Digitized Medicine

EHR Interoperability is a Nervous System

For those familiar with using email applications such as Outlook, Gmail or Apple Mail, it might not seem like it should be very hard to send and receive electronic health information.   But as it turns out, maintaining privacy, security, HIPAA compliance and electronic patient consent is very complex when exchanging electronic health data over the Internet.   It is not easy even for physicians and hospitals using fully functional EHRs.

Virtual Scenario:  Imagine that your patients’ electronic medical records are packaged in individual charged impulses that can propagate along the axons of a national health IT nervous system. This neuronal circuit provides the infrastructure needed to send one of those charged impulses containing the right information on the right patient to the right receiving provider whenever and wherever needed. As physicians know, the charged impulses will propagate along the tubular-shaped axon until they reach the terminal end, which does not directly connect with another axon. Instead, there is a gap or synapse which prevents the impulses from proceeding unless an intermediary event occurs. This constraint prevents chaotic, asynchronous transmissions of impulses that would result in unwanted movements or seizures. So, trusted intermediaries (i.e. neurotransmitters, ions) are needed at the gaps or synapses to enable axons to “talk” with one another in a standard and controlled manner. This allows the charged impulses to proceed in a synchronous manner. The axons, gaps, synapses and intermediaries must work together, or be “interoperable”, so that the charged impulses travel in a secure, coordinated manner all the way to their intended destination.

In this scenario the imaginary national health IT nervous system is analogous to the real-life health IT infrastructure being developed at the national and state levels through National Health Information Network (NHIN) Direct project and the State Health Information Exchange (HIE) Cooperative Program.   The charged impulses represent each patient’s electronic health information.  The axons represent each physician’s cable to the Internet.   The gap or synapse represents the present-day constraints on our ability to send and receive electronic health information to one another.   The trusted intermediaries represent local health information exchanges (local HIEs) and health information service providers (HISPs) that allow each physician’s axon to communicate through the Internet with axons from other physicians and hospitals.  The interoperability needed among all parts of the virtual health IT nervous system is analogous to the interoperability needed among all parts of the real-life health IT infrastructure including EHRs, local HIEs and HISPs.

The Nationwide Health Information Network (NHIN), through the NHIN Direct project, defines standards, services and policies at a national level for health IT interoperability.  At the core of NHIN Direct are trusted intermediaries that physicians can connect to in order to allow electronic health information to traverse the synapses between their axons and those from other physicians and hospitals.   These trusted entities are called health information service providers (HISPs). HISPs are able to authenticate the senders and recipients of electronic health information.   This provides verification regarding who really sent information and who really received it while also maintaining privacy and security while the data passes across the axonal synapses.

The Office of National Coordinator for Health IT (ONC) is making an effort to trickle down NHIN Direct standards and protocols to each state.   Through the State HIE Cooperative Program, ONC grants funds to states who submit plans to build statewide health IT infrastructure to support interoperable health information exchange.   In order to be funded the states must adhere to NHIN Direct standards.

For example, the Texas Health Services Authority (THSA) is using the grant funds to serve as a statewide convening entity that has gained consensus from a broad base of healthcare stakeholders on a three-pronged strategic plan for HIE in Texas:

1. Local HIE Program— Local HIEs are another type of trusted intermediaries, like HISPs, that physicians can connect to in order to allow electronic health information to pass across the synapse to the axons of other physicians, labs, radiology centers, hospitals or others with electronic health information. Twelve local HIEs were launched in 2011-2012 with partial funding through the THSA’s Local HIE Grant Program. Some are currently operational and actively providing HIE connectivity to physicians and hospitals in their area 
2. State-level IT infrastructure and services—The goal is to develop statewide infrastructure and services that can be used by local HIEs to help them provide HIE services locally as well as to enable exchange of data from one HIE to another (statewide HIE services); also to support a transparent governance structure and develop policies and strategies that guide maturation of statewide health IT infrastructure
3. “White Space” initiative—The goal is to make available basic health information exchange services to physicians and hospitals in regions of the state without local HIEs (the “white space”) by creating a marketplace of health information service providers (HISPs); physicians can apply for “vouchers” from THSA to offset the initial costs of connecting with the HISP they select.

