Lay the Foundation

Implementation of an electronic medical record (EMR) is an evolutionary process. Re-engineering dataflow and methods of documenting patient care takes time and commitment. This is true even if the enterprise involves only one clinician. We advocate a systematic approach addressing hardware, software and peopleware. False starts and unrealistic expectations can be avoided by careful planning, software customization and adequate training. The following is intended only as a guide. It is not all inclusive and should not preclude other considerations.

Vision or Mission Statement

First, lay a proper foundation by allocating enough time and resources. It is very important to manage expectations early and establish shared priorities. There are always limits (both time and money) to be considered. This task may be accomplished by one person or a team. If a team is available, consider representation from Administration, Physicians, Nurses, Transcription and Front Office Staff. The primary objective is to focus on information goals, select the operating system and hardware configuration. In a concise statement (limit to one page maximum), list the reasons to computerize medical records, the informational tasks required for reimbursement and specific areas where measurable cost savings can be achieved. Each member of the team should complete and prioritize the checklist provided on Page 4.

The mission statement should be widely communicated (circulated) among ALL involved persons and feedback invited prior to introducing any computers or software. Obtain signed mission acknowledgement from all enterprise members and file these along with their comments and concerns.

Workflow

Sketch a floor plan detailing terminal locations, workstations, printers and all the other items of hardware. Include the following:

Power / Network Connections (Network server should be in protected area to avoid unauthorized tampering)
Window Locations (consider glare problems)
Thoroughfare logistics (do not block traffic flow)
Printer (consider potential noise problems)
Heat sources, vents, etc. (computers + heart = problems)
Equipment ventilation (electronics generate heat)
Screen Locations (consider maintaining patient eye contact in exam rooms - one alternative is a rotating pedestal for monitor)

Practice Profile

_____ 1. Number of Physicians
_____ 2. Number of active patients
_____ 3. Number of active accounts
_____ 4. Number of visits per month
_____ 5. Number of statements per month
_____ 6. Number of System Users
_____ 7. Number of workstations / computers needed
_____ 8. Number of Simultaneous Users
_____ 9. Number of Printers Needed
_____ 10. Budget/Finance Available
_____ 11. Levels of Complexity

Simple
Problem focused
Expanded
Comprehensive

Evaluate your current system.

_____ 1. What Operating System is presently supported?

DOS
WINDOWS
NT
OS/2
MACINTOSH
UNIX
MUMPS
OTHER

_____ 2. Hardware supported

Intel 286
Intel 386Intel 486
Pentium
Macintosh
IBM
Mainframe
Other

_____ 3. Networking Links:

None
Shielded Twisted Pair
Unshielded Twisted Pair
Coaxial Cable
Fiber optic Cable
Wireless-Radio
Wireless-Infrared
Wireless-Cellular
Other

Checklist: The EMR. Vision/Mission

On a scale of one to five (1 = Mission Critical) rank each of the following.

1 2 3 4 5 (1. Better Charge Capture
1 2 3 4 5 (2. Improved Searching Capability
1 2 3 4 5 (3. Communication between caregivers
1 2 3 4 5 (4. Longitudinal medical record
1 2 3 4 5 (5. Outcome reporting and measurement
1 2 3 4 5 (6. Quality documentation
1 2 3 4 5 (7. Risk Management (less "lost" data)
1 2 3 4 5 (8. Clinical alerts and reminders
1 2 3 4 5 (9. Improved patient education and assessment
1 2 3 4 5 (10. Fewer medication errors
1 2 3 4 5 (11. Improved patient confidence/compliance
1 2 3 4 5 (12. Identification of population subsets
1 2 3 4 5 (13. Improved productivity and efficiency
1 2 3 4 5 (14. Improved health care delivery
1 2 3 4 5 (15. Improved Legibility
1 2 3 4 5 (16. Improved security and confidentiality
1 2 3 4 5 (17. Access to data when & where it is needed
1 2 3 4 5 (18. Integrated, multi-disciplinary medical record
1 2 3 4 5 (19. Less photocopying of charts
1 2 3 4 5 (20. Less call-backs from patient & pharmacy
1 2 3 4 5 (21. Less filing into charts
1 2 3 4 5 (22. Less time retrieving/hunting/filing charts
1 2 3 4 5 (23. Rewarding work environment (less paperwork)
1 2 3 4 5 (24. Increased income or income preservation
1 2 3 4 5 (25. Reduced malpractice risk and cost
1 2 3 4 5 (26. Reduced waiting for information
1 2 3 4 5 (27. Reduced patient waiting for medication refills
1 2 3 4 5 (28. Reduced test/procedure duplication
1 2 3 4 5 (29. Reduced transcription costs
1 2 3 4 5 (30. Reduced risk of audit and associated penalties

Data Flow

Develop specific flow charts as to how informational tasks are performed now and how they will be performed in the future. Consider the following tasks.

