Prep Time: Planning for the EMR

It’s been about six months since the five-physician group, Medical Arts Center in Kearney, Mo., installed the Cerner PowerWorks EMR, says James LaSalle, MD, and the group is more than satisfied with their progress.

“The thinking was that everybody will have to have EMRs within the next few years, so let’s start looking at systems,” LaSalle says. Choosing a system was challenging, he says, because there are so many different systems and so much promise. “They all have some interesting components, but you have to look at the overall usability of the system.”

It’s not rocket science

Preparing for the transition to the new system and reviewing the hardware needs were the group’s two biggest challenges. They needed to decide how many monitors were needed and what telecommunications and electronic equipment were best, among other details. Once wiring was done, “it pretty much wasn’t rocket science to do this,” LaSalle says. Cerner provided an implementation template that really helped, he adds. It included a realistic timetable to prepare for implementation, what to consider regarding data entry, and how to get the EMR, insurance information and billing system in synch.

LaSatte recommends that facilities consider more than just the actual software program. “I think sometimes that’s not thoroughly thought through in the rush to implement electronic records. This is a whole process. It’s about patient flow and efficiency and how you’re going to utilize the system once it’s in place.”

LaSalle says that his group decided to phase in the EMR to give everyone time to learn. A “big bang” implementation would have required that they drop patients to account for ineffective utilization of the program. “We didn’t think we could afford that. That turned out to be a wiser decision that we would have ever thought.” Within six months of the go-live date, everyone in the practice is using the system and seems comfortable with it.

A hard transition

Carolina Internal Medicine Associates in Asheville, N.C., first implemented electronic medical records in 1993, says Ken Kubitschek, MD, and now uses the Misys EMR (Misys recently merged with Allscripts). While he says that the original system was more of a database management system than a true EMR, the steps for each major upgrade along the way have been fairly consistent.

Kubitschek says the first step should be working with your vendor to iron out exactly who is responsible for what. His group used a spreadsheet for each significant upgrade. They also conducted surveys to assess readiness, fears, barriers and skills. He also says that convincing people to get on board with electronic records is part of the process.

Kubitschek says that not only have the physicians who initially resisted electronic records come on board, they became not just adopters, but proselytizers. “It wasn’t immediate,” he says. “It’s a transition and it’s a hard transition. I don’t think anybody should diminish that it’s a challenging thing to do, but the benefits are dramatic.”

A common pitfall is inadequate upfront education. “To get everybody educated in a relatively good-sized office is hard. It takes time and thought, and it’s not something that happens by itself.” Sometimes, he says physicians will refuse to take the time to learn and then quickly blame the software when it doesn’t work for them. He recommends efforts to make the process fun, such as pizza parties and gift certificates when users meet certain levels of skills. “You can create a sense of accomplishment. People respond to that.”

A massive effort

Dublin Methodist Hospital in Ohio, part of OhioHealth, just opened an all-digital community hospital that features Horizon Patient Folder (HPF), a document imaging system from McKesson. This new hospital took several years to plan, but HPF will be rolled out to other OhioHealth facilities in the next several months.

Electronic records let clinicians have immediate access to patient records, says Diane Setty, corporate director for health information. “That’s a more effective and efficient way to use medical records.” She admits that preparing for electronic records is a huge project. “We have engaged everything from the IT side to a communication plan for physicians to education for all of the technical and nontechnical users. It’s a massive effort.”

“You cannot underestimate the need for preparing for workflow redesign and appropriate time to effectively educate physicians and all other users,” says Michael Krouse, senior vice president and CIO for OhioHealth. The technology is actually a small, relatively simple piece, he says. “Preparing everyone for the technology is really the key for success.”

Krouse says it’s common for people to default to the capabilities of the technology rather than fully understanding and mapping out the process. If you don’t go through all those processes, you’ll end up simply automating the old way of doing things and not getting the full value out of the technology. Another plus was the ability to integrate HPF with other elements of the McKesson Horizon Clinicals suite the physicians were already using. As a result, the doctors didn’t also have to learn a new entry point.

OhioHealth began preparing well before they started working McKesson on the implementation. The health information management department developed workflow graphs that showed every key process affected by automation.

Document preparation was part of the prep work, according to Setty. She recommends making sure as many forms as possible are barcoded. She built a forms library where each is identified and coded so the system recognizes it. “If you go live with 50 percent or more of your forms not prepared to be scanned that infinitely complicates your life and your ability to provide a product to your users.”

No matter how well you have communicated and prepared, there’s nothing quite like when the system is up and running, Krouse says. “You’ve got to have resources deployed that can hand-hold the physicians through the process. No amount of upfront training or preparation fully ingrains the process into the minds of physicians like actually doing it.”

In the end, the implementation went off “almost without whisper”—an encouraging sign, says Setty. “If you get a lot of chatter and complaints with a huge implementation, that means people are confused and it’s not going well.”

The time has come

For those practices and facilities considering electronic record systems, “the time has come,” says Kubitschek. “Given the requirements we have for managing data, the paper system is just not tenable anymore.”

The Medical Arts Center’s electronic record system “will allow us to have much better data, diagnoses and medical records, but I think that getting from point A to point B is not always easy,” says LaSalle.

He believes that insurance companies are going to require electronic records at some point. “That’s inevitable. The question is when do you implement.”

Kubitschek agrees that electronic records will become a requirement. “You might as well get on board now.”

“It’s absolutely critical to be moving into this space for a wide variety of reasons not the least of which are patient safety and quality of care,” says Krouse. “At a time when reimbursement for facilities is getting tougher and tougher, anything we can do to digitize contributes on all fronts.”