Costs and Benefits of an Enterprise Electronic Medical Record – Theory and Operations -

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Costs and Benefits of an Enterprise

Electronic Medical Record

– Theory and Operations -

Theory and Operations

Joint Conference on

Medical Informatics in Taiwan

Saturday 22 November 2008

Saturday, 22 November 2008

Dick Gibson MD PhD MBA

Senior Vice President and Chief Information Officer Legacy Health System – Portland, Oregon, USA

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Agenda

• Physician Offices and Hospitals in the US. • Paying for Medical Care in the US.

• Physician Office and Hospital EMRs.

• Legacy Health System and its EMR Project • Legacy Health System and its EMR Project. • EMR Costs.

EMR B fit • EMR Benefits.

• Managing to Obtain the Benefits.

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Agenda

• Managing to Obtain the Benefits. • Conclusions.

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Physicians in the US

(1 of 3)

• US population: 300 Million. • US Physicians: 600,000 (1:500). • Practice setting:

• 70%: Office-based (including surgeons who have offices and operate in hospitals and outpatient offices and operate in hospitals and outpatient surgery centers).

• 20%: Hospital-based (emergency, anesthesia, radiologists, pathologists).

• 10%: Government: Veterans Administration, Public Health Service others

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Physicians in the US

(2 of 3)

• Of the office based physicians:

• 50% are Primary care (family medicine, internal di i b t t i / l di t i ) d medicine, obstetrics/gynecology, pediatrics) and shrinking fast.

• 28% are Medical Specialists and growing.28% are Medical Specialists and growing. • 22% are Surgical Specialists and growing. • 75% own all or part of their practice.

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Physicians in the US

(3 of 3)

• Office Type:

• 36% of doctors in solo practice. • 43% in single-specialty office. • 21% in a multi-specialty office.

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Hing, Characteristics of Office-Based Physicians and Their Practices: US 2003-04, Series 13, No. 164, Hyattsville MD: Natl Cent Health Stat 2007.

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Agenda

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Paying for Medical Care in the US

(1 of 3)

• Government (50%) provides insurance for: • The elderly or disabled: Medicare.

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The elderly or disabled: Medicare. • The poor: Medicaid.

• The military: Department of Defense and the y p Veterans Administration (VA).

• Many people have private insurance (35%) paid by: Th i l

• Their employer. • Themselves.

S l (15%) h i d d • Some people (15%) have no insurance and end up

paying very little of their bill. Often causes them to go bankrupt. Causes hospital to shift bill to other

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Paying for Medical Care in the US

(2 of 3)

• Most hospital care (75-90% ) is fixed fee based on diagnosis (Diagnostic Related Groups (DRGs)) so the incentive is to manage costs

incentive is to manage costs.

• Some hospital care (10-25%) is paid based on

charges so if you use less resources your revenue charges so if you use less resources, your revenue and net income will go down.

• Most physician office care is paid based on charges, p y p g , so less incentive to manage costs. Not true for

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Paying for Medical Care in the US

(3 of 3)

• Physician sends bill for Professional Fee to insurance company (if patient has insurance).

• Hospital sends bill for Facility Fee to insurance company (if patient has insurance).

• Patients & their insurance companies end up with multiple bills from:

M lti l h i i

• Multiple physicians. • Multiple hospitals.

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Health Maintenance Organizations (HMOs)

have a Fixed Monthly Fee

Covers all inpatient care, outpatient care, and

medications. No billing is required because providers are employed by the HMO Examples:

are employed by the HMO. Examples:

• Kaiser Permanente covers 8 Million people.

• US Government Veterans Administration is for injured and retired military.

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Agenda

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US Medical Payment System

Gives Rise to Medical Software

• Much early computer use in healthcare was for billing.

Gives Rise to Medical Software

y p g

• In the US, most clinical computer systems were built by academic hospitals, such as:

• Brigham and Women’s Hospital-Boston • Brigham and Women s Hospital-Boston,

Massachusetts.

• Regenstrief Institute-Indianapolis, Indiana. • LDS Hospital-Salt Lake City, Utah.

• Approximately 40 year history of clinical computing in the US.

the US.

• Electronic Medical Record (EMR): the record used in a given facility or organization.

