Shady Grove Fertility Reproductive Science Center
The Shady Grove Fertility Reproductive Science Center was opened in 1991 by founders
Arthur Sagoskin, MD and Michael Levy, MD. It started as a one office fertility and in-vitro
fertilization practice in Rockville MD but quickly grew to 3 offices within 2 years. Now Shady
Grove is considered one of, if not the largest fertility and in-vitro fertilization practices in the
country. They have 9 offices in the Washington DC metropolitan area. The offices reside in
Rockville MD, Annapolis MD, Frederick MD, Columbia MD, Baltimore MD, Leesburg VA,
Annandale VA, Fair Oaks VA and Washington DC.
The practice consists of 21 physicians. Of the 21 physicians, 14 are partners and 7 are
associates. As a whole, Shady Grove Fertility RSC now performs approximately 4000 in-vitro
fertilization cycles per year and approximately 7000 intra uterine insemination cycles per year.
The patient demographics consists of both female and male infertility patients. The ages
can range from 21 to 50 years of age but the majority is 34 to 43 years old. It is estimated that
Eighty five percent of the patients pay through some type of insurance, while the remaining 15%
pay out of pocket.
Shady Grove Fertility RSC is not affiliated directly with any hospitals and probably
performs less than 1% of their procedures in a hospital setting. They essentially are an office
based practice. While it is not part of a hospital or managed health care system, Shady Grove
Fertility RSC is part of a national network of fertility clinics called Integramed America. This
network consists of over 100 fertility specialists. Integramed America, as part of their
contractual agreement with the Shady Grove Fertility RSC practice, is responsible for all of their
back office processing including; billing, HIT and office personnel. Essentially all non
physicians are contracted through Integramed America. Also part of this agreement was the
provision, installation, integration and maintenance of an EMR system.
Dr. Sagoskin, one of the 2 founding physicians of the Shady Grove Fertility RSC practice
was our primary source of contact while performing this study.
Right from the opening of the Shady Grove Fertility RSC practice there was a strategic
objective to expand the practice. In just the first 2 years the number of offices had gone from 1
to 3. By the year 2000 the practice had expanded much farther. With multiple offices,
communication between them was always a problem. Patients going through fertility treatments
often have to be monitored on a daily basis. The patient might have a consult in one office but
need procedures to be done in a separate office. This can be due to where they live verses where
they work. Charts would have to be pulled and information faxed for each patient as they were
seen between various offices. Duplicate charts would have to be housed in the various offices.
On weekends patients could only be seen in certain offices for monitoring. Every Friday the
charts of any patient under treatment had to be pulled and information faxed to an available
weekend open office. Dr Sagoskin estimates that each nurse spent approximately 3 to 4 hours of
their day finding and organizing charts and information.
It was in 2000 that Dr. Sagoskin championed the idea to research EMR availability and
how practical it would be to implement into their practice. Dr. Sagoskin was a believer that
through EMR technology Shady Grove Fertility RSC could: save time for nurses, make chart
access instantaneous from any office, allow physicians to access charts from home, eliminate
many human errors in chart entries, improve speed of retrieving lab results and generally
improve patient care. Although Dr Sagoskin thought there would also be a cost savings over
time, it was not a primary objective up front. What was a primary objective was to be able to see
more patients in a more efficient manner and enable the practice to continue to expand and allow
for improved patient care.
The actual decision to implement an EMR within Shady Grove Fertility RSC had to be
approved by all the shareholders or practice owners. The idea was presented as a joint effort
between Dr. Sagoskin and the VP working directly with their practice from Integremed America.
It was not a hard sell on how the EMR was going to help the practice reach its strategic goals but
there was always the psychological apprehension of moving away from paper. Questions arose
on availability, complexity, privacy and security of an electronic system. At the time of the
initial acceptance of integrating an EMR system, outside entities such as payers (insurance
companies) or government were not considered. Also due to the contractual agreement with
Integremed Americas cost was not a primary factor, an initial cost analysis was not performed.
