Creating Space - in Your Practice - for Your New EHR

Congratulations. You're making the leap into an electronic health record (EHR); there's buy-in from top to bottom in the practice; and you've selected the system of your dreams. Goodbye filing cabinets, cluttered desks, and piles of forms; hello great open spaces, right? Wrong! Installing an EHR is only the midpoint of the sometimes long journey to digitizing a medical practice.

Kevin Mullen, project director for the non-profit Massachusetts eHealth Collaborative, says eliminating storage space for paper records is not the only or even the most significant result of implementing an EHR. The Collaborative has guided EHR installations at hundreds of practices - most recently for 300 physicians in the Beth Israel Deaconess Physicians Organization, LLC. Mullen says many people underestimate the impact an EHR can have on work flow in a medical practice.

"Many of the practices we work with have very little internal real estate and things are already quite congested so it's not as easy as just walking in, loading the application, and telling the staff to start scanning all the records into the EHR," Mullen says. "We make a considerable effort to identify what is the best footprint for the technology."

The footprint of new technology may be bigger than you think. Scanners and card readers use counter space. And it may take time - six months to a year - for the records room to empty, especially if you digitize paper records only as patients show up for appointments.

Scott Somers, AIA, principal architect and owner of Arch-101, a Spokane Valley, Wash., firm specializing in ambulatory medical office design and project management, cautions that information technology places unique demands on an office.

"The records room may be going away or shrinking but your IT space might grow from a closet to a room with extra HVAC needs for equipment and, perhaps with one or two people working in that room, too," Somers says.

Many medical practices are in spaces that were never carefully planned, he says. Those inefficiencies don't go away just because you bought new software.

"Ninety-five percent of the time the design of a medical office's space is an afterthought," Somers says. "If someone is in 3,000 square feet and needs another one or two thousand (square feet), they'll just call around, find a bigger space, and lease it."

The better way to go about things, whether you are moving or staying put, is to take a whole systems approach to measuring and designing work flow, starting as soon as you make the decision to buy an EHR. Once it's installed, you'll be too busy trying to pull productivity back up as physicians and providers acclimate to a new way of working.

Careful approach

Placing a PC with monitor in an exam room - and doing it properly - isn't as easy as it sounds. Most physicians are loath to turn their backs on patients while documenting a visit. But the placement also must allow the physician to reach the patient easily without stepping around a workstation. The physician, medical assistants, and the patient will all need clear pathways to reach the door, the exam table, or other equipment in the exam room; again, without having to sidestep obtrusive computer parts. And don't forget the cables needed to make the EHR run and interface with other systems. If exam rooms are not identical in size and shape, then each will need its own work flow design. And then there are the administrative and clinical staff's work areas and work stations to consider.

Taking a careful and strategic approach to planning for a new EHR and a new work flow isn't an easy sell to most practices because it takes precious time, says Cynthia Dunn, a consultant with the Medical Group Management Association (MGMA) Healthcare Consulting Group.

"People are not looking at their work flow and process steps in enough detail because they don't see any return for all that effort," Dunn says. "It doesn't have a CPT code attached to it but the time and effort to plan your new work flow will pay off in the long run."

Mullen says his Collaborative clients should expect a 20-week implementation period leading up to the go-live date.

He calls the implementation period "a continuum of touch points." Ideally, the medical practice has a project manager - an air traffic controller - coordinating relationships and communications with the EHR's vendor, IT technicians, construction crews, an office furnishings supplier, and, perhaps, the architect redesigning the practice's physical space. The project manager, who could be an employee of the EHR vendor or an independent consultant, will also guide the practice's lead contact - usually, the administrator or manager - through critical EHR implementation steps consisting of:

IT inventory. Listing and assessing all information and technical systems currently in use and deciding which ones to replace;

Work flow assessment. Understanding the practice, its complexities, how patients move through different domains of the practice – from front office to mid office to checkout - and where information handoffs are made, both inside the practice and externally;

Gap analysis. Identifying top concerns and barriers to overcome when moving from the current paperwork-oriented work flow to a more efficient work flow using the new EHR system;

Data migration assessment. Determining how the practice will transition from its current system (paper, document imaging, or an EHR to be replaced) to the new EHR;

Interface needs. Listing the types of information exchanged with internal departments and external diagnostic and radiology labs, hospitals, pharmacies, referring physicians, and others;

Diagnostic equipment assessment. Listing the equipment (EKGs, spirometers, etc.) in the practice that must interface with the EHR; and

Site remediation plan. Going through the practice's offices to identify cabling, electrical, task lighting, wireless networking, and heating and air conditioning needs for the new EHR.

Based on the needs identified in these implementation planning steps, the project manager and practice representative will decide where to place workstations and new devices, such as card scanners and PCs.

Mullen says complexity and duplication of effort are the gaps uncovered most often in these assessments.

