Shady Grove Fertility Center

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					Shady Grove Fertility Reproductive Science Center

Practice profile

        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.

Business Case

       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.

EMR Implementation

       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.

Workflow Analysis

       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

dictation services.

       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

for implementation.

       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

fertility arena.

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