Logical Steps to Selecting and Implementing an EHR
EHR implementations are complex affairs. They are not simply IT projects. They are practice transformation projects that should be considered socio-technical-economic initiatives. If approached as simply software to be installed and users to be trained in using the software, an EHR implementation will undoubtedly falter or even fail. Thus, health care organizations involved in implementing an EHR are wise to spend a lot of time planning. A few of the many questions an organization needs to both ask and answer prior to implementing an EHR are: Why are is the practice doing this? Who should be involved? How will this impact end-users and how should they be prepared ? What will be the major barriers? What should the practice start doing now to overcome identified barriers and is it ready for change? How will the change be managed? Implementation of an EHR can be divided into three separate, yet intertwined phases: Pre-implementation, implementation and post-implementation.175 While each phase is distinct, the success of subsequent phases depends upon the thorough planning and execution of the prior stages. Pre-implementation begins with deciding whether to purchase an EHR (it is rare for a health care organization to create one themselves these days) and ends with signing a contract with a vendor for a specific EHR. This requires a thorough understanding not only of the organization’s needs and current state but also of the selected software’s abilities and limitations. The main activity in pre-implementation is choosing the EHR that will be used, but several steps that might be done during implementation, such as workflow mapping, may be done and some say should be done, during pre-implementation. Workflow mapping involves a detailed step-by-step description, typically utilizing a flowchart of how a particular process is accomplished. For example, how are notes created or how are patient messages handled or how are prescription refills managed?176 Implementation of the EHR starts with the signing of the contract and ends with the go-live date. Experts in IT implementations often categorize facets of implementation into People, Process, or Technology issues.177 Alternatively, they can be termed: Team, Tactics and Technology. People issues are particularly important in an EHR implementation. Unless the people issues are managed well from the start, later adoption of the varied functionality inherent in an EHR will likely suffer. Key people issues are leadership, change management, goal establishment and expectation setting. An implementation will have three key types of leaders: a project manager, a senior administrative sponsor, and a clinical champion. The clinical champion will invariably be a physician, but hospital settings will typically have a nurse champion as well. The need for a project manager, someone knowledgeable and experienced in managing a complex IT project with overlapping timelines and multiple stakeholders, is obvious. Senior leadership sponsorship and support is also essential, because an EHR implementation will affect nearly all aspects of a hospital or clinic’s operations and thus consistent support from the organization’s leader or leaders will be required as inevitable bumps in the road are encountered. Some healthcare organizations have learned the hard way that implementing an EHR without one or more physician champions can be disastrous. When it comes to clinical matters, physicians rely on other physicians. Because an EHR affects clinical practice in so many ways, respected, supportive, influential clinicians are needed to encourage other physicians to accept and utilize the system effectively.178 In inpatient settings, a nurse or clinical champion is essential to ensure that decisions made incorporate all disciplines within the facility. When implementing an EHR it is important to view operations from all perspectives (e.g. physicians, nurses, medical assistants, pharmacists, other support personnel and administrators). Without a nurse champion, decisions made might be solely physician-focused. Additionally, nurses commonly drive the change process in hospitals. Commitment to success, engagement of everyone, and a shared interest in improvement is paramount, so attitude is everything.179 Because of the degree of change involved in implementing an EHR for the first time, change management skills are needed. This topic is beyond the scope of this book but many good resources can be found on it. One good introductory and classic resource is Kotter’s book Leading Change.180 An important part of change management is setting goals and establishing expectations. Be realistic, look at the EHR myths and sins, noted in the info box. Many specific process (or tactical) decisions are determined during implementation. How will the EHR be used to redesign our workflows? What is the data entry strategy? Which data will be entered discretely, which will be scanned and which (if any) will be left out of the EHR? Who will do this data entry and when? What order sets will be created? What other information systems will the EHR connect to and what kind of interfaces will it require? Will the practice follow a big bang (all personnel/sites and EHR functions at once) or a phased implementation approach (certain user groups and/or certain sites/departments and or certain EHR functions in sequential order)? How will user training be conducted? What about note templates? How much customization will be allowed? How will super-users be utilized? What about the technology? EHR software does vary in its complexity. Software designed for larger practices tends to be more customizable but also more complex, requiring more IT support. Deadly Sins:
- Not doing your homework
- Assuming the EMR is a magic bullet
- Not including nurses in the planning stages
- Not participating in training
- Thinking one can implement the same processes as paper
- Not asking for extra help
- Being short sighted 181-183
|EHR Myths and Deadly Sins|
Small practices may adopt EHRs as a subscription service (SaaS) where they only need to maintain an internet connection and user terminals and everything else is done for them remotely. Large practices may be completely self-contained with their own servers, intranet, backup, terminals and IT staff. Large practice and hospital IT departments will often maintain three software environments for the EHR – production (live), test, and training. Implementation of the EHR is followed by the post-implementation phase which remains in effect for the duration of EHR use. This phase involves maintaining, reassessing and improving the EHR’s content and capabilities, facility workflows/processes, and staff training with a focus on continuous improvement and patient safety. In a sense, EHR implementation is never done. As clinical sites learn more about the software from using it, they often learn how to use the software in previously unanticipated ways. And certainly as the EHR software is periodically upgraded, new functionality is added that increases efficiencies or opens up new possibilities. Post-implementation can also be referred to as maintenance, sustainment or optimization.
