Practice Management & EHRs: Interface or Integrate?
Any effort to combine a practice management system (PMS) with an EHR is rife with options and decisions. Interfacing eliminates the cost of replacing a host of legacy systems, while integration is costly but could streamline workflow to the degree that efficiency results in increased revenue. Interfaces can give practices enhanced functionality without the upheaval that often occurs when integrating the two systems. What is the best path for your practice?

Building up, while building out

Baystate Health, an integrated delivery network that includes three hospitals and 70 physician practices in Springfield, Mass., transitioned first to computerized physician order entry (CPOE) in 1991 and then to an EHR about five years ago.

"We continue to purchase new practices as well as restructure and develop new practices," says Neil R. Kudler, MD, medical director of clinical informatics.

A unidirectional interface between the PMS and EHR means that when a patient calls to schedule an appointment, the encounter is established in both systems. That means that any changes further down the line, from appointment changes to referrals, require entry into both systems, a limitation of this interface design.

The systems were interfaced before Kudler joined Baystate, but the goal was always an enterprise-wide EHR, he says. "With long-standing legacy products, you don't know how many software products run through this system. Prior to the initial implementation of our EHR, we already had scheduling and registration systems, so we had no choice but to interface."

Kudler would like better integration. "Compared with 10 years ago when so many institutions had a strategy of purchasing best-of-breed products, Baystate was considering an enterprise product. We anticipated what we're seeing now in healthcare: There's a lot of demand for integration. For instance, the final rule for accountable care organizations [ACOs] is all about integration," he says, "Integration works best with an enterprise system and there's no doubt that integration is the most highly functional strategy."

Organizations with a long-standing infrastructure and dozens of legacy programs create contingencies for EHR implementation, Kudler says, because both financially and practically speaking, replacing all of that is just not feasible.

Large network allows for integration

When Lehigh Valley Health Network (LVHN) in Allentown, Pa., was looking for a new EHR for its owned physician practices, they decided to bring together the PMS and EHR. The organization adopted a new EHR for 400 employed physicians in more than 70 practices five years ago. At that time, LVHN also had another EHR and a different vendor for its PMS, says Lori Yackanicz, IT department administrator. During the implementation of the EHR, much work took place to integrate the workflow of the PMS to the EHR.

Once the practice was up and running on the new EHR, the workflow between the two systems became seamless. Now, the PMS and EHR are first connected when a patient appointment is made. The appointment is entered into the PMS and automatically interfaced to the EHR. The front desk staff notes in the PMS when a patient arrives for an appointment and the physician is notified through the EHR, streamlining patient flow.  

Unless the practice purchases a system that has a PMS and EHR fully integrated, it is difficult to create this seamless workflow. Being part of a larger network allows a practice to focus on the workflow and not the technical challenges of making the systems talk to each other, Yackanicz says. "There's always some resistance within the practice when moving to an automated environment. Physicians need to enter a lot of data into the system, including ICD-9 codes." LVHN has developed a workflow where a daily bill/charge-hold file is created with all codes entered in the EHR by the clinical staff. The file is released at the end of the day, and the responsible staff member can review charges before sending to the practice management system, which allows for data integrity checking.

Transitioning to an electronic environment is always challenging, Yackanicz says, but practices that use an integrated EHR tool have access to labs and diagnostic images done by other network services. Physicians also have the ability to message each other about patients and their care. "That's the beauty of an integrated EHR."

There are options for implementing the PMS-EHR integration gradually, Yackanicz says, but oftentimes, "it is just as easy to implement integration up front and conduct training just one time." Whether they will make the switch piecemeal or all at once is "driven by the culture of the practice and their willingness to embrace the new technology. At LVHN, we have developed a standard implementation protocol, which is replicated in all owned practices. This has turned into a 'best practice,' which has allowed for much of our success over time."

A gradual conversion

St. Francis Hospital in Wilmington, Del., converted to an EHR system for overall efficiency, says Dana Bussey, senior manager of reimbursement, practice management outpatient services. "The EHR we implemented had its own practice management tools. You couldn't have the one system without the other."

To jump-start the integration process, Bussey tackled the PMS first. All financial data had to be re-entered and all costs reloaded. From there, it was time to create a plan to convert all of the paper charts to electronic charts. A practice with patients going back 20 to 30 years and all of their x-rays, lab results and consults has a lot of paper to scan in. Two years later, St. Francis is still in the process, with about 60 percent of its records converted.

"We see in excess of 2,000 patients a month, so it may take up to five years to convert all the patient data," Bussey says. As patients are put on the schedule, that prompts her team to move forward with converting that record.

A St. Francis team, which includes physicians, nursing, clerical, billing and staff, meets weekly to direct the conversion. "Everything seems to be flowing in the right direction," she says. But, the data flow never stops. Patient phone numbers and insurance information change constantly, and nurses can see those important changes when ordering blood work or other lab tests. Overall, the system "makes things a lot more efficient," from updating demographics to tracking messages.

Advice from the field

Bussey recommends carefully considering the amount of resources required to carry out a PMS-EHR merger. "We weren't prepared for how long each process was going to take with the hundreds of pieces of paper." She set up a workgroup to determine the minimum information the physicians needed for every patient visit and make sure each record had that.

Although it may seem easier to adopt an enterprise system, Kudler says, it's simply not an option for many organizations. "I would advise that you establish clarity from the get-go with the vendors in terms of their ability to interface and remain flexible in creating opportunities for a progressive stance on integration."

The CMIO needs to translate the perspective of the physician and the patient to the IT team, while simultaneously providing a broader understanding of the technological side to the physicians. "The CMIO also needs to make the business case for either the investment in solid bidirectional interfacing, or true integration of the system," Kudler says.

The interface-integrate debate will remain on the front burner, he says, because we're "living in the context of health information exchange—watching and participating. The next step after enterprise systems is strategically situating oneself for information exchange. That, at this point, is interface dependent."