Physicians should stay abreast of health IT interoperability efforts like these, especially those in their own communities like the local HIE efforts in Texas.  Physician input and involvement in these initiatives helps ensure health IT is spliced into the healthcare industry's genome in way that promotes high quality care.

Community HIE decisions are best made in collaboration with local physicians who use EHRs

Physicians who use electronic health records (EHRs) in their offices are increasingly being called upon in their communities to participate in the development of local health information exchanges (HIEs).    During the early stages of HIE planning there are important decisions that are best made in collaboration with local physicians.   As with any health information technology usage, the anticipated benefits of exchanging electronic health data must be balanced against the inherent risks of the technology.   Physicians who use EHRs already have valuable experience with some of the inherent risks associated with electronic health data usage, but may not have experience with the clinical risks associated with the exchange of electronic health data.    The following case scenarios are intended to raise awareness and understanding of key patient safety risks associated with the clinical use of electronic personal health information (PHI) that could be obtained through a community-wide HIE.  

Conflicting data scenario:  A nurse records a penicillin allergy in the hospital EHR when a patient experiences GI symptoms after receiving a penicillin injection.   The next day, the patient is seen by her primary care physician (PCP).   After reviewing the history, the PCP is convinced that the reported symptoms were unrelated to the penicillin injection.   She records “No Known Allergies” in her office EHR.   The local HIE retrieves “allergies” from both EHRs and displays this patient’s allergies as both “no known allergies” and “penicillin.”  

In such cases, the physician will have to reconcile the data by considering the sources, dates, and times of each and decide whether additional investigation is necessary.   

Segmented data scenario (this applies only if the HIE will allow patients to exclude some or all of their data as a part of the consent process):   For privacy reasons an HIV patient decides to exclude his diagnoses from the HIE which results in a problem list so that it does not disclose his HIV status.   He also excludes data from two sources: his psychiatrist and a psychiatric hospital.   This patient had suffered an episode of neuroleptic malignant syndrome secondary to an antipsychotic medication a year ago while under the care of the psychiatrist at that hospital.   Since records from the psychiatrist and hospital are excluded, the HIE will not contain this information.   A physician viewing the patient’s information through the HIE will see no record of the patient’s susceptibility to a life-threatening event from a certain class of medications.  

Informing the viewing physician that the patient has excluded some data from the Problem List and some data from both a physician and a hospital may prompt important additional questions and dialogue with the patient that could prevent an avoidable adverse event.  

 Clinical Risk Management

Community-wide HIE initiatives are increasingly turning to local physicians who use EHRs to assist with assessments of both the benefits and risks associated with the clinical use of electronic health data shared across their community.  The clinical risks outlined in these scenarios can be managed through the following principles: 

1.  An HIE must provide physicians access to the source, date and time for all displayed data

 2.  An HIE must alert clinicians when data or data sources are excluded  

• The alert should specify the type of data (“lab results”) or type of source (“hospitals”) that have been excluded from the HIE through the patient consent process

3.  An HIE must inform physicians about:

• The patient consent policy used by the HIE (and of policy changes when they occur
• A list of the specific types of data they are generally able to access through the HIE
• A list of the specific sources of data that the HIE exchanges with

Improve Physician Leadership Through Recruitment, Education and Training

A recent discussion among my colleagues about increasing physician leadership in this age of electronic health records (EHRs), Meaningful Use, healthcare reform and Accountable Care Organizations (ACOs) caused me to think about how a physician even starts to go about becoming a leader.   I considered physicians in my own community who are recognized leaders and appreciated that their rise to leadership started by simply getting involved in something.   Their leadership was born out of getting involved just like my colleagues were doing when they began discussing solutions to this particular issue!

