Work Flow

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:

DOQ IT Guide

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:

Workflow II 

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:

Workflow III

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.

Getting the Most From EMR Vendor Product Demonstrations

Vendor demonstrations can provide valuable information when comparing electronic medical record (EMR) products.  Physicians need to know, however, that vendor demonstrations are time-consuming and that demonstrations are inherently variable from day-to-day, salesperson-to-salesperson and from vendor-to-vendor.  As discussed in previous blogs, it is best for physicians to first identify what they need an EMR to do and then narrow down the list of suitable EMR products (that meet those needs) to a handful before arranging vendor demos.  This prevents wasting  clinician's time on demonstrations of EMR products that will not meet their needs and will improve decision-making.  

The following list of suggestions will help the physician not only get the most out of the vendor demonstrations, but also help compensate for the inherent variability between them:

  • Prepare questions in advance and send them to the vendor
  • Create several scripts of clinical scenarios using different patient types typically encountered in office
  • Send these scripts to vendor well ahead of time and ask them to prepare demo around your scenarios
  • If demo is to be onsite find out what is needed
    • Conference room with enough chairs?
    • Projector?
    • Screen?
    • Internet access?
    • Computer?
  • If demo is remote over the internet (Webcast) find out what is needed
    • Conference room
    • Conference phone
    • Computer/internet access
    • Projector (if needed for expected of people)
    • Access codes, phone numbers, IDs, passwords?
    • Software download before Webcast?

  • For Webcasts ask vendor to allow you to log into the event 10-20 minutes ahead of time; colleagues will appreciate not enduring log-in process, connection issues

  • How long should demos last?
    • Onsite demo 1 ½- 2 hours
    • Webcasts 1- 1 ½ hours
  • How many demos should a physician office plan for?
    • Narrow initial list down to manageable number, perhaps 3-6?
    • May need to invite 2 or 3 vendors back for second or third demo towards end of selection process
  • Try to focus on what the EMR does, not what salesperson does
  • Some vendors have strong salespersons, others do not
  • Salespersons have both good and bad days
  • Salespersons do not necessarily know everything the EMR can do
  • Write down questions during demonstration to ask at a “break”; otherwise demo gets fragmented, difficult to follow
  • Focus on EMR functions most important to the practice and on what potential the EMR has for desired future workflows
  • Consider holding vendor demos as close together as possible to help compare “look and feel”
  • Plan for 30 minutes immediately post-demo to collect feedback from attendees; details and feelings tend to fade quickly
  • Use the same functionality scorecard or ratings checklist for all vendors
  • Document concerns raised
  • Document functionalities you did not see that you think the EMR needs to have
  • Document any other deficiencies in the product
  • In the week after demo provide vendor a list of these concerns, deficiencies and any remaining questions; ask for a follow-up phone call to discuss further
  • If you have participated in vendor demonstrations and have other suggestions, please feel free to add those in your comments!

    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

    Using an Electronic Medical Record (EMR) Vendor Comparison Scorecard to Evaluate Products

    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).

    Using a vendor comparison scorecard to evaluate ambulatory EMR products is a useful way to identify an EMR product that is a good fit for a physician practice.  An important assumption, however, is that the scorecard is customized to the individual practice.  This hyperlinked example of an EMR Comparison Scorecard adopts the "Best Uses" of EMRs as recommended by DOQ-IT resources as well as other recommendations that frequently surface in reports on successful EMR implementations. In order to customize a vendor comparison scorecard the physician should:

    1. Perform a comprehensive work flow analysis of their practice
    2. Identify current processes that are "bottlenecks" and other key processes that the practice desires to improve
    3. Review lists of "Best Uses" of EMRs such as:
      • DOQ-IT
      • (Health IT Toolbox)
      • (Certification Commission for Health IT)
      • Networking with colleagues (especially those in same specialty)
      • Medical and specialty organization's resources such as websites and listservs
    4. Identify how an EMR could be used to improve the identified key processes
    5. List any other desired uses of an EMR 
    6. Prioritize all of these intended uses of an EMR
    7. Identify what an EMR needs to be able to do in order to be used in these ways
    8. Prioritize these EMR needs
    9. Modify the EMR Product Comparison Scorecard to align with customized EMR needs
    10. Focus the EMR comparison on the top priorities

    CCHIT certification provides some comfort to physicians that the certified EMR can meet all of the EMR functional requirements that are listed on the CCHIT website.  What CCHIT certification does not tell physicians is how well the EMR works for each function.  If an EMR comparison is limited to CCHIT-certified EMR products, then the physician can focus primarily on their own "Top Ten" list of things the EMR must do well for their practice rather than worry about all of the hundreds of other things the EMR is certified for.  By taking time upfront to clearly identify a prioritized list of the top things an EMR must do well, the physician practice will be well-prepared to select an EMR that will meet their unique needs.   


