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Service Delivery Innovation Profile

Electronic Medical Record–Facilitated Workflow Changes Enhance Quality and Efficiency, Generating Positive Return on Investment in Small Pediatrics Practice

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Four Seasons Pediatrics, a three-physician group in upstate New York, redesigned its workflow, reduced staffing costs, and enhanced quality of care in the process of adopting an electronic medical record. The group also achieved a positive return on investment within 2.5 years, earning financial rewards through the Bridges to Excellence program and other pay-for-performance programs.

Evidence Rating (What is this?)

Moderate: The evidence is based on before and after comparisons of efficiency, selected outcomes, patient satisfaction, and charge capture, which demonstrate a clear link between the implementation of the EMR-facilitated workflow changes and improved results.
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Developing Organizations

Four Seasons Pediatrics
Clifton Park, NYend do

Date First Implemented


Problem Addressed

Electronic medical records (EMRs) can assist practices in redesigning workflows, leading to the potential for improved efficiency and enhanced patient outcomes; however, small practices often find the costs and effort associated with EMR implementation to be prohibitively high.
  • Many physicians do not use EMRs, especially those in small practices: A 2005 survey estimated that only 13 percent of solo practitioners and 16 percent of groups with 2 to 4 physicians have adopted EMRs, compared with 29 percent of groups with 10 to 19 physicians and 39 percent of groups with 20 or more physicians.1
  • Financial and other barriers to adoption: Barriers to EMR implementation include lack of adequate capital, high maintenance costs, complex contracts, and lack of time. Many practices do recognize the potential financial benefits (e.g., improved capture of patient charges on insurance claims, reduced transcription costs and staff expenses, increased revenues) as well.1
  • Numerous components contribute to high EMR costs: One-time implementation costs include hardware and software acquisition, system training and installation, workflow redesign, conversion of paper to electronic charts, productivity loss during implementation, technical/network system support, and other implementation costs. Recurring costs include software maintenance and support, hardware replacement, internal and external labor costs, and other ongoing costs.1
  • High costs lead to concerns about return on investment (ROI): Studies show that many health care providers are reluctant to adopt EMRs because of a concern that the high costs associated with adoption will prevent achievement of an adequate ROI.2

What They Did

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Description of the Innovative Activity

Four Seasons Pediatrics redesigned its workflow starting in the spring of 2005, including revision of the practice's chronic care management systems and processes. This change was facilitated by the adoption of an EMR. Key changes are described below:
  • Redesign of workflow associated with a patient visit: Inspired by the functionality of the EMR, Four Seasons has revamped the workflow associated with the typical patient visit. Key changes include the following:
    • End of paper charts: Physicians bring a tablet computer with them to the patient examination room instead of the paper chart. Physicians call up the patient record and input new data using checklists/templates that are built into the EMR.
    • Patient education: Physicians and nurses use the EMR to educate the patient by showing relevant screens during the visit (e.g., a graph can be shown depicting a child's growth trends compared with the norm, parents of a child on antidepressants can be informed about the black-box warning for use of the drug in children). Educational materials can also be printed and sent home with the patient and family.
    • Prescription ordering: Prescriptions are ordered through the EMR and printed out for the patient before departure.
    • Monitoring lab and other results: A nurse is assigned the responsibility to check the EMR daily to monitor a list of laboratory results that have not been returned; the nurse can follow up with the laboratories to ensure that no tests have fallen through the cracks. The system also facilitates the mandatory reporting of immunizations as required by state law.
  • Chronic care workflow redesign to focus on proactive care: The EMR has allowed Four Seasons to redesign its chronic care management workflow, with a focus on more proactive management of those with chronic diseases and conditions.
    • Automatic appointment reminders: When a patient is diagnosed with a chronic illness (e.g., asthma, attention deficit disorder), the system automatically generates a letter introducing the need for regular appointments to monitor the patient's condition and regular education to help the patient and family better manage the condition.
    • Embedded standards of care: Standards of care based on national guidelines are incorporated into templates for consistent collection of history, examination, testing, treatment plan, and education.
    • During-appointment triggers: When patients arrive for an appointment, the EMR triggers a set of questions for the provider to ask the patient, along with a standard education module for the provider to use. The physician documents the answers and the fact that the module was provided. At the next visit, the provider is again prompted with appropriate questions, and a new education module is prompted.
    • Followup for recommended tests and treatments: The system automatically generates needed referrals for laboratory tests, specialty visits, and follow up visits. Completed laboratory tests are tracked and abnormal values flagged for clinician followup with patient.
    • Follow up appointment reminders: The EMR triggers reviews of adherence to recommended follow up appointments; patients who have not made a follow up appointment first receive a letter, then a series of telephone calls (1 week apart), and finally a physician telephone call to prompt the follow up visit.
  • Performance reports and benchmarking: The physicians use the EMR to generate comparative reports on practice patterns related to quality of care (e.g., antibiotic prescribing rates); physicians meet weekly to share best practices and then rerun reports to measure improvement.