El t i H lth R d (EHR) EMR th d • Electronic Health Record (EHR): an EMR than can send

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Many Commercial EMR Vendors in US

• Niche hospital systems: emergency department, intensive care, anesthesia, obstetrics, and others. • Hospital EMRs.

• Physician Office EMRs (also called outpatient or ambulatory systems).

• Hospital billing systems • Hospital billing systems.

• Physician office billing (practice management) systems.

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Most US Physicians Don’t Have an EMR

The larger the office, the more likely the office is to use an EMR:

Solo doc: 7% of practices have an EMR. 2 docs: 9%

2 docs: 9% 3-5 docs: 13% 6-10 docs: 17% 11+ docs: 27%

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Hospital EMRs Classified by Function

5050 out of about 6000 US Hospitals

Stage 7: fully electronic interoperable EHR 0 1% Stage 7: fully electronic, interoperable EHR 0.1% Stage 6: physician documentation, full clinical 1.0%

decision support, full digital images decision support, full digital images

Stage 5: closed loop medication ordering+admin 1.3% Stage 4: docs order at computer, decision support 1.9% Stage 3: nursing documentation, error checking, 33%

digital images outside of radiology

Stage 2: clinical data repository & med vocabulary 33% Stage 1: electronic ancillaries: lab, rad, pharmacy 13% St g 0 l b d h t t ll l t i 17%

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Stage 0: lab, rad, pharm not yet all electronic 17%

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Agenda

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Portland Metro Area: 2 Million people 2 Million people.

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Legacy Health System

Metropolitan Area of Portland, Oregon

• 5 hospitals – 1100 beds – 53,000 admissions per year. • 200,000 emergency department (ED) visits per year. • 40 clinics – 300,000 visits per year.

• 10,000 employees, not-for-profit. Also ser es Vanco er Washington • Also serves Vancouver, Washington. • 250 employed physicians:

• 150 in offices (including surgeons) • 150 in offices (including surgeons). • 100 in the hospital only.

• About 1000 private physicians use our hospitals.

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Legacy’s New System Installation

• In 2008-2011 we will replace eight partial and niche systems from multiple vendors with an Enterprise EMR and Billing System

and Billing System.

• All the hospitals and all Legacy physician offices will be on one electronic medical record and billing system

on one electronic medical record and billing system. • The patient will have a web front-end into this same

EMR and billing system.g y

• We are building an economic model to set expectations for financial return and to set goals for administrators to achieve.

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Legacy Health System

Current Applications

• Vendor A: Partial hospital EMR and partial office EMR (4 hospitals and 35 clinics).

V d B F ll h it l EMR d f ll ffi EMR • Vendor B: Full hospital EMR and full office EMR

(1 hospital and 5 clinics).

• Vendor C: Physician Office Billing System Vendor C: Physician Office Billing System (for all clinics).

• Vendor D: Hospital Billing System (for all hospitals). REPLACING WITH

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The Financial Model

Costs both Capital and Operational including the cost of • Costs, both Capital and Operational, including the cost of

labor of Legacy’s Information Services staff.

• Benefits from both avoided costs and increased revenue • Benefits, from both avoided costs and increased revenue. • Costs and Benefits phased in over a six year time frame.

I ti t (IP) Ad itt d t th H it l • Inpatient (IP) means Admitted to the Hospital. • Outpatient (OP) means

E D t t

• Emergency Department.

• Ambulatory Hospital-based Clinics.

• Mostly means Legacy employed Physician Offices • Mostly means Legacy-employed Physician Offices.

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Agenda

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Costs of an Enterprise EMR & Billing System

• Capital Costs.

• One-Time Operating Expenses. • On-Going Operating Expenses.

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Capital Costs

(1 of 2)

• Software License for EMR.Software License for EMR.

• Software Licenses required from other vendors. • Central Hardware (servers).

• Central Hardware Operating Systems.

• Central Hardware Thin Client Licenses (Citrix) • Central Hardware Thin Client Licenses (Citrix). • Replacement Hardware as equipment ages.

• Peripheral Hardware (personal computers, laptop computers on wheels, tablets, printers).

• Network Hardware (wired and wireless)

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• Network Hardware (wired and wireless).

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Capital Costs

(2 of 2)

• Implementation Services from Vendor.

• Implementation Services from Outside Consultants. • Labor to build EMR by Employed Staff.

