Karen Appold

Before choosing an electronic medical records (EMR) system, first determine your needs. “Make a list of what capabilities are important to you, and do your research,” says Melissa G. Young, MD, FACE, FACP, ECNU, endocrinologist at Mid Atlantic Diabetes and Endocrinology Associates LLC, and medical director of Novo Nordisk Diabetes Center, both in Freehold, NJ.

As part of your research, examine surveys. Which EMR systems are highly ranked by similar practices? “Some might be good for larger practices, while others are more suited for smaller practices,” Dr. Young says. “Some are geared toward certain diseases or specialties. When I was looking, I found that most focused on symptom-focused visits, such as those for pain, fever, or injury. Most didn’t have templates geared toward chronic illness management.”

For Dr. Young, it was important to find an EMR system that allowed her to create or edit templates on her own on the fly. “If guidelines change, new medications become available, or I determine that there is a question I ask often, I can add it in as I go,” she says.

The field of endocrinology, particularly in the management of diabetes, changes rapidly. “I need to be able to edit templates every few months,” Dr. Young says. “At a previous practice, if we wanted to change a template we had to ask the company to do it for us. That took days or even weeks.”

The system Dr Young chose includes a patient portal that allows patients to send their glucose readings between visits, which are downloaded from patient's insulin pumps and meters. “It is important to be able to save that data directly into patient charts,” she says, adding that she can tell patients if changes are necessary.

An EMR system vendor needs to be available 24/7/365. “We rely on a lot of data to make clinical decisions,” Dr. Young says. “If that data is unavailable, I’m in trouble.”

Dr. Young advises asking other endocrinologists for vendor referrals and feedback. Ask them if a vendor responds promptly, if they can address issues remotely, and if they are accessible on holiday weekends. “Diseases don't take days off, so the EMR system can't either,” she says.

If your practice doesn’t have an in-house information technology (IT) person/department, ask if your EMR system vendor can act in that capacity, Dr. Young advises. “For a time, I had a different company handle the hardware and the network,” she says. “When things didn't work right, the question always was ‘is it the software, the hardware, or the network that’s causing the issue?’” It required calling both companies and having one blame the other one. Now her EMR system vendor has a sister IT company; staff overlaps and they communicate with each other, so it only requires one phone call and they figure out who's responsible for what.”

It is much easier to start a practice with an EMR system. “There won’t be any transition from paper to software,” Dr. Young says. “You’ll create your workflow around the EMR system.”

If you have to transition to an EMR system, you’ll need to accept the fact that the workflow differs with the system. “I recommend only giving new patients an EMR; then slowly transition established patients a few at a time,” Dr. Young says. “Expect a learning curve, and that processes will take longer at the beginning. Make appointment times longer to give you time to chart. As you get more adept at it, you can shorten visit lengths again.”

There are definite benefits to electronic records-easy access from anywhere, allowing multiple users access to the same chart simultaneously, legibility, and flowsheets. “Although there are days I miss the old-fashioned scribbling of two lines,” Dr. Young concludes.

Articles

Haven't switched to an electronic health record system yet? endocrinologist Melissa Young, MD has a few tips on getting started. 

What to Look for in an Electronic Medical Records System

[[{"type":"media","view_mode":"media_crop","fid":"60891","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1093506138046","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7695","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 218px; width: 300px; float: right;","title":" ","typeof":"foaf:Image"}}]]Overhead expenses always seem to be going up. In order to stay viable, a practice should make efforts to keep these costs down-even small savings can add up. Melissa G. Young, MD, FACE, FACP, ECNU, endocrinologist at Mid Atlantic Diabetes and Endocrinology Associates LLC and medical director of Novo Nordisk Diabetes Center, both in Freehold, NJ, details some strategies that she employs in a variety of areas to keep her practice’s overhead under control.

 “Plan well and use rooms wisely,” Dr. Young says. “The office I purchased had a lot of wasted space. A large room was previously used for radiology procedures and then for medical records storage. We turned it into our procedure room. We maximized exam room space by keeping cabinet and countertop space to a minimum. We really didn’t need more than a few inches of countertop space next to the sink; this allowed us to comfortably fit an exam table, scale, visitor's chair, and a physician's chair and desk.”

. Look on the Internet for furniture without specifically searching for “office furniture.” Dr. Young has found that to be more expensive. “I found nice waiting room chairs and breakroom furniture on a discount furniture site,” she says. “I buy desk chairs, trash cans, and lights bulbs at a warehouse club when they’re on sale.”

 Find a good contact person at a medical supply company who is willing to work with you and match competitor’s prices. “My representative makes it easy to order; I usually just email him my order and he knows what size I need and how many to send based on prior orders,” she says.