Getting involved is a common attribute of physician leaders because there is obviously little merit or trust when a physician leads an effort without previously participating in a similar effort.   Participation is the initial step to gain such trust.   Once a physician gets involved with a successful initiative their community deposits a “coin of trust” into his pocket.    If the physician obstructs progress, though, some coins of trust are removed.   A physician who eventually collects a pocketful of coins is looked upon as a trusted “community leader” who is knowledgeable and experienced, even if he did not actually “lead” any effort.  This is because many successful healthcare initiatives are known to be moved forward by people who are catalysts for collaboration and effective at resolving conflicts between stakeholders.   One does not have to be an ACO board chairman or a formal project leader to be such a catalyst.  In fact, it is often advantageous to be in a more neutral position when exerting that type of influence.

So an increase in physician leadership will initially involve an increase in physician participation in healthcare initiatives.   A good place to start is with local health initiatives such as a Regional Extension Center (REC), health information exchange (HIE)  or Accountable Care Organization (ACO).   Participating in a local initiative provides physicians with the valuable experience of working together, perhaps for the first time, with multiple stakeholders.  Physicians will see the types of communal efforts that are successful at promoting change.  They will gain valuable knowledge about healthcare reform, health IT or other important topics.   They will learn how public policy is developed. They will encounter the frustrations and complexity of efforts that fail.   But they will learn to keep their focus on the long term and not be deterred by a short term failure that they come to realize will not matter at all in 40 years.     

Understanding this process illuminates a path to increase physician leadership.  It starts with the active recruitment of physicians into local, statewide or national activities.  It is accelerated through concurrent education and training to hone leadership skills.  County and state medical societies, who have established physician relationships and are experienced with physician education/training, are ideal entities to facilitate the growth of leadership.  The medical societies could actively identify new and ongoing healthcare initiatives and contact them to ensure there is adequate physician participation.   They could also assist with physician recruitment and training when needed.

Texas Physicians With Other Stakeholders Collaborate on Local and Statewide Health IT Funding Decisions

New federal funding for the adoption and use of electronic medical records (EMRs) is accelerating progress on many existing health information technology (HIT) initiatives, providing a jump-start for some languishing HIT efforts and triggering other innovative activities.   Most of the additional funding is designated as incentive payments to physicians and hospitals that successfully adopt and use EMRs.   Some of the new funding is targeted for the development of technical infrastructure and processes that are needed to maximize the value of EMR usage by clinicians. 

Over the next year decision-makers at the federal, state and local levels will determine how billions of dollars will be spent on HIT over the next decade.   Physician participation in these decisions will help maintain a focus on using HIT to improve quality of care and patient safety.  The following information is an overview of the HIT landscape at the federal, state and local levels.

Physician Incentives

The American Recovery and Reinvestment Act of 2009 (ARRA), commonly referred to as the $800 billion Recovery Act, designates $19 billion toward the adoption and use of EMRs.  In particular, the bill provides $17 billion of incentive payments to individual physicians and hospitals who demonstrate "meaningful use" of EMRs.  Medicare physicians may qualify for a maximum of $44,000 based on 75% of their annual Medicare payments (see chart below).  The Medicaid incentive payment formula is different and based on the actual implementation and operating costs of the office EMR.  Physicians with a Medicaid patient mix >30% may qualify for up to $63,750 and those with a Medicaid mix of 20-30% may qualify for 2/3s of that amount. 

 "Meaningful Use"

In order to qualify for incentive payments ARRA requires physicians  to demonstrate "meaningful use" of an EMR.  The Department of Health and Human Services (HHS) is defining "meaningful use" based on the following guidelines:

Qualifying physicians must:

   

1. Use an EMR certified for "meaningful use" by HHS (different than CCHIT certification)
2. Use e-prescribing
3. Be able to "connect" their office EMR to other health IT systems (such as a lab or a state immunization registry) and exchange data
4. Be able to report on specified quality measures

HHS has released details on the preliminary definition of "meaningful use" and the final definition is expected later this winter or early spring.  A website hosted by the Office of the National Coordinator of Health IT (ONC) provides more details and ongoing updates on physician incentives and meaningful use. 

HIT Regional Extension Centers (RECs)

ARRA funds are also available to create about 70 RECs spread geographically across the nation.  Their purpose is to provide assistance to physicians in the successful selection, implementation and meaningful use of EMRs.  RECs will focus assistance on small physician groups and rural physicians. 