• Travel for everyone above.

• Interface equipment to patient monitors. • Interface software licenses

• Interface software licenses.

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One Time Operating Expenses

• Training of information services staff at vendor’s campus.

• Training of our end users (clinicians & billing staff). • All development and implementation after first site

goes live on software is an operational expense.

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On-going Operating Expenses

• Annual maintenance fee on: • EMR software.

• Required extra software. • Central hardware (servers). • Hardware operating system.p g y • Thin client software (Citrix).

• Interface hardware and software.Interface hardware and software. • Training of:

• Technical staff in Information Services • Technical staff in Information Services. • End users in clinical and billing areas.

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$60

Annual Capital Cost and Operating Expense in $Millions

$50 $40 $30 Total Capital $20 Total Support Staff OneTime OpEx $0

$10 OneTime OpEx _{Hardware/Software Maint}

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$0

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Agenda

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Avoiding the Continuing Costs of the

Current Systems once we turn them off

• Annual Maintenance Fees to Vendors: • Vendor A Hospital and Office EMR. • Vendor B Hospital and Office EMR. • Intensive Care Unit EMR.

Emergenc Department EMR • Emergency Department EMR. • Hospital Billing.

• Physician Office Billing • Physician Office Billing.

• Information Services Labor to support current systems.

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pp y

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Phase Out Costs of Old Systems

Cost Avoidance 2008 2009 2010 2011 2012 2013 Vendor A Hospital & Office EMR _0% _0% _0% _50% _100% _100% Vendor B Hospital & Office EMR _0% _0% _0% _100% _100% _100% Intensive Care Unit EMR _0% _0% _0% _100% _100% _100% Emergency Department EMR _0% _0% _0% _90% _100% _100% Hospital Billing _0% _0% _20% _50% _75% _100% Physician Office Billing _0% _0% _10% _40% _60% _100% IS Labor for Current Systems 0% 0% 30% 70% 90% 100%

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Avoiding Current Systems Cost per year in $Millions

$25

$20 Total Cost Avoided

$15 Operational Expense $10 Operational Expense $5 Capital Cost 34 $0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

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Aggressive Calendar to Install New System

gg ess ve Cale da to stall New Syste

Sep 2008: Software load. Design and Build. Apr 2009: Testing.

Aug 2009: Upgrade to new version. N 2009 T t i

Nov 2009: Test new version.

Feb 2010: Start 35 clinics. Finish Aug 2011. Apr 2010: Hospital #1

Apr 2010: Hospital #1. Aug 2010: Hospital #2. Nov 2010: Hospital #3.p

Jan 2011: Upgrade to new version. Mar 2011: Test new version.

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The Benefits of an Enterprise EMR

• Unnecessary Lab Tests.

• Unnecessary Radiology Exams.

• Transcription.

• Medical Records Labor. • Better Drug Use.

• Adverse Drug Events.

• Lab Staff Labor.

• Charge and Order Entry. g

• Length of Stay. • Nursing Overtime.

g y

• Paper Forms.

• Better Charge Capture. Nursing Overtime.

• Hospital Unit Clerk Labor. • Hosp Pharmacy Productivity

Better Charge Capture. • Less ED Diversion.

• Convert Chart Space

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Model Assumptions

• One integrated, enterprise system for Hospital and Office EMR and Billing.

• Physician is entering 80-90% of the IP orders at the • Physician is entering 80 90% of the IP orders at the

computer - Computerized Physician Order Entry (CPOE) with Clinical Decision Support (CDS).

Physician is entering 100% of the OP orders at the • Physician is entering 100% of the OP orders at the

computer, with CDS.

• Hospital responsible for IP drugs; doctors write OP prescriptions to be filled at outside drug stores and the patient or insurance pays for those drugs.

• Adjustments will be made for decreased revenue due j to decreased charges.

• Bar-coded medication verification is part of new EMR. This model does not include benefits from PACS

• This model does not include benefits from PACS (Picture Archiving and Communication System).

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Decreased Unnecessary and Duplicate

Lab and Radiology Tests

• Doctors have more of the record available with EMR. • Doctors can see prior results more easily.

• Clinical Decision Support warns of duplicates.

• Doctors get advice about which test is preferred. • Doctors are shown the cost of the test.

