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Soul Road: One Solo Doc’s Extensive EMR Journey

January 28, 2014
by Gabriel Perna
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A Q&A on EMR implementation from solo pediatrician Galen Chock, M.D.

When it comes to health information technology (HIT) adoption, solo practitioners have it a lot tougher than their colleagues in larger practices.

This isn’t advocate-driven conjecture, it’s a fact. Recently, researchers at the Commonwealth Fund, the Washington, D.C.-based nonprofit, released a study that said as much.  Looking at data from the 2012 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, the researchers found that half of physicians in solo practices use electronic medical records (EMRs), compared with 90 percent of those in practices with 20 or more physicians.

The challenges solo practitioners deal with in implementing HIT are obvious and undeniable. There is, of course, the matter of cost, both in maintenance and upfront expenditures. Furthermore, small staffs mean a reduced level of support from a clinical, administrative, and technical standpoint. And as Galen Chock, M.D., a pediatrician in Honolulu, says, “When it comes to implementing HIT, support makes a big difference.”

Dr. Chock would know about having to overcome these obstacles. As the solo practitioner explains in an interview with Healthcare Informatics Senior Editor Gabriel Perna, his own EMR implementation journey was fraught with failure and frustration, and ultimately, success. The two recently talked about this journey, how he has been able to optimize his EMR and thrive where other solo docs have struggled.

Below are excerpts from that interview.

Galen Chock, M.D.

When did you start on your journey to implement an EHR?

I started practicing in 1982. When I started, it was paper charts. You just wrote things in. About five years into practice, because pediatrics has a lot of volume, my handwriting was deteriorating and I figured I had to do something better. We went initially to Word Perfect, then Microsoft Word, and we started building word templates. I’d see the patient, I’d type up a note, and we’d glue it in the patient chart. I was fine with doing that for 10 years.

Sometime in 2009, I was here one evening finishing my notes, and I figured there had to be a better way of doing things. At the time, our HMSA (Hawaii Medical Service Association), the Blue Cross and Blue Shield here, was offering a financial incentive to [implement] an EMR. Originally, I was okay with sticking with the word templates and gluing them into the chart. At some point I did some research, and right before the end of that incentive, I changed my mind and figured we should go to an EMR.

We went with a company called MedeNotes, because I heard that it was a good program for pediatrics. It also turned out one of the local practice management companies was supporting it. So I thought that was an ideal world, an EMR built by a company on the main land, but had local support here in Hawaii that could help me with any bugs. We went with that at the end of 2009 and it was tough. You had to build a lot of templates that were not that intuitive. Even though I was used to word templates, it took a lot of time.

Low and behold, within six months, it got bought out by another company [Editor’s note: In 2008, MedeNotes was bought by Eclipsys]. That company said [to me], “You should transition to a better EMR.” Fortunately, I did not. I stuck with [what I had] and then about a year later, that company also got bought [Editor’s note: In 2010, Eclipsys was bought by Allscripts]. The newer company said the same thing. “You have to move to the better EMR.” At that point, I said, “Maybe I do need to move to a better EMR, but let me look around.” Fortunately, I had seen Amazing Charts (North Kingstown, R.I.-based EMR vendor) in the past. I thought about it. I was concerned about not having local support. I tried a free download and tried it for six months. I decided to go with them in the summer of 2011.

What made you go this route?

I think the biggest thing; the reviews were excellent on Amazing Charts. It’s hard to find reviews on EMRs, but whatever I did find on it, it was always 4-5 out of five stars. That was one. Two, they allowed me to download the program and use it without paying for it, which no other EMR did. I learned from the last one, you can look at it all you want, but you don’t know until you use it. Thirdly, it was affordable. I’m a solo practitioners, I had already spent money on an EMR. If I’m going to another one, I had to be conscious how much I was going to spend for an EMR. Also, it was a stable enough program that I myself could load it into a server and get it into my work stations without much difficulty.

I’m a solo practitioners, I had already spent money on an EMR. If I’m going to another one, I had to be conscious how much I was going to spend for an EMR.

What are some of the ways you’ve optimized your EMR to cater to your needs as a solo practitioner?

One of the tailors we’ve done is we’ve implemented it at my speed. We’ve found that when the Epic team implemented the outpatient system (at the local hospitals), they’ve been telling providers, “You need to cut your practice down 5-10 patients per day, for a couple of weeks, until you are used to it. Then you can gradually ramp back up.” For a Pediatric provider, saying I’m only going to see five patients per day is impossible. We implemented the system at a rate that my staff and myself could handle. We said, “We’ll do prescription refills first, then we’ll do telephone messages next.” Before you know it, within two weeks, we were 100 percent on the EMR.

For a Pediatric provider, saying I’m only going to see five patients per day is impossible. We implemented the system at a rate that my staff and myself could handle.

The other thing we did, in the fall of 2011 HMSA started their patient-centered medical home (PCMH) program for primary care physicians. I was very sure, going through the details of the program, I wanted to track some quality metrics in my EMR. So I wanted to have the EMR up and running before we started that. The HMSA program, partly through the advice of a lot of the local pediatricians, had us do a “Children with Special Health Care Needs” screener. This is a six question questionnaire. We were charged with getting it filled out, reviewing it, and tracking it, because HSMA was not confident they could track it themselves. AmazingCharts has a decision support module, and we built a “Children with Special Health Care Needs” screener as one of the tracking items in that module. We needed to track whether the patient had filled one out, and whether it was positive or negative, and if it was positive, why was it positive.  

We track it with V (using ICD-9) codes and CPT (current procedural terminology) codes. It’s worked out very well.  Across the country, about 15 percent of pediatric practices should have children with chronic diseases, and “Children with Special Health Care Needs” identifies them. We have in order of 15-17 percent of our patients who fulfill this criterion. 

You are also tracking certain Healthcare Effectiveness Data and Information Set (HEDIS) measurements in the EMR?

Amazing Charts prebuilds them into the program. It’s a threefold measurement: Has your child had their height, weight, and BMI (body mass index) percentage calculated, and have they undergone physical activity and nutritional counseling. We have been using that since 2011. This year, HSMA will measure what percentage of children has fulfilled that. We also measure lipid screening, anemia, and Chlamydia, which were also prebuilt into the EMR.

What is next for you in terms of EMR implementation? Is this system interoperable? Can you connect with others in the area?

Interoperability is, of course, a big concern, everyone is talking about that. We do have (an organization) working on a common inter-connectability. I understand Amazing Charts is looking for inter-connectability with Epic. The majority of hospitals (in Hawaii) have Epic, so if we want to communicate with them then there has to be some inter-connectability.  The other area of we’re looking inter-connectability is with the immunization registry. We do have interoperability with labs though.

What advice would you give to solo docs going on the EMR implementation journey?

Do your homework. You got to look at these systems. A lot of my colleagues are going with the crowd. Each person thinks slightly different, each person likes to input data a different way, and each person has a different workflow. It’s important to try and match those needs with what your EMR can do.

A lot of my colleagues are going with the crowd. Each person thinks slightly different, each person likes to input data a different way, and each person has a different workflow.

It’s likely that one EMR is not going to be the absolute right package to do everything for you. We were always looking for other things to add on. When we went with our first EMR, our practice manager said, “Don’t expect this to be the only EMR you get.” And I looked at him and thought, “No this is it.” Sure enough, he was right. Rather than than cry over spilt milk, we took the lessons learned and moved forward.


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