Digitized Medicine

Twitter Chats and Physicians (#eRx630)

Today I (as @drmattmurray) and @TexMed moderated our first Twitter Chat that focused on the topic of e-prescribing. To participate in a Twitter Chat a physician must have a Twitter account and must know the date, time and Twitter hashtag for the Twitter Chat.  In our case the hashtag-- #eRx630--refers to e-prescribing and the date, June 30th, by which time physicians must meet the CMS requirements regarding the use e-prescribing. Physicians who fail to use a qualified e-prescribing system or certified EHR to enter at least 10 e-prescriptions during eligible Medicare encounters will incur a 1% penalty on 2012 Medicare claims.    On the other hand, those who meet this requirement are eligible for a 1% bonus. 

Despite the high importance of this subject matter, there were not any other physicians participating on this particular Twitter Chat.   At least none that we heard from.   It was lonely.  

However, we considered this to be an experiment and a chance to experience what it is like to actually moderate a Twitter Chat.    Without a lot of participating "chit-chat", it was difficult to coordinate questions and answers with my friends @TexMed and @TexMedHIT.     We basically asked each other questions or even asked ourselves for our own answers.  I think we did get out some excellent information, but this would have been more valuable with some active back-and-forth dialogue.   Again, though, the purpose of this venture was to dip our toes in the water to see how this type of format could be used in the future. 

Twitter Chat among physicians will certainly have challenges, but I think it will find it's place as a useful mode of communication for specific purposes and in certain situations.  The format will need to be refined, and this means we will have to try it (like today!), experiment with it, refine it and keep doing that PDSA thing to it (Plan-Do-Study-Act).   Eventually it will find a place where it serves as an effective way to communicate some things.     I already have found Twitter useful at large medical conferences that use a hashtag to communicate real-time information.    It is a matter of finding the right niches. 

One of the useful aspects of a Twitter Chat is that a transcript can be created of the entire conversation.  This means that you don't have to be "online" and engaged in the Twitter stream for the entire duration of the chat.   Since most physicians are hard pressed to find an un-interrupted hour, they would find it very helpful to be able to access and peruse the transcript at their leisure.

Here is a transcript of today's Twitter Chat #eRx630:

 
 
 
 
 
 
 
 
 

Help Available For Small Physician Practices to Overcome Technology Challenges

American Medical Association (AMA) President, Cecil B. Wilson, M.D., said in an AMA Commentary this week, "Physicians should take the time to explore their practice needs, assess their practice's readiness to adopt health IT and select the right system for the practice --and its patients".    This is wise advice that I wholeheartedly agree with.

I also agree that the successful adoption and meaningful use of electronic health records (EHRs) impose many new challenges onto physician practices and that overcoming these barriers is especially difficult for physicians in small practices or solo practices that are constrained by limited resources.   My only disappointment with Dr. Wilson's message to physicians is that it failed to highlight how Regional Extension Centers (RECs) can be leveraged by physicians to address these issues with EHR adoption and use.

The HITECH portion of the 2009 Reinvestment Act (ARRA) included over $677 million in grant funds to establish RECs across the nation to cover every geographic region.   The purpose of each REC is to provide consulting services to physicians that help them overcome many of the described barriers to the adoption and use of EHRs.   It is important for physicians to know that the RECs receive federal subsidies specifically based on and proportionate to the number of primary care physicians in solo or small group practices (<10 physicians) that they successfully help adopt, implement and meaningfully use an EHR.  In other words, RECs are financially dependent on providing effective health IT consulting services to a segment of physicians who have the greatest need for such services.

In Texas there are four RECs including the North Texas REC (NTREC) for which I volunteer time as Board Chairman.    Other Texas physicians volunteer their time to comprise 50% of the governing boards for each of the four RECs.   Our goal is to ensure that our RECs are physician-friendly and remained focused on providing high quality services that meet the technology needs of small physician practices in each region.   Texas RECs collaborated with each other to create a common business plan that leverages the federal subsidies to charge Texas physicians a token fee of $300 for IT consulting services worth over $5,000.    

NTREC will receive 100% of their allotted subsidies if we successfully help 1,500 physicians adopt EHRs and achieve meaningful use.   Since last October more than 500 North Texas physicians have enrolled for NTREC services; over half of them have already successfully implemented an EHR and are now working on the achieving meaningful use of their investment.

