Digitized Medicine

Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

 

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

Physicians Use E-mail With Patients Safely By Avoiding Misuse, Mishandling and Medicolegal Issues

Effective communication is a hallmark of patient satisfaction with their physician as well as with quality outcomes.  It is not surprising that surveys reveal more than 90% of patients desire to e-mail their doctors.  Physicians, however, are tentative about moving forward. In a 2009 survey by the Texas Medical Association, only about 20% of physicians reported the use of e-mail with their patients.

Those of us who do successfully use e-mail with patients know that we must be attentive to the risks involved to use e-mail safely. We also recognize that in order to use this technology efficiently we have to think about our work flow and be smart about redesigning it.  The risks of using e-mail with patients can be categorized into misuse, mishandling and medicolegal issues.

Misuses of physician-patient e-mail include:

• seeking or providing new diagnoses/treatments
• using e-mail with new patients with no previous face-to-face encounter
• communicating on sensitive matters such as HIV, sexually transmitted infections, genetics and mental health
• using e-mail for urgent or emergent issues
• writing long, complex messages
• using e-mail attachments with formats that patient’s computers may not be able open and read
• forwarding e-mails from patients without their consent
• advertising or promoting goods and products through e-mail

Mishandling issues with physician-patient e-mail include:

• problems with e-mail triage or distribution within the office such as failure to adhere to established protocols or meet expected turn-around times for actions/replies
• physicians using their personal e-mail accounts to send e-mail to patients
• misunderstandings by patients/office staff regarding over who actually received, sent or replied to messages (authorship issues)

Medicolegal, privacy and security issues include:

• failure to properly identify patients and verify e-mail addresses
• privacy breaches
• security problems with the e-mail system or related computer systems
• not getting e-mail communications into the patient’s medical record
• repudiation issues (i.e. patient denies sending or receiving an e-mail)
• accountability issues
• legal e-discovery issues
• medical liability associated with diagnoses/treatment
• failure to follow Texas Medical Board rules, HIPAA regulations or other on privacy/security regulations

These issues are certainly not insurmountable.  With an awareness and understanding of the rules, regulations and guidelines published by one’s state medical board, HIPAA, professional societies and other professional organizations such as the AMA, a physician can develop a set of policies and procedures to safely and efficiently use e-mail with their patients.  The procedures should include oversight mechanisms, adequate training of staff, adherence to privacy and security regulations, appropriate identification and authentication of each patient who consents to the use of e-mail and patient education to clarify what the physician will allow e-mail to be used for.  Patients should also be educated on how the office will manage e-mail messages and on what the expected turn-around times for replies will be.

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.  

Work Flow Analysis Helps Physicians Select Ambulatory EMR That Meets Needs

In a previous blog the methods used to perform a work flow analysis in a physician's office as a part of the EMR selection process were described.  The  next steps are to:

Determine at a high level the future desired work flows (when an EMR will be used)

Prioritize this list of work flow desires

Develop a prioritized list of EMR functionalities needed to meet those  desires 

Compare EMR products based on these priorities

Document Future Desired Work Flows

An analysis of current work flow identifies bottlenecks in the physician's practice.  Changes in work flow may alleviate those bottlenecks.  Some of the identified changes may not be dependent on having an EMR and could be made immediately.  The other work flow changes that are dependent on using an EMR and will later become part of the EMR implementation.   

It is not readily apparent to many physicians how an EMR could improve work flow in their office.  There may also be unrealistic expectations about how an EMR could improve things.  Therefore, it is helpful to first gain knowledge about the "best uses" of ambulatory EMRs as experienced by other physicians before identifying desired future work flows.  To gain insights on the realistic and best uses of EMRs physicians may be wise to engage a knowledgeable IT consultant.  Alternatively, physicians may use other resources  to gain insights such as:

• DOQ-IT's Operational Redesign Workbook
• AHRQ Health IT Toolbox
• CCHIT
• Networking with colleagues
• Physician professional organizations

The knowledge gained on EMR "best uses" and the identified work flow  bottlenecks can now be analyzed together to determine at a high level what future work flows are desired for the practice. 

Prioritize this list of work flow desires

The physician practice may now discuss these desired work flow changes and prioritize them.  For the purposes of discussion let's suppose the practice has identified a top ten list of desired work flow changes that they want make when they implement an EMR.

Develop a prioritized list of EMR functionalities

The prioritized top ten list of desired work flow changes will naturally translate into a list of EMR functionalities that are top priority.  For instance, a practice that determines "refilling 80 prescriptions/day" is currently their top bottleneck, then the most important EMR functionality to compare among products is the usability of the EMR's e-prescribing feature.  A different practice may identify their top bottleneck to be getting patients through the check-in processes and determine that they want to reduce time patients spend filling out papers on clipboards by providing online registration forms and using a self-serve kiosk in the waiting room.  They also desire an EMR that can quickly register and check-in patients.  In that practice the most important EMR functionalities will be a robust patient portal, efficient integration with kiosks and the fewest number of necessary screens and "clicks" when registering or checking-in patients at the front desk.