Patient Encounter Note or Record of Visit

Chief Complaint and History of Present Illness (SOAPware Subjective)
Patient Examination (SOAPware Objective)
Impression of Patient’s Problems or Diagnoses (SOAPware Assessment)
Treatment Plan (SOAPware Plan)
Education: Routine set of basic instructions for aftercare
- Activities: Such as bed rest, return to work or school, etc.)
- Restrictions: Things to avoid, which developments should be reported to physician)
- Diet: Low calorie, low cholesterol, etc.
- Interventions: OTC meds, Treatments administered in the clinic, injections, etc.)
- Referrals: Cardiology, Urology, etc.
- Other Goals: Items not included in any of the above categories

Which of the following method(s) best describes how you presently create clinical documentation and how you would like to create clinical documentation in the future?

Present Method(s) Future Method(s)

PRESCRIPTIONS (SOAPware Medications)

[ ] Doctor writes them out [ ]
[ ] Assistant writes them out [ ]
[ ] Doctor calls them in [ ]
[ ] Assistant calls them in [ ]
[ ] Pre-Printed Scripts [ ]
[ ] Computer prints out Scripts [ ]
[ ] Fax to Pharmacy [ ]
[ ] Electronic transfer (PC to PC) [ ]

TIMING:

[ ] At time of Encounter [ ]
[ ] After the Encounter [ ]
[ ] Other [ ]

REFILLS:

[ ] Doctor writes them out [ ]
[ ] Assistant writes them out [ ]
[ ] Doctor calls them in [ ]
[ ] Assistant calls them in [ ]
[ ] Pre-Printed Scripts [ ]
[ ] Computer prints out Scripts [ ]
[ ] Fax to Pharmacy [ ]
[ ] Electronic transfer (PC to PC) [ ]

Return Appointment(SOAPware Follow-Up)

Letters

These letters are usually a repeat of what the doctor placed in the clinic note. SOAPware allows the doctor to automatically generate letters using the same information contained in the clinic note.

Referral letters to other doctors
Letters to patients
Letters to third parties

Other Routine Tasks

Telephone Calls
Admission Orders
Super Bill (ICD and CPT codes for proper billing)
Patient Notes for Work or School
Loose Reports (from outside sources such as hospital, laboratory, consultation reports)
Release of Information

Peopleware

Develop a list of all persons within the enterprise that will in any way be using or affected by the new information system implementation. Access their skill level. Involve all office personnel involved early in the decision process. List them on a separate paper along with their skill. The socio-political issues (peopleware) related to upgrading information systems are always greater than the technical issues (hardware / software). Identify the key personnel who will aid the implementation. It is just as important to identify the personnel likely to resist implementation. Once the players are identified, make a list of action plans to be utilized to facilitate implementation of the electronic medical record.

Computer Skill Assessment

Prior Computer Experience: (circle one)

Never used a computer
Some use of computers
Some word processing experience
Home Computer experience
Work Computer

Prior Typing Skills: (circle one)

None
Hunt and peck
Both hands
High level typist

Prior Windows Skills:

None
Basic Mouse experience
Basic Trackball experience
Advanced Windows knowledge

What is a TWIT?

Persons thwarting progress will be referred to as TWITs (Third World Information Trouble).
Persons who promote progress and improvement in the information system are GUERRILLAS.
Action taken to re-engineer the information system is referred to as an APE (Ant Procrastination Effort).

In third world countries, there is often an inability to make any type of progress due to individuals who are in positions of power and authority who have a vested interest in keeping things in a backward state. They will thwart progress even if it means that most in the system suffer. There will never be a system that offers everything wanted by everyone. Nobody desires to be the Castro of medical information systems. Building a complete information system can be compared to trying to build a house in a third world country where there are no standards addressing issues such as what voltage of electricity will be delivered to the home and what shape the receptacles in the walls should be. An evolving list of various TWITs you may encounter is available on page __.

