What to Do After EHR Implementation

When Angel Burnette first joined two-physician Desoto Family Medical Center as practice and financial services manager, she was surprised to find that the Southaven, Miss., practice had been paying for its EHR for years - it just hadn't been using it. That translated to about $7,000 down the drain each month in maintenance fees. "I don't think they had the supervision and the knowledge to make it work," says Burnette.

While she attributes much of the EHR barrier her practice experienced to a system that lacked user-friendliness, even with the best EHR and a smooth implementation process, your practice could experience similar problems fully optimizing its system. That's because transitioning from paper takes ongoing effort.

"I think people need to recognize that there's an enormous amount of work that goes into being on an EHR," says Tucson, Ariz.-based family physician Kenneth Adler, whose three-physician practice, part of a 124-physician medical group, implemented its system in 2004. "I think what people underestimate is that this is a never-ending learning process because typically the technology isn't static; so any good vendor is going to continually upgrade their product and there will be new features, new functions, new capabilities that ideally someone will keep up with and take advantage of." But learning to more fully utilize the system is not the only task your practice will face. Keeping staff and physicians engaged, ensuring all electronic information is secure, using the system efficiently, and retraining staff members are just a few of the tasks that should top your post-implementation agenda.

If you do these things on an ongoing basis, post implementation, the payoff is huge - just ask Burnette. In 2008, Desoto Family Medicine finally scrapped its old system and transitioned to a new EHR. This time, Burnette took extra precautions, like ensuring physicians received adequate training and helping them get their questions answered quickly. Today, Desoto has already attested to Stage 1 of meaningful use and is now preparing for Stage 2. To ensure your practice experiences similar EHR success - the first time around - we asked physicians and health IT experts to weigh in. Here's what they said every practice must do as it moves from implementation to full-fledged use.

Step 1: Identify a leadership team

You likely had a leadership team at your practice during your EHR selection and implementation process. Don't let that team dissolve after your go-live date. As the system evolves you will need to "have alignment among the leadership of the practice to ensure you are moving in the right direction," says Voorhees, N.J.-based family physician and geriatrician Mark Van Kooy, director of informatics and physician lead at health IT consulting company Aspen Advisors.

This leadership team is critical to ensure EHR-related decisions - such as what changes need to be made to the system, when and how use will be monitored and improved, who will have access to which parts of the system, which modules to add, and what ongoing training is necessary - are made quickly. "I think a small practice is an especially risky environment for casual decision making, and some of these big-ticket decisions really need to be made explicitly and with everyone in agreement, so when the issues come up, you can efficiently and effectively deal with the issue rather than starting to figure out your decision-making approach at that time," says Van Kooy.

Step 2: Foster engagement

A strong leadership team is also critical to ensure your staff and physicians are invested in learning to use the EHR as effectively and efficiently as possible. Unfortunately, fostering staff engagement is also one of the most common EHR-related struggles practices encounter, says Rhonda Morgenstern, an independent EHR consultant based in Philadelphia. For that reason, it's critical to set expectations of staff and physicians from day one. "They definitely need to set up expectations and have a strong leader that says, 'Hey, I know there are some issues, but we're really committed to utilizing this, so not utilizing it is not an option for you,'" says Morgenstern, noting that leadership also needs to make it clear that it will provide staff and physicians with as much support as necessary, as they begin using the system more fully. "A lot of practices are reluctant to set that expectation, which can cost them, big," she says.

Also, make it clear to users that they are an important and valued part of the EHR learning process by asking for their feedback as they use the system. "I think it's important to get feedback from not just physicians but employees about what seems to be working well and what isn't, and then evaluate that," says Adler, who is the medical director for information technology at his medical group. He suggests smaller practices solicit this feedback during meetings and larger group practices through surveys.

Step 3: Train and train again

Providing staff and physicians with post-implementation training is another way to foster engagement, says Greg Mertz, director of consulting operations at health system consulting firm Healthcare Strategy Group, noting this need for additional training is often underestimated. "After you've used it a few months, you realize that there were lots of things you 'shoulda, coulda' asked [during initial training], but you didn't," he says. A second round of training provides an opportunity to get these questions answered. It can also be helpful to provide additional training when EHR upgrades occur or when you're embarking on a big project, such as the second stage of meaningful use.

More training brings other perks. For instance, it's a great way to make sure staff and physicians are using the EHR as efficiently as possible. "Sometimes there are small changes that they can make that can actually save them many minutes per visit or per day, and even though things may have been covered in the initial or the pre-go-live training, the average person, if they don't use it right away, they're not going to retain it," says Morgenstern, noting that it's helpful to have a trainer observe staff and physicians as they are using the system. That way the trainer can identify and resolve issues in real time.

Step 4: Institute a progress plan

Once you implement the EHR, learning to use it more effectively is crucial. That's where the real investment value lies, and we're not just referring to the meaningful use incentives. Your overarching goal should be to use the system to improve care quality by doing things like more thoroughly tracking and monitoring certain patient populations.

Still, don't overwhelm users by pushing more advanced EHR features too soon. "Early on, the most important thing is to use it appropriately, which means all of the information ends up in the [EHR] in the right format, in the right place," says Mertz. "Once they're comfortable seeing patients, going room to room, documenting the information, and most critically, at the end of the day or the end of the visit locking that record," then it's time to look at more advanced EHR features, like patient recall, he says.

To ensure continued progress when using the EHR, Mertz suggests creating a timeline. List all the features the system is equipped with, then set dates by which users should be using them. By the end of 12 months, Mertz notes, everyone should be using all the features appropriately.