Compare EMR products based on these priorities

EMRs have hundreds of functionalities.  It is not humanly possible to effectively compare hundreds of functionalities between different EMRs.  Comparing EMRs without focusing on specific needs easily leads to frustration and/or confusion.  Using the described list of prioritized EMR needs will improve the comparison process. 

Physicians might consider limiting their comparison to EMRs that have been certified by CCHIT (and soon to those certified for "Meaningful Use" as well).  One can be confident that a CCHIT-certified EMR has all of the functionalities that are described on the CCHIT website.  There are hundreds of such functionalities.   However, CCHIT does not necessarily quantify how well the EMR performs each function.  So, if a physician practice limits their comparison to CCHIT-certified EMRs, they can be assured the EMR can do those hundreds of things an EMR should be able to do and instead spend their time comparing how well the EMRs meet their own, identified "top ten" needs.  

Using an earlier example of an identified "top ten" EMR need, a comparison may find that EMR Product "A" allows prescription refills to be completed in 45 seconds using three screens and 17 clicks, while Product "B" refills prescriptions in 15 seconds (30 seconds faster) on one screen with 6 clicks.  Since the work flow analysis revealed that the practice has 80 refills/day, refilling prescriptions using Product "B"" would take 40 minutes less each day as compared to Product "B".  

In summary, it is helpful for a physician practice searching for an ambulatory EMR to perform a work flow analysis to identify the major bottlenecks in the office, gain insights on how EMRs can improve work flow, use this knowledge to develop a prioritized list of desired future work flows, identify the "top ten" things an EMR needs to do to meet those desires and then compare CCHIT-certified products based on this prioritized list of EMR needs.

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

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

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Physicians, EMR Implementations and the Science of Project Management

For those who enjoy the ease and convenience of online shopping or use of self-pay kiosks for everyday activities like purchasing gasoline and groceries, it is hard to understand why medicine has remained so heavily paper-based.   On the other side, those who work closely with healthcare providers during and after technology projects recognize how complex and difficult it is.   Almost two thirds of technology projects fail as they run into problems such as unplanned costs, excessive delays, poor quality, expectations not being met and excessive numbers of unresolved issues.   When such “failures” are analyzed it is common to discover preventable causes such as poor planning, inadequate testing, poor work flow redesign, failure to identify and manage risks, poor communication, faulty implementation strategies, selection of the wrong technology products or the use of good technology in a way it was not designed to be used.   Although there are not simple recipes to follow that guarantee successful health IT implementations, there is a large body of knowledge regarding how best to manage technology projects in general.   A major resource for this knowledge is the Project Management Institute which promotes the science of project management throughout the world.   Although the details of project management are beyond the scope of blogging, there are eight knowledge areas that describe the principles of project management:

Procurement management	Obtain/purchase products and services, contract management, vendor management
Cost management	Budget and monitor costs
Project integration/communication	Objectives/goals, project plan, execution, monitoring status; managing changes; managing internal and external communications;  review/close project
Scope management	Establish scope of work needed, monitor and manage all processes and changes related to scope
Time management	Establish timeline based on work required, resource availability and scope; monitor and manage time constraints and schedule changes
Resource management	Who does what, when, where and how; establish project team; monitor and manage resource constraints and bottlenecks
Quality management	Test the application/product; follow project management principles
Risk management	Risk analysis, work flow analysis, risk mitigation planning, work flow redesign; change management

Understanding the basics of project management is more important for physicians than to understand the technology.  

Before selecting a technology product, these principles direct the physician to first identify the goals (or “objectives”) that are expected to be achieved by using the technology.   Defining the expected objectives allows the physician to then determine what the technology product specifically needs to do (the “requirements”) in order to achieve those goals.  This aligns technology purchases with the physician’s actual needs and expectations.  A common error is to select a technology product first and then figure out how to use it.   The risk with this faulty strategy is that, even if some value is gained, the physician’s actual goals and needs may remain unmet.  

The scope of a project is defined by what needs to be implemented in order to meet the identified goals and requirements.   A project plan and timeline can be created by determining how much work is required, within this defined scope, who is available to do that work (physicians, staff, temporary labor, vendor resources, consultants) and how much time those people have available to do project work.   Project management principles keep technology implementations “on track” by monitoring the scope and maintaining a balance between known work, known resource availability and established timelines.  It is easy for physicians or staff to become enamored with potentially valuable, but initially unplanned, uses of new technology during an implementation.  If these unplanned uses are piled onto the original scope of a project, then there is more work to do.   

The consequence of more work is the need for more people or time to complete the project.   Sometimes the additional work results in unbudgeted costs such as paying a consultant for additional hours to do the unplanned work.   Unplanned “scope creep” like this is a common malady that derails technology projects but can be avoided or contained by adherence to project management principles.  

And finally, an important aspect of project management is attentiveness to policies and procedures.   Policies and procedures that successfully manage risk within a paper-based work flow will become obsolete if technology creates a new electronic work flow.   A comparison of current work flow to future work flow along with a risk assessment during the project will identify needed changes to policies and procedures.