My hope is that physicians in other states will emulate our efforts by actively engaging in the governance of their region's RECs to ensure that they are physician-centric and remain focused on addressing the unmet needs of the small physician practices.

 

Private E-mail Communications Between Physicians and Patients—Identity proofing, Authentication and Encryption

Case study:   A plaintiff claims that his physician sent him an e-mail with poor medical advice that led to an adverse medical event.  The defendant physician agrees that the e-mail in question provides grossly negligent advice, but claims that she never sent such an e-mail.   Unfortunately, the physician had been using her own, personal home e-mail program to communicate with patients without using encryption or authentication software.  A costly investigation eventually proved that the e-mail had originated from an unknown third-party spammer who used a technique called “spoofing” to insert the physician’s e-mail address into the "From" field in the e-mail that was sent to the patient.

Although this physician avoided a malpractice suit, she bore the financial burden of a technical investigation to prove the e-mail was not from her. This is only one example of a number of privacy and security issues with physician-patient e-mail. But these problems are avoidable and e-mail can be safely used if the physician can be sure of four things:

1. They are using the authentic e-mail address of the patient
2. A message received from the patient has actually been sent from their authentic e-mail address
3. Each message (sent or received) has not been changed while traversing across the Internet
4. Only the physician and the patient are able to read each other’s e-mail messages

E-mail encryption programs and secure messaging programs both provide safeguards that ensure this level of privacy and security needed for physician-patient e-mail.   From a legal perspective, these technologies, when combined with appropriate procedures of use, make it very difficult for someone to successfully repudiate (deny sending or receiving) an e-mail in a legal situation.   As noted in this case, regular home and business e-mail programs do not typically include such safeguards.

The Texas Medical Board (TMB) specifically requires physicians to “authenticate” patients prior to initiating e-communications, and to only use e-communications with established patients.   Although the TMB does not specify how this is to be accomplished, the procedure typically involves “identity proofing” patients during an office visit.   Patients physically present themselves to an office staff member who is authorized to register new “users” into the physician’s secure e-mail system.   After being registered in the system, the patients will receive the “credentials” that allow them to receive and send messages through that system.  The type of e-mail system used by the physician determines the type of “credentials” the office will provide.  The credentials may be a password, a biometric feature (i.e. finger print), or a physical device such as a CD, smart card, or thumb drive that contains a password “key”.

After the patient is identity proofed, secure e-mail systems are able to use built-in “authentication” technologies to ensure:

• a message received has actually been sent from the credentialed patient’s mailbox
• a message sent or received has not been changed while it traveled over the Internet
• a message sent can only be received and decoded by the credentialed patient.

Taking care to set up authentic e-mail accounts with identified patients and using an e-mail program (encrypted e-mail or secure messaging) that includes "authentication" technologies are necessary to establish the trust needed when engaging in private medical conversations.   In addition, these work flow procedures and technologies will help the physician stay within HIPAA regulations that require encryption when PHI is sent over the Internet.

Comparison of Web-based vs. Traditional EHRs For Physician Offices

An ambulatory electronic health record (EHR) can be provided to the physician practice through one of two different models:    

1. Web-based-- also referred to as a "hosted EHR" or the "ASP Model" where the physician accesses the EHR through an Internet connection
2. Client-Server (C/S)--  the traditional model where the EHR server may physically resides in the  physician's office

Both models are considered to be acceptable, but each has inherent pros and cons to consider.   The traditional model of choice has been the “client-server” model.   In this model the EMR software is installed on a server that is typically located in the physician’s office.  The physician and staff access the EMR through computer devices that are connected to the server through a local area network (LAN) set up in the office.  The computers may be connected wirelessly to the network if desired.   This model has a few similarities to loading Quicken on your home computer and then using Quicken to pay bills online: 

1. After loading Quicken onto your computer you will periodically be advised by Quicken to take "updates" to fix known "bugs" in the software.  Similarly, you will load the EHR software onto the server in your office and physically download any updates to fix "bugs" that the vendor discovers and fixes.     
2. Microsoft periodically advises you to take security updates on your home computer.  Similarly, the EHR server will need to take periodic updates from Microsoft.
3. You may later decide to upgrade Quicken to its latest version, and then purchase and install the Quicken upgrade on your computer.  Similarly, you will want to upgrade your EHR software periodically, usually every 12-18 months.
4. You may decide in the future to purchase a new home computer that is faster;  you will have to then load the Quicken software onto that new computer and transfer all of your old Quicken data to the new computer.  Similarly, you will need to periodically replace the EHR server with a newer one that is faster, stronger and/or meets future recommended requirements of the EHR software.  And make sure your data gets transferred as well.