Twit Management

At no time should any individual be directly labeled a TWIT. These are labels of convenience to assist Guerrilla Leaders in their efforts to plan change strategies. Some weapons or techniques proven useful in the struggle for improving the common good will is to BUILD TRUST. Define and communicate clear objectives to all involved parties. Define and address obstacles as they occur. Define and address the enterprise’s uninterruptible functions. Last but not least - NEVER UNDERESTIMATE THE POWER OF PIZZA AND SOFT DRINKS. Once it appears reasonable that the guerrillas have adequately countered the TWITs, then (and only then) move forward. Otherwise, expect major battles and possibly a lost effort.

COMMUNICATE: It will be necessary to communicate issues and request feedback. List scheduled methods to communicate and conduct regularly scheduled staff meetings (at least once a week) with some teams meeting on a daily basis at certain stages. Use a Bulletin Board with "sign-off" list or E-Mail for effective communication of issues.

TWIT Directory

ACADEMIC

Individuals recognized by their ivory tower abode and the length of the nose with which they aim downward toward those around them. Their attitude is one of "if it did not originate here, then it must not be any good." Any period of practice in the real world excludes one from membership in this group. Even during an influenza epidemic, you should always perform a complete (Junior Medical Student) style document at each patient encounter.

APATHY

Individuals who don’t really care about dealing with issues related to improved information systems or anything else for that matter.

BRAND-NAME

Individuals who refuse to look at any product which does not carry some specific brand name (e.g. Macintosh or IBM)

BUCK-PASSING

These individuals express an interest but point to another party as being responsible for buying or implementing information systems. When the other party is approached, they pass the buck back to the original buck-passer resulting in a never ending loop.

BURN-OUT

Individuals who are "burned-out" and thus fail to have the interest or energy to make progress.

CASTROLLIAN

Individuals who fear that any system that is acquired will become obsolete.

COMPUTER BUFF

The readily available computer "buff" or self proclaimed authority who advises the practice as to how to progress. Unfortunately these "buffs" often have rather narrow biases such as "the system has to operate under MS-DOS, or has to be written in the "C" programming language. One day they perhaps successfully turned on the computer so now they are "computer experts". If you don’t believe it -- just ask them.

CONFIGURATION

Individuals who will only consider products which are in a particular operating system or development environment.

EGO

Individuals who lean toward narcissism and resist any activities which they perceive as not increasing their obvious personal worth.

FINGER POINTING

When more than one vendor, supplier, department, etc. is involved, one will point fingers at another when there are problems (who you going to call).

OSTRICH

These individuals seem to have their heads buried in the sand and are oblivious to the changes happening around them. They are almost surprised to learn that there is such a thing as an electronic medical record.

PARANOID

These individuals automatic reflex is to assume that the effort to improve information systems is an evil plot perpetrated upon them by the government, unscrupulous sales people, or others trying to take advantage of them. Always be cognizant of the clinician’s fear of loss of control. In essence, in the new paradigm, the focus is switching from improving the clinician to improving the enterprise health care delivery which necessitates computers and information systems.

POWER

Individuals in positions of power and authority who have a vested interest in keeping things in a backward state. They will thwart progress even if it means that everyone in the system suffers.

PROJECTION

Another major impairment toward progress being made in clinical information systems is the clinician who is of the opinion that "patients will not accept it." Research has consistently demonstrated that patients accept information technology much more readily then clinicians. This issue is in fact more of a problem of "projection" by insecure clinicians of their own fears and uncertainties.

STRUCTURE

These individuals resist progress because they fear that they will have to learn how to structure more of their information. An example would be the resistance to "SOAP" notes. These individuals become almost hostile when they see a protocol / template being used to assist in medical documentation. The give away here is the dilated pupils, flushed face and angry voice that arises soon after a template is entered into an encounter note.

STUCK

These individuals do not feel that they can easily change jobs.

TOTALITY

These individuals take the position of not moving forward because there is not a system out there that offers everything they want. In other words, "If I can not have everything I want, then I just will not do anything different." Again this thwarts progress and causes everyone to suffer. There will never be a system that has everything, so this individual can forever be used as an excuse not to progress.

VAPOR

Some individuals, often associated with a software company distributing some type of medical product, forever advises a practice to not install any other system because they are on the verge of having a superior product. The vaporware product just never seems to materialize or arrive.

VENDOR

These individuals have sold or installed some type of information system in a practice and then play "King of the Mountain" fighting off any other type of product regardless of its worth. The newer the technology, the more inflated or misleading the vendor’s claims will be.

IMPLEMENTATION PROCESS

DECISIONS! DECISIONS! DECISIONS!