Step 5: Start a dialogue

Improving EHR use, however, is not just confined to using more features; it also means using the EHR in smarter ways. For instance, identifying more efficient ways of accomplishing certain tasks. As Morgenstern notes, there are often different ways of using the system that could improve efficiencies. While additional training can help shed light on them, often the users themselves will discover these tricks as they explore the system. Make sure you provide them with a way to share what they've found with the rest of the physicians and staff.

Adler's group, for instance, created an Internet portal where users could share tips and best practices with each other. He also creates and sends out group-wide bulletins with EHR tips, tricks, and guidance on new features.

Another way to learn to use the system better is through outside resources, says Morgenstern. For instance, talk to your local regional extension center, your vendor's user group, or other similar specialty practices using the same EHR.

Step 6: Monitor for problems

As staff and physicians begin using the EHR on a daily basis, monitor them to ensure they are using it correctly. That way any errors, bad habits, or inefficiencies are identified before they become big problems.

The easiest way to monitor use is by running and assessing EHR utilization reports. Most EHRs will "have an administrative function which shows you how many scripts were created, who's creating them, who's used them, who's done electronic ordering, how much has been done, how many notes are created, that sort of thing, so you can see if there are certain functions that different users aren't taking advantage of," says Adler.

Mertz recommends running and monitoring these utilization reports weekly in the first few months after implementation, then quarterly once everything is going smoothly.

Step 7: Take precautions

Implementing an EHR could open you up to a variety of potential HIPAA privacy and security violations. Post-implementation, it's crucial to ensure you have adequate security policies and procedures in place, says Sarasota, Fla.-based registered nurse Karen Fuller, a principal at CSC's Health Delivery Group, a global consulting organization. She stresses the importance of secure passwords, logging off the record when not in use, and monitoring user access.

Security-specific staff training is also important, says Morgenstern. For instance, training on how to handle a call from an individual claiming he is with the vendor and needs a user password. "There should really be a series of questions or a procedure that's been mapped out so that [staff] can actually guarantee that it is someone from the vendor," she says.

Other precautions include data backup policies and procedures, and a plan for how to handle downtime in case of emergency, says Van Kooy. "Many times we've been told that, 'Oh, the system's so reliable that will almost never happen.' Well almost isn't good enough."

Finally, identify a solid IT support system, such as a local outsourced IT professional. "Even a fairly simple office system, if it's hosted locally, especially, [and] has a server or a number of servers, it has network infrastructure, it's got numbers of devices that have to connect effectively and efficiently," says Van Kooy. "Anytime you have that level of complexity you need to know who you can call if the system isn't working right."

Step 8: Use it 'meaningfully'

As soon as you implement the EHR, determine how your physicians will use it to satisfy the Stage 1 requirements for meaningful use. "From the day they implement it they should be working toward qualifying for those incentives," says Mertz, noting that the time to qualify for the Medicare and Medicaid EHR incentive payments is dwindling. In fact, the deadline to attest for the full five-year Medicare incentive payment of $44,000 has already passed. If you attest by the end of 2013, however, you could still receive a total of $39,000 in incentive payments. "If you don't start aggressively pursuing the incentives, you're going to miss out on tens of thousands of dollars," says Mertz.

Ease patient frustrations during the EHR transition

Your physicians and staff will move slower than usual in the weeks following an EHR implementation. Here are some tips from Sarasota, Fla.-based Karen Fuller, a principal at CSC's Health Delivery Group, to ensure that efficiency lag doesn't lead to dissatisfied patients:

1. Inform. In the months leading up to implementation, be upfront with patients about the upcoming transition. "Just kind of let them know this is coming and what it would mean to them as a patient [and] have a number they can call if they want more information," says Fuller, who is also a registered nurse. "If a patient portal is going to be part of this new implementation, you can start, sort of, marketing and messaging that as it gets closer."

2. Practice PR. Be positive about the EHR, even during those initial growing pains. "I've actually been in offices, as a patient, where they'll say 'Well, we're putting in a new system and we're just so overloaded, and we're just trying to make it through the day,'" says Fuller. Instead, "Make it a good positive spin, but be realistic about it."

3. Plan ahead. "People can't be learning a new system and new ways of doing things and have the same efficiencies," says Fuller. During implementation, and a week or so after, allow for longer patient visits so patients don't experience long wait times.

A critical EHR implementation task

If you did not do so before implementing your EHR, verify that it enables you to properly document clinical content. If not, and in the event of a bad outcome, the likelihood increases that a successful professional liability claim could be made against you, says Ronald Sterling, president of Sterling Solutions, Ltd., a consulting firm based in Silver Spring, Md. For a podcast with Sterling on some of the key precautions to take to avoid this scenario, visit http://bit.ly/Verify-EHR.

Tips on implementation

For more tips on how to optimize your EHR implementation from Rosemarie Nelson, a principal with the MGMA Healthcare Consulting Group, visit http://bit.ly/Optimize-EHR.

In Summary

Your EHR post-implementation to-do list:

• Identify a leadership team to monitor use and progress, make key decisions, and foster engagement;

• Provide staff and physicians with additional training;

• Set dates by which users should be using certain EHR features;

• Encourage staff and physicians to share best practices;

• Monitor EHR utilization reports for problems;

• Create policies and procedures to ensure EHR use does not raise security and privacy issues;

• Ensure you have a solid IT support system in place; and

• Immediately start preparing to meet the meaningful use requirements.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the April 2013 issue of Physicians Practice.