The web-based model is gaining popularity.  In this model the EHR software is located on a server at a remote location designated and hosted by the EHR vendor.  The physician and staff access the EHR through the Internet on computer devices in the office.  This is analogous to online banking that you access on your home computer and use to pay your bills online (instead of using Quicken).  Using this analogy: 

1.  You will not physically have to take updates because the bank will update the software themselves
2.  Microsoft will not ask you to take Microsoft security updates to the online banking server because the bank hosts the server and will do that themselves
3. When there is an upgrade to the online banking software, you do not have to purchase and physically load that software on your computer because the bank does that on their server that you are simply accessing.
4. If the online banking server is too slow you will not have to purchase a new server, the bank will do that (if enough customers complain)...and they will migrate your data over to that new server)

Here is a comparison chart for these two EHR models:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personally, the business side of me is strongly averse to allowing a 3^rd party vendor to take care of the “heart and soul” of my practice (i.e. the revenue dollars and the clinical data).   Hence, in private practice I would strongly favor keeping the server in-house.     However, the clinic I currently work at is a small part of a large academic institution.   For our ambulatory EMR I am leaning toward recommending a web-based model.  The presence of an institutional IT Department whose primary purpose is to support the education of thousands of students, not to understand and dedicate the resources needed to provide a high level of clinical IT support required for a clinician using an EHR.  And I know who is most likely to get trumped down the road when conflicting priorities arise!

Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

• EHR implementation and project management;
• HIT education and training; 
• Vendor selection and financial consultation; 
• Practice and workflow redesign; 
• Privacy and security compliance education; 
• Meaningful use analysis, tracking, and monitoring; 
• Assistance in meeting meaningful use requirements for CMS incentives; 
• Collaboration with state and national health information exchange (HIE); 
• Ongoing technical assistance; and 
• Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are:

• Gulf Coast Regional Extension Center (GCREC)
• CentrEast Regional Extension Center (CEREC)
• North Texas Regional Extension Center (NTREC)
• Texas Tech University Health Science Center

North Texas Regional Extension Center's Successful Start and Current Activities

Today, while wearing my hat as the Board Chairman of the North Texas Regional Extension Center, I am writing a message primarily to my colleagues who practice medicine across North Texas.   I am sharing this message through my blog, however,  because others may be interested to see and hear what is happening at the grassroots level of local and regional health IT initiatives:

 

  
 February 2, 2011

To my physician colleagues across North Texas,

On behalf of the volunteer physician board members of the North Texas Regional Extension Center (NTREC), I am writing to inform you that registration for the federal electronic health record (EHR) incentive program has begun and that the money is already flowing.   In January, for example, two Oklahoma physicians at the Gastorf Family Clinic of Durant, OK, received $21,250 each for having implemented a certified EHR.   If you are considering making the jump to an EHR, or if you already use one, you may become eligible for EHR incentives up to $44,000 under Medicare or $63,750 under Medicaid by meeting “meaningful use” requirements.

NTREC receives federal grant funds for providing on-site technical consulting to enrolled physicians who are selecting, implementing or using an EHR.   This federal subsidy allows NTREC to charge primary care physicians only $300 for consulting services valued at $5,000.  

NTREC is focused on helping you:

• Select and implement a certified EHR (or upgrade your current EHR to a certified version),
• Optimize your practice workflow,
• Achieve meaningful use,
• Qualify for EHR incentives, and
• Obtain CME credit hours along the way

I am happy to report that NTREC services were successfully launched four months ago.   Since then, 289 physicians have enrolled for services and another 370 physicians have enrollment contracts in progress.   Our goal is to provide services to more than 1,500 physicians in North Texas by the end of 2011.   Our operational plans will enable us to scale physician services to even higher levels if needed to meet physician demand.  