Search this site for other blogs on EMR Selections and EMR Implementations

 

 

What Physicians Need to Know about Work Flow Analysis Before Selecting and Implementing an Ambulatory EMR

Work flow analysis is valuable when selecting and implementing an ambulatory electronic medical record (EMR).   The results of this analysis will help the physician identify which EMR products are best suited to meet their expectations.   Physicians should have an understanding of the effort involved and prepare their practice for this important assessment.

Work flow analysis is hard work and takes a lot of time.  With time pressures on physicians to see patients and a payment system that rewards them more for higher numbers of patient visits than for higher quality of care, many physicians find it difficult to carve out enough time in their day for efforts like this.    As a result, work flow analysis is often not performed or is less than comprehensive during an ambulatory EMR selection and implementation.

Physicians essentially have two options to obtain a work flow analysis:

1. Hire a consultant
2. Perform the work flow analysis themselves

Hiring an IT consultant who is experienced with work flow analysis at the beginning of the EMR selection process is a more expensive option but will likely result in a more comprehensive analysis.  The consultant will interview key physicians and staff, create work flow descriptions and maps, analyze the results, review them with the practice and develop recommendations.  The physicians and staff will spend time with the consultant during this process, but most of the time and effort necessary for the documentation and assessment will be done by the consultant.

Alternatively, physicians may decide to perform work flow analysis on their own.  If so, there are a variety of methods and tools available to assist the effort.  These include:

1. AHRQ’s Health IT Tool Box website
2. DOQ-IT Operational Redesign Workbook
3. PITO Physician Information Technology Office Needs Assessment

These tools will guide the physician through the documentation of current work flows, an analysis of them and then considerations of redesigned future work flows.  The initial tedious steps to document current work flows are to:

1. Collect all paper forms used in practice
2. Select a workflow guide to facilitate analysis (i.e. one of the three listed above)
3. Identify major processes to map out (key processes vs. all processes)
4. Gather information on each process by interviewing people involved in each process
5. Write detailed descriptions of each process
6. Create detailed work flow maps (at least for the major processes)

Collecting paper forms will help identify specific paper-based processes that are unique to the practice.  The purposes of paper-based processes are important to understand and account for when future work flows are redesigned.  If the new technology tools and work flows do not account for the purpose of a paper-based work flow, and that purpose remains pertinent, then a work-around will need to be discussed and designed.  The goal should be to convert all paper processes to electronic ones, but the limits of technology or the costs involved will limit the ability to fully achieve this.

A work flow analysis guide will help the practice identify other key work flow processes that are generally known to be important for physician practices to assess when selecting and implementing an EMR.  As shown in the snapshot below of part of the DOQ-IT Workbook, these guides will lead the practice through questions to ask about each process:

After interviews with people involved in the process are completed, a description for each process is documented and then used to synthesize current work flow maps. A work flow map serves as a visual representation of the described workflow.  As described in a previous blog, these maps are useful when analyzing current work flow and redesigning them into future work flows.  My next blog will describe how the results of work flow analysis will facilitate the selection of an EMR that meets the needs of the physician office.

Why Work Flow Analysis, Redesign Are Keys to Successful EMR Implementation...and EMR Selection

Work flow analysis and future work flow redesign are often cited as key factors of successful implementations of ambulatory electronic medical records (EMRs) in physician practices.  This is the first in a series of blogs to discuss the value of performing workflow analysis before selecting an ambulatory EMR.

It is unfortunate that work flow analysis, if performed at all, is typically not done until an EMR has been selected and the implementation initiated.  Although physicians intuitively understand the value of good workflows in the office, how workflow analysis helps the physician choose an EMR is not so obvious. 

Workflow analysis can provide the physician practice insights on what to look for in their new EMR product if done early in the selection process.  To get the most out of a work flow analysis it is best to start with a clear purpose in mind.   Some important reasons for initiating work flow analysis before selecting an EMR are to:

• Identify current office inefficiencies
• Initiate critical thinking about desired future work flows
• Develop a prioritized list of desired future workflows (what are the most important ways an EMR is expected to help the practice?)
• Develop a prioritized list of the most important EMR functionalities that are needed in order to realize these desired future work flows
• Set realistic expectations on how the EMR is expected to help achieve goals and attain better workflows 

When a work flow analysis is completed the physician practice should expect to see: 

• Detailed descriptions of current office work flow
• Detailed work flow maps of key office processes
• An analysis that identifies current inefficiencies, bottlenecks and opportunities for improvements
• A high-level outline of desired future workflow redesigns (how the office will work when a EMR is operational)
• A list of changes that could be made now...even before selecting an EMR

A workflow analysis will initially result in written descriptions of the key processes that the physician practice thrives on each day.  These written descriptions are then synthesized into a workflow map that may look something like this:

 

This current workflow map can be used by the practice to design better workflows.  Using the current workflow example from above, the draft development of a future workflow map might initially look something like this:

Developing workflow descriptions and critically thinking about desired future workflows will help identify what an EMR needs to be able to do well for the practice.  Knowing what the EMR needs to do well will help the practice identify and prioritize needed EMR functionalities.  This knowledge will simplify the comparison of EMR products as discussed in the next several blogs.

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).

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