The paperless plunge

The only thing that anyone can count on for sure in the arena of paperless veterinary practice is that the experience is different for everyone. For one thing, practices choose their software for different reasons: to make the front desk run more smoothly, to allow doctors to go home earlier, to present a sophisticated image to clients, to stop looking for lost charts. But at the heart of most of these reasons is a single motivating theme—a desire for greater efficiency and consistency, which leads to better patient care, client service, and practice profitability.

We talked to four practice leaders—two owner doctors and two hospital administrators—about their experience with paperless practice. What do they think of their systems and the available technology at this point in time? We got an earful, and we'll let you in on what we heard.

But first, some definitions are in order. What exactly are we talking about when we say "paperless" anyway? While the term can mean different things to different people (and, as we'll see later, is often a misnomer), for our purposes here we're talking about a computer system that integrates appointment scheduling and reminders, electronic medical records, invoicing, and a way to store information from external sources such as labs and referral hospitals. While some software does these basics and no more, others are more sophisticated, offering the ability to network with diagnostic equipment and digital imaging technology.

So whether you're thinking about just throwing away the paper appointment book or you're ready to outfit every workstation to view digital radiographs, let the insights of these savvy users guide you in your next steps.

'I saved two full-time equivalents at the front desk'

In Rochester, Minn., home of the Mayo Clinic, people have certain expectations about what good medical care entails, says Linda Wenner, practice manager at the four-doctor Cascade Animal Medical Center in Rochester. "Clients assume when they come in that we're going to be paperless," she says. "This system is an important part of the image we present—that we are a sophisticated, state-of-the-art hospital."

The bottom line

In 2001 Wenner and her husband, Dr. Mark Wenner, built a new facility and wired it to be paperless. But not until 2003, when a new veterinarian joined their practice after working in a paperless environment, did they begin to seriously consider the possibility. "She was a big proponent," Wenner says. "Also, my husband and I had been to a couple of CE meetings that discussed medical records from a legal aspect and the trouble doctors could get into with incomplete records. The thought that we could miss something that would come back to haunt us scared me. It made it obvious that this was the only choice."

The Cascade team had taken an initial step toward going paperless in their old building with the switch to an electronic appointment scheduling system. "We told the front desk staff we were going to take away the paper book, and they did not like it," Wenner says. So she let the receptionists keep a paper appointment book as backup. After one week they threw the book away.

Later, when the hospital was ready to go fully paperless, team members and doctors talked about the process for months beforehand. During staff meetings they would view the system on a projector screen and discuss what it would look like and how the transition would work. "When a phone call came in, how would it be different? What would the doctor's day be like?" The team discussed these issues and more.

However, Wenner says, if the managers had not set a definitive end date on paper record keeping, the team would have discussed it forever and the transition would never have happened. So she pulled the plug, said "today's the day," and the practice hasn't looked back since. "The doctors initially were a little frustrated because it took a while to get our templates set up," Wenner says. "But now they wouldn't give it up for anything."

Cascade's system creates a report card for every pet that comes into the clinic. Team members and doctors follow the report card setup to document their findings and enter charges along the way. When the client goes to check out, the invoice is ready and waiting, drawn from the information entered during the exam. The client gets a printout of the report card, complete with the pet's history, pays, and the record is completed and closed. "It's completely seamless," Wenner says.

If a client calls with a question for a doctor, she continues, the receptionist can call up the patient record, create a phone call reminder such as, "Mrs. Smith wants Fluffy to have more phenobarbital; please advise," and send it to the doctor's daily planner. When the doctor checks his planner at his next break, he sees that he has a message, returns the call, documents the conversation, and closes out the record.

Wenner says that the financial benefits have been considerable—most notably, she's saved two full-time equivalent positions at the front desk. "We don't need someone to make new files, pull files, update files, or go look for files," she says. "We used to need five receptionists; now we need just three." Plus, she says, "the reduction in lost charges was amazing. We had been losing up to 25 percent of our lab fees because of poor communication. Now we capture all of that."

Her advice: Wenner encourages practices considering paperless software to make sure the company they choose provides good technical support. "We spend a lot of time on the phone asking questions, and our vendor addresses our concerns quickly," she says. If you do this, she adds, you don't need an internal technical support staffer. "If you can use the Internet and talk on the phone, you can fix your computer," she says.

'I had to bail on our original system'

Dr. William Griffin, co-owner and medical director of Black Horse Pike Animal Hospital in Turnersville, N.J., chose a paperless system about three years ago. "It had always seemed obvious to me that you needed this kind of technology to be efficient and provide high-quality medical care," he says. "There's nothing more frustrating than looking for a lost chart and not finding it."

Dr. Griffin says the first system he used looked great on the surface. "It was flashy and it doubled as a client education tool as well as a medical record," he says. And it probably would've been fine if his practice were smaller. "But as soon as we started pushing the limits as far as what it could and should do, we became acutely aware we had chosen the wrong system."

Dr. Griffin spent countless hours trying to develop the system's capabilities, standardize processes and communication among doctors and employees, and build the hospital's protocols into the software. "I personally invested a lot of time, but eventually I realized that the foundation just wasn't there," he says. "When the company's developers started calling us with questions, we knew we had a problem."

So it was back to the drawing board. Dr. Griffin spent about a year researching various paperless systems and even created a spreadsheet to analyze subjective and objective observations with a numerical scoring system. "We were trying to eliminate the 'gee whiz' factor," he says. "We didn't want to say, 'Gosh, this is pretty' but overlook some major deficiency."