"Even in a small practice, information pathways can be very complex and obscure at times, such as how a simple prescription refill request is handled," he says. "We need to find the most effective information path so that the work isn't stacking up for the physician at the end of the day."

EHR implementation don'ts

After working with medical groups attempting to adjust to a new EHR, Dunn says she sees a pattern of implementation mistakes.

"The saddest part is that they often don't know why they are struggling so much after their new EHR is installed," Dunn says. "They would figure it out if they would take the time to examine their work flows and look at how many people they have touching the information, but nobody feels they have time anymore."

The struggles are often rooted in the following failures:

Failure to train. "Everyone is trying to do more with less in this economy and training always seems to take the hit first," Dunn says. Follow the EHR vendor's training suggestions and, if possible, add more time for those whose computing skills need more work, she suggests.

Failure to understand the EHR's capabilities. "I've seen staff printing out information from the EHR then carrying it over to a fax machine to send with a handwritten cover page, when they could have sent it directly out of the EHR in seconds," Dunn says.

Failure to tap into other users' knowledge. "Sometimes you just have to see the system being used well for the new knowledge to gel," Dunn says. She recommends sending key staff to view the EHR in action at another practice, even if it's not the same specialty or in the same city. "The knowledge your staff can get will more than pay for their time out of the office or travel costs," Dunn says.

Failure to be flexible. Some physicians will need to ease into the system while others can jump right in, says Dunn. Plus, with today's EHRs there's no need to demand all physicians use identical hardware to access the EHR. "If one doctor wants to use a notepad and another wants a hardwired PC then make it happen," Dunn says. "Do whatever makes it flow better for the provider.

Failure to get a portal. Web portal access allows the EHR to reduce incoming calls from patients about appointments, lab reports, even simple prescription refills. Lacking a portal you'll be forced to print out far more patient visit summaries to meet the federal government's meaningful use requirement for EHR incentive bonuses. "If you don't have a portal and you are struggling with incoming calls and keeping up with the patient visit summaries and other requests then all I can say is, 'I feel your pain,'" Dunn says.

Expect resistance

Mullen says there's always resistance to change; what's hard to predict is where the resistance will come from when a new EHR is installed. He's seen physicians nearing retirement accept an EHR with open arms while younger physicians dig in their heels because the new system is different from the EHR they used in residency training.

"What works best is to have a few physician-champions of the system and a few staff who are natural teachers that you've invested in for extra training," Mullen says.

Some practices ease into the digital world by introducing electronic prescribing for a few months, then move on to documenting certain types of visits in the EHR, and then bring in more extensive templates to document visits, followed by other technologies, such as computer physician order entry. Others just dive in.

"It's important to remember that going live is really just the halfway point - there's another 12 to 16 weeks of optimizing the system after that," Mullen says.

The biggest single success factor in EHR implementation and optimization success may be a matter of attitude: being open to a period of disruption and chaos.

"We are taking these practices and turning them upside down and shaking everything out," Mullen says. "Being cognizant of that and open to the process lends itself to quicker success with EHR."

Trends aided by EHR

Architects specializing in medical office design see the presence of an EHR working hand in hand with several emerging trends in office design and work flow. These include:

Teaming spaces. "In creating teaming spaces, the provider or physician can work with nurses, medical assistants, patient advocates, dieticians, social workers, community resources as a team," says Craig Mulford, president of Boulder (Colo.) Associates. "It helps the physician work as a quarterback to monitor the provision of care by all the other team members with the result that physician time is better leveraged and is treated less like a commodity that you are just trying to maximize."

On stage-off stage. By segregating the patient flow from the areas where physicians, nurses, and other staff work - sometimes by separate corridors to exam rooms - the physician's time is maximized, says Kent Gregory, cofounder and principal of TGB Architects, in Edmonds, Wash. "We're seeing this a lot more as an outgrowth of lean management analysis," Gregory says. "It allows staff to have medical records on screen, talking to pharmacies, referral physicians, and each other without compromising privacy. It also becomes less likely that patients might complicate the work flow by engaging physicians in the hallway after their visit."

In Summary

A carefully planned pre-implementation process will help medical practices ease the disruption and avoid catastrophic mistakes when installing an electronic health record (EHR).

• In a period of 20 weeks before the EHR's go-live date, practices should assess: current technologies in use, work flow patterns, data migration needs, and potential changes to furnishings and physical space needed to accommodate the EHR.

• Experts also suggest taking advantage of all training opportunities and making site visits to other EHR users.

• A successful implementation does more than eliminate paper records; it will eliminate unnecessary steps in clinical and administrative processes, improve overall work flow, and make better use of physicians' time to manage patient care.

Robert Redling is a freelance writer based in Tacoma, Wash. He has been practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speechwriter for the American Academy of Family Physicians. He can be reached via editor@physicianspractice.com

This article originally appeared in the November 2011 issue of Physicians Practice.