Context of the Innovation

Four Seasons Pediatrics, LLC, a group of three pediatricians and two physician assistants in Clifton Park, NY, was motivated to redesign its work processes by the financial incentives offered by Bridges to Excellence, a not-for-profit organization that encourages physician practices to improve the safety, quality, and efficiency of care. The group realized that to achieve and document the necessary improvements in quality, they would need to increase their use of information technology. With the Bridges to Excellence incentives in mind, the practice conducted a cost–benefit analysis using a simple Excel spreadsheet, tallying the estimated costs of EMR adoption against the potential revenue enhancement (e.g., the potential financial benefits offered by Bridges to Excellence and commercial insurers). This analysis revealed that the Bridges to Excellence incentives alone could enable achievement of a positive ROI in a relatively short period of time, prompting the physicians to pursue the comprehensive workflow redesign effort.

Did It Work?

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The EMR-inspired workflow redesign at Four Seasons Pediatrics has resulted in enhanced efficiency and quality of care, high levels of patient satisfaction, and a positive ROI.
  • Improved efficiency: Four Seasons has increased efficiencies in a number of areas—for example, the practice no longer has to deal with misplaced charts. As a result of these efficiency gains, the number of support staff has been reduced through attrition. The billing staff has been reduced from two to one, because the provider generates the bill inside the EMR, which is sent electronically to the billing staffer. In addition, reception staff has not increased despite the growth of the practice from two full-time equivalents providers to three. In addition, the system has helped to increase use of generic drugs; for example, use of generic antibiotics increased from 68 percent before the system's implementation to 82 percent afterward.
  • Improved quality: Data from insurance companies suggests that Four Seasons has improved quality on a variety of measures, including provision of recommended tests (e.g., lead tests), HEDIS® (Healthcare Effectiveness Data and Information Set) scores, and asthma control. Four Seasons Pediatrics has achieved 100 percent of incentives from all insurers in the last 2 years. These incentives are for well care, HEDIS® scores, and asthma control. For example, the largest insurer with whom Four Seasons Pediatrics contracts reported that there was a 38 percent increase in use of inhaled corticosteroid treatment for Four Seasons Pediatrics over the last 18 months, while the network rate fell 12.5 percent. As a result, many insurers highlight the practice's Bridges to Excellence certification on their Web sites and directories as an indicator of quality care. Bridges to Excellence certification is achieved by passing specific performance measurement criteria administered by one of three performance assessment organizations [the National Committee for Quality Assurance, MassPRO (Doctors Office Quality - Information Technology), or the Minnesota Measurement Collaborative (Buyers Health Care Action Group)].
  • Consistently high patient satisfaction: Patient satisfaction scores have remained high (with between 94 and 100 percent of patients rating care as excellent), despite concerns that use of the EMR during the patient visit would impede physician–patient communication.
  • Improved charge capture and documentation: Four Seasons Pediatrics experienced a 10-percent increase in laboratory charges that were missed. This occurs when a provider forgets to circle the encounter form during the visit. With the EMR, documentation of the test automatically pulls in the charge.
  • Greater contracting leverage: Although no hard data are available, the practice reports enhanced leverage with insurers as a result of its Bridges to Excellence certification.
  • A positive ROI: The EMR-facilitated improvements in processes and documentation have allowed Four Seasons to receive bonuses as a part of several insurer-developed, quality-based incentive programs, including the national Bridges to Excellence program (which has provided more than $30,000 in 3 years) and three other insurer-sponsored pay-for-performance programs (one of which provided funding to help with the purchase of the system, along with additional funding because the system included certain functionalities the insurer valued). As a result, Four Seasons achieved a positive ROI within 2.5 years of implementing the EMR.

Evidence Rating (What is this?)

