Learn from the past

February 1, 2010

"Getting an EHR is like getting married," says Jonathan Hager, M.D., an internist with Alexander Medical Group in Rochester, N.Y. "Once you are in one of these systems, you are in it. You've got to take the time and make sure you know what you're doing."

“Getting an EHR is like getting married,” says Jonathan Hager, M.D., an internist with Alexander Medical Group in Rochester, N.Y. “Once you are in one of these systems, you are in it. You’ve got to take the time and make sure you know what you’re doing.”

We asked 10 practices to reveal the best lessons they learned from their electronic health record (EHR) adoption experiences. Although the lessons are different, the physicians and practice managers with whom we spoke echoed Dr. Hager’s comments: do your research. Take time to investigate the systems and what each would mean for your practice.

The $44,000-per-physician incentive from the Centers for Medicare and Medicaid Services for proving “meaningful use” of an EHR has many practices considering adoption this year.

The incentive was courtesy of the federal economic stimulus package announced in February 2009, specifically a measure called the Health Information Technology for Economic and Clinical Health Act. A 2009 report by the Congressional Budget Office predicted that 90 percent of physicians would have an EHR system by 2019, in part due to the incentive.

In the later months of 2009, EHR vendors began to offer money-back guarantees that physicians would achieve “meaningful use” with their systems, putting even greater pressure on practices to make the jump.

But with a potential $14,500 to $63,600 in software, hardware, and training costs per physician as well as $7,500 a year for maintenance, according to a 2006 report in the Journal of the American Health Information Management Association, practices are understandably cautious of the project.

To help bolster your research, we asked physicians and practice managers how they selected a vendor, prepared their staff, implemented the system, and endured the first few months in the new digital world.

The top 10 lessons from 10 practices:

1. Involve the whole staff.

Ensure that everyone on the staff knows why you’re making the EHR transition, how it will benefit the practice, and how it will help make their jobs easier, says David Ellis, M.D., a urologist and president of Academic Urology of Pennsylvania LLC, a 30-physician, 11-office practice in the Philadelphia area.

The physicians at Academic researched and tested EHR systems for six months but, Dr. Ellis confesses, they never shared with their 120 midlevels and office staff why the practice should eliminate paper charts. In hindsight, he wishes he had included them earlier.

“The staff had no clue about the value,” he says. “They didn’t know what it meant, and it sounded like a threat to them.”

To calm and motivate the staff about the transition, Dr. Ellis arranged for the vendor to visit the practice for two days. They invited non-physician office leaders from their offices to use a demonstration model and ask questions before the training.

“They left feeling very excited,” Dr. Ellis says. “It was a complete reversal.”

2. Study your workflow.

Electronic health record adoption does not mean you should replicate your paper chart processes in a digital world, says Jim Glennon, M.D., an internist and chief medical officer of Core Physicians, a 95-physician, 24-location multispecialty practice in Exeter, N.H. Create a new workflow, he says.

Dr. Glennon’s practice went live with its EHR in 2003. A few months in, physicians noticed they had more administrative tasks - such as medication refill or lab work orders. Although it took only a few taps on a tablet, the administrative duties were becoming too intrusive - and an inefficient use of the physician’s time.

“We had providers doing a lot of data entry that really should’ve been delegated to clinical staff,” Dr. Glennon says. “It took a long time to correct that and engineer it out of our processes.”

Dr. Glennon set up new protocols at the offices. Routine tasks, such as medication refill phone calls or referral request updates, went to other clinical staff and were confirmed later by the physicians.

3. Ask for help.

When you opened your practice, an attorney probably helped with the paperwork. An accountant likely helps you with your income and business taxes. EHR adoption is just as important and no less complex. If you’re feeling overwhelmed by the size of your project, ask for help from a healthcare consultant experienced in EHR implementation, says Jonathan Hager, M.D., an internist with Alexander Medical Group in Rochester, N.Y.

Dr. Hager was one of four practices in 2009 to pilot the EHR Preparation and Selection Services from TransforMED, a subsidiary of the American Academy of Family Physicians, and Welch Allyn, a medical device manufacturer but not an EHR vendor.

The $1,795 selection program is a 10-step project with nearly 40 assignments and four hours of in-person consulting. Practices can access a Web portal that contains electronic worksheets, templates, surveys, and tables to organize, analyze, and distribute EHR project data between internal staff and EHR vendors.

Even if he didn’t use the selection program, he would’ve hired an objective adviser to assist with the project, he says.

“It’s worthwhile to use some kind outside consulting group, unless you have a doc who has a lot of time to put into it,” says Dr. Hager, who points out that his practice consultant didn’t push them to one vendor but rather offered the advantages and disadvantages of the two final systems in consideration.

4. Consider a patient portal.

Shari Crooker, RN, practice manager for Gwinnett Center Medical Associates PC in Lawrenceville, Ga., says her practice used to receive 400 to 500 calls a day from patients. Many of those calls were for medication refills, referral requests, and lab results.

The solo-physician practice chose an EHR that included an online patient portal that could complete those routine tasks without the patient speaking to a nurse or the physician. Crooker sent a letter to patients about the portal and posted a sign about the service at the office checkout. Over a couple months, the practice’s call traffic dropped by more than 200 calls a day.