     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

    Setting Practice Goals for Ambulatory Electronic Medical Record (EMR) Leads to Implementation Success

    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).

    The selection and implementation of an electronic medical record (EMR) in a physician practice is a complex and expensive effort.   An important factor for success is the early development of EMR goals that identify what the practice wants to achieve by implementing an EMR.  These EMR goals create a common vision that everyone in the practice can understand and share.  Involving a broad representation of each discipline within the practice during the development of EMR goals will create a team-oriented environment and "positive energy".   Such an effort will naturally involve a lot of communication between the staff and physicians.   Sharing a common vision, creating a team environment and maintaining effective communications help create trust and promote buy-in for this complex endeavor.   Weaknesses in any of these areas are known pitfalls that can sabotage an implementation.

    EMR goals will help the practice make better decisions, keep the EMR implementation activities on track and act as a catalyst that keeps the project moving forward.   When important decisions are discussed, dialogue on how well the various options align with established goals is valuable.   When one person or a group of people get diverted onto rogue activities, a good project manager, with a finger on the pulse of planned project tasks and on the EMR goals, will proactively identify these and re-align efforts back to the goals.   During difficult times the EMR goals can become a rallying point for the practice to hang on to until smoother days arrive.

    What are the best kinds of goals to develop?   In general a practice will discuss goals that relate to ways to improve patient care, become more efficient or be more productive.   But it is helpful for the EMR team to focus on developing a set of EMR goals that is really meaningful to them.   Every physician practice is unique and every physician practice has a different set of priorities.   Goals that are meaningful to the practice are more likely to unite the physicians and staff and and remain useful throughout the EMR implementation.

    Ideas for EMR goals may be developed by discussing questions such as the following:  

    • What are three things most important things the practice wants to achieve with an EMR?
    • What three changes will be most meaningful to the practice?
    • What three quality improvements do we want the EMR to help us achieve?
    • What three gains in efficiency are desired with the new system?
    • What changes, if any, are expected with regards to productivity?
    • What financial impact is expected?
    • What else is desired to be gained or lost?
    • What is expected to not change significantly?

    The following suggestions may be helpful for the EMR project team to consider when developing EMR goals:

    • Invite participation and/or feedback from all of the physicians and staff in the office
    • Goals should be challenging but also realistic—they need to be achievable
    • The best goals are meaningful to the physicians and staff
    • Gain insights on EMR "Best Uses" (how other practices have successfully used EMRs to improve care or gain efficiencies)
    • Identify current workflows and processes that are bottlenecks or cumbersome; consider how an EMR could facilitate an improved workflow for those processes
    • Consider other future workflow redesigns that your practice could benefit from based on EMR "Best Uses" insight
    • Instead of focusing on the technology, focus on the workflow or process
      • "Implement and use an e-prescribing tool" is focused on technology
      • When this goal is viewed from the process perspective it becomes, "Reduce time spent refilling prescriptions"; now it becomes more meaningful and is measurable
    • Consider starting with broad goals (related to quality care, efficiency or productivity) and then refining them to more detailed, meaningful goals
    • Not all broad goals can be refined— but they may still be considered important milestone goals
    • Broad goal examples:
      • Improve revenue per patient visit
      • Improve our revenue cycle
      • Decrease amount of time spent on phone
      • Qualify for "Meaningful Use" incentive payments
      • Improve adherence to preventative care guidelines
      • Perform patient satisfaction surveys
    • Related but more specific goals might be:
      • Increase charge capture by X% (through EMR's chart documentation and intelligent charge capture)
      • Decrease the number of accounts receivables days
      • Reduce pharmacy call backs by using e-prescribing
      • Send the identified Meaningful Use quality reports to CMS as specified
      • Identify and notify diabetic patients who have not had an HgbA1C in the past year
      • Improve patient satisfaction by a certain percentage
    • Selecting a smaller number of specific, meaningful goals will likely be more satisfying than a large number of broad, ambiguous goals
    • At least some of the goals should be measurable and baseline measures known
      • i.e. for the aforementioned e-prescribing goal, spend a couple of days tracking time spent refilling paper prescriptions, then repeat 6 months after EMR implemented
    • Other goals should be quantifiable:
      • i.e. track total # of patients that were recalled for being deficient on a HgbA1C lab
    • Prioritize the list of goals
    • Document pre-implementation measurements
    • Develop a plan and timeline to assess goals post-implementation (i.e. 2 weeks, 6 months, 1 year later….)
    • Share these with everyone in your office; perhaps some can be shared with your patients
    • Remember to measure the progress toward goals after the EMR implementation


