Technology: Behind Closed Doors – EMR Disaster Stories

Yelling. Cursing. Silent treatments and behind-the-back sniping. People at their absolute worst. Difficult patients? Nope. These are some of the behavioral boo-boos committed by medical practice staff while implementing their EMRs. Vendors assisting practices transfer from paper to paperless have repeatedly witnessed these very human meltdowns.

Physicians Practice asked several leading EMR vendors to relay real customer implementation snafus in hopes of heading off problems when you decide it’s time to upgrade your practice. Here’s some of what we learned:

Lesson No. 1: The Practice That Upgrades Together Stays Together

Making sure your entire staff climbs on board the EMR train is key to success; any less tempts trouble.

Paul Stinson, senior vice president of product management for New Jersey-based Emdeon, tells of a 10-provider practice that saw nothing wrong with some of its staff continuing to use paper while the rest used its newly implemented EMR. Confusion quickly ensued. “The whole staff has to adopt the new technology,” says Stinson; otherwise, a practice’s work flow gets stuck somewhere between past and present.

An essential element of any effective EMR implementation is to analyze the work flow and processes a practice already has in place and understand what modifications need to be made before making the switch. “There’s not a consistent work flow for every medical practice,” says Stinson. “So it’s very important for customers to understand their own work flow and then see what will change with the EMR.”

Sarah Corley, a physician who is chief medical officer of NextGen, a national provider of practice management software and EMRs, recommends that practices ready to implement an EMR conduct an initial, comprehensive work flow analysis to evaluate their everyday processes. Corley says practices should examine “every single step that is involved in the process of seeing patients.”

She explains that this means writing out what happens “when a patient calls for an appointment, when the patient comes in, when the nurse takes a patient to the exam room, the process of gathering their vital signs, getting their medication and allergy lists. You need to look at who does what in the practice and when. Is it done in a central location or in the exam room? How much time is spent doing each step? If you look at these steps before implementation and you find areas where you’re less efficient than you want to be … it’s great to identify those and then see how the software can improve them.”

Corley notes that many of the benefits EMRs provide are often overlooked because they require changes in the way things were previously done. For example, EMRs allow staff members other than physicians to take a patient’s history, which can give physicians additional time with patients to address other issues. EMRs can also alert staff to needed tests or immunizations. Because such regular procedures are “standing orders” built into the technology, physicians no longer have to write out orders for them, freeing up more of their time and making their support staff more useful.

Lesson No. 2: A Ship Without a Captain Is Bound to Sink

Experts agree a physician is the ideal choice as the final decision-maker when a practice chooses and implements a new EMR. This person should act as a “clinical champion” and a contact person throughout the entire process. Unfortunately, many practices fail to do this, especially in multiphysician offices.

Stinson tells such a tale. “[This four-provider office] tried to run their implementation like a democracy, where everyone did what they wanted to do,” he recalls. “There was no one person who was in charge of making decisions.”

With no one ultimately at the helm, the practice’s EMR implementation quickly fell into chaos. It was severely impeded by the group’s inability to agree on standardized work flows, processes, templates, and general organization. “They found that they really needed one person with a plan and a focus who could help them get in the right direction,” says Stinson.

Ideally, this “physician champion” should be an EMR technology advocate who is prepared to navigate confidently through troubled waters. “Customers have to understand there’s going to be resistance,” Stinson says. “Not everyone’s going to want to adopt this new technology and new change, and change is difficult for a lot of people. That’s when it’s really helpful to have a solid leader on the clinical staff who will encourage their staff to adopt the new technologies and understand the benefits that are going to come from them.”

Donna Frazier, implementation supervisor for Companion Technologies in Columbia, S.C., tells an even more unsettling story of a client who failed to involve a lead physician. In this practice, the cardiac surgeon’s office manager “did everything for him, and she [said that she] absolutely, positively knew what [the surgeon] wanted” regarding the new EMR’s templates, says Frazier. “She spent a lot of time building these templates and never asked him to look at them. Then, on the first day of ‘go-live’ … he looked at the templates and blew up.”

The office manager’s tears mixed with the physician’s anger equaled “not a good time,” Frazier recalls. “I can’t tell you how much easier it makes it when you have physicians who participate.”

Lesson No. 3: Keep Sour Grapes at Bay

In most practices, a spiffy new EMR system will be more or less well received, says Frazier. Expect about half of your staff to be accepting. Another 25 percent wll have an undying, gung-ho enthusiasm for the new technology.

And then there are the naysayers.

Often, these are physicians who want an EMR but were outvoted by their peers regarding which vendor to choose, and so have decided not to accept the system.

“We had one physician who was computer-savvy, but the EMR the practice chose wasn’t the one he wanted,” Frazier says. From day one he warned everyone how terribly it would turn out. “We published the schedule of which physician was going to be trained when, and he would go to each physician before they were trained and tell them, ‘This is going to be bad.’ He was poisoning the well before anyone got there.”