R f di 0 % d i l b • Range of studies suggest 10-15% decrease in labs

and radiology exams.

• 5-7% decrease used in this model • 5 7% decrease used in this model.

Bates. Am J Med 1998;104(4):361-8 Bates. Am J Med 1999;106(2):144-150. W J H lth I f M t 2002 16(4) 50 55

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Wu. J Healthcare Inf Mgt 2002;16(4):50-55.

Girosi. Pub Number MG 410. Rand Corp, Santa Monica, CA. 2005. Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS 2006. Thompson. JHIM 2007;21(3):49-60.

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Decreased Drug Use

D t t ti t d i b t hi h d i • Doctors get pertinent advice about which drug is

preferred.

Clinical decision support based on physiological • Clinical decision support based on physiological

parameters limits drug use, dosing, and duration. • EMRs make it easier to show literature references • EMRs make it easier to show literature references

pertaining to the order at hand.

• Peer-vetted, literature-based Order Sets narrow Peer vetted, literature based Order Sets narrow variation and promote best practice.

• EMRs can automatically limit duration of antibiotics y and risky drugs.

• 5% decrease in IP drug cost used in this model.

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Decreased Adverse Drug Events (ADEs)

• ADEs involve patient harm, without or with error. ADE 6 9% f h it l d i i (U d 7%)

• ADEs: 6-9% of hospital admissions. (Used 7%).

• CPOE, CDS, and Bar-coded Med Verification all help. • ADEs: 28-70% are preventable (Used 40% in model) • ADEs: 28-70% are preventable. (Used 40% in model). • Bates: of the errors causing preventable ADEs:

• 56% occurred at ordering stage. (Used 44%).g g ( ) • 6% occurred at transcription stage.

• 4% occurred at dispensing stage.

• 34% occurred at administration stage. (Used 10%). • $5000 average cost of ADE used in model.

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Bates JAMA 1995;274:29-34. Bates JAMA 1997;274:29-34. Bates JAMA 1997;277(4):341-342. Bates JAMA 1998;280:1811-6.

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Decreased Length of Stay

• Assumes Plans of Care are built into EMR.

• Recovers only the nursing cost - $275 per day. • Figures opportunity for each of the top 30

• Figures opportunity for each of the top 30 Diagnostic Related Groups (DRGs).

• Calculated savings if Length of Stay brought to Calculated savings if Length of Stay brought to within 117% of ideal used in this model.

• About 5000 patient-days opportunity in this model.p y pp y

Dexter NEJM 2001;345(13):965-970. Meltzer Ann Int Med 2002;137:866-874. Laughlin Nurs Mgt 2003;34(12):51 52 Girosi Pub NoMG 410 Rand Corp Santa Laughlin Nurs Mgt 2003;34(12):51-52. Girosi Pub NoMG 410 Rand Corp, Santa Monica, CA 2005. Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS

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Decreased Inpatient Nursing Overtime

• Time savings is not enough to put fewer nurses on the floor but efficient charting can avoid overtime.g

• Nurses use more standardized charting forms than doctors and can do more documentation at point of care.

• Nurses need to transmit more information at end of shift and computers are good at that.

• Nurses tend to work in a single location and more likely • Nurses tend to work in a single location, and more likely

to get paid training, support from clinical leaders. • Nurses save time with the medication process.

• 60-70% overtime reduction used in this model.

Smith Nurs Case Mgt 1998;3:266-270. The Nursing Shortage: Can Technology Help? Prepared by First Consulting Group for California Health Foundation 2002. Wong

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Crit Care Med 2003;31(10):2488-2494. Girosi Pub NoMG 410 Rand Corp, Santa Monica, CA 2005. Poissant et al. JAMIA 2005;12(5)505-16. Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS 2006. Featherly Healthc Quart

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Decreased Inpatient Unit Secretary Labor

• Unit secretaries great visitors, enter orders, insert g , , papers in the chart, schedule tests and procedures, and respond to requests for patient information.

• Decreased unit secretary labor with CPOE and

complete electronic documentation by nurses and doctors.

doctors.

• Magnitude of savings determined by whether a given floor can eliminate a second secretary position or y p get by without any secretary at all.

• 20% fewer hours used in this model.

