VIEWS: 13 PAGES: 10 POSTED ON: 12/30/2011
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 system. 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 charts. 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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