Once you have identified the datasets you wish to implement, you are ready to customize. Decide which data entry method you will use. Retrospective, Prospective, Concurrent or a combination of these. Remember you do not want or need to burden yourself or your staff by entering everything on everybody from day one. You can always collect more data in a graduated fashion as you become comfortable with the software. It is a subjective judgment. Use common sense. There are no hard and fast rules for determining the adequacy of the pilot implementation - it is a "judgment call".
The first clinical team to attempt to actually use the electronic medical record in a "real-time" setting should be comprised of Guerrilla team members as well as "average employees". This group usually includes those persons responsible for creating the data sets. The data sets will need to be edited both before and after the initial implementation pilot. Vendors and/or consultants can often provide much savings in this area.

Before general implementation, the preliminary stage of customization should be accomplished. After the pilot implementation is taken down and critiqued, another set of customizations will most likely need to be performed.

GOAL SETTING

You and your staff will do your best to select realistic goals, but do not be surprised if you are fooled the first few times. Initially, you probably will underestimate and your staff will overestimate the goals that are achievable. Goals will fluctuate from time to time because they reflect the unique but every-changing idiosyncrasies of your practice. Develop a week-by-week implementation schedule. When you reach what you consider to be maximum achievement, set a new goal.

EDUCATE AND MOTIVATE

After the pilot and prior to general implementation, plan for general training. Allow for as much one-on-one training as possible.

First train in the Windows operating system
Next train in use of SOAPware
Last train in the specifics of how SOAPware has been customized for your practice setting.
Establish written protocols which should be widely distributed (post at each work station).
Develop User Surveys: Develop Post-Training Survey
Dislikes Training received
Likes Functionality after training
Problems created What functions need additional training?
Problems solved
Productivity
Your Changes
Suggestions

Maintain a training folder where each user’s progress and feedback is stored. The users should receive a certificate upon completing various states of training. Copies of the certificates should be placed in both the Training folder and their Employee File.

Identify, Address Barriers, Plan Actions to Meet Goals

You want to quickly identify and remove barriers that impede productivity. By means of day-to-day observations, meetings with staff, scrutiny of EMR information and User Surveys, you detect problems, institute procedural changes and intervene in other ways to upgrade the EMR implementation. This reduces the chance that problems will remain undetected.

Common Barriers

1. Lack of Customization and Inadequate Planning

Changes in computer technology have a significant impact on the volume of work, the quality of data and the services proved by most clinicians. Keeping pace with these changes can be an exciting and often mind-boggling experience. Though you make a Herculean effort to keep up, you may find that implementation is lagging behind.

2. Lack of Computer Skills and/or Knowledge of SOAPware

On-going training is an absolute must to maintain and continually upgrade skills. Skilled staff members are the most important asset in a practice. You can identify areas in which your staff lack necessary skills through the Self-Assessment Tests included in the SOAPware manual. Sometimes, staff members have the computer skills and knowledge to perform a job, but they do not fully understand why the task must be done or why it must be done in a particular manner. An important educational tactic is to give your staff information about the purpose and overall plan for implementation within the electronic medical record environment. Your staff must be informed as to when and why changes are necessary and the impact these innovations will have on their job.

3. Inadequate Resources: Staff and Equipment

Insufficient numbers of employees or inadequately trained staff, as well as obsolete equipment may prevent you from meeting EMR goals. If you discover that existing equipment wastes man-hours because it frequently breaks down, or doesn’t have enough memory to function in a timely manner, you will need to consider hardware upgrades or replacement. For example, if a dot matrix printer is too slow, a laser printer may need to be considered. Another example is the use of wireless network products with pen-based notebook computers to access the EMR. Doctors and nurses may come to consistently prefer mouse-keyboard entry to pen. Therefore, a desktop PC strategically placed at a workstation or in each exam room may be more efficient. Wireless, pen-based technology is at present three times more expensive than desktop machines. The desktops are not only much less expensive but are faster and easier to maintain. They also do not have to be carried around.

4. Lack of Staff Motivation

The first three barriers involve problems with systems, skills and resources that are well defined and that suggest specific solutions. The fourth barrier - problems with motivation or people management - is difficult to define and solve but essential to overcome. The most important interface is the HUMAN one. People make the difference between mediocre and superior EMR implementations.
Do everything in your power to assist your staff to be as successful as possible. You succeed only if they succeed. If you don’t encourage your staff and provide appropriate support, direction and rewards -- they learn just enough to "cope with the new system". If you want to create an environment that is conducive to greater productivity--one in which you improve clinical outcomes, patient satisfaction, productivity and staff satisfaction, then create an environment which values change. The following factors make it difficult to inspire staff to improve their achievement levels:

Lack of achievement and recognition
Lack of involvement in the management of the change process
Department or territorial barriers

Staff members should feel that their work is worthwhile and challenging. Look for opportunities to provide additional training, job rotation and promotion to assignments with greater responsibility.