The federal EHR incentive program and these discounted NTREC consulting services are unprecedented and genuine.   Please call NTREC to enroll and set an appointment for on-site consulting at (469) 648-5140 or by visiting  www.ntrec.org.   The NTREC’s dedicated team of experts will be considerate of your valuable time and show you how they can help you identify and meet your unique needs.

If you have questions, please don’t hesitate to contact me.

 

Sincerely,

 Matt Murray, M.D.

Brown Lupton Health Center

Texas Christian University

 

cook children 

For Meaningful Use Payment: Goin' to the CHPL, Gonna Get a "CMS EHR ID"

Use of certified electronic health record (EHR) technology is a core requirement for physicians and hospitals to become “meaningful users” and to be eligible for payments under the Medicare or Medicaid EHR incentive programs.    Operationally, CMS requires providers who apply for these payments to submit the "CMS EHR ID" that their certified EHR technology is assigned.   Physicians and hospitals will benefit from an awareness of several issues revolving around EHR certification and on this CMS EHR ID, especially when "goin' to the CHPL" as noted below.

Awareness Issue #1:  The Office of the National Coordinator for Health Information Technology (ONC) in 2010 established a temporary certification program for EHR products.    A permanent certification program, which builds upon the current temporary program, is expected to be ready to launch by the end of 2011.   This program uses ONC-Authorized Testing and Certification Bodies to test and certify EHR products.   The list of certified EHRs is updated as new products are certified and posted on the Certified HIT Product List (CHPL) website.    CHPL is maintained by ONC and is the sole, designated authoritative list of currently certified EHR products.  

Awareness Issue #2:    ONC certification is different from that provided by the Certification Commission for Health Information Technology (CCHIT).    CCHIT certification is based on more comprehensive criteria.    CCHIT certification continues to be an important resource for those who are in the process of selecting an EMR because of this more comprehensive testing.    ONC certification testing, on the other hand, is specifically based on the CMS Meaningful Use criteria. 

Awareness Issue #3:   EHR products are tested and certified by ONC as either a Complete EHR or a Modular EHR.   A Complete EHR product is defined as an EHR product that meets all of the certification criteria for meaningful use.  A Modular EHR product is defined as an EHR product that meets at least one but not all meaningful use criteria.

Awareness Issue #4:   When a physician or hospital apply for their incentive payment they are asked to submit to CMS the "CMS EHR ID" that is assigned to their EHR product(s).  The CHPL website is the only place where this ID number can be found.  

Awareness Issue #5:    When looking for this CMS EHR ID number, it is helpful to know that this is not the same number ONC provides the EHR vendors when they are certified.    This is because some providers may decide to use a modular approach and combine Modular EHR products from different vendors in order to achieve meaningful use (i.e. a basic EMR without e-prescribing from one vendor and an e-prescribing module from another).  

Awareness Issue #5:   As the website works today, the CMS EHR ID can only be found on the "Grocery Cart" page and only after the <Get CMS EHR ID> button is activated.    One first selects their EHR product(s), puts them in their "Grocery Cart" and then goes to their <Grocery Cart> page.    The button becomes available when one has either:

• selected a certified Complete EHR product

                                     or

• selected a set of certified Modular EHR products that meet all of the certification criteria      

It interesting and helpful that CHPL provides real-time feedback when selecting a set of Modular EHRs.  Once all of the criteria are met, the <Get CMS EHR ID> button becomes available.  

Awareness Issue #6:    Regarding the modular option, the CMS certification process does not include integrated testing of all the possible permutations of Modular EHR sets that can be selected.    So even though a set of Modular EHR products may produce a CMS EHR ID on the CHPL website, this does not mean that the selected set of products were tested as an integrated unit.   This does mean that the physician or hospital who is in the EHR selection process should not depend on the CMS EHR ID to determine whether the selected products can be interfaced or work together.     Due diligence will still be needed to ensure all of the selected Modular EHR products are compatible.   

In other words, if you're goin' to the CHPL and gonna' get an CMS EHR ID, it's best to know your EHR partners well before purchasing and implementing them!

Enhance Safe Use of EHRs By Aligning Implementation To Quality Goals

Safe use of electronic medical records (EMRs) is enhanced when physicians focus their EMR implementation on quality of care improvements.  Effective communication among the staff about these key goals creates a positive environment that serves as a catalyst for successful use of the EMR.  In addition, large healthcare systems and small physician offices are both less likely to encounter patient safety issues when they align their health information technology (IT) strategies to quality of care goals.  

