Health information technology (HIT) is driving the transition of health care past the era of modern medicine into the contemporary era of digitized medicine. Knowledgeable and experienced implementations of HIT are known to improve the delivery of health care and improve health outcomes. However, knowledge and experience with implementations of comprehensive ambulatory electronic medical records (office EMRs) remain distant from the average office physician. Less than 10% of U.S. physicians are using a fully functional EMR according to a 2008 article in the New England Journal of Medicine (NEJM, Volume 359:50-60, July 3, 2008, No. 1). Also, the growing body of knowledge about successful HIT implementations does not contain a field-tested “cookbook” that physicians can follow to ensure their EMR implementation will be a success. This is concerning in light of a report from Modern Healthcare that 19% of ambulatory EMR implementations had failed and EMRs de-installed among 800 respondents to a 2007 Medical Records Institute survey. There are relatively small numbers of skilled and experienced EMR implementation resources, and those available tend to be concentrated among EMR vendors and some IT consultants.
A disciplined and knowledgeable approach to ambulatory EMR implementations will lead to a successful implementation. The unfortunate situations of EMR implementation failures are avoidable and most typically related to poor implementations rather than poor technology. A study by Lorenzi and Riley (Lorenzi N. Riley R. Knowledge and Change in Health Care Organizations. Stud Health Technol Inform. 2000; 76:63-69) finds eight main reasons for EMR implementation failures. Only one of those reasons is technology failure. Most EMR failures are due to poor management of change, straying from basic project management principles, insufficient effort put into work flow redesign and configuring the EMR, uninformed decision-making, underestimating or ignoring the work involved, ineffective leadership and inadequate training.
Over the next 5 years the physician incentives in the ARRA/Stimulus Package will help pay for the purchase and meaningful use of office EMRs and will subsequently lead to record numbers of physicians seeking and implementing EMRs. This has raised the concern that physicians may hurry into the EMR implementation quagmire without knowledgeable and experienced resources to facilitate success. ARRA does fund a new entity, called “Regional Extension Centers”, that is intended to provide physicians assistance implementing EMRs. When these can be established and how successful they can be are unknown. At this point it is therefore important to educate physicians on HIT issues including the selection and implementation of EMRs. This is the impetus for two concurrent series of Digitized Medicine medblogs. The first one called “EMR Selection: Ready, Set...Go Compare!” was outlined in a July 28th blog entry. Today the outline of the second series, “EMR Implementation: I’ve Selected an EMR. Now What?” is described.
The goal is to develop a practical physician resource of best practices for the selection and implementation of office EMRs. The EMR Implementation Guide (miniaturized below) is a one-page conceptual overview of this process:
The descriptions in blue boxes on the left side depict seven high-level concepts for physicians to understand during an EMR implementation. These are primarily created from the office EMR perspective, but have relevance to hospital electronic health record (EHR) implementations as well.
The Tasks in the middle column are specific tasks or categories of actions that office physicians and staff will work on during the implementation process. Although an office physician may choose to lead the EMR implementation himself or to assign one of his staff to lead the effort, the amount of effort and time involved should be carefully considered. One blog will delineate the effort involved and make a reasonable case for hiring an outside consultant, project manager or advisor to manage the EMR selection and implementation. It is very easy for internally managed projects to allow daily office activities to overwhelm implementation efforts and result in a languishing implementation.
The Objectives column on the right identifies the purpose and goals of the efforts involved in each of the seven concepts of an EMR implementation.
This guide and the medblogs to follow are derived from ongoing personal research on the best practices for EMR implementations. Relevant references and websites are listed below and will be added to as appropriate. I hope physicians will find the information useful and I look forward to your comments.
Relevant references:
1. Arnold S. Guide to the Electronic Medical Practice: Strategies to Succeed, Pitfalls to Avoid. HIMSS. 2007.
2. Doctor’s Office Quality- Information Technology. Electronic Health Record Implementation in Physician Offices: Criticial Success Factors. Available at www.lumetra.com/uploadedFiles/programs/california-quality-connections/DOQ-IT-SuccessfulEHRImplementationBrief.pdf. Accessed July 29, 2009.
3. Forrester Research. Electronic Medical Records: A Buyer’s Guide for Small Physician Practices. California Health Foundation, October 2003.
4. Glaser J. Lessons Learned: Implementing a Clinical Information System Can Offer a Rich Education. Healthcare Informatics. September, 2002.
5. HIMSS Ambulatory Paperless Clinics Work Group. EHR Implementation in Ambulatory Care. 2007. Available at www.himss.org/content/files/Amb_EHR_Implemention081507.pdf . Accessed July 29, 2009.
6. Holbrook A, et al. A Critical Pathway for Electronic Medical Record Selection. Proc AMIA Symp. 2001;264-268.
7. Keshavjee K, et al. Best Practices in EMR Implementation: A Systematic Review. Proc 11th International Symposium on Health Information Management Research- iSHIMR 2006.
8. Larkin, H. How to do an RFP for an EHR. Medical Economics. Jan. 19, 2007.
9. Lorenzi N. Riley R. Knowledge and Change in Health Care Organizations. Stud Health Technol Inform. 200; 76:63-69.
10. Marcus, David D., Lubrano, John. Electronic Medical Record Implementation Guide. Texas Medical Association. 2007.
11. Markle Foundation. Achieving Electronic Connectivity in Healthcare. July, 2004. Available at www.connectingforhealth.org/resources/chf_aech_roadmap_072004.pdf. Accessed July 30, 2009.
12. McDowell SW, Wahl R, Michelson J. Herding Cats: The Challenges of EMR Vendor Selection. Journal of Healthcare Information Management. 2003; 17(3):17.
13. Miller J. Implementing the Electronic Health Record: Case Studies and Strategies for Success. HIMSS. 2005.
14. Misys Healthcare Systems. Critical Success Factrors for Practice-Wide HER Implementations (White Paper).
15. Smith D, Mancini MN. A Physician’s Perspective: Deploying the EMR. Journal of Healthcare Information Management. 2003; 16(2):71.
Websites:
1. American Medical Directors of Information Systems (AMDIS) http://www.amdis.org
2. Center for HIT http://www.centerforhit.org
3. Certification Commission for Health Information Technology http://cchit.org
4. College of Healthcare Information Management Executives http://www.cio-chime.org
5. HIMSS http://www.himss.org 6. Office of the National Coordinator for HIT http://healthit.hhs.gov 7. Texas Medical Association http://www.texmed.org
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