Technology: EMR Success in 8 Easy Steps

OK, the truck rolls up to your office, and you take delivery of your new EMR system. What do you do with it?

Of course, the process isn’t anything like this. But a surprising number of physicians make a big investment in an EMR without thinking much about how they’re going to implement it. This careless approach can be fatal, even to a thriving practice. Your financial and professional future may depend on how you prepare for this crucial step and carry it out. So you better think it through upfront and know what you’re going to do when the “go-live” date arrives.

Here’s a primer on some of the most important areas you need to address to implement your EMR successfully.

1. Be committed. Many a practice has purchased an EMR because one or two physicians thought it was a great idea. But that doesn’t necessarily mean the other clinicians are on board. If some of them aren’t, the group is wasting its money, because the implementation will fail or limp along.

“The biggest cause of abandonment of EMRs is that docs start with every 10th patient, and they start to see it’s going to take them more time, and they’re not willing to do it,” says Ron Rosenberg, a health IT consultant in Sausalito, Calif. “Or they’re willing to do it in a modified way, by dictating or by having paper notes scanned in and having their assistant enter codes.”

To ensure that every physician uses the EMR properly, it’s essential to have a champion who brings everyone else along. “You have to be able to build consensus and buy-in, otherwise you don’t get there,” notes family physician Christopher Crow, who leads an eight-doctor family practice in Plano, Texas, that implemented a GE Centricity EMR a few years ago.

Staff members must also be involved in implementation, Crow adds, “because all these work flows involve multiple people. You have to decide how to make decisions as a clinic.”

2. Be prepared. Assuming you’re committed, solid preparation for the “go-live” on your EMR is the single-biggest determinant of success. That means analyzing your work flow, deciding how to adapt it to the EMR, customizing the system to your needs, entering key data, setting up the hardware, hiring technical support, and arranging for lab interfaces.

Don’t skimp on training time, or you’ll pay for it later in lost productivity. Training of staff members should occur right before the go-live date so that they won’t forget it when they have to use it. Physicians should also have an opportunity to play with the EMR prior to using it in live encounters.

Internist Edward Hook recalls that before his 16-physician practice in Emerson, N.J., went live on its Sage EMR, “There was a two-week period that the trainers call ‘playing in the sandbox.’ We had the system up and running in demo mode. It was our data, but it wasn’t live. So you could pull up one of your patients you were familiar with, with all their data that had been transferred over, and play with it. That’s a very helpful thing to do.”

3. Enter key data into the EMR. It can be disconcerting to encounter an established patient, open his or her record, and see nothing about that patient. To avoid having to enter the missing clinical data yourself, make sure that your staff does it before the visit. One method is to have the nurses start inputting data on active patients three months or so before go-live. Ron Sterling, a consultant in Silver Spring, Md., and author of the book “Keys to EMR Success,” suggests that you create a paper-chart face sheet that includes data in the same categories and format that the EMR uses. Your nurse can put in new medications and problems as patients visit your office.

Only key information need be entered, notes Crystal Upson, director of ambulatory implementations for Allscripts, a large EMR vendor. That includes medications, problems, allergies, immunizations, and lab results (say, within the past three months). While it takes time (and often overtime) for your nurses to enter this data, it will pay off in spades when you start charting electronically. Some documents, such as past encounter notes and hospital reports, can be scanned into the system, but don’t go overboard. It’s expensive and time-consuming to scan old charts, and you don’t really need everything.

On the other hand, try to go paperless as soon as possible. Otherwise, you’ll end up using paper charts alongside the EMR - which is more inefficient than using paper alone. For example, Merrimack Family Medicine in Tewksbury, Mass., didn’t enter all key data elements ahead of go-live, and it had a lot of trouble getting other parts of its charts scanned in. As a result, nearly a year after the practice implemented its EMR, some of its four physicians and three NPs - all of whom charted electronically - were still bringing paper records into exam rooms.

4. Re-engineer your work flow. If you try to use an EMR to automate your current work, you will likely fail. Your existing work flow grew out of paper-based processes (symbolized by the ubiquitous “sticky note”) that will have to change if the EMR is going to make you and your office more efficient.

For example, instead of hunting down your nurse and telling her to order a test for the patient you’ve just seen, you should use the internal messaging feature of the EMR and add that to her task list, notes Rosemarie Nelson, an MGMA consultant in Syracuse, N.Y. Or you may find that you need to revamp your process for rooming patients. In the current system, your nurse might measure and record the patient’s weight and blood pressure before bringing him into the exam room; in the new system, you have to consider whether she has a computer nearby so she can enter the data into the EMR.

To prepare for this process re-engineering, have your staff collect data on your current work flow, following representative patients from arrival through departure. Your vendor’s implementation team should help you analyze this data and make recommendations for work flow changes. Processes you may need to re-engineer include prescription refills, phone triage, appointment scheduling, and lab results. “Those are the kinds of things you do over and over, no matter what kind of practice you are,” notes Crow. “Although they’re simple, they’re the ones where you get the benefit.”

