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EMR / EHR: Challenges and Forces Driving its Adoption
| Author: Michael D. Paquin, FHIMSS |
| Article Date: 3/15/2008 |
In this second of many segments on Electronic Healthcare records, being sponsored by Physicians Office Resource, we will look at the challenges and forces that are impacting Physicians today. As you begin to enter the technology market place of an Electronic Healthcare Record (EHR) there will be many things that you will want to consider. Some of your choices will have very positive impacts and benefits and some of your choices can and will impact your future negatively if not thought out carefully. In this issue, as well as issues to come, we will give you the tools to make your EHR choice a positive improvement to your practice.
Clinical and Operational Transformation
To insure an effective PMS and EHR implementation, healthcare organizations need a 3rd party organization to assist with implementation oversight and Clinical and Operational Transformation. For the past two years, we have been evaluating best practices in PMS and EHR implementations. However, instead of finding numerous best practices, we found that 73% of physicians are not using their EHR for 80% of their patients after one year. Therefore, we classify this as an EHR failure, since the practices have not fully automated clinical and operational processes after a year. Therefore to insure success, healthcare organizations need 3rd party help with configuration, training and product optimization from a business process approach, not just the vendorÕs technical approach.
Adopting Technology
Before beginning the adoption of new technologies, an organization should review and establish new operating policies and procedures designed to maximize the benefits of newer technology while reducing the negative effect of ÒChangeÓ. Each organization must consider Òclinical and operational transformationÓ. You will need to maximize the use of the installed EHR while insuring the data collection and reporting of data required by internal and outside agencies. Clinical and Operational Transformation (COT) processes have been around for years, but not until recently have organizations embraced the concept for ambulatory physician offices. Deciding to adopt an EHR is one of the most important decisions made by any practice. The transition to an EHR from a paper system can be challenging due to the fact that it will change the way everyone works. EHRs can change current documentation method(s), workflows, billing practices, scheduling, patient follow-up methods, communication, messaging, etc. EHR adoption usually requires re-engineering current systems and can dramatically change the way practices run. Considering the vast changes that have to happen to adopt an EHR, extensive planning must occur for a successful implementation.
You must establish a base-line approach towards optimization and then be able to provide your practice with guidelines for EHR implementation success. You will need to develop an operational plan based on the following phases:
Planning Phase:
The planning phase is the most extensive and time consuming phase of the implementation process. The planning phase provides a great opportunity to map out the entire process which may include planning the following: conversion of data from the paper charts and what information to convert, current workflow analysis, redesigning new workflows for the EHR, deciding on methods of documentation (template creation, voice recognition, voice capture, partial dictation), staff training strategies, software testing, hardware testing (whether to consider using mobile devices and wireless technology), security rights and authorized access and system piloting. EHR adoption should be an evolution, not a revolution, and with proper planning you can get your EHR up and running smoothly with a minimal amount of staff frustration and loss of productivity.
Identify goals and base your planning strategies around these goals. First identify broad goals for the EHR and then develop more refined goals. Examples of broad goals may be: to identify and follow-up all patients who are not meeting the preventive health maintenance guidelines; analyze patient profiles based on demographics; create a referral tracking system; create tight security controls to reduce the risk of compromising the integrity of the chart; ensure that the hardware configuration will allow the provider to maintain eye contact with the patient, etc. Identify specific areas within the EHR to reach goals successfully. Share all goals with the staff as well.
Decide what data needs to be retrievable: It is common for practices to begin entering data into an EHR only to discover that the data is in a non-reportable format, not consistently entered, or not entered in any standardized manner by all providers. Therefore, this data is not reportable or incomplete, rendering it useless for queries. Identify what data will be useful for reporting purposes, such as certain diagnoses and medications prescribed per physician; graph of BMI in a pediatric population after a pediatric exercise program was introduced; incidence of tobacco use within the patient population; diabetic patients who have not received an HbgA1c in a specified period of time, etc.
Your pre-determined goals and data that you want captured for reporting purposes should drive the decisions made during the planning phase. Utilize this information to create customized libraries, pick-lists, standardized and/or required data fields that everyone will use consistently for desired reportable information. Ask the vendor how data in certain areas of the system is stored and ask if this data is reportable in that format.
Be aware that ÒFree TextÓ may not be reportable. For many EHR programs, if the data is not in discrete data fields, the information cannot be captured by an internal report writing program or a third-party report writing program. Utilizing a fully-integrated speech recognition software program within the EHR, which captures voice dictated text, is in a free-text format as well, and therefore may be non-reportable. There is a growing trend in the industry at utilizing artificial intelligence to attempt to capture free text as discrete data usable by the EHR for reporting. This functionality may be available in the not too distant future.
Phased implementation is highly recommended. Most EHRs lend themselves well for phased implementation because many of their functions are in discrete modules such as lab order entry, messaging, E&M coding, preventive health maintenance, patient tracking, e-prescribing, etc. If a phased implementation is chosen, map out the phasing and rationale for the order of implementation. The staff will appreciate adding additional modules after they have adequately digested previous modules.