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Increased Inpatient Pharmacy Productivity

p

y

• Inpatient Pharmacists or Pharmacy Technicians enter p y the doctor’s handwritten order.

• Pharmacists verify the clinical need and use of drug. • Pharmacy technicians dispense meds and pharmacist

checks for accuracy.

• Model assumes that pharmacists would take on other • Model assumes that pharmacists would take on other

clinical duties instead of being laid off. • Little literature support at this time.

• Model assumes labor as 25% Pharmacist and 75% Pharmacy Technician.

25% l b i g d i thi d l

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Decreased Physician Transcription

• Physician Office Transcription can decrease to near zero. • Inpatient Daily Progress Notes move to computer but they

are handwritten now so no financial savings with EMR. • Inpatient dictation/transcription may still be used for:

• History and Physicals. • Consult Notes.

• Operative and Procedure Notes. • Discharge Summaries

• Discharge Summaries.

• 90% decrease in OP transcription and 35% decrease in IP transcription used in this model.

transcription used in this model.

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Decreased Medical Records Labor

(called Health Information Management in US)

• With less need for paper chart, there is less labor: • Finding. • Assembling. P lli • Pulling. • Filing. • Copying • Copying. • Transporting.

• 35% IP labor decrease used in this model • 35% IP labor decrease used in this model. • 50% OP labor decrease used in this model.

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Greene Top Heal Inf Mgt 2002;23:26-36. Girosi. Pub Number MG 410. Rand Corp, Santa Monica, CA. 2005. Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS 2006.

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D

d OP L b Cl k O d E t L b

Decreased OP Lab Clerk Order Entry Labor

• In Physician Office, paper lab slips sent to Lab for entry into lab system. OP EMR with CPOE avoids this.

d f ll d l b d

• Literature does not specifically document lab order entry but many articles on decreased labor to manage orders and patient charts.p

• 50% decrease in outpatient lab order entry labor used in this model.

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Decreased Ancillary Department Order,

y

p

,

Charge, and Result Entry Labor

• Lab labor already accounted for in previous slides. • This slide accounts for clerical labor in radiology,

l h l h l d

nutritional services, physical therapy, employed physician offices.

Literature does not specifically document ancillary • Literature does not specifically document ancillary

order, charge, result entry but many articles on

decreased labor to manage orders and patient charts. • 20% labor decrease used in this model.

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Greene Top Heal Inf Mgt 2002;23:26-36. Girosi. Pub Number MG 410. Rand Corp, Santa Monica, CA. 2005. Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS 2006.

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Decreased Preprinted Paper Forms

p

• Assumes electronic patient signing at registration.p g g g • Includes forms for:

• Patient permissions and authorizations • Patient permissions and authorizations.

• Nursing, therapist, and physician documentation. O d

• Orders.

• Literature has little specification of form use.

• 70% decrease in printed forms used in this model.

• Model includes 33% increase in use of plain computer paper

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Increased Revenue due to faster charging,

higher charge levels fewer missed charges

higher charge levels, fewer missed charges

F f h

• Fewer forgotten charges.

• Fewer days before final bill is sent out.

F d li d h b f l t

• Fewer declined charges because of more complete documentation.

• Charging at higher level of illness and injury is g g g j y supported by more complete documentation.

• 0.25% higher revenue used in this model ($2.75M).

• 6 days less in Accounts Receivable and Discharge Not Yet Final BilledÆ $18M recovered at 6% interest, used in this model.

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Awarding IT: Improving Healthcare; HIMSS Davies Award; HIMSS 2006. Featherly Healthcare Quart 2007;10(1):101-110.

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Increased Revenue due to Increased

Admissions due to Less Ambulance Diversion

• If ambulances pass you by because your Emergency Department (ED) patients cannot get a hospital bed, you lose ED revenue and hospital admission revenue. you lose ED revenue and hospital admission revenue. • Efficient EMRs can increase patient throughput and

have the effect of more hospital beds without the p brick and mortar expense.

• Legacy had 5300 hours on ED diversion in a year, 90% estimated due to hospital being full Æ about 2.5 lost admissions per hour.

$4 2 Milli i l i d i hi d l • $4.2 Million a year in lost income used in this model.

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Increased Revenue due to Converting Space

Previously Used to Store Paper Charts

• Chart room in offices with 10-12 doctors can take up the space of two exam rooms

the space of two exam rooms.