In Texas there are four non-profit entities that are collaborating with each other and have segmented the state to assure full coverage of every county.  These four grant applicants are anchored by UT Health Science Center Houston, the Dallas-Fort Worth Hospital Council, Texas A&M Health Science Center and Texas Tech Health Science Center.  The Texas Medical Association (TMA) and other state organizations are working collaboratively with each of the grant applicants.   Each REC has committed to a 50% physician representation on their governance boards.  Under the proposed plans local Tarrant County physicians will have access to the North Texas Regional Extension Center (NTREC) where Matt Murray, MD (Fort Worth), David Bragg, MD (Dallas) and Kenneth Haywood, MD (Tyler) are physician board members.  The federal REC grants are expected to be announced in March 2010. 

Health Information Exchanges (HIEs)

Technology and processes exist that can provide physicians access to a consolidated set of patient data that was entered into electronic systems at hospitals, labs, pharmacies, radiology centers, emergency rooms or even other physician offices who use different EMRs in the community.  An entity that provides this "connecting" infrastructure is called a health information exchange (HIE).  The value of an ambulatory EMR increases significantly if there is a local HIE to connect to that provides the physician online access to data about his patients that has been entered in other systems across the community. 

At a national level the National Health Information Network (NHIN) effort is establishing standard models for the exchange of health information between EMRs.  The federal HIE Cooperative Agreement Program created in 2009 will provide federal grants to each of the 50 states to develop HIE infrastructures at the state level.  In return the states are expected to align their HIE models with NHIN standards.  

HIE Cooperative Agreement Program Funds in Texas

In December, 2009, HHS announced that the Texas Health and Human Services Commission (HHSC) will receive $28.81 million over four years to fund the planning and implementation of HIE networks.  HHSC contracted with the Texas Health Services Authority (THSA) to develop strategic and operational plans that describe how Texas will create a robust HIE infrastructure.  THSA consequently created four workgroups and, with assistance from the TMA, appointed at least one Texas physician on each workgroup:

Governance and Finance:   Susan Blue, MD (Fort Worth)

Technical Infrastructure:   Matt Murray, MD (Fort Worth) and James S. Walker, MD (Refugio) 

Privacy and Security:   James Merryman, MD (Austin)

EHR Adoption and Consumer Engagement:   Tim Barker, MD (Waco)

There are currently over a dozen HIE entities in Texas in various stages of development.  Sandlot is an operational HIE in Fort Worth.  The DFW Hospital Council is leading another local HIE effort that is in a developmental stage.  Lessons learned and work already completed by existing HIE entities will be leveraged as the Texas HIE model develops.

Texas Medicaid HIE Pilot 

House bill 1218, 81st Legislature, Regular Session, 2009, requires HHSC to establish an HIE pilot for the exchange of Medicaid-related data.  A 16-member HIE Advisory Committee with Joe Schneider, MD (Dallas) serving as chairman was appointed to assist with the development and implementation.  The TMA worked to ensure adequate physician representation on this advisory committee as it is likely that the Medicaid pilot project will influence the statewide HIE model development going forward.

Building consensus among providers, payers, consumers, HIT vendors and other public, private and government entities is difficult but vital for technology to be successfully used in health care.   Perhaps the most encouraging trend over the past year is the increasing number of successful collaborative efforts such as those outlined in this overview. 

First published in Tarrant County Physician, January 2010 (reprinted with permission)

by Matt Murray, MD 

 

 

 

 

 

 

EMR Selection: Roles of Project Team, Project Manager and Decision Making Process

  

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

 EMR Project Team:

The implementation of an ambulatory EMR requires expertise and effort from a variety of individuals within the physician's practice.  Knowledge is needed for all of the processes used in the practice on a daily basis such as telephone answering, message taking, appointment scheduling, check-in processing, weight and vital signs recording, history-taking, encounter documentation, medication administration, referral management, discharge instructing, billing and check-out processing.  Establishing an EMR project team will help bring this collective set of knowledge together.  This is important because the initial goal of the EMR project team, even before selecting and implementing an EMR, will be to clearly understand why the practice is going to implement an EMR and how it will impact all areas of the practice.  Once an EMR product is selected and purchased, the focus of the team will naturally shift to the successful implementation of the selected EMR.