    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



    How to Select an EMR Without a French Toast Fiasco

    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).

    Electronic medical records (EMRs) admittedly have nothing to do with French toast, but common pitfalls encountered when selecting an EMR for a physician practice are very similar to the pitfalls encountered when going grocery shopping.  Consider the following series of events subsequent to my family deciding at dinnertime that I am going to cook French toast for breakfast tomorrow.  Knowing we are out of milk I realize I need to go grocery shopping this evening in order to be prepared for the morning.  I check the refrigerator and note that not only do we need milk, but we need eggs as well.  I check the bread drawer and see a nearly full loaf of bread. When looking in the spice cupboard I see a small container of cinnamon, but it is nearly empty. With eggs, milk and cinnamon in mind I proceed to the store and go promptly to the dairy section.  After selecting the needed milk and eggs I head back toward the front registers.  Along the way, however, four other items conveniently catch my attention and find their way into the grocery cart.  I had quickly convinced myself that not only were they were needed, but they were also good deals.  

    In retrospect, I was wrong about that.  But at least I maintained some semblance of shopping discipline by resisting the temptation to pick up several other items that were on sale such as maple syrup.

    I drive home and begin putting groceries away.  As I put the first “extra” purchase into the pantry, I am disappointed to see that my wife had already purchased a large quantity of the same thing.  My purchase subsequently sat on the shelf unused and was thrown out a year later when it reached its expiration date.

    As I put the second extra purchase away, I was happy to see we have none of this item.  However, as time went by we never needed it.  It was also thrown out a year later when the expiration date passed.

    As I put the third extra item away in the refrigerator, a delicious family dessert, a cold, dark feeling creeps through my chest and stomach as I read some fine print on a label that I had not seen while hurrying through the store.  My fear confirmed-- it contains peanut traces.  My daughter is severely allergic to peanuts.  I had made this spontaneous purchase with family enjoyment in mind.  My wife and daughter did not experience the intended joy.

    As I put the fourth extra item away, a kitchen appliance that was on sale at half-price, my wife walks in and remarks how happy she is that I had remembered to get a replacement for our broken appliance. However, this half-priced, off-brand appliance never worked the way it was supposed to work.  We threw it out within a month.

    The next morning I get up early to fix the French toast.  When I open the bread sack I discover that it is moldy.  When I look for the maple syrup in the cupboard I find none.  I now spend added time and effort to go back to the grocery store a second time.  I realize that I am fighting a fire that I could have prevented with better preparation the first time.  Its not the store's fault I was not prepared.  For added insult the maple syrup is no longer on sale less than 12 hours from my first visit. 

    As I prepare the French toast, I lament over my failure to spend the time and effort necessary upfront to adequately identify our grocery needs. I lament lacking the discipline to create and adhere to a simple shopping plan. I recognize that overlooking the value of good preparation and making hurried decisions on-the-fly resulted in more work to do and ended up being costlier.

    And then the final curtain falls on the French toast fiasco.  In the same instant I initiate a motion of my right hand toward the spice cupboard, a hot pain sears through my head as I realize my failure to remember the cinnamon.  To my mental lamentations I quickly add, “failure to write down a grocery list”.

    The pitfalls encountered when selecting an EMR are quite similar to the French toast fiasco.  EMR selection pitfalls occur when a practice fails to spend the time and effort needed upfront to identify a shopping list of what is really needed or fails to adhere to a shopping plan that maintains a disciplined focus on comparing how well EMR products align with the practice’s known EMR needs. These pitfalls include:

    1. Purchasing an EMR that does not meet the needs
    2. Having to go shopping two or more times to get all needs met
    3. Purchasing EMR items/functionalities that are not needed—unneeded functionalities that sit on the shelf unused
    4. Unplanned purchases of additional items
    5. Purchasing an EMR that fails to do what the practice thought it would do
    6. Creating unrealistic EMR needs that cannot be met with today’s technology
    7. Preventable increases in total EMR cost

    EMR selection pitfalls can cause a significant amount of dissatisfaction with the selected EMR as well as unplanned additional work, unplanned additional costs or even EMR implementation failures.