“What took us 10 or 15 minutes per patient - if we could find the chart - was now down to 30 seconds,” Ms. Crooker says. “It was very quick. We were back to our normal patient volume in a few weeks. We’re even seeing a few more now.”

5. Customize your notes.

Jeffrey Pearson, D.O., a family physician in San Marcos, Calif., says he likes some of what his EHR does for his practice: They don’t lose charts anymore, and labs send them results electronically, but he still has one major gripe: The progress notes.

“The doctor’s note system is terrible - and we’ve got a major brand,” he says. “As a result, we’re not using a lot of the [other] features.”

Dr. Pearson says he didn’t have time to customize the progress note template on his EHR system, installed in 2008. The notes template included with the system doesn’t allow him to input the information he wants during the visit. When contacted in early November, he wasn’t using the EHR for notes during visits.

Elaine Pearson, the practice manager, says the two-physician practice will customize the note template.

“The doctors feel they don’t have this time to do that kind of work,” Ms. Pearson says. “You’ve got to invest the time to design the note the way you want it.”

6. Consider a digital pen.

For doctors who hate typing, taping screens, or clicking a mouse, a digital pen and paper system may be an alternative, says George Brick, M.D., a family physician who manages Brandon Healthcare, a family practice in Brandon, Fla. (Full disclosure: Dr. Brick says neither he nor his practice holds financial interest in any digital pen or paper company.)

The digital pen Dr. Brick uses, by Tampa, Fla.-based RoverInk, has a tiny camera to store all the handwritten data as it writes on the digital paper. The paper has a dot pattern printed in the background and corresponds with the pen. After the visit, the physician inserts the pen into a docking station and the exam information uploads into the EHR. When the writer first uses the pen, he or she must write several sentences until the device learns the user’s handwriting style.

“I was really interested in making eye contact with my patients,” Dr. Brick says. “The nice thing about the pen is that I’m able to dialogue with the patient and write down other information with the pen, which may help me arrive at a diagnosis.”

The RoverInk pen and paper system costs $1,500 to $2,500 per user. Lease options are available.

7. Start with the basics.

Eventually, you should learn the whole EHR system (see below), but first master the basic functions you will need in every appointment and expand your skills incrementally, says Kurt Kastendieck, M.D., a family physician at a two-physician clinic in Santa Fe, N.M.

“It can definitely be overwhelming,” Dr. Kastendieck says. “It’s nice to have all the bells and whistles, but if you don’t have communication between your secretary and your nurse, you’re going to have a lot of things fall through.”

Dr. Kastendieck, his physician colleague, and the practice’s two physician assistants focused on the basic day-to-day functions of the EHR and practice management system, both installed in August 2007. After numerous follow-up phone calls with vendor, the physicians added new functions to their expertise, such as confirming that their lab company performed the correct tests.

“As the practice started getting busier, of course, you try to be more efficient,” he says. “There were things built into the system that we never realized were there.”

8. Learn the whole system.

Because most EHR systems have so many functions, most doctors believe that they won’t need to learn them all. Not a good idea, says Gregory Oliver, D.O., a family physician at Oliver Family Healthcare in Indianapolis.

Dr. Oliver went live with his EHR in 2003 after spending a week at the vendor’s office in North Carolina learning and customizing the system. On the first day, he and his nurse practitioner saw 60 patients and “never looked back,” he says.

“I can build chief complaint lists, history of present illness lists, [rest of systems] templates, physical exam templates, management protocols, and anything that makes the system work better for me,” he says. “By knowing this and actually doing it, I know where everything in my EHR is and how to use it quickly. That way, every note and chart is complete when I leave the room with the patient. Physicians are very smart people. . . . If we can understand the workings of the human body, an EHR should be childs’ play.”

9. 'Go live' only when ready.

Patricia Brown, practice administrator for Summit Medical Associates PC in Hermitage, Tenn., studied EHR systems for four years, narrowed down the vendor list to five after two years, and spent a weekend retreat with her 16 physicians and five nurse practitioners to test the systems. Finally, they settled on one system and decided on a “go live” date in June 2007.

When that date arrived, however, the physicians still weren’t confident using the system in the exam room. Ms. Brown and the doctors decided to wait another six weeks.

“They didn’t feel like they could move through system comfortably,” Ms. Brown says. “Just because you set a go live date doesn’t mean you can’t move it.”

Although productivity dropped 40 percent on the first day with the EHR, within three weeks, Summit was back up to its normal patient load of 27 to 30 patients per physician per day.

“Day three was harder than day one,” Ms. Brown says. “That’s when all the labs started coming back.”

10. Tech support must be accessible.

Regardless of how much training or how many test runs you do with your practice’s new EHR, technical problems will occur and you will need to contact the vendor to figure out what’s wrong, says Francie Carr, practice administrator for Columbia Gorge Family Medicine in Hood River, Ore.

Columbia Gorge acquired its EHR in 2007 through the region’s independent physicians’ association. Although the software is from a national vendor, the technical support company that installed and trained the providers is a spinoff company of the association. The firm, Central Oregon Electronic Medical Records, performs the EHR upgrades, monitors hardware, and solves technical problems.

“We didn’t just buy from a company that was far away and have them come out for a week and give us some training and disappear,” Ms. Carr says. “We got much more support than we would’ve gotten from a vendor that was a couple thousand miles away, and it was really instrumental to our success.”

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