. Shop around. “Buy things that are on sale or have rebates,” Dr. Young says. “I've found the best price on envelopes at a warehouse club. They also offer a small discount on stamps.” Stock up when you find a great price.

Having a good agent is key. Regarding health insurance, determine how much coverage you want for yourself and employees. “Good benefits, not necessarily salary, is what keeps employees happy (and staying at your practice),” Dr. Young says.

. First determine if marketing is actually necessary, and if so, determine whether you want to target referring physicians or patients. An inexpensive way to promote your practice is to give lectures, either to other physicians or the community. You can also print inexpensive postcards or brochures, or advertise in a local newspaper.

. Determine your needs. Will regular phone service suffice or do you need 

 (VOiP), which is much more expensive and requires a very fast Internet connection. If you use an electronic medical records system, will you need a server or will you use a cloud-based service? Having your own server will cost you more upfront, but the monthly fees can be higher for a cloud-based service.

Outside professional services (legal and accounting)

. Ask colleagues to recommend a good firm. And don't be afraid to name drop. “If your colleague has been using the same accountant for 10 years, his rates might be lower for him than for a new client, but his accountant may extend his rate to you since he referred you,” Dr. Young says. Another tip is to check with a local hospital or state medical society-they may have contracts with professional service companies that provide discounts to physicians.

The bottom line is, in order to protect 

 bottom line, you need to do your homework-shop around and take the time to do the necessary research.
 

Keeping hard costs under control isn't magic and it does require some time and research, but your bottom line will thank you. 

How to Keep Overhead Under Control 

When a nurse practitioner or physician assistant is hired, initially they receive some type of orientation and training. The nurse practitioner at the Center for Endocrine Health at Hunterdon Medical Center in Clinton, New Jersey, shadowed the endocrinologists for a month so that she could gain a sense of how they interacted with patients and understand how the endocrinologists evaluated patients, says Felice Caldarella, MD, an endocrinologist at the center. This would ultimately enable a more seamless transition from the endocrinologist to the nurse practitioner. The endocrinologists also provided her with literature to review, which contained the American Association of Clinical Endocrinologists’ most recent algorithms on diabetes management and weight loss.

Similarly, Marilyn Tan, MD, clinical assistant professor of medicine (endocrinology) at Stanford University School of Medicine, and chief of the Endocrine Clinic at Stanford Healthcare in Stanford, California, reports that the nurse practitioner initially saw patients with the clinic’s physicians to become familiar with how they specifically provide endocrine-related care before she saw them independently.

At the Mayo Clinic in Rochester, Minnesota, the nurse practitioner dedicated to the thyroid practice observed patients with a thyroidologist for the first 6 months at that practice, says Marius Stan, MD, associate professor of medicine.

Richard Levy, MD, an endocrinology consultant affiliated with multiple hospitals in the Chicago, Illinois, area, says nurse practitioners review cases and are taught patient management by example and by reviewing the literature.

At North Raleigh Endocrinology & Diabetes Center in Raleigh, North Carolina, Amit A. Patel, MD, an endocrinologist, has new physician assistants shadow him seeing patients during the morning of their first day on the job. Then, they transcribe for him the remainder of the day. “This helps them to understand the flow of our charting and electronic medical record system,” he says. The next day, they see patients on their own and Dr. Patel reviews each case prior to signing off on it.

On a daily basis, Dr. Caldarella says endocrinologists touch base with the nurse practitioner and ask if any patients have concerns or issues. “We have an open dialogue,” he says. “We have informal discussions on a weekly basis to see if there’s anything she wants to discuss with us. But in between, she may also send us a quick question or note through the electronic health record system.”

Endocrinologists seek feedback from patients regarding their interaction with the nurse practitioner and also obtain feedback through chart notes reviews. In addition, they keep metrics on the endocrinologists and nurse practitioner through the electronic health record system.

Dr. Tan says nurse practitioners receive feedback from all staff, including medical assistants, registered nurses, and physicians, as well as patients. The clinic manager evaluates them and provides feedback, and their charts and documentation are periodically audited. When the nurse practitioner sees patients independently, physicians are always available to give advice about more challenging cases.

As requested by the nurse practitioner, the thyroidologist will discuss individual cases, discuss the nurse practitioner’s role in the practice at thyroid core group meetings, have the nurse practitioner involved in case conferences, and support the nurse practitioner in academic projects.

Dr. Levy reviews the physician assistant’s and the nurse practitioner’s notes, and they agree on an assessment and plan.

Dr. Patel reviews new physician assistants’ notes and makes recommendations accordingly. By having an endocrinologist and a physician assistant alternate seeing patients, he can better track the physician assistant’s performance.