Create timelines but be flexible. Timelines are great tools for project planning but be aware that they must constantly be re-evaluated, especially if you are designing time lines for phased implementation. Keep assessing progress as the implementation process moves forward, and ensure staff that time lines are adaptable to current situations to help reduce their stress level. Entire implementations including training can span a couple of weeks for small practices (1-2 physicians) to several months for larger practices.
Perform a workflow analysis: Analyze existing work processes while looking for opportunities for improved productivity and efficiency. Design new work flows that could be accomplished with the tools available in the EHR and develop a transition plan.
Staff Considerations and Planning:
Appoint a Physician Champion. A physician champion can be instrumental in the success of the EHR adoption. This person should be motivating, enthusiastic, have a good working knowledge of the EHR and be able to articulate the specific benefits that the EHR will provide.
Appoint an in-house Project Manager. Most vendors will supply a project manager for large group installations but in addition, have a key person on staff to oversee the entire project. This person should have extensive knowledge of all areas of the EHR as well as how the EHR will interact with each type of provider and support staff. This person is crucial for the ÒBig PictureÓ viewpoint and to know the rationale for decisions that are made.
Communicate to the staff the practiceÕs desire to acquire an EHR before the purchase. Better yet, include them in the decision of which EHR vendor to choose. It is common for a physician to choose an EHR with no input from the support staff. This can create a feeling of resentment among staff and a feeling that their input is not useful or necessary. The staff will more likely embrace a system that they have had input in choosing, and will then be more acceptable to the adoption.
Be aware that support staff may feel that they could be replaced by an EHR. In certain cases this may be accurate particularly with file clerks or other types of staff; be sensitive to this possible concern.
Have end-user staff involved in the system set-up. Many times practices rely on only one person to set-up system files, pick-lists, defaults, templates or libraries, customizable options etc. This presents a problem in that only one person has an understanding of the rationale for the decisions that were made at that time, and that knowledge will be lost if that person leaves the practice. It is best to utilize the end-users for system set-up decisions because they are the ones who will be performing the tasks that the system parameters will affect. They have the detailed knowledge of present procedures and workflows and therefore may know ramifications of such system set-up parameters on other functionality.
Map out Workflows utilizing current staff members: Map out current workflows on paper and bring in the end-users who perform the current workflows to help design new workflows for the EHR. No one knows their job better than the person who does it everyday but more often practices do not go to the source for this crucial input.
Learning curves are usually underestimated. The learning curve for complete and successful adoption of the EHR is usually vastly underestimated. Even if productivity is not affected initially during the go-live phase, most providers do report an increase in the length of time necessary for documentation, especially if templates are used and the providers are not familiar with them. Most providers will spend additional time at the end of the day documenting notes after a go-live. Usually within 6 months to one year, most providers are leaving the office at their normal times. It is difficult to predict length of learning curves and the impact of learning curves on productivity. Utilize the vendorÕs knowledge for benchmark learning curve estimates.
Clinical and Operational Transformation
To insure an effective PMS and EHR implementation, healthcare organizations need a 3rd party organization to assist with implementation oversight and Clinical and Operational Transformation. For the past two years, we have been evaluating best practices in PMS and EHR implementations. However, instead of finding numerous best practices, we found that 73% of physicians are not using their EHR for 80% of their patients after one year. Therefore, we classify this as an EHR failure, since the practices have not fully automated clinical and operational processes after a year. Therefore to insure success, healthcare organizations need 3rd party help with configuration, training and product optimization from a business process approach, not just the vendorÕs technical approach.
Adopting Technology
Before beginning the adoption of new technologies, an organization should review and establish new operating policies and procedures designed to maximize the benefits of newer technology while reducing the negative effect of ÒChangeÓ. Each organization must consider Òclinical and operational transformationÓ. You will need to maximize the use of the installed EHR while insuring the data collection and reporting of data required by internal and outside agencies. Clinical and Operational Transformation (COT) processes have been around for years, but not until recently have organizations embraced the concept for ambulatory physician offices. Deciding to adopt an EHR is one of the most important decisions made by any practice. The transition to an EHR from a paper system can be challenging due to the fact that it will change the way everyone works. EHRs can change current documentation method(s), workflows, billing practices, scheduling, patient follow-up methods, communication, messaging, etc. EHR adoption usually requires re-engineering current systems and can dramatically change the way practices run. Considering the vast changes that have to happen to adopt an EHR, extensive planning must occur for a successful implementation.
You must establish a base-line approach towards optimization and then be able to provide your practice with guidelines for EHR implementation success. You will need to develop an operational plan based on the following phases:
Planning Phase:
The planning phase is the most extensive and time consuming phase of the implementation process. The planning phase provides a great opportunity to map out the entire process which may include planning the following: conversion of data from the paper charts and what information to convert, current workflow analysis, redesigning new workflows for the EHR, deciding on methods of documentation (template creation, voice recognition, voice capture, partial dictation), staff training strategies, software testing, hardware testing (whether to consider using mobile devices and wireless technology), security rights and authorized access and system piloting. EHR adoption should be an evolution, not a revolution, and with proper planning you can get your EHR up and running smoothly with a minimal amount of staff frustration and loss of productivity.