• Typically the space can be recovered two years after EMR is implemented as need for the paper chart p p p

diminishes over time.

• Addition of 14 exam rooms used in this model.

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Increased Revenue due to Changing

Practice to Care for Higher Acuity Patients

g

y

• With the patient accessing their doctor’s EMR online, th i d d d f ti i it

there is decreased need for routine visits.

• With EMRs, more patient-physician interaction can occur online and on the phone.p

• Doctor’s schedule can accommodate more new patients, and more ill patients, on the same day they call.

• Offering patients openings on same day increases loyalty • Offering patients openings on same day increases loyalty. • Insurance companies starting to pay for e-care.

• If Fee-for-Service, then increased revenue for ill patients that need to be seen that day.

• If Health Maintenance Organization, then costs are decreased by doing more care appropriately online. decreased by doing more care appropriately online. • Proposed benefit only; not used in this model.

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Increased Revenue: Better Charging Increased Revenue: Less ED Diversion

Sources of EMR Benefits - $Millions per year

Decreased Physician Transcription Decreased Lab & Rad Use Increased Revenue: Better Charging

I d R M E R

Decreased IP Nursing Overtime Decreased Drug Use

Decreased Medical Records Labor Decreased Length of Stay Increased Revenue: More Exam Rooms

D d Ad D E t

Decreased IP Unit Secretary Labor Decreased Paper Forms

Decreased Lab Clerk Order Entry Labor Decreased Ancillary Department Labor Decreased Adverse Drug Events

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$0 $1 $2 $3 $4 $5

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$80 Annual Benefits and Costs - $Millions $60 Benefits $20 $40 Net Benefit $0 $20 ($20) $0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 C t ($40) Costs ($60) Year 4

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$400

Cumulative Benefits and Costs - $Millions

B fit $300 $400 _Benefits $200 $300 Costs $100 $

Cum Net Benefit

$0 ($100) 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 56 ($200) Year 7

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$400

Cumulative Benefits and Costs - $Millions NPV (Net Present Value)

$300 $400 Benefits $200 $300 Costs $100

Cum NPV Net Benefit Costs

$0

Cum NPV Net Benefit

($100)

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

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Agenda

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Are Decreased Costs and Increased Revenue

d e to EMR or to Workflo Optimi ation?

due to EMR or to Workflow Optimization?

• Benefits often come from operational improvements p p made at the same time as EMR implementation but may not be directly attributable to the EMR.

• Since EMR implementation can dramatically change workflows, it is a good time to optimize workflows if the organization has the will to do it.

the organization has the will to do it.

• General areas of improvement for EMR installers: • Billing improvements.g p

• Improved patient flow.

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EMRs Promote

Continuous Process Improvement

• Some process improvement can be done with paper methods but it is so time consuming, most hospitals are limited to doing 2 4 such studies at a time

are limited to doing 2-4 such studies at a time. • EMR continues to deliver financial improvements

because clinicians and administrators can get the because clinicians and administrators can get the data they need to evaluate process change.

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Capturing the Benefit

• An administrator needs to be assigned for

monitoring each of the workflow changes made possible by the EMR

possible by the EMR.

• Organizations need to standardize processes across different nursing units and different facilities

different nursing units and different facilities. • Process change needs to be measured quarterly.

B d t t t i l d EMR ffi i i • Budgets set to include EMR efficiencies.

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Model is Financial Only – and Only for the

Health System - and Does Not Include

Quality Benefits to the Patient

• Patient is back to home and work faster.

• Fewer medical misadventures due to unneeded tests. • Better use of drugs and avoided drug injury.

P id h l t d t t ti f

• Providers have complete data at time of care. • EMR data can be used for research.

• Physician more likely to deliver indicated care • Physician more likely to deliver indicated care. • EMR data can be accessed by the patient online.

• Patient doesn’t have to reenter data at each office.

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Agenda

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Conclusions

• We embark on EMR implementation because we believe it is required to manage complex and chronic care effectively and efficiently

chronic care effectively and efficiently.

• We need more literature on proven financial and clinical benefits of implementing EMRs

clinical benefits of implementing EMRs.

• We need to engage in Optimized Workflow Change at the time we implement the EMR in order to get p g the full benefit from the EMR.