be able to pre-populate demographics as well as pre-procedural and post-procedural diagnoses, and have this information transferrable between ASCs and offices or hospitals. The long-term goal of electronic records is to be able to have these systems interact with one another to avoid continual rewriting of diagnoses, treatments and processes every time a patient moves from one facet of healthcare to another.
JM: What are some of the most important quality and safety features ASCs should look for in an EMR?
CI: As I discussed earlier, the self-policing functionality is critical. It must provide assurance that when you close that chart, you know the record is complete and you've done everything you need to do. On the flip side, if the record can't be closed, it's because you haven't completed all of the proper and required documentation.
The ability for the system to provide medication and allergy alerts is critical as well. In fact, drug-to-drug allergy interaction check is a meaningful use requirement when a physician is signing his or her orders. A good EMR will have all the functionality that provides for patient safety and it does it for you for every patient, every time. Portability is also an important feature. You want a system that allows physicians access to information from a remote location and have the ability to assist patients at their fingertips.
Another thing to look for is a system that decreases the need for physicians to write notes by hand. It is a standing joke that physicians have illegible handwriting, and that is even more apparent when they are in a rush. When they are busy treating patients, the writing part of their work becomes secondary. It is important from both a liability and a quality patient care perspective that the patient's record is clear to all who need to view it. Legibility is not just a physician issue — nurses are also frequently pressed for time. It's much easier for them to be able to electronically document.
Lastly, it also greatly helps an ASC system to offer standardization options for the items that physicians repeat with particular procedures. Take cataract surgery, for example. Ninety percent of the time the process is pretty much the same, with the differences usually being right or left eye and the power of the lens. The record should be able to automatically input all standard information with each cataract surgery case, eliminating the necessity of dictating the entire procedure each time, or writing the entire post-op note when nothing has changed. The physician can then go right into his next case because this information is taken care of in a keystroke.
JM: What about critical efficiency and ease of use components?
CI: We talked about the value and importance of the system allowing real-time, easy access to information anywhere — not just in the physical plant. It's also important that the EMR be physician, nurse, staff and patient friendly. It has to be universally accessible and make it easy to find information. Somebody looking at electronic records must find the system that is as intuitive as possible. Why is this so important? For one thing, if the record is going to be portable, there will be people accessing the record that may or may not know the particular software system. The system has to produce a chart that's logical to follow, where someone can click through the history or operative report and easily find what they are looking for. The EMR has to have a reasonable menu and a straightforward way to navigate through this menu without requiring a lengthy educational process for every user.
From an efficiency standpoint, it's imperative that the communication between the practice's software and ASC's software be such that the practice software can help to populate key areas in the ASC's software. This might be in areas such as pre-op diagnoses and pre-op history and physical. And it should happen visa versa, where once the procedure is finished, information from the ASC system should be able to then be downloaded on to the office charts to complete that chart.
JM: Should it include any business-related features?
CI: Absolutely. It should have customizable reports and provide an ASC with the ability to look at all aspects of care and cost, to identify efficiencies and inefficiencies associated with equipment, supplies and even individual physicians. To have all of that information readily available is the most valuable component of an EMR from an administrative standpoint. The system should make gathering of data a thing of the past because now, with a few clicks, you should be able to put together reports to help manage the increasingly difficult task of keeping costs down while increasing efficiency
The EMR should also include both internal and external benchmarking tools. For internal benchmarking, an EMR should be designed to essentially do this for you. With just a few clicks, a good EMR can gather data in areas such as outcomes, procedure completed time and supplied used in a case. If all of that data is gathered for you in the electronic record, it is a keystroke away.
For external benchmarking, the ASC Association, accrediting bodies and other organizations require you provide them data to participate in external benchmarking programs. You send your data and then you receive back reports as to how your ASC is performing in comparison to other like organizations. If you don't have an EMR, then you will need to put together spreadsheets and gather information chart by chart. With the right EMR, you can gather the information through the electronic record, and in a matter of minutes provide the information to the external benchmarking organization.
JM: What do you see as the most important qualities an ASC will want to look for in the vendor of the EMR it is considering?
CI: You will want to strongly consider partnering with a vendor that has a history of working with ASCs. You want to know your prospective partner is familiar with the needs and wants of the ASC. You don't want to be on somebody's learning curve.
You will want to look for positive references, specifically from organizations similar to yours so you know the company has good experience working with like facilities, whether they are single- or multispecialty ASCs.
Lastly, you want to look for a vendor that provides strong customer support. While not imperative, I think it's really desirable to have a contact person or a customer service contact number where you can receive 24/7 support.
JM: In the white paper "10 Reasons Your ASC Needs an EMR Now (pdf)," you are quoted as saying "Any organization that is not using an EMR will ultimately be spending more money to get inferior results." Why do you feel that is the case?
CI: You avoid redundancy. You increase profitability by analyzing the physician, equipment and supply utilization of the center. The manager gets on-the-spot answers as to how efficiently the organization is working. You get easy and appropriate benchmarking without having to spend management and staff time gathering data from individual charts. You get immediate reports. You get the assurance of accuracy in your charting, which can avoid litigation problems later on, and you get the assurance that when you pull a chart, it's closed, complete and everything that should be in there is in there.
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