Dr. Griffin and his colleagues eventually chose the system that had the most extensive set of features and that they believed had the potential to develop into something even better. "It's an evolutionary process," he says. "It's not perfect, but we believe the company is putting its weight behind the product and the developers have the vision and commitment to keep optimizing how it should function."

Learning the limitations of your system, and overcoming them, is the key to using it successfully, Dr. Griffin says. He sees a difference between electronic medical records in veterinary medicine and those used in human medicine. There's more consensus and oversight in the human health world, he says, and therefore companies have been able to progress more rapidly in developing sophisticated programs. "I've been hands-on with some human EMRs [electronic medical records] and gotten to see what they're like," he says. "It's not all peaches and cream over there either, but it's more finished than what we have in veterinary medicine."

For one, Dr. Griffin would like to be able to organize and search his notes by a certain medical condition, but at this point he can't. "You have to devise ways to develop something like that within your system," he says.

Despite those observations, Dr. Griffin says that after a year with his current system he's fairly satisfied. "It's exciting," he says. "If you can be more efficient and quicker with repetitive tasks, you can focus on providing better medical care."

His advice: Dr. Griffin emphasizes that a paperless system is only a tool, and if a practice doesn't have proper standards and protocols in place, the tool won't help and it might make existing problems worse. "Many practices like the idea of being paperless, but they haven't really thought about how they're going to interface with the software," he says. "My number-one piece of advice is this: Everyone needs to understand that they'll be using the system for standardization and consistent application of protocols. If a clinic has seven doctors and they all want their own exam form, that's not a best practice. You have to be committed to standards of care before you even touch the software."

'Our revenue increased 24 percent'

Kathy Bradfield is the hospital administrator for Westlake Animal Hospital in Austin, Texas. She says that in the first two months after going "paper-light," the practice's gross revenue jumped 24 percent. "In the last 20 years we've never had that much growth in one month, much less two," she says. "That was a good indication that we were on the right track."

Bradfield attributes this increase to fewer missed charges, greater efficiency and productivity, and adherence to practice protocols. Specifically, she says, in the year following the transition the practice saw a 50 percent increase in gross revenue from lab services and a 30 percent increase in radiology charges. With the medical templates built into the paperless system, the doctors were consistently following the appropriate protocols, making top recommendations, and enhancing the consistency of care—and clients were complying.

In 2007 the practice made the decision to close on Saturdays, something the owners thought was important for the doctors' and team members' quality of life. Even with this change, the hospital saw an 11 percent increase in gross for the year. In fact, January 2008 was just $600 short of their best month ever—and January is usually considered a slow month.

Numbers aside, Bradfield says, there's a client "wow factor" with their paperless system. "In Austin we have a very computer-literate clientele," she says. "They come in expecting you to be able to pull up and process their record quickly." Westlake, like many hospitals, lost charts regularly when it was paper-based—not good, Bradfield says. "When you lose patient records, you don't just waste time and lose out on efficiency," she says. "You actually insult the client. That person assumes you don't care."

Her advice: Bradfield offers these recommendations to a practice that's transitioning to a paperless system:

1. Set a timetable. Just like any project, you need to have goals for when major steps in the transition will be accomplished. For example:

• April 1: Start scheduling all appointments electronically.

• July 1: Start entering all new patients in computer system.

• Sept. 1: Stop pulling paper files.

• Jan. 1: Start using electronic signature capture.

2. Work on your medical templates. Don't expect them to be perfect at first. Bradfield said it took the doctors at Westlake a year before they were satisfied that they had good templates.

3. Start every new client in the paperless system. Don't even create a paper chart for them. For existing clients, enter their information into the system as they come in for appointments. (For more detailed information about this process, visit vetecon.com; see Look Online.)

4. Invest in plenty of memory. These systems burn through memory quickly, especially if digital images such as radiographs and ultrasounds are a component. A file server with a seriously hefty capacity may be the best way to go.

'I love it, but we have a ways to go'

Dr. Jeff Rothstein, MBA, a Veterinary Economics Editorial Advisory Board member, has been paperless since he bought his first practice in 1994. Back then he dictated his notes and a transcriber came in once a week to type them up. "Even though it was cumbersome, it was important to me to be paperless from the beginning," he says. "You don't lose charts, and everyone can read your handwriting."

Those days are long gone now—for one thing, Dr. Rothstein realized he could type just as fast as he could record into a Dictaphone. For another, he owns a group of clinics, The Progressive Pet Animal Hospitals and Management Group, and they're all paperless, including three Banfield hospitals, which have their own proprietary system (see Look Online). More important, though, is that veterinary medicine is beginning to catch on to the concept of a true EMR. Beyond simply typing notes into a glorified word processor, for example, radiographs and ultrasounds can be included in the medical record.

"However," he says, "I'm not convinced that any of the half-dozen or so major providers have mastered the potential for true electronic medical records. In my opinion, most are relatively simplistic at this point. But the potential is great."

Dr. Rothstein hopes future versions of his software will include better templates with fewer screens to navigate to write medical notes. He also says the software needs to offer doctors an easy way to denote abnormalities on an animal's anatomy on screen. "On a paper chart, we can draw diagrams," he says. "We need that."

His advice: Pull on your walking shoes and visit two or three paperless practices in your area. Is their software choice the right fit for your clinic? Also, attend at least one major veterinary conference and meet with representatives from software vendors.

Practice software is improving every year. Dr. Rothstein breaks it down: Most patient information can be kept in electronic records. Modern computers are beefy enough to handle the data storage. Vendors have made more forms and templates. The future is the paperless practice. But whether the software today does what you need it to do is a question only you can answer.