Five Steps to Upgrade From Anesthesia Paper Charting to EMR Software

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By Dr. Jeffrey Zavaleta, Chief Medical Officer at Graphium Health 

Comparing EMR (electronic medical records) versus paper medical records, it’s easy to see why electronic is the clear choice for any anesthesiology practice.

Though anesthesia paper charting is the tried, trusted, and oldest method for medical record keeping, it has its downfalls. Paper records lose most of their value when the case ends. Paper gets lost, or even worse, stolen. More importantly, your practice data becomes “locked” in a clunky, difficult to read, and inaccessible format. You ultimately will pay more for billing, compliance, and reporting services.

EMR software brings medical records management into the 21st century with its ease of use and functionality. An investment in the right EMR should ease the burden of data capture and improve your practice’s bottom line.

Let’s explore what it takes to integrate EMR software into an anesthesia practice’s daily operations.

Transitioning From Anesthesia Paper Charting to EMR Software

Implementing anesthesia EMR software involves these five steps:

  1. Evaluating your practice’s needs
  2. Auditing existing technology
  3. Demoing EMR software
  4. Selecting an EMR provider
  5. Installation and training

1. Evaluating Your Practice’s Specific Needs

There are many EMR software platforms available, but before you start your evaluation process, first understand why you’re making the change. It is important to define the value in converting from paper to electronic data capture. For example, is it to make documentation easier with automated vital sign integration or is it to improve your bottom line by leveraging a direct billing interface? One costs money while the other makes money. 

Simply saying, “It’s time to get rid of all the paper” isn’t good enough. Ask why (and there are plenty of reasons), and you’ll be better equipped to find the right technology partner.

2. Auditing Existing Technology

Most EMR software requires purchasing accompanying hardware. Since you’re an anesthesia practice you likely travel between hospitals and work in a heterogeneous environment that includes different EHR vendors at different facilities. As such, you’ll want to consider both how mobile the platform is as well as its integration capabilities. Today’s cloud hosted, mobility-focused solutions rival paper’s ability to “work anywhere”, but what if your practice is already using a hospital-purchased EMR in the ORs? How can your prospective EMR vendor work with (and in) the hospital to still achieve your goals?

Additionally, what billing software does your RCM partner currently use? Is it able to accept a standard billing interface? What’s your current process for achieving MACRA compliance? If not participating, why not? How do you get your hospital their required quality reports for 3rd party hospital providers? How do you collect your performance data to negotiate insurance contracts?

The answers to these questions include use of technology and incur “hidden” operational costs for your practice. Here is where you’ll find the value for why transitioning from paper to EMR is key to remaining competitive.

3. Set up Product Demos

Before diving head-first into using EMR software, test out a few. There are large, “legacy” vendors which probably carry a prohibitive price tag for an anesthesia group, and there are other cloud-based solutions that are remarkably affordable.

Product demos should show you a software’s actual functionality – avoid slide decks of screen shots. You can also double-check specific concerns, such as HIPAA compliance qualifications.

Demos also serve another purpose — they help you evaluate the company providing the software. Consider:

  • Did the sales rep take you on a deep dive into the software?
  • How knowledgeable were they? (The devil is absolutely in the details!)
  • Were all of your specific use cases addressed?
  • Are they able to demo to your RCM vendor to better gauge interfacing ability?
  • Are they willing to put you in touch with existing customers to serve as references?

4. Selecting the Right Software Provider

The EMR partner you choose will become your “de-facto” IT department, working with your providers, your hospital administrators, and your 3rd party IT staff. They become an extension of your brand.

It is important to ask for references and actually speak with them. Selecting the right software is more than just adopting the right technology stack. You’re purchasing a team of experts whose goal is to make your group successful. This team includes developers, database engineers, interface experts, clinicians, and support staff. You will need all of them. Your software vendor should become a resource of knowledge to explain real technology limitations and explore new potentials.

5. Going Live 

By far the most anxious part of adopting an EMR is “turning it on”. Transitioning to your own EMR involves many different parties. Your billing team, hospital IT, integration vendors, and not to mention all of your physicians and CRNAs will have different needs and expectations. Existing workflows will need to change, but when done correctly, processes will become easier and more efficient. Installation and training doesn’t have to be a major ordeal.

When evaluating different EMR vendors, ask for details about the on-boarding process. What is typically needed? How long does it typically take? How are providers trained and how long does it take? How do we get analytic reports out of the system?

Converting From Anesthesia Paper Charting to EMR Software: Beyond the Upgrade

Converting to EMR software designed specifically for your anesthesia practice may sound intimidating, but it’s absolutely worth the effort when done right. Keep in mind that software will need occasional updates, and additional training may be required. 

Working with the right EMR software provider means you’ll have a partner long after EMR  makes your old paper records obsolete.

With these five steps, the transition to EMR software is quick and easy. You’ll be enjoying the benefits of modern medical record keeping before you know it.

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