Identify goals and base your planning strategies around these goals. First identify broad goals for the EHR and then develop more refined goals. Examples of broad goals may be: to identify and follow-up all patients who are not meeting the preventive health maintenance guidelines; analyze patient profiles based on demographics; create a referral tracking system; create tight security controls to reduce the risk of compromising the integrity of the chart; ensure that the hardware configuration will allow the provider to maintain eye contact with the patient, etc. Identify specific areas within the EHR to reach goals successfully. Share all goals with the staff as well.
Decide what data needs to be retrievable: It is common for practices to begin entering data into an EHR only to discover that the data is in a non-reportable format, not consistently entered, or not entered in any standardized manner by all providers. Therefore, this data is not reportable or incomplete, rendering it useless for queries. Identify what data will be useful for reporting purposes, such as certain diagnoses and medications prescribed per physician; graph of BMI in a pediatric population after a pediatric exercise program was introduced; incidence of tobacco use within the patient population; diabetic patients who have not received an HbgA1c in a specified period of time, etc.
Your pre-determined goals and data that you want captured for reporting purposes should drive the decisions made during the planning phase. Utilize this information to create customized libraries, pick-lists, standardized and/or required data fields that everyone will use consistently for desired reportable information. Ask the vendor how data in certain areas of the system is stored and ask if this data is reportable in that format.
Be aware that ÒFree TextÓ may not be reportable. For many EHR programs, if the data is not in discrete data fields, the information cannot be captured by an internal report writing program or a third-party report writing program. Utilizing a fully-integrated speech recognition software program within the EHR, which captures voice dictated text, is in a free-text format as well, and therefore may be non-reportable. There is a growing trend in the industry at utilizing artificial intelligence to attempt to capture free text as discrete data usable by the EHR for reporting. This functionality may be available in the not too distant future.
Phased implementation is highly recommended. Most EHRs lend themselves well for phased implementation because many of their functions are in discrete modules such as lab order entry, messaging, E&M coding, preventive health maintenance, patient tracking, e-prescribing, etc. If a phased implementation is chosen, map out the phasing and rationale for the order of implementation. The staff will appreciate adding additional modules after they have adequately digested previous modules.
Create timelines but be flexible. Timelines are great tools for project planning but be aware that they must constantly be re-evaluated, especially if you are designing time lines for phased implementation. Keep assessing progress as the implementation process moves forward, and ensure staff that time lines are adaptable to current situations to help reduce their stress level. Entire implementations including training can span a couple of weeks for small practices (1-2 physicians) to several months for larger practices.
Perform a workflow analysis: Analyze existing work processes while looking for opportunities for improved productivity and efficiency. Design new work flows that could be accomplished with the tools available in the EHR and develop a transition plan.
Staff Considerations and Planning:
Appoint a Physician Champion. A physician champion can be instrumental in the success of the EHR adoption. This person should be motivating, enthusiastic, have a good working knowledge of the EHR and be able to articulate the specific benefits that the EHR will provide.
Appoint an in-house Project Manager. Most vendors will supply a project manager for large group installations but in addition, have a key person on staff to oversee the entire project. This person should have extensive knowledge of all areas of the EHR as well as how the EHR will interact with each type of provider and support staff. This person is crucial for the ÒBig PictureÓ viewpoint and to know the rationale for decisions that are made.
Communicate to the staff the practiceÕs desire to acquire an EHR before the purchase. Better yet, include them in the decision of which EHR vendor to choose. It is common for a physician to choose an EHR with no input from the support staff. This can create a feeling of resentment among staff and a feeling that their input is not useful or necessary. The staff will more likely embrace a system that they have had input in choosing, and will then be more acceptable to the adoption.
Be aware that support staff may feel that they could be replaced by an EHR. In certain cases this may be accurate particularly with file clerks or other types of staff; be sensitive to this possible concern.
Have end-user staff involved in the system set-up. Many times practices rely on only one person to set-up system files, pick-lists, defaults, templates or libraries, customizable options etc. This presents a problem in that only one person has an understanding of the rationale for the decisions that were made at that time, and that knowledge will be lost if that person leaves the practice. It is best to utilize the end-users for system set-up decisions because they are the ones who will be performing the tasks that the system parameters will affect. They have the detailed knowledge of present procedures and workflows and therefore may know ramifications of such system set-up parameters on other functionality.
Map out Workflows utilizing current staff members: Map out current workflows on paper and bring in the end-users who perform the current workflows to help design new workflows for the EHR. No one knows their job better than the person who does it everyday but more often practices do not go to the source for this crucial input.
Learning curves are usually underestimated. The learning curve for complete and successful adoption of the EHR is usually vastly underestimated. Even if productivity is not affected initially during the go-live phase, most providers do report an increase in the length of time necessary for documentation, especially if templates are used and the providers are not familiar with them. Most providers will spend additional time at the end of the day documenting notes after a go-live. Usually within 6 months to one year, most providers are leaving the office at their normal times. It is difficult to predict length of learning curves and the impact of learning curves on productivity. Utilize the vendorÕs knowledge for benchmark learning curve estimates.