The EMR project team should include a physician champion, a project manager who leads the team and a broad representation of the office staff and clinicians.  At a minimum even a small office should include an office manager, nurse, physician and a representative from the “front” and “back” desks.

Creating a multidisciplinary EMR project team such as this will:

• Foster a team-oriented environment from the start
• Energize the staff
• Create a natural means of good communication
• Promote trust, “buy-in” and support from all areas of the office

The concept of a project team and adherence to project management principles may be new to the physician and to the office staff. They may not at first understand the purpose of following structured project management principles and they may feel that it is excessively rigid. However, during the EMR implementation the value of adhering to project management principles will become apparent when the team finds itself working harmoniously toward the same vision and a common set of goals. The team should therefore be educated about how project management principles provide the structure and means that foster:

• Clear expectations
• Realistic timelines
• Responsible management of costs (including the cost of staff time and effort)
• Proactive management of bottlenecks
• Effective decision-making
• Effective communication

Project management plans and principles are described in more detail in “EMR Selection: Developing a Project Plan and Adhering to Project Management Principles” (next week). 

The Project Manager:

During the selection and implementation of an EMR the practice should identify a single person to develop and coordinate the EMR project plan. The options for physicians are to:

1. Manage the project themselves
2. Assign management to someone else in the practice
3. Hire an outside IT consultant as a project manager

Before deciding to take on the responsibility of project management themselves a physician should consider carefully the amount of time and effort that this will involve. It is the opinion of this author that the physician champion should not serve as the project manager who is responsible for creating the project plans and coordinating all of the selection and implementation activities.  Assigning project management to an internal staff person may be considered especially if there is a trusted person with project management experience. It is the opinion of this author that physician practices strongly consider using a consultant experienced with EMR implementations and project management. Some responsibilities of the project manager are to:

• Develop the project plans and project timeline
• Identify tasks and available resources to do the work for each task
• Assign responsibility for tasks to individuals
• Monitor progress on tasks and progress on the timeline
• Manage project issues and project constraints that develop
• Coordinate communications within the office and among the vendors
• Coordinate demos, site visits, phone calls, travel arrangements
• Document meeting notes, phone call conversations, decisions made, action items and follow-up
• Create the EMR functionality scorecard, RFP and other documents
• Coordinate implementation activities with the EMR vendor
• Follow project management principles to keep the activities aligned with goals
• Coordinate contract negotiations
• Work closely with the physician champion
• Lead the EMR project team meetings

Coordination of the activities of a comprehensive work flow analysis and documentation of the practice’s requirements for an EMR will be time-consuming for the project manager early in the EMR selection process.  Developing a shared implementation plan with the EMR vendor and coordinating the execution of the project plan will be time-consuming later in the project.  

Decision-Making:

As the project manager, physician champion and EMR team are established there needs to be clarification about how decisions will be made going forward. Trust and support are strengthened by a clear and transparent decision-making process. The best practice in project management is to designate a single stakeholder who has the authority to make final decisions during the project. This is usually the physician champion or other lead physician in the group. At the beginning of the project everyone should be informed on how decisions will be made. The stakeholder most commonly will delegate day-to-day decision-making to the EMR project team which includes the project manager and the physician champion. Through regular progress reports the project manager should keep the stakeholder aware of all strategic decisions and other important decisions being made.  If a consultant is managing the project they should also follow these basic project management principles.   

When the project team cannot reach consensus on a decision the stakeholder serves as the escalation point.  If the stakeholder is unsure about a decision that has been made or is presented with an escalated issue that requires a decision, he/she should seek the perspectives of the individual project team members, IT consultants, EMR vendors and others in their practice who can provide valuable insights that will facilitate a good decision.

 

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

EMR Selection: Physician Champions

 

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

An enduring axiom about electronic medical record (EMR) implementations remains unchanged: “If no physician champion, then don’t implement”.  The physician champion’s role in an EMR implementation is to keenly focus on strategic implementation decisions, education of colleagues on the EMR, process/work flow redesign and on the design, configuration, build and testing of the EMR.

