The ambulatory-care clinic of Cass County Health System (CCHS), located in southeastern Iowa, was losing $100,000 a month before it implemented eMDs in April 2011. Now the 14 doctor, 4 site practice generates a surplus of $100,000 a month, and the EHR has helped the physicians improve the quality of their care.

Steve Stark, Assistant Administrator and CIO of Cass County Health System, attributes the clinic’s financial turnaround to the increased efficiency and higher revenues that eMDs has facilitated. “We now have a solution that works quite well for us,” he says.

The ambulatory-care EHR and practice management system that CCHS used prior to eMDs had serious problems, Stark recalls. For one thing, when CCHS’ outpatient practice became a federally designated Rural Health Clinic (RHC), it could no longer use E&M codes to bill for services to Medicare and Medicaid patients, but the earlier system’s billing module was unable to accommodate the change. eMDs, in contrast, enabled CCHS to comply with the government’s billing rules easily.

On the clinical side, the CCHS physicians were unhappy with their original EHR, which reduced their efficiency and made it difficult for them to find essential patient information. So when CCHS started looking for a new system, their administrators knew that it was critical to find an EHR software that the physicians liked and would use. After a lengthy search that included input from its doctors, CCHS settled on eMDs.


The implementation of eMDs “was very aggressive and fast-paced,” says Stark. “We met all of our milestone goals with help from eMDs. They sent a lot of folks here who did extensive training.”

The trainers taught not only the clinicians, but also the administrative staff how to use eMDs. This was a big change, Stark notes, from the previous vendor, which barely trained the billing staff at all. As a result, he says, “we had money sitting in buckets out there that we didn’t know about, so the accounts weren’t being worked. Because of the training we had in eMDs, we learned the system so much better.”

The physician learning curve on eMDs was not as steep as expected. CCHS had anticipated that the physicians would restore their former level of productivity within 90 days of the go-live date. But that actually occurred within 30 to 60 days, depending on the provider, Stark says. Today, he adds, “the numbers show they’re seeing as many or more patients than they were seeing before.”


eMDs has pleased CCHS physicians in many ways, but what they like most is that it enables them to finish their day’s work more quickly. Under the old system, Stark recounts, “they were spending four or five hours after the clinic closed finishing up dictation, signing off on reports, and trying to catch up on their administrative responsibilities. But with eMDs, they’re pretty much out of here by 5:00 or 5:30 every night, and they’ve got all their stuff done. That’s a change of life for them. We hear a lot of good things about that.”


eMDs has made the entire clinic more efficient. The introduction of a fax server, for example, has eliminated lost or misplaced faxes and has enabled CCHS to centralize its fax lines so that they roll over to the next line when the first one is busy. A staff member can route all the faxes to the right inboxes in the system. “There’s an audit trail, it’s instantaneous, and the faxes don’t get lost,” Stark says.

Another big efficiency gain for the clinic has been the reduction in transcription, which has enabled CCHS to shift several staff members to other duties such as scanning old paper records and handling the faxes.


Physicians did not use templates for documentation in the old EHR; instead, they typed or dictated their notes. Not only did this take longer than entering notes in eMDs’ templates, but it also made it more difficult for the doctors to retrieve data when it was needed. With the new eMDs system, physicians started using templates.

Of course, the physicians had to agree on which templates to use and how they wanted them customized; and even today, a physician champion tweaks the templates in response to her colleagues’ suggestions, Stark notes. But in the end, this approach to documentation has contributed to better patient care.

One reason is that the templates follow evidence-based guidelines. Because physicians have to document that they asked certain questions as they go along, they’re more likely to follow the protocols and to record what they did than when they dictated their notes. Moreover, the doctors can build in prompts to remind themselves when a patient needs particular services. For example, a diabetic patient with an elevated HbA1c may require testing at more frequent intervals. The system can suggest this to physicians at the point of care. This is just one of many clinical decision support functions built into eMDs.


Additionally, more complete documentation has led to more appropriate E&M coding. “If you answer the questions the template is forcing you to ask, that automatically may take the visit from a 99213 to a 99214,” Stark points out, referring to two common E&M codes for visits of differing complexity. “So now you’re generating more revenue if you’re calculating it that way.” “Although E&M coding no longer makes a difference to CCHS for Medicare and Medicaid business,” he adds, “it’s still a big factor in revenues from commercial payers.”

With all of these factors in play, Stark notes, “We went from losing approximately $100,000 a month to making $100,000 a month since we acquired eMDs. That’s a $200,000 a month swing. It’s the difference between losing $1.2 million a year and making $1.2 million.”

Soon eMDs will generate a new revenue stream for CCHS: In June, its physicians will attest to Meaningful Use and collect their first-year incentive payments from the federal government.


CCHS is continuing to find new ways to utilize eMDs and to fine-tune its current use of the system. For example, eMDs is interfaced with the hospital system for lab results and transcribed reports, but not for lab orders. That awaits the installation of a new interface this summer.

CCHS has also installed eMDs’ patient portal and is working out the details of how it will be used. The physicians need to agree on how much information they want to publish on the portal and how much they want to automate their workflow.

At a minimum, the portal will be used for prescription refill and appointment requests, and physicians will be able to deliver lab results and visit summaries to patients via the portal. Eventually, Stark said, it will also play a key role in open-access appointment scheduling.

“We couldn’t be happier with eMDs, and we look forward to using new refinements in the system as they are built,” Stark concludes.

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