    The following strategy will help a physician practice prepare a “grocery list” of realistic EMR needs and establish a plan to select an EMR that is aligned with the practice’s needs:

    1. Gain insights on realistic EMR “best uses” for physician practices. This may include performing an EMR needs assessment, performing a current/future office workflow analysis, networking with colleagues already using EMRs and other research on available EMR best uses
    2. Identify why your practice wants to implement an EMR (what are your realistic goals?)
    3. Identify the most important future workflow changes that you want the EMR to facilitate
    4. Identify what EMR functionalities are needed in order to facilitate those prioritized workflow changes or to meet your other EMR goals (i.e. e-prescribing, real-time eligibility verification…)
    5. Create a “grocery list” of these EMR needs
    6. Prioritize the list of EMR needs
    7. Go shopping with your list in hand
    8. Compare prices, quality and usability of EMRs that meet all of the highest priority needs on your list


    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



    Site Visits Help Physicians Select an EMR Product Aligned With Practice Needs

    One of the important ways for a physician practice to analyze whether an electronic medical record product is a good fit for their practice is to visit another physician practice that is actively using the product.  Ideally the selected practice is the same specialty and has a similar practice model, case mix and other attributes of the visiting practice.  Even if those attributes differ significantly, however, site visits provide an opportunity for the visiting practice to gain other information that will help them select an EMR product that is aligned with their unique needs.

     Site visits are time-consuming for the physician and are therefore usually reserved until late in the EMR selection process when the number of potential EMR products has been narrowed down to two or three.  It is important for the physician practice to be prepared to get the most out of the time spent and effort exerted.  The following is a list of suggestions to help physicians maximize the value gained from site visits.  If you are a physician already experienced with site visits and have additional advice to share with your colleagues, please feel free to comment to this blog:

    • Site visits can provide valuable insight on:
      • Workflow
      • Workarounds
      • Implementation "Do's and Don'ts"—write them down
      • Technical glitches
      • Quality of customer support
      • How the vendor works with physician offices

    • Try to select sites similar to your specialty, patient mix, patient volume, practice size, practice model and office structure

    • The most important thing to do is to stand back and observe workflow for an hour or two


      • Observe the front desk, check-in, clinical care, workroom and back desk areas
      • When you observe effective workflow, visualize how that would work in your office


    • Observe for inefficient workflow or workarounds and ask why it is done that way. Observe for computer glitches and ask how often they occur. Clues to look for include:


      • Pen or pencil being used for something—what and why?
      • Printer or fax noise….paper being printed for some reason…what is done with it?
      • Staff gets up and walks to a different area to get/do something…why? Workaround?
      • Paper chart being used for something
      • Paper being routed somewhere, used for something
      • Excessive amount of time spent entering something in computer…is that typical?
      • Screen response time is longer than 5 seconds….how long does it get?
      • Impatience with computer… is computer slowness an issue for that person?
      • Frozen screens, frozen cursors
      • Staff or physician reboots a computer or laptop
      • Person left screen, then went right back into same screen…why? How often does that happen? Same questions when you see multiple clicks without anything being entered.



    • Visualize whether your desired workflow appears feasible using this product

    • Ask questions:


      • What workarounds are they currently using that they hope to remove in the future?
      • What problems are they most looking forward to having resolved?
      • How well does the EMR vendor respond to requests?
      • How much software training time was provided?
      • What EMR implementation difficulties did you overcome?
      • What are the software upgrade and update schedules like?
      • What are their favorite (specific) electronic medical records features?
      • What are their least favorite features?
      • How well does the EMR system fit into each element of your medical practice?
      • Do they get the quality reports they need? What reports do they wish they had?



    • Understand the site's technical infrastructure and how it is different from what you are planning. For example, if they are not using wireless but you are planning to, consider how that changes the picture. Alternatively, if you were not planning to do something they are doing and you see it is effective, should you reconsider?

    • Observe how physical set-up is different from yours. What works and what doesn't work so well. What did they change? What would they like to change now that they have used the EMR for awhile?






    If you are experienced with site visits and have other advice to share with physicians, please feel free to comment on them

    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.  


    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