In a June 30th Digitized Medicine blog (High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles) the evolution of the role of physician champions within health information technology (HIT) is described.  In the 1970s physician IT champions typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects.  Since the 1990s the implementation of more expensive and increasingly complex clinical technologies, such as EMRs with computerized physician order entry (CPOE), has led to the need for an executive CMIO role at a majority of hospitals.  As described in the blog, the CMIO role is different than the physician champion role of the 1970s. The CMIO, in fact, needs to recruit , mentor and infuse the clinical expertise of physician champions from within the organization into health IT implementations.  Similarly, an office practice should identify a physician champion before selecting and implementing an EMR.

Most of the work involved in successful EMR implementations is not technical, but instead involves changes in process and work flow. The physician champion must be closely involved in the redesign of processes and work flow to ensure the changes align well with how the clinician works and thinks best.  The physician champions also are the “subject matter expert” for the EMR’s clinical design, configuration and build. They work on structured documentation templates, order sets, clinical decision support tools and, most important of all, work flow redesign to optimize how the EMR design is used. The champion is a key figure for strategic decisions that need to be made during an EMR implementation. The physician champion works with colleagues to identify their unique needs. At the same time he/she educates colleagues on the value of and garners their support for standardizing their template-based documentation and orders as much as possible.

The effort needed to garner support, design the EMR and redesign processes/work flow is often underestimated.  Implementations that proceed without physician champions or without enough time for the physician champion to adequately participate are more likely to encounter significant problems when the EMR “goes-live”.  Examples of such problems are:

• Documentation takes too much time because there are too many required answers that the physician has to enter
• Documentation takes too much time because of work flow issues
• Inability to easily get quality reports that were expected from the EMR, because the data is entered differently or in different places by different doctors
• Pick-lists have so many choices that it frustrates the doctors
• Poor template design makes it easier for clinicians to just free text; data needed for quality reports does not get entered into discrete fields that allow it to be reported on
• Poor work flow redesign slows down patient flow in the office, productivity goes down

Decisions about what quality data needs to be entered in the EMR and standardization over where it gets entered are needed before even designing templates.  Limiting the amount of “required fields” to these pre-determined data needs helps prevent documentation templates that are to elaborate to enter data quickly. This is important for the physician champion to drive because physicians generally expect to be able to capture quality data, produce quality reports and exchange information with registries or other health information exchange entities in their area once they have an EMR. These reports and registries are tools physicians expect from EMRs to help them improve population care.

Capturing and reporting on quality data will be required to qualify for “meaningful use” incentive payments for physicians using EMRs (under the ARRA/Stimulus package) most likely starting in 2013.  The physician champion will have a key role helping the practice qualify for these incentive payments as “meaningful users”.

The physician champion has strategic roles and post-implementation roles as well.  The physician champion will be a key participant in strategic decisions that the practice will have to make during the EMR implementation, including the go-live strategy ("big bang" vs. phased in) and what to do with the current paper charts or old EMR data.  Post-implementation the physician champion helps optimize and maintain templates, order sets, decision support rules and other EMR tools.  He/she should be the main point of contact with the EMR vendor and manage the timing and scope of future updates and upgrades to the EMR.

The importance of strong physician leadership is stressed in much of the EMR implementation literature. The following characteristics help this lead physician be effective:

• Well-respected as a clinician
• Strong interpersonal skills
• Ability to “makes things happen”
• Teaching mentality (a typical trait of most physicians)
• Strong negotiating skills
• Commitment to successful EHR implementation
• Ability to sell EMR benefits to other physicians and office staff
• Sets realistic expectations

It should be noted that although an interest in computers is helpful, technical skills are really not needed for this role. Much more important than technical proficiency is a willingness to learn and teach.

There is one final caveat based on personal experience that this author would like to share. Unless it is a small 1-3 doctor practice, the physician who is the designated EMR physician champion should not be the individual who develops, monitors and coordincates all of the tasks of the EMR implementation project plans. This is discussed further in "EMR Selection: Project Team, Project Manager and Decision Making".  The physician champion’s role is to keenly focus strategic implementation activities, process/work flow redesign and on the design, configuration, build and testing of the EMR.  Larger practices should consider compensating the champion for the time and effort required to successfully accomplish these tasks.

