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Implementing an EMR is more about people than computers

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EMR ImplementationGetting started isn't so simple when it comes to electronic health records. Close to 20 percent of healthcare organizations surveyed by the Medical Records Institute in 2007 either had uninstalled an EHR system or were in the process of doing so. The federal government estimates that the EHR failure rate tops 30 percent. Most of the time, the culprits are all-too-human problems—poor planning, poor communication, and poor training. EHR implementation, it turns out, largely depends on how you handle people, not computers. After all, you're asking colleagues and staff to learn new skills and change their work habits. To help them adapt, you've got to follow directions that never appear in an owner's manual.

An excellent article By Robert Lowes from Medical Economics

Assemble a project team

TeamEHR implementation is like moving day for a homeowner, except that you're moving data from paper to computers and the process lasts for months instead of days. So, who are your movers, and who's in charge?

If you're a soloist, you're the de facto leader, even though you may delegate technical and administrative tasks to others. Likewise, group practices need a "physician champion." This role should go to a respected colleague with a gift for communication, and not necessarily to the resident computer geek, says computer consultant Rosemarie Nelson in Syracuse, NY. "The rest of the office will identify more with a nontechie, and think, 'If it can work for her, it can work for me,' " says Nelson. "And your computer guru may use a lot of jargon that goes over everybody's heads."

You'll also need a project manager to coordinate the rollout with your EHR vendor. In a small practice, the office manager normally fills this role. Practices with more than seven doctors may need to hire a full-time project manager on a temporary basis. Your vendor probably can steer you to someone at a local IT or consulting firm who's helped other practices with EHR deployment, says FP Kenneth Adler, medical director of information technology at the 106-doctor Arizona Community Physicians in Tucson.

In a small office, everybody belongs on the implementation team, with good reason. If you don't ask your medical assistant for ideas on exploiting EHR power in her job, you can expect little buy-in from her. In a large group, you'll also want to solicit everybody's opinions, but you must limit the size of the team to manageable proportions. Recruit a member from each department—billing, front desk, nursing, medical records, and so on. While department heads are likely candidates, they may be too busy to serve, notes Nelson. "You may be better off with an enthusiastic rank-and-file person," she says.

Some larger groups also have relied on project management software to set goals, assign tasks, and monitor progress toward achieving a digital office. If that sounds like too much work, at least set up a poster in the break room or hallway that displays your implementation timetable and indicates how far you've come. Every step forward will boost morale.

"The people in charge often forget to communicate to the troops what's going on," says Adler. "If they don't get people revved up, they could meet resistance."

Aim for a gradual rollout

RolloutWhen it comes to an EHR timetable, medical practices have a choice of two approaches. The first is based on the "big bang" theory—on a single day, you switch over completely to the new system, with all its bells and whistles. The second approach is incremental, introducing various features over a period of six months to a year.

The big-bang approach lets a group achieve a quicker return on its EHR investment, notes FP Lou Spikol in Allentown, PA, a former consultant for the American Academy of Family Physicians' Center for Health Information Technology. "However, you and your staff could find the sudden changeover so frustrating that you give up," he says.

Incremental implementation is usually easier on everybody's nerves. Not surprisingly, vendors and EHR experts tend to recommend this gradual approach. "Start low, and go slow," says FP Tripp Bradd III in Front Royal, VA, a veteran EHR user who shares his digital savvy in magazine articles and talks.

The trick is knowing where to begin. If the EHR system has a billing and scheduling module, introduce that first to make sure you'll get paid, says internist-pediatrician Sal Volpe in Staten Island, NY. Interrupted cash flow is a surefire way to become an EHR statistic.

The next features to activate might be e-prescribing and intraoffice messaging, which lets doctors and staff communicate electronically inside the EHR program instead of passing paper notes. "Shoot for what can produce the quickest and easiest gains in efficiency," says Spikol.

Then, graduate to viewing clinical data on a computer screen. Activate your electronic connection to labs to import test results; do the same for diagnostic imaging reports from radiologists. As patients' electronic charts become richer in data, they'll be more attractive to you and your colleagues, boosting their usage.

Experts recommend that charting patient encounters with the templates that come with the program be the last phase of the rollout. Since many doctors find such data entry intense and frustrating, it's usually best to save it until they've mastered easier features.

When you design or customize templates for patient visits and conditions, however, remember that your medical assistants will be using them as well, notes Tripp Bradd. Keep these electronic forms as simple as possible. "Sometimes doctors make templates so complicated the staff won't use them," he says.

Another complication to avoid is individualized templates for group practice doctors in the same specialty, says William Henderson, practice administrator for Upstate Neurology Consultants in Albany, NY. "Having consistent templates makes it easier to capture clinical data on a group-wide basis to share with insurers," he says.