Case Study:  Several years ago the leadership of an Accountable Care Organization (ACO) formed between a local healthcare system and a multi-specialty physician group began working collaboratively on a common vision for patient safety excellence.  System-wide integration and use of medication reconciliation were top priorities.  The EMR used by the hospitals have an ambulatory component that meets all of the critical requirements determined by the physician board members.  If implemented, the ambulatory and hospital EMRs could be integrated and share the same master patient index, drug formulary, medication index, allergy index and set of clinical decision support rules.  However, the physician board, influenced by several leading opinion-makers who favored an alternative EMR, convinced ACO leaders to allow the physicians to purchase their own ambulatory EMR and use system resources to purchase and develop a data repository that could send/receive (bi-directionally) and store data between multiple sources.  The vendors involved promised they could provide the infrastructure and tools necessary to capture and manipulate the data.  Two years later a patient suffers a severe anaphylactic reaction after receiving an antibiotic injection in one of the physician offices.  An investigation reveals that although the EMR had properly displayed the allergy, the antibiotic order had not triggered an allergy alert.  Further research reveals multiple ways for an allergy to be entered into their customized, bi-directional medication reconciliation tool that would successfully display the allergy in the ambulatory EMR, but not trigger an alert during the ordering process.  Their conclusion is that the use of different EMRs with multiple drug formularies, multiple medication and allergy indices and different clinical decision support rules is more complex than anticipated.  They suspended use of the medication reconciliation tool until they could determine whether they could more effectively execute their current strategy.

Key Points:  Effective organizational characteristics and a focus on quality of care are important catalysts for safe EMR use.

Cultivating a culture of safety, promoting transparent communications and alignment of strategic planning with prioritized goals to improve quality of care are examples of organizational characteristics that facilitate safe EMR use.  In this case the organization did well creating a shared vision with common goals/priorities regarding quality of care.   However, organizational alignment fell apart when the unbalanced interests from one part of the organization created the perceived need for an alternative strategy.   Although the new strategic plan was plausible, the organization did not have the resources or organizational discipline to effectively execute plans that were considerably more complex.   It will be paramount for ACOs to effectively manage such issues in the future.  Similarly, even the small, individual physician practice is more likely to be successful with an EMR implementation when they develop a strategy to improve quality of care through the implementation of an EMR.  

"Think Simple" When Developing Order Sets and Clinical Content Screens for EMRs

Physicians would prefer that an EMR computer screen emulate a tri-fold flow sheet that inspires a "gestalt feel" for the whole clinical situation.   Instead, data split among multiple screens with the need for numerous mouse clicks and excessive scrolling in order to see all the information tends to frustrate clinicians.  The frustration comes as a result of the fragmentation of our thought processes and patterns which have developed over time.    In addition, "user interface" issues can become a patient safety risk.  The following case study provides an example of such an issue.   

Case Study:   A small practice had their EMR vendor develop a custom report called the Patient Summary that “pulls in” EMR data including lab and radiology results.  This report is useful while on-call because they can remotely access it from home over the Internet.   Over one weekend the on-call physician discovered that some of the lab results for one of his patients did not show up on the Patient Summary.    He checked several other patients and found another example of missing results.   He decided that this report was unreliable and that he would not use it until the issue was understood.  The EMR vendor was notified on Monday.   They quickly determined that the report was working normally and no data was missing.   They suspected the doctor forgot that this report displays a little <+> symbol at the bottom of the screen if there are additional lab results that will not fit in the space provided.   At that point the physician realized that he had used his new iPhone for the first time and that the small viewing display had made it very difficult to for him to see the small <+> symbol.

 

Key Points:

• Displaying medical data on a computer screen in a manner that meets the cognitive challenge at hand is difficult and can fragment a physician’s thought processes

 Since tri-fold computer screens are not a practical solution today, physicians need to involve themselves in the development of the EMR content screens that they will be using on a day-to-day basis.  For most EMR products these screens can be configured and used in various ways.  In this case the small display inherent to smart phones was inadequate when viewing the report.   But this is because it was not designed with the small viewing area and resolution of a smart phone in mind.  If presenting this data on a smart phone is a requirement for this physician, a new report will have to be developed in order to meet that new need.  

