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Implementing An EMR in A.C.S.

Lay the Foundation, Create the Mission Statement

After having been involved in 200 implementations of electronic medical records in the ambulatory setting, we highly recommend that implementation of an electronic medical record (EMR) be approached as an evolutionary process. Re-engineering data flow 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 reduced by careful planning, software customization and adequate training. The following is intended to serve only as a very generalized overview of the issues.

First, lay a proper foundation by establishing the major goals, and allocate adequate time and resources. It is very important to manage expectations early and to establish shared priorities. There are always limits (time, money, skills) to be considered. This early implementation task may be accomplished by one person in a small clinic or by a team in an enterprise setting. If a team is planned, consider representation from administration, physicians, nurses, transcription and front office staff. We suggest that the primary objective be to focus upon establishing informational goals which will subsequently determine the selection of the operating system, software, hardware, and vendors / consultants . In a concise statement (limit to one page maximum), list the reasons to computerize medical records. The reasons should focus upon the new and evolving informational tasks required for reimbursement, and list specific areas where measurable cost savings can be achieved. The mission statement should be widely communicated (circulated) among all involved persons and feedback should be invited prior to introducing any computers or software. Obtain signed acknowledgment of "buy-in" of the vision from all enterprise members, and file these along with their comments and concerns.

Work Flow

Sketch a floor plan detailing terminal locations, workstations, printers and all the other items of hardware. Then journey across the drawing while simulating the performance of various tasks.

Data Flow

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

Practice Profile

Collect basic statistical information such as the number of clinicians, number of patients, number and types of payers, etc.

Inventory and Evaluation of Your Current System

Inventory the current hardware, software, peopleware, and financial resources currently at your disposal.

 

Patient Encounter Note or Record of Visit Data Elements

Regardless of the nature of your practice, there are several consistent and predictable data sets which will need to be managed:

Define 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:

Peopleware

Develop a list of all persons within the enterprise that will be affected by the new information system implementation. Access their skill levels. Involve all office personnel involved early in the decision process. The socio-political issues (peopleware) related to upgrading information systems are usually greater challenges than the technical issues (hardware / software / networks-communications). Identify the key personnel who will aid the implementation. 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. One of the best techniques which has consistently proven useful in the struggle for improving the common good 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. Once it appears reasonable that the problem issues have been adequately addressed, 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 and schedule methods to communicate, and conduct regularly scheduled meetings (at least once a week) with some teams meeting on a daily basis at certain stages. For example, you may chose to utilize a Bulletin Board with "sign-off" list or E-Mail for effective communication of issues.

 

Implementation Process

Once you have identified the data sets you wish to implement, you are ready to customize. Decide when the data elements will be gathered from the patient during the course of the encounter and decide when they will be entered into the medical record. For example, data entry can occur retrospectively, prospectively, concurrently, or a combination of these. In our experience, it is neither wise nor necessary to electronically enter all data elements on all patients in the beginning. More often than not, this will involve a stage where there is a dual system of both an electronic and paper chart. Over time, you will phase out the paper chart. You can always collect more data electronically over time in a graduated fashion as you become increasingly proficient with the system. Use common sense. There are no hard and fast rules. It is a series of "judgment calls".
The first clinical team to attempt to actually use the electronic medical record in a "real-time" setting should be comprised of a small group of sophisticated users as well as "average employees". This group should include the persons who are responsible for creating the preliminary or starter data sets , (templates or macros). These initial data sets will need to be edited both before and after the trial implementation (pilot). Vendors and/or consultants can often provide much in the way of time savings in this area.

Set Goals

Select realistic goals, but do not be surprised if your initial plans prove to be unrealistic. Goals will fluctuate from time to time because they reflect the unique but every-changing idiosyncrasies of your practice and its unique setting. However, you should still 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. We suggest that you allow for as much one-on-one training as you can reasonably afford.

Develop User Surveys

Maintain a training folder where each user’s progress and feedback is stored. List users on a separate paper along with their skill level. The users should receive a certificate upon completing various states of training. Copies of the certificates should be placed in both a training folder and their employee file.

Address Barriers and 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 early. Institute procedural changes and intervene in other ways to upgrade the EMR implementation as indicated. This reduces the chance that problems will remain undetected. The following are examples of some common barriers:

Do everything in your power to assist your staff to be as successful as possible. 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 are examples of some common problems which make it difficult to inspire staff to improve their achievement levels:

Staff members should feel that their work is worthwhile and challenging. Look for opportunities to provide additional training, job rotation, and individual 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 unduly discouraged by them. Instead, try to break down the barriers over which you have some influence, and encourage others to do the same.

Evaluate and Select EMR Vendors -- General Issues

Do they have installations of similar size & settings? Do they have any patient data sets equal to your practice setting now? Do they have any patient data sets equal to your practice setting as anticipated in five years? Are there references available? Is there a list of features currently in development? Is there a list of future features planned? Is there access to a "Users Group"? Is there a Newsletter? Is there an adequate number of installed user sites? What is the largest number of users at one site on the system? What does it cost to add an additional license fee or workstation? What does it cost to add a customized interface? Does it cost the end user to add customization to their software? Is the software vendor financially and professionally sound? Does the vendor have a sound track record? Does the vendor provide an escrow agreement setting terms under which source code and documentation are made available? Is training and support adequate and affordable?

Implementation Schedule - General To Do List

Concluding Points

The days of handwritten and dictated charts are fading fast. Changes in the RBRVS reimbursement system, managed care, and the malpractice crisis have increasingly 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 initial general focus should be upon reducing 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 and dictated charting must go because they are inefficient and inadequate. In fee for service environments, higher levels of service can often 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 automate or delegate charting tasks thus freeing them to see more patients while performing less paperwork.

Whether written or dictated, most doctors are repetitively creating redundant information while not going to the trouble to document the pertinent negatives or the true extent of the evaluation and treatment plan. While this seems redundant to the physician; it is not so to any outside party. Remember, if it was not entered into the chart then it was not addressed.

Plan to continue to struggle with the pervasive tendency for physicians to consistently overestimate the adequacy of their current method of documentation.