Ace the training process

TrainingOne big job facing the implementation team is figuring out how to streamline work routines with an EHR. Renewing a prescription is one chore crying out for automation. In the paper world, a doctor's office might receive a fax from the pharmacy stating that a patient wants a renewal. A medical assistant then pulls the chart and gives it to the doctor, along with the fax. If the doctor decides to renew the prescription, he instructs the medical assistant to relay the order to the pharmacy.

E-prescribing eliminates these hand-offs. The pharmacy bypasses the medical assistant by electronically notifying the doctor about the renewal request. The doctor can renew the prescription with a few mouse clicks, without involving anyone else.

Once you create new workflows, you and your employees must learn how to perform them using the EHR. Training is a crucial stage that you can't afford to botch. Someone who doesn't know how to click his way through a program with confidence is likely to abandon it.

To save money, some practices cut back on the amount of training offered by EHR vendors and end up with an underused system, says FP Robert Eidus in Cranford, NJ. "Don't scrimp," he advises."I once led an EHR seminar and asked what percentage of the audience used at least 75 percent of their electronic capability. Only 10 percent raised their hands."

Likewise, practices don't always schedule enough uninterrupted time for training, so receptionists and medical assistants are often left to learn the system between patients. To carve out time, you may need to close the office an hour early for a few days or conduct training at night, says Lou Spikol.

Assess the basic computer skills of your employees; if they can't minimize windows, drag and drop a file, or use a Web browser, EHR software will stymie them. If necessary, invest in remedial computer training. And gear EHR lessons to the lowest common denominator, adds Tripp Bradd. "Sometimes a trainer goes through mouse clicks and keystrokes so fast that nobody can follow along."

"Go live" without going crazy

Go LIVEEventually, you move from training on an EHR to using it on the job. If you take the incremental approach, every newly introduced function will have a "go live" day. Give each function a trial run ahead of time to ensure that the software and hardware are working.

The potentially most disruptive go live day is when you dispense with paper charts entirely and use the EHR for charting patient encounters. This D-Day could be Disaster Day if you don't plan ahead. Go live during a slower time of the year, as opposed to flu season, and never on a hectic Monday morning.

Schedule only 50 to 70 percent of your normal patient load to give yourself a time cushion as you get comfortable with the technology. And make sure a trainer or "super user" is on hand to help you over software humps.

During the first week of going live, you and your employees should meet frequently, perhaps daily, to assess your progress, troubleshoot problems, and celebrate digital accomplishments, perhaps with a pizza lunch. As your EHR implementation proceeds, such meetings will be less frequent, but still valuable as you fine-tune templates and workflows based on what you learn.

Make a commitment to success

EMR ImplementationIn any EHR rollout, the biggest danger is not a hard-drive crash, but a motivation crash among physicians and employees. Avoiding this requires a dose of "change management."

For starters, set realistic expectations about the hard work and perseverance required to go paperless. Otherwise the first computer glitch could sink morale. "Some doctors think they can do everything on the system the first time around," says Tripp Bradd. "But there's a learning curve."

At the same time, listen to any and all complaints, and respond calmly and respectfully, says Lou Spikol. "People want to be heard, even if they don't expect everything to go their way," he says. Discourage complaints, and you could be ignoring a problem that will doom your EHR, adds Sal Volpe.

"If a biller hasn't learned how to submit an insurance claim after four days of training, you better hope that she knocks on your door and requests one more day," says Volpe. "Otherwise, your cash flow will suffer."

Listening becomes especially important when you deal with fellow doctors who are learning the ropes. "You can read a lot between the lines," says Spikol. "A doctor who says 'I can't use the system' may be really saying 'I won't use the system.' "

Uneven adoption of an EHR among doctors in a group increases the chances of failure, because they end up with two parallel record systems—one paper, one electronic—along with two different workflows. A strong physician champion can persuade colleagues to commit to the paperless approach come hell or high water, and even lean on them a bit, but remaining flexible is just as important.

"Maybe you need to hire a part-time person to be in the exam room with Dr. A and enter data for him at first," says Spikol. "Why be stubborn and ask him to do things exactly like the other doctors?"

You arguably can require an employed doctor to embrace electronic charts, but you can't run roughshod over a partner, lest he turn around and sabotage the project, either consciously or unconsciously. "Once employees know that he isn't using the system, they may stop using the system, too," says Tripp Bradd.

However you do it, converting skeptics to believers is the goal, says FP Ben Park in Lebanon, IN, whose practice has gone through six different EHR programs since 1979.

"The most important aspect of the implementation is the commitment," says Park. "Yes, it is going to be hard. Yes, there will be times of great frustration. But the bottom line is that, in the end, we are going to use an electronic health record because that is the only effective tool we have to measure and improve the care we deliver. That's what drives our commitment."

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Last Updated ( Sunday, 06 July 2008 19:33 )  

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