There are other barriers to implementation beyond your control or influence, such as software or hardware limitations. Do not be put off or discouraged by them. Instead, try to break down the barriers over which you have some influence.

Conclusion

The days of handwritten charts are fading fast. Changes in the RBRVS reimbursement system, managed care, and the malpractice crisis have placed EMRs in the spotlight. More than ever before, ambulatory care is coming to rely on timely and complete documentation. By carefully planning and implementing an EMR, change agents can re-engineer patient care and methods of creating medical record documentation.

The general idea is to reduce clinician paper work burdens while improving quality of documentation and quality of patient care. It is essential that physicians start upon the path toward electronic patient records. Handwritten charting must go. Free dictation is inefficient and inadequate. In fee for service environments, higher levels of service can be justified. In managed care environments, data is being collected which will improve efficiencies. In both systems, protocols (templates) can be implemented which allow clinicians to do most of the clerical work freeing the physician to see more patients and perform less paperwork.

Whether written or dictated, most doctors are creating redundant information and usually do not go to the trouble to document the pertinent negatives or the true extent of the evaluation and treatment plan. This seems redundant to the physician; however, to any outside party - if it was not entered into the chart then it was not addressed.

Implementation Schedule - To Do List

Lay Foundation

Establish Vision or Mission statement: Design information process

Define Enterprise Objectives/goals
Select Operating System Select Hardware (Draw Floor Plan Map of Power/Network Connections; Window locations (consider glare problems); Thoroughfare logistics (do not block traffic flow); Printer (noise problems); Heat sources, Equipment ventilation; Screen Locations w/rotating pedestal to maintain patient eye contact
Identify Information Logistics
Netware (if applicable)
Software (EMR)
Peopleware

Identify Challenges

Barriers
Personnel Issues
Action Plan (Behavior modification; Change management; Consensus; Education and Awareness)
Build Trust (Define & Communicate clear objectives to ALL involved parties; Define and Address obstacles; Define and address uninterruptible functions)

Inventory Data Flow -- Work Flow:

Sign in (patient registration)
Patient Encounter (diagnosis and procedure codes)
Sign out
Follow up

Design Pilot Implementation / Simulation Model

Data Entry Method: Keyboard__ Mouse__ Trackball__ Pen__ voice__ Dictation: Digital__ Tape__.
Communication: Circulate "Issues" lists and encourage feedback from ALL users
Operator Support
Technical Support
Customization

Educate and Motivate

Design customized implementation manual
Basic Windows Training
Basic SOAPware Training
Procedure Design

General Implementation Schedule

Short and Long Term Goals
Monitor Progress - Develop User Surveys and Post-Training Surveys
Reassess and redesign work flow: Continually focus on improved data capture, clinical processes and flexibility.

Hardware

PC: Desktop__ Portable__
Monitor: 14__ 15__ 21__
Pointer: Mouse__ Trackball__ Pen__
Memory: 8MB__ 16MB__
Hard Disk: Size___________________
Floppy Drives: 3-1/2__ 5-1/4__ Both__
Printer: Laser__ Dot Matrix__ Ink Jet__
Modem:
Shredder:
Backup:
Auxiliary emergency power - UPS units
Software:
DOS Version:
Windows Version:
SOAPware Version:
Netware: (Other Netware may be used - these are the most common)
Wireless
Windows NT
Windows For Workgroups
Novell
Peopleware (Tasks may be redistributed to fit your practice; these are only suggestions) System

Administrator

Primary Duties: Coordinate Customization, Training and Ongoing Support List of current services

Handouts for patient education and aftercare instructions
Review / edit templates
Review / edit system codes
Review / edit normal exam
Review / edit Review of Systems
Modify Follow-up default
Set user preferences and defaults: Screen Size, auto date, auto code expand, age calculation, Auto
Health Maintenance and Artificial Intelligence, Direct Print
Security: prevent unauthorized access
Custom Reports: Rich Text, Bolding Routines, Superbill, Mail list, SOAPnote, Summary, Letters,
Recall notices, telephone, no show, cancellations)

Physician

Primary Duties: Assist with above tasks

Data Entry: Objective, Assessment, Treatment Plan (Level of Service), Follow-up
Patient Educational handouts; Discharge Instructions

Nursing Staff: RN, LPN, PA, RNP