Physicians are transitioning to EHRs, some by need, some by desire and others simply because they have to. As Records Management Professionals this transition to Electronic Medical Records is becoming a more prominent focus within Record Centers as they strive to serve their medical clients. I was fortunate enough to travel to the MGMA conference in Atlantic City and watched Dr. Kenneth W. Faistl,M.D., F.A.A.F.P. speak on EMR Implementation. Dr. Faistl has lived in the Electronic world as an early adopter for Personal Health Records for over 12 years. His insight is not only insightful but the plan he laid out for other physicians to follow was invaluable. At the end of his session I asked if I could write a white paper with direct references to his session, he was kind enough to agree. His Phased Approach vs. Big Bang theory is well said and was excerpted directly from his talk. Again my thanks Doctor Faistl for allowing me to share his experiences and expertise with the readers of the Smart Storage Solutions blog.
The Ten Essential Elements to a Successful EMR Installation
1. Project Planning
There is one unanimous sentiment for those who have installed and implemented EMR systems in their offices regardless of the specialty, ultimate success is a factor of pre-installation planning, team commitment and goal setting. Any and all EMR systems, regardless of the price tag or the sophistication of their functionality will fail without proper preparation. The first step in every office should be to ask the following:
- What are you looking to achieve in your office specifically?
- Review your current workflows. Review how you would like them to work in an electronic mode. What steps can you reduce, eliminate, or do you need to add. These workflow reviews need to be covered from all aspects of the practice.
- What problems exist today? How can you affect change in those areas?
Your internal team is a critical success factor. How will changes you are anticipating affect staff? It is critical that staff is involved during all reviews. They need to understand what changes are coming so they have time to prepare. Staff can ensure a project succeeds or ultimately fails.
2. Workflow, Workflow, Workflow
Workflow is the core component of the operation of an office. What changes can you make to work better, smarter? What changes may be forced on you by a new solution? Test the workflows. Does it match what you are trying to accomplish? Many times theory and reality are two different things. Before you design your system around what you think is a new and improved workflow, make sure it doesn’t adversely impact another part of your practice. Attention to detail will help you for years to come, take the time to do it right.
In workflow processes you need to think integration. What orders do you currently write and how will you interact with various suppliers in an electronic world? Communication to referring physicians and information you currently send and/or received needs to carefully reviewed. What forms do you currently use? Consider which of these are needed in the electronic world, which should be revised before the transition and which can be eliminated?
3. Needs Assessment
Once you have your goals established and workflows reviewed you can identify your organizations specific needs. Include everything from basic infrastructure and resources, to changes in communication with partners or related organizations.
4. Select a EMR Project Director and Physician advocate
Each implementation needs a leader, a Project Director; a single individual from within the organization responsible for directing the implementation and working in cooperation with the Solutions Team Manager. The Project Director must have a thorough understanding of how the office currently functions, and have a clear vision of the organizations goals moving forward. Timing is critical during the implementation phase. The Project Director must be given authority to make decisions and have access to people and information needed during the implementation phase. The Physician Advocate is generally the Managing Practice Partner and will work hand and hand with the Project Director. Decisions made by the implementation team should be reviewed periodically to make sure the project is in line with the desires of the physician community. A team approach and buy in is imperative.
The EMR Project Director also needs to spread enthusiasm about the project through the staff community. Get staff involved in the project early so they feel part of the project. Give them some ownership over specific, small items, to get them involved and excited about the coming changes.
5. Process Assessment
Analyze current processes within the practice. This goes beyond just workflow to individual roles and duties, to specific processes that lie within scheduling, administration, and clinical parts of the organization. Who does what, and how may that change in an electronic world? Use the EMR implementation to include a review of all systems and processes.
6. Gain Buy In
You need to gain support. Staff buy-in is critical to the success of any major project. Team meetings should occur early and often during the project planning and transition process. Some roles, functions and responsibilities will inevitably have to change. Staff will need to change to meet the needs of the changing practice. Your organization may consider working with individuals or organizations that specialize in change management. These organizations can help your management identify obstacles and can help staff work through concerns, fears, and hesitancies related to the transition. It is best to know early in the process if specific personnel aren’t suited to the new vision for the company – it does happen. When identified, it is important to acknowledge, and address the issue quickly and work to reassign the individual to other duties in the organization or assist them in finding a more suitable working environment. Maintaining a positive environment in the team is an important requirement.