Moderate: The evidence is based on before and after comparisons of efficiency, selected outcomes, patient satisfaction, and charge capture, which demonstrate a clear link between the implementation of the EMR-facilitated workflow changes and improved results.

How They Did It

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Planning and Development Process

The Four Seasons physicians carefully selected process improvement projects and chose to undertake a phased implementation process that was feasible for a small, independent practice. Key steps included the following:
  • Assessment of various EMR options: The physicians talked to different EMR vendors as well as local practices to obtain opinions about various EMRs. Vendors came to the practice to demonstrate the system to the staff; physicians then gathered staff input on the various systems.
  • Paper chart scanning: The practice hired a current patient (a high school student) to scan the existing paper charts into the system.
  • Phased implementation: For the first month, the clinicians used the system on a limited basis to acclimate themselves to how it worked. After a month of voluntary use, the practice chose a date on which the EMR had to be used to input all patient physicals. After another month, the practice mandated that the reception staff use the EMR to input all telephone messages. After the third month, the practice mandated that all immunizations be tracked using the EMR. Additional requirements were set monthly; 7 months after the "go-live" date, the EMR was fully functional.

Resources Used and Skills Needed

  • Staffing: The system required no new staff; in fact, as noted, staff levels were reduced after implementation.
  • Equipment and software: The practice purchased the EMR software, upgraded billing software, tablet personal computers, a high-quality scanner (which scans 100 pages per minute) with a maintenance agreement, and a dedicated printer for prescriptions (which is secured with a lock). The practice purchased five tablet and five desktop computers.
  • Costs: Initial costs for all hardware, software, upgrades, and maintenance fees totaled approximately $30,000.
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Funding Sources

Four Seasons Pediatrics
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Tools and Other Resources

Bridges to Excellence Web site. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Consider all resources available to fund workflow redesign, including Bridges to Excellence and other pay-for-performance programs.
  • When calculating ROI, consider lost revenues as a result of the paper-based system, such as billing oversights and the failure to document services that were performed.
  • When making a final choice of an EMR, select a product that can easily and quickly be customized to practice style. Consider whether the layout is easy to use and enables the clinicians to move around quickly. Consider vendor reliability and responsiveness, including how long the vendor has been in business, the quality and timeliness of technical support, and whether the vendor is open to suggestions regarding product enhancements. Ensure compatibility and interface with existing practice management software (or make sure that bridging software is available) and the systems of outside laboratories, radiology departments, and hospitals used by the practice.
  • Develop templates to enhance efficiency and ensure thorough documentation; templates help standardize history, examination, testing, and treatment plans.
  • Start transferring information immediately, including patient demographics (which can be done by receptionists or office staff); clinical information, such as immunizations, family history, allergies, past medical history/surgery (which can be done by nursing staff); and other information (which can be abstracted from medical records by providers). Use the scanning function to transfer information whenever possible.
  • Identify an early adopter. One physician should be highly enthusiastic and committed to working through the inevitable problems associated with EMR adoption. This individual should become proficient at using the EMR and encourage staff members to approach him or her for assistance.
  • Undertake a phased implementation, beginning with voluntary use of the system and slowly ratcheting up requirements over time. Forcing full use on a "go-live" date can be frustrating for physicians and patients, whereas phased implementation allows clinicians to acclimate to the system.

Sustaining This Innovation

  • Hold weekly or biweekly meetings to allow clinicians to air problems or issues and share best practices.
  • Seek to continually improve ROI by identifying and leveraging quality incentives offered by insurers.
  • Consider purchasing ongoing technical maintenance and support for the EMR; maintenance agreements should include all updates.
  • Add new modules gradually; once the staff is fully functional with the basic system, new modules can be added to enhance functionality.
  • Develop or participate in an online forum with those who use the same system to share best practices, ask for help, and prompt vendor changes to the software.

More Information

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Contact the Innovator

Harry Miller, MD
Four Seasons Pediatrics, LLC
532 Moe Road
Clifton Park, NY 12065
(518) 383-2425

Innovator Disclosures

Dr. Miller has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.


1 Rippen H. Summary of the findings assessing the economics of EMR adoption and successful implementation in physician small office settings. Office of the Assistant Secretary for Evaluation and Planning. October 13, 2006.
2 Simon SJ. An examination of the financial feasibility of electronic medical records (EMRs): a case study of tangible and intangible benefits. Int J Electron Healthc. 2006;2(2):185-200. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 17, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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