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

EMR Implementation: "I've Selected an EMR. Now What?"

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).

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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

High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles

Physicians with health information technology (HIT) implementation experience are in high demand for a variety of roles in organizations that are implementing clinical IT systems such as electronic medical records (EMRs).  The roles and responsibilities of these physicians has been evolving and growing.  IT physicians in the early 1970s typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects.  In the 1990s the need for IT physicians increased as more hospitals implemented clinical IT systems.  Throughout the 1990s a series of studies on the high prevalence of medication errors and the ability of HIT tools to reduce these errors culminated in the 1999 Institute of Medicine report, "To Err is Human".  This led to external pressure on hospitals to more aggressively pursue implementations of more advanced clinical technology tools such as electronic medication administration records and computerized physician order entry (CPOE).  Some of these implementations failed and others experienced sub-optimal results.  Strong clinical leadership, management and oversight at the executive level became recognized as a key factors in successful implementations.  The project-oriented, physician liaison role was still needed but no longer sufficient.  A new generation of IT physician leaders, the Chief Medical Information Officers (CMIOs), have been added to a majority of hospital executive staffs to meet these leadership needs.    

The increase in complexity of EMR implementations is due to the development of HIT products that provide more advanced functionalities and more configuration options for users to evaluate and implement.  This increase in the number of functionalities available creates more work to do during the design, build and testing of the systems. More importantly, the advanced clinical IT tools such as CPOE impact a greater number of direct clinical care processes including the daily work flows for patients, nurses and doctors.  These changes to processes and work flows cross over cultural boundaries in a way that organizations have not previously experienced.  The transformational effort needed to overcome these cultural boundaries requires strong clinical leadership, communication skill, consensus-building skill, political maneuverability, strategic thinking, adaptablility, strong interpersonal skills and sensitivity to the organization's nuances and uniqueness. These skills describe some of the ideal characteristics of today's CMIOs.

It is important to reiterate that physician champions who are clinical "subject matter experts" remain in high demand for clinical implementations in addition to the CMIO.  These physicians essentially become part of an informatics team with the CMIO.  Even in small organizations it is obviously not possible for the CMIO to be the subject matter expert for every clinician for every clinical project. The CMIO can, however, be the catalyst to get the right amount of clinician participation with the right clinical expertise into clinical IT projects. The CMIO can facilitate the redesign of hospital committee structures and roles to ensure ongoing support and governance of a new EMR.  To be effective, then, the experienced CMIO manages time by differentiating between situations that require their expertise through close, detailed involvement from other situations that are best managed as a facilitator, educator or mentor. 

The value of a multidisciplinary informatics team with physician, nursing and other clinical liaison members is recognized by organizations.  Organizations today should therefore consider planning for a multidisciplinary informatics team not just for their initial major clinical implementations, but also for ongoing optimization and support of these expensive systems.  This group is the source for clinical "subject matter expertise" during IT implementations.  After the implementation this group of clinicians becomes an invaluable resource for the continual optimization and support of clinical technologies.  Some members, such as the physician champions, will not need to spend as much time with the informatics team post-implementation, but their experience and expertise will be tapped into.  Some hospitals have decided to attract physicians to this role by creating an inpatient Medical Director for the EMR / Computerized Physician Order Entry (CPOE) and an outpatient Medical Director of Ambulatory EMRs for their physician offices.  Some are full-time positions and others are part-time, dependent on the size of the organization, and they work closely with or report to the CMIO.   

The early physician IT champion role of the 1970s evolved into an executive level CMIO role as clinical technologies became more advanced, more costly and more complex to implement.  CMIO positions have subsequently become common within hospital organizations.  Physician champions, however, also remain in demand as clinical "subject matter experts" for their clinical IT systems.  As organizations continue to implement, upgrade, optimize and support their  expensive clinical IT systems, CMIOs and clinical IT liaisons including physicians, nurses, lab technicians and pharmacists will remain in high demand.   

drmattmurray