• “Think simple” when developing EMR screens that clinicians interact with

Complexity makes EMR use even more difficult and less safe.   Most EMRs allow modifications to some EMR screens that physicians interact with such as documentation templates, reports, orders and order sets.   Good advice to those who develop these screens is to “think simple”.   For example, if six gastroenterologists decide to each create their own list of 25 order sets to accommodate personal preferences, their EMR order set screen will display 150 order sets.   Creating a screen that displays 125 choices for physicians has a pre-determined fate.  They would be better served by collaborating on 25 evidence-based order sets to share.   The result will be less frustration, less variation from evidence-based medicine and less work when annually reviewing the content of order sets.

How to Shame or Acclaim the Same EMR Through Work Flow

It is not uncommon to find physician groups who use the same version of the same electronic medical record (EMR) product but with significantly different degrees of satisfaction.  How can this be?  The following case study illustrates how successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals.  This is the second of six case studies being used to describe the safe use of EMRs.

Work Flow and Communications Case Study:

A pediatric group in the final stages of selecting an EMR product sent their “physician champion” on site visits to two similar practices who had implemented identical versions of the same EMR.  At the first site visit the physicians are very pleased with the EMR and describe how clinical decision support tools help them achieve their goals.  For instance, during an 8 month-old Well Child visit the EMR defaults in a developmental history template that prompts age-appropriate questions.  With a single click on the order button an order set with routine orders for an 8 month-old Well Child visit displays.  The orders are completed in 30 seconds.  The pediatricians proudly tout the weight-based dosing option that calculates medication doses based on the patient’s current weight.

At the second site the physicians, parents and staff grumble about “going electronic” and complain about how long it takes to enter orders.  The visiting physician gains much insight while observing an 8 month-old Well Child visit.  The physicians rarely make eye contact with the parents as they struggle to find age-appropriate developmental screening questions from a long pick-list of questions they had built on a single developmental history template used for all patients.  They order each immunization, test and prescription separately.  Each test requires at least 5 clicks, three screens and a lot of scrolling.   They also manually calculate medication doses and type them onto the e-prescribing screen.   It takes several minutes to complete the orders.   When you ask why they don’t use the EMR’s weight-based dosing option, they reply that they discovered the weight-based dosing function is not safe to use.

Key Points:

• Successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals

Most EMRs have at least some features that can be designed and configured to work in different ways, or not used at all, such as order sets, documentation templates, health care maintenance tools and other clinical decision support tools.  Understanding these capabilities and designing optimal ways to leverage them are critical for successful EMR implementations.  The first group knew their goals and designed the EMR to achieve them.  They were particularly adept at leveraging the EMR’s capabilities to streamline work flow.  The second group, on the other hand, is floundering with poor work flows and no apparent goals for the EMR other than “going electronic”.

• Automation of inefficient paper-based processes is a common risk to avoid

In the first office the physicians consider weight-based dosing to be a real time-saver and patient safety enhancement, but the second office considers it to be a patient safety risk.  It turns out that in the second office the nurse opens up and uses a single documentation template to enter documentation during the entire patient visit just like she did with paper records.  She keeps this template “open” because it takes too much time to submit part of the documentation, then re-open it to document more, then submit, re-open and so on.  So when the physicians used the weight-based dosing option, “today’s” weight would not display because the nurse had not yet submitted that data.  Thus, their poor work flow design and lack of synchronization not only slowed them down, but created a patient safety issue if the weight-based dosing option was used.  In the first office they avoided this by designing a “Vital Signs” template that the nurse used at check-in.  After the vital signs were entered into the template and “submitted” by the nurse the next logical documentation template conveniently popped-up to use. This group had used an IT consultant to help them redesign their work flow to take advantage of a paper-less environment.

• EMRs can interfere with physician-patient and physician-nurse communications

The lack of eye contact noted by patients in the second office is an example of how EMRs can impede communications in healthcare settings. It is prudent to be aware of the potential for such communication problems and to consider ways to avoid them.

I am using six case studies to illustrate that most EMR-related problems, even those involving hardware and software, can usually be traced back to some controllable factors.   The safe and meaningful use of EMRs is facilitated by leveraging these controllable factors to minimize these problems.