For Dr. Caldarella, the biggest challenge resulting from having a nurse practitioner on staff is that patients are unclear about her role. To overcome this issue, the practice created a handout that tells patients who she is and how she fits into their diabetes management plan. The brochure is given to patients when they schedule their first appointment with the nurse practitioner.

At times, Dr. Stan says the nurse practitioner has had challenging cases that did not fit neatly into a clear algorithm. The solution was to have a thyroidologist available at all times and to have periodic discussions as a group to decide whether the nurse practitioner’s spectrum of practice is appropriate.

Approaches to orienting and training a nurse practitioner, keeping lines of communication open, and overcoming challenges are discussed.

What Roles Can NPs and PAs Play in a Practice? Part 2

Nurse practitioners and physician assistants can perform a variety of tasks that assist endocrinologists in their practices. Felice Caldarella, MD, an endocrinologist at the Center for Endocrine Health at Hunterdon Medical Center in Clinton, New Jersey, says his practice hired a nurse practitioner to see patients with diabetes who were starting a new medication or insulin and needed frequent follow-up, required intensification of therapy, or had weight loss challenges.

“New patients first see an endocrinologist, who performs an initial evaluation and creates a treatment plan,” Dr. Caldarella says. “Then, the endocrinologist decides if the patient would benefit from seeing a nurse practitioner. After seeing a nurse practitioner two or three times, the endocrinologist will assess the patient and decide whether the patient should continue seeing the nurse practitioner or not.”

The nurse practitioner doesn’t have her own panel of patients but instead sees them on an as-needed basis, Dr. Caldarella explains. In addition, unlike the endocrinologists, she has a more open schedule. “If a patient calls with a semi-acute problem or was recently hospitalized and needs re-intensification of therapy, the patient can see the nurse practitioner. She’ll consult with the endocrinologist as needed,” he says.

Before the nurse practitioner joined Dr. Caldarella’s practice, she had already worked as an inpatient diabetes educator. Her background in diabetes and weight loss management make her an ideal fit for his practice. “We are able to leverage her skills to help improve patients’ glycemic control with not only medication management, but also lifestyle optimization,” he says.

Marius Stan, MD, associate professor of medicine at the Mayo Clinic in Rochester, Minnesota, says the nurse practitioner at his practice follows patients with low-risk thyroid cancer, patients with benign thyroid nodules in need of monitoring, and patients with hypothyroidism. The nurse practitioner employs a straightforward algorithm in managing patients that can be easily implemented. “If patients develop concerning changes in their conditions, the nurse practitioner consults the physician initially involved and usually the patient is returned to his or her care,” he says.

According to Marilyn Tan, MD, clinical assistant professor of medicine (endocrinology) at Stanford University School of Medicine, and chief of the Endocrine Clinic at Stanford Healthcare in Stanford, California, nurse practitioners make a tremendous contribution. They see patients independently, answer patient questions by phone and email, educate patients, assist with prescription refills and laboratory orders, triage calls, process messages from patients, and help guide registered nurses and practice coordinators.

Richard Levy, MD, an endocrinology consultant affiliated with multiple hospitals in the Chicago, Illinois, area, including Rush University Medical Center, says he works for endocrinology practices that employ both physician assistants and nurse practitioners. These healthcare providers see patients; handle calls from patients, other caregivers, and insurance companies; write notes on patient charts; write letters to referring physicians and appeals to insurance companies; write prescriptions; and teach students. “They are smart, personable, task oriented, and have prescriptive authority,” he says.

Physician assistants and endocrinologists alternate seeing patients at North Raleigh Endocrinology & Diabetes Center in Raleigh, North Carolina, says Amit A. Patel, MD, an endocrinologist. They also help endocrinologists engage in quality and preventative measures.

Dr. Caldarella has found that a team approach to diabetes management is ideal because in addition to needing a treatment plan, diabetes patients may have lifestyle and psychosocial issues that need to be addressed.

The team approach allows for more eyes on the patient, so more information can be gathered to help pinpoint any barriers to care the patient might experience when trying to manage his or her diabetes. “Patients tend to tell different healthcare providers different things,” Dr. Caldarella says. “By having more contact with patients, healthcare providers can better understand a patient’s needs and challenges. In addition, patients may be more comfortable talking to a physician about certain things, and with a nurse practitioner about other aspects of their lives.”

The team approach allows for more eyes on the patient, so more information can be gathered to help pinpoint any barriers to care.

Karen Appold

Articles

What to Look for in an Electronic Medical Records System

How to Keep Overhead Under Control

What Roles Can NPs and PAs Play in a Practice? Part 2

What Roles Can NPs and PAs Play in a Practice? Part 1