To diffuse the dampening effect a naysayer can have on a group, a practice may opt to train that person first. “They’ll say, ‘If we can get that person up, we can get anybody up,’” explains Frazier.

Unfortunately, that rarely works. The naysayer will focus on any specific negative aspects discovered during training and try to infect others’ attitudes. What’s Frazier’s solution? “Start with the people who want to be doing it first, who will spread the positive and the good, and that makes it a lot easier for that last person.”

On top of this, Frazier says practices should be aware of the “freak-out level,” which sometimes occurs when people fear the new technology will mean they’ll lose their jobs. One remedy here is to communicate well with the staff, Frazier says. “It’s a reasonable expectation for people to have,” she says, but if you are honest with your staff about it, and let them know the likelihood of their job being eliminated right away is small, you can ease some tensions.

Lesson No. 4: Don’t Skimp on Time and Training

Frazier notes that a practice often “just assumes that by purchasing an EMR, it’s going to be exactly what they want it to be out of the box.”

The result? Failure to set aside adequate training time required for the effective implementation and full utilization of the new technology.

Allowing sufficient time for training before going live is critical. “It just makes it less stressful,” says Frazier, citing an internal medicine practice with a doctor who was “so excited about the EMR, and he was so convinced it wasn’t going to slow him down, not only was he going to book a full schedule, he actually overbooked that day.”

Had it just been him, she says, this approach might have worked, “but practices have to understand [a new EMR] affects everyone in the office,” she says.

Frazier says practices should realize that during “the first days of ‘go-live,’ there are going to be slowness and adjustment issues. You’re not going to be able to see all the patients you saw the day before when you were working with paper. And everyone needs to recognize it’s a learning experience.”

Going hand-in-hand with miscalculating training time is underestimating the extent of the training itself. Glen Tullman, CEO of Allscripts in Chicago, tells the story of a large practice on the East Coast that, on the first day of implementation, gave the entire staff 25 minutes of training before patients started coming in. Needless to say, Tullman relates, “by midday they were running almost two hours behind.”

Physicians often don’t understand that absorbing the ins and outs of a complex new technology involves a learning curve that arcs differently for each staff member. “Even in the best cases, training takes time,” says Tullman.

Sue Weis, director of PowerWorks Delivery for Cerner Corporation in Kansas City, Mo., concurs. “Physicians also often don’t understand the technology will require ongoing work,” Weis says. “They don’t believe that it will take the time that it does to genuinely understand it. And that weeks after [the installation] they will still be learning it.”

Lesson No. 5: Learn From Others’ Mistakes

Stinson says all of these problems can be addressed, and that a reputable vendor will always return to meet with its clients, go through every factor, and get installations back on track when they go awry.

To avoid falling off that track in the first place, a practice should carefully plan an implementation’s timing. Stinson suggests going live during a relative down time, such as “during a week that they’ve reduced the number of patients they see in their schedules.” This gives everyone a chance to absorb the new technology and understand fully the how, why, and when of their new responsibilities.

Analyze your office’s work flow to determine each staff member’s role after implementation. Frazier points out that with paper charts, information is written in by various people, but with electronic records, a practice must decide precisely who will enter patient information. “So the practice really needs to decide the new work flow before the EMR,” she says.

Training may cost extra, but don’t skimp, vendors say. “Software is expensive, so [practices] feel they can cut costs on training, when training is what makes all the difference,” says Corley. “Even if the software has every feature known to man, if you don’t have good training on the software, you’re not going to do well.”

You might elect to form a committee to discuss possible paths you can take during your transition, especially if your practice is large. That’s fine, but resist joining the growing trend to make decisions communally, with majority ruling. This serves only to reduce a doctor’s sense of personal ownership of the project. “When you have a large group of disparate doctors who’ve been practicing in their own ways and suddenly you’re saying ‘We’re all going to do things the same way,’ that requires a whole lot of planning ahead of time to get physician buy-in,” says Corley.

Select an operations chief, preferably a physician. “You’ve got to have executive sponsorship - someone in the organization who will say, ‘We will make this work,’” Tullman says. “A physician champion is very important.”

And remember: EMRs are complex systems; expect their implementation to be complex as well. Unlike earlier types of electronic systems in which clinicians didn’t need to be as involved because the technology was principally used for billing or administration processes, today’s EMRs are integral to a physician’s actual work; hence, their critical involvement. “The higher the involvement, the greater the success for the clinician and the staff,” says Weis.

Realize that once an EMR is up and running, everyone is fully trained, and quality data is improving and quickening your processes, this new way of conducting business will benefit you, your staff, and your patients. This takes time, but that’s OK. “If we could teach everybody something here, it’s that this is not a horse race,” says Weis. “And it’s well worth living through.”

Sarah Schmellingis a writer in Washington, D.C., who has contributed to many publications including Clinical Lab Products, Medical Imaging, Sleep Review, and the Los Angeles Times, and she is the former editor of Rehab Management magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the October 2006 issue of Physicians Practice.