The EMR system to be chosen for Shady Grove Fertility RSC had actually been
purchased by Integramed America. It was licensed for Shady Grove Fertility RSC’s use through
their contractual agreement with Integramed America. Due to the specialization of Shady Grove
Fertility RSC’s practice very few EMR systems back in 2000 met their medical and technical
specifications. Some of Shady Grove Fertility RSC’s main focal points were ease of use,
uninterrupted patient flow, progress notes, interface between labs, medication and ultrasound
monitoring to compare to previous days, review and signoffs of daily monitoring, checklists of
tests and results, correspondence and connection to dictation services, consistent availability and
external access by physicians. It was determined that Shady Grove Fertility RSC could not
tolerate a down time of more than 15 minutes. Electronic prescribing was not considered a
necessity at the time.
The EMR which was implemented was called Artworks. This EMR was in its infancy
and had only been implemented in 2 previous fertility practices. The original creator of the
software was from Sweden. One of the perks of purchasing this EMR was the ability to
customize it to fit the practice. A user group was quickly formed between the 2 current
installation practices and Shady Grove Fertility RSC to mold Artworks in to the system it is
today. As other practices joined Integremed America they were joined to the user group. Shady
Grove Fertility RSC could be considered a beta site for the systems development. The contract
from Integremed America included maintenance, consulting, training and an unlimited site level
license. Originally, upgrades and enhancements were included but some are now negotiated
outside the contract.
Artworks is a clinical EMR, it does not have its own integrated patient registration,
billing, or clinical decision support modules, although interfaces can be created to other systems
handling this functionality. Pharmaceutical prescribing is done through printing or faxing and
there is an electronic link to one pharmaceutical distribution firm. What Artworks handles
extremely well according to Dr Sagoskin is nurse and doctor documentation, clinical data
management and daily patient management.
Artworks was implemented as an application service provider (ASP) model hosted by
Integremed Americas. Shady Grove Fertility RSC accesses the application through a Citrix
server utilizing the internet. The data is also stored on Integremed Americas servers located in
White Plains NY. Although Shady Grove Fertility RSC does not house the data, it does own the
data. Now all the electronic communication between Shady Grove Fertility RSC’s different
offices happens through Integremed America’s servers in NY.
Shady Grove Fertility RSC made a strategic decision that the acceptable down time in the
case of a disaster or communications failure was 15 minutes. This is due to the sensitive medical
procedures that they perform in their offices, which are time sensitive. To adhere to this
requirement a hot site was created where data is transferred in 15 minute increments. In the case
of a disaster where the main database server was destroyed or unavailable, the hot site could be
switched to within the expectable amount of downtown. To minimize the risk of communication
failure a database server is kept on site at one of Shady Grove Fertility RSC’s offices. This
server contains a read only copy of the database from the previous day. At the most the data
would be 24 hours old. They also are implementing a wireless router through to Integremed
Americas circumventing the last mile of communication issues.
Dr. Sagoskin knew that to make the implementation of the new EMR system a success he
had to gain the support of all the physicians in the practice. One physician downplaying the
importance or even worse working against the effort could be fatal to the project. Everyone had
to be made aware that problems would occur and there would need to be an adaptation period
where patience and maybe even a sense of humor would go a long way. He started
psychologically preparing his staff and colleagues months in advance. It was significant that the
champion of implementing the EMR was one of the founders and majority stakeholders of the
practice. In order to prevent people from getting frustrated multiple times, a decision was made
to implement the system in the “big bang” approach, all at once. Legacy data was handled by
only entering current patients being observed into the system. Dictations from the prior 2 to 3
years for these current patients were entered into the Artworks by copy and pasting from
archived dictations by 3 to 4 college students over a summer.
Dr. Sagoskin described a situation after the initial implementation where one of his
partners was in the middle of a procedure with a patient and was having a problem utilizing the
new EMR to access some necessary information. The doctor paged a nurse and asked that the
paper chart be brought in instead of asking for help navigating the system. Dr. Sagoskin walked
into the room instead of the nurse and refused to produce the chart. He reminded his partner of
his acceptance of the system and that he was now going to have to use it. He told him once he
learned it he would never look back. That could only have been accomplished since the
champion came from the top of the organization.
The implementation from the time that Artworks was selected to the time it was
integrated was approximately six months. This included all customization, training and
psychologically preparing the practice. The actual physical implementation took about 2 weeks
to iron out most of the wrinkles. During the physical implementation Dr. Sagoskin did not see
patients for a 1 week period of time. All other physicians saw their full patient load. The hardest
part of the implementation was dealing with the human cultural issues of people having to accept
change from paper to electronic medical records.