5. Get the right hardware and support. You can buy your own computers or get a turnkey system, including hardware, from an EMR vendor. Either way, you must provide everyone in the practice with the proper level of system access when and where they need it.

“If you limit that access, you’re going to undermine the ability of people to do their jobs,” notes Sterling. “Some practices don’t spend money on workstations for the staff, and the doctor becomes a data entry clerk.”

You don’t need wireless laptops or fancy tablet computers to have a successful implementation. For example, Crow’s practice put in wired desktop PCs, because they’re less expensive, don’t require a wireless network, and don’t use batteries that can run out of juice at inconvenient moments. By buying a lot of PCs, Crow says, the practice provided adequate access.

But Sterling advises practices to invest the extra money in tablets or laptops, because they reduce time wasted in running around to find available computers. Over the lifetime of tablets, he says, they cost about $2 per clinical staffer per day more than desktops do. Higher productivity can easily justify that, he notes.

As for technical support, make sure you find a local computer technician who can keep your computers running and come to your office in an emergency. This is a mission-critical application, and you don’t want to be stuck on the phone with a far-off tech person who’s trying to talk you through a computer glitch that’s crippling your practice. If you buy a turnkey system that includes hardware, make sure that the vendor has a local office or a service contractor in your vicinity.

6. Make sure your practice management system works. You’re likely to buy a new practice management system when you get a new EMR. Whether that system is part of an integrated package, or is made by a company other than your EMR vendor, make sure it works properly before you start using your EMR. Charting in the EMR is probably going to reduce your productivity for a while, and you don’t want to worry about getting paid as well.

“You may need to wait three to six months to be sure that your data conversion from your old [practice management] system went smoothly, and that your electronic claims submission is working correctly,” says Nelson. “So if there’s any blip in your cash flow, it has stabilized before you attack the EMR.”

Family physician Frank Osborn and his colleagues at Merrimack Family Medicine found this out the hard way. They decided to start using their eClinicalWorks EMR even though they’d had problems with the system’s billing module, which wasn’t connecting with the practice’s clearinghouse. Osborn says it was a good thing Merrimack temporarily stuck with its old billing software, to keep the money flowing. But he acknowledges that it slowed the clinicians down, because they had to record their charges twice. “The EMR demands that you document billing within the note, and in addition, we were filling out our old encounter forms,” he says.

Merrimack and many other practices have also discovered that it’s difficult to download demographic data from old billing systems into new ones - and into their EMRs. Sterling recommends that practices get rid of obsolete data - like information on departed patients and defunct health plans - and change their coding, if necessary, so that they can dump this data into the new system the right way. You should also test the data conversion before you tell the vendor to carry it out, he says. Otherwise, you could be in for a world of trouble.

7. Implement the EMR gradually. You should phase in the EMR, starting with internal messaging, lab results, and electronic prescribing, before you start documenting visits, Nelson says. Those components boost efficiency and make life easier for the staff, she notes. Also, if everyone is comfortable with the EMR’s work flow features, they’ll be able to support you better when you go through the trauma of learning to chart electronically.

“Putting in an EMR changes everything,” notes Sterling. “You basically have to take apart the practice and put it back together again. If you have everyone doing everything on Day One, you’re putting a lot of risk into the equation. Because if you have problems that have to be worked out, you and your staff are going to be running around like crazy and you’re not going to have the support you need to be successful in using the EMR.”

Your practice can minimize its productivity loss during the go-live phase, says Rosenberg, if the evangelist doctor in the practice starts documenting first. That way, he can get over the rough spots and help his colleagues do the same.

8. Customize templates. The biggest challenge of EMR documentation is adapting the software to the way you practice. Some of this is inherent in the software, of course. Nelson suggests that you choose an EMR that’s easy to customize but that also comes with a large selection of prebuilt templates, or visit forms. The customization process, she adds, should be confined to your most frequent types of encounters. “Follow the 80/20 rule: If you have a lot of diabetic visits, create the template for the 80 percent of patients who are well-controlled. In the other 20 percent, there are going to be exceptions, and it’s never going to be perfect. So you can dictate those visits - as long as you use the system for meds and orders. That way, you’ll get the benefit you’re looking for from the system without forcing a square peg to fit into a round documentation hole.”

If you hope to use the EMR to improve quality, however, you and your colleagues have to agree to use the same templates. “You can’t show improvement in clinical quality unless you can report on quality,” says Crow. “So you have to be able to standardize it so you can compare apples to apples across your practice.” This standardization, he adds, can also show how your group is doing compared to other practices.

Family physician Paul Helmuth of Springfield, Mass., explains how his practice got everybody on board. First he and a nurse practitioner customized the templates they received with their Allscripts EMR by following the sequence of paper forms that the doctors were already using for visit notes. This made the changeover easier, he explains: “Instead of putting a check next to a box with pen and paper, you put a check next to an electronic box. We were used to organizing our thoughts in that way, and it made our transition pretty smooth.”

Ken Terry is a New Jersey-based freelance writer and the author of the book “Rx for Health Care Reform.” He can be reached via editor@physicianspractice.com.

This article originally appeared in the September 2008 issue of Physicians Practice.