There will be times when frustrations will occur. This is common in almost every implementation regardless of size. Know that it will occur and work with your partners and staff to address issues as they occur – not at some later date.
7. Hardware Assessment
The solution you decide on will dictate some of your computer hardware needs. You will need in-house servers, access to some offsite hosting facility, or simple high speed internet access to utilize the EMR from within the office. Main system access is generally available through PC’s in each exam room or tablet PC’s assigned to key individuals who will carry them from room to room. PC’s on carts is also common, giving physicians the ability to ‘wheel’ their PC around the office. The goal is that the hardware not come between the interaction between the physician and patient, but actually enhances the interaction. Look back to your workflow and discuss with your team how the hardware can best be used as a communication tool between staff and the patient.
8. Disaster Recovery
Develop a disaster recovery plan around your new EMR. The disaster recovery plan needs to include processes that get you back and running as soon as possible after a hardware, software, or natural disaster. Disaster recovery can include copying each days data onto a separate machine in a separate office or running redundant systems in separate data centers or ‘co-locations’. Develop a plan and put processes in place that force you to periodically test your back-up processes. The best case is you will never need it – the worst case is you will be prepared.
9. How will you implement: Phased Approach or the Big Bang Approach
The approach best for your practice will depend on your specific situation and the complete ‘solution set’ you are implementing. In some cases, an all at once just isn’t possible due to the complexity of your organization. The complete suite planned for implementation should be reviewed and analyzed to identify the best approach for your staff and your patient’s.
- The Phased Approach allows a system to be phased in over a period of time. This allows a transition through a series of go-lives and training specific to areas being used. Each phase is planned and staff buy-in is obtained as each section of the system is implemented. This allows users to get used the system over time. A phased approach creates its own set of complexity because for a period of time you will be running a hybrid paper/electronic system. In addition, a phased approach generally costs more money because it takes longer to get from start to finish.
- An ‘Big Bang Approach’ implementation is where all facets and functions of the EMR go live at the same time. Of course the implementation time frame via this method is quicker. The team will very quickly see the value of the fully operational system. This method has a smaller period of adjustment for staff and requires a higher commitment to initial training as many capabilities will be put into use simultaneously.
IMPORTANT: Regardless of your transition methodology, you must decide ultimately what to do with your paper records. Some physicians have had all their records scanned to CDs and stored off-site. Others have sent their files to off-site storage with associated retention schedules and destruction dates noted. Charts must be kept for varying periods often from 7 years for adults to 25 years for children. Laws differ from state to state, age of patient, type of record and so on. All of this information can be captured electronically and a document management company can notify you when your charts can be destroyed according to the destruction dates you have established. This is an important, necessary step in any and all transitions.
10. Training
The last but probably most important step is training the Project Director should have extensive training on the system, including administration functions to understand the full power of the EMR solution. The Project Director must know all aspects of the practice and marry the practice needs and goals with the capabilities of the system. The Project Director becomes your champion in communications with your staff and coordination/cooperation with partners. The Project Director will lead or participate in all staff training sessions. In many cases training occurs in phases so areas of the practice are not left ‘unmanned’.
It is extremely important that clinicians spend time with hardware prior to go-live. They must commit to knowing how to use a system before putting it in front of patients. Assuming all PC’s work exactly the same is a mistake. Create test scenarios and require all users to practice. It is also important to train your patients. Inform them of the coming change, let them know why and provide patients a list of short-term and long-term benefits you expect to make available to them.
Note: In any transition it is always good to inform your patients. They can complete forms on-line prior to visit and assist in the effort. Patients will know the office is investing in their future and will appreciate features such as eprescribing. Equally important, it will give them some insight as to why things have changed or may be not as they have been on their prior visits. Don’t forget this variable as in the end that is whom are there to serve.
Summary
Implementations have high failure rates due to one variable: PREPARATION. With the proper planning and workflow analysis you invest in your success both short term and long term. There are no short cuts. If a vendor sells you on a quick fix, there simply isn’t one. You must study your needs, goals and workflow without exception. This front end investment of time equates to a greater ROI on your EMR/EHR as well as increased patient satisfaction. Implementation is a process, a plan to create positive change for both patient and practice. Done correctly, an EHR represents enormous progress for providers and their ability to improve safety and patient care for years to come. Ultimately a successful EMR outcome can be defined by the ability to improve the way a physician practices medicine, it is then you can consider the implementation a success.