According Dr. Sagoskin one of the major changes in workflow was the handling of
charts. Not only did nurses not have to pull charts any more for patients being seen at that office
but they also could stop faxing information to satellite offices. The physicians also have the
ability and often do consult other physicians about a patient, with both being able to access the
electronic chart simultaneously. Checklists are now generated in the application to make sure all
necessary tasks are completed and documentation has been input correctly.
Many different pieces of data flow electronically into the EMR negating the need for a
human to interact and manually enter information into the chart. This includes internal lab
results, stimulation protocols, ultra sound measurements and blood results. Removing the human
element of data entry removes the chance for error or illegible writing. It also removes the
chance of information being entered into the wrong chart. Dictation services are still being
utilized by many of the doctors at the Shady Grove Fertility RSC practice but the dictation now
flows directly into the EMR rather than being physically placed in the chart. Some doctors have
chosen to use templates and type directly into the system, thereby decreasing the need for
At this time Shady Grove Fertility RSC does not have the ability to accept electronic
signature from patients nor do they have a scanning/image retrieval capability. They will have
scanning and retrieval capability in the next few months. For this reason any consent form
which needs to be signed by the patient still needs to be kept in a paper file.
Communications between the physicians and office staff has been greatly simplified
through the EMR system. Email can be sent directly from the system allowing better
communications between nurses and physicians. The patients name and NPI number will
automatically be added to the email for ease of communication. Electronic messaging from
physician to the patient is not being allowed due to privacy and HIPAA regulations.
Cost / Benefit Analysis ROI
Due to the fact that Integremed America actually bought the Artworks EMR system and
Shady Grove Fertility RSC has contracted for its usage as part of an overall back office service
contract, we were not able to obtain the cost of the Artworks system. Dr. Sagoskin is quick to
point out that even though he cannot breakout the initial cost, he believes the EMR was well
worth the effort. He reminded us that a quick return on investment was not their driving factor
Dr. Sagoskin is a strong believer that the Artworks EMR system has enabled the Shady
Grove Fertility RSC practice to ultimately reach its strategic goal of being the nation’s largest
fertility and IVF practice. Without an EMR system he does not think it would have been
possible. Before implementing the EMR, Shady Grove Fertility RSC was averaging
approximately 500 in-vitro fertilization cycles a year. They are now performing approximately
4000 per year. They averaged approximately 2000 ovulation induction cycles per year and now
average approximately 8000 ovulation induction cycles per year. Staff has increased to meet
these demands but he believes nowhere near what they would have needed without the EMR
We asked Dr. Sagoskin to give us tangible and intangible benefits for different types of
professionals in the practice and we learned the following:
Office Manager – Responsible for quality assurance, she saw a dramatic increase in
data accuracy which she attributes to better patient care.
Nurse: - Saving approximately 4 hours per day in time pulling and faxing
information. Each of the 21 physicians in the practice now
averages 2 full time nurses at approximately $65,000 a year. He
believes that each doctor would need at approximately 3
nurses without the EMR. That is a potential savings of $1,365,000
for the practice a year.
Doctor: - Dr. Sagoskin estimates that every time he sits to review charts he is
saving about 2 hour by having the EMR system available. He can
also access data from where ever he can find an internet
connection, untying him from his office when he is on call. Due to
some doctors typing directly into the EMR and using templates
there is a likely savings in dictation costs.
Billing and Insurance Coders - Save a number of hours per day by obtaining
information from Artworks and not needing to look for
One last benefit that Dr Sagoskin realized was the ability for Shady Grove Fertility RSC
to now do their voluntary reporting of IVF information to the CDC electronically, through
Integremed America. Prior to the EMR it took personnel a number of months to compile the
data. The quality control of that data before sending it now takes 3 weeks.
As can be clearly seen and is noted by Dr. Sagoskin, the purchase of Artworks EMR by
Integremed America and the integration into Shady Grove Fertility RSC Fertility RSC has been a
win-win situation for all parties involved. Shady Grove Fertility RSC was able to meet the
strategic goal of growing the practice, while maintaining quality care for patients. Integremed
America has the availability of an EMR package called Artworks that rivals the best in the