In the next section the logical steps towards selection and implementation of EHRs are presented:
- Develop an office strategy. List priorities for the practice. Is the goal to to save time and/or money or just go paperless? Is the practice looking to be more competitive by offering patient satisfaction-related features like secure messaging, virtual visits, a portal and connectivity with the medical community? Is remote access to computing needed by the clinicians? Is the practice seeking improved workflow to expedite chart pulls and provide easier refills? Is more reporting capability needed? Is better integration with your practice management system needed? Is there a need to integrate disparate programs? Now is the time to study work flow and see how it will change your practice. This is when frequent conferences with the front office staff will be critical to get their input about the processes that need to improve. Make sure physicians are committed to using the EHR. Look for at least one physician champion and be sure your staff is onboard. Do not proceed if there are hold-outs. Do not proceed if your only goal is to receive federal money. Factor in your future requirements. Will more partners or offices or specialties be added? Plan for initial decreased productivity.
- Research the EHR topic:
- Take a short EHR course at a community college or university
- Utilize expertise from regional extension centers (RECs) (see Chapter 1)184
- Read an EHR textbook185-189
- Read important articles, monographs and surveys190
- Network with information on web sites such as the 2013 HealthIT XChange where there are articles and discussions about each stage of EHR planning and implementation sponsored by all of the major informatics organizations.191 Also consider the National Learning Consortium hosted by ONC that covers multiple topics related to EHR implementation.192
- The 2012 EHR User Satisfaction Survey received 3,088 responses from family physicians, reporting on 160 EHR systems (129 were used by 12 or fewer respondents). Thirty one EHRs were used by the majority of respondents (87%) and this served as the corner stone of the survey. The EHRs for the VA, DOD and Indian Health Service were included. A chart correlated the top EHRs by practice size and the number of respondents using the specific EHR. Another chart ranked the 31 EHRs based on 19 dimensions. A third chart ranked EHRs based on whether they were easy and intuitive to use (usability). A fourth chart rated training and support. A fifth chart evaluated whether the EHR enables the user to practice higher quality medicine compared to paper charts and a sixth chart rated the level of overall satisfaction. An average for all respondents was included for benchmarking. Only 38% of respondents agree or strongly agree that they are satisfied with their system. Clearly, cost and EHR size did not correlate with user satisfaction.193
- The 2012 Black Book Rankings of the top 20 EHR vendors for family physicians had similar results to the AAFP.194
- Utilize HIT Consultants:
- Consulting firms such as AC Group provide consulting for EHR purchase. In addition they have several fee-based monographs on the subject.195
- KLAS is an independent HIT rating service that vendors pay to join and end-users pay to receive reviews. Their reviews cover EHRs and components based on practice size and include letter grades on implementation, service and product. Their input usually comes from office managers or IT specialists and not necessarily end-users. Physicians can evaluate survey data on individual vendors free if they are willing to complete an online questionnaire.196-197
- List EHR features needed in the practice. Review the key components section of this chapter. Choose the method of inputting: keyboard, mouse, stylus, touch-screen or voice recognition? Don’t forget backup systems, e.g. dual failover.
- Analyze and re-engineer workflow. Processes such as prescriptions, telephone triage, lab ordering, appointments, scheduling, registration and billing will change with the use of an electronic health record. Healthcare workers must embrace business process engineering (BPR) and business process automation (BPA) to create a digital office. It is wise to map the various processes to see what changes must occur and where computer terminals to execute the process electronically should be added. Some choose to use workflow software to map office workflow. HIMSS offers a toolkit “Workflow Redesign in Support of the Use of Information Technology within Healthcare” for its members.198 Other resources on workflow and process mapping related to EHRs are available.199-200
- Use Project Management Tools. A variety of tools exist that improve organizational skills during the planning process. Consider using standard matrices that are glorified checklists and timelines that help organize your efforts.201-203
- Decide on client-server or the application service provider (ASP) option. One early decision that must be made is whether the practice wants to purchase a standard client-server EHR package which means having the software on your own computers. The other choice is an ASP model which uses a remote server that hosts the EHR software and your patient data. Each has its merits and shortcomings. Almost all EHR vendors now offer both models. Features of an ASP Model:186
- Vendor charges monthly fees to provide access to patient data on a remote server. Fees will usually include maintenance, software upgrades, data backups and help desk support. Monthly fee may be a fixed amount or based on number of users.
- Lease agreement commitments range from one to five years.
- ASP may charge a fixed amount or charge for the number of users.
- ASP can be completely web-based or can require a small software program (thin client) to help share processing tasks.
- Pros: Lower start-up costs; ASP maintains and updates software; saves money by eliminating or reducing need for local tech support; generally a better choice for small practices with less IT support; enables remote log-ons, for example, from home or satellite offices.
- Cons: If your ISP is out of service, then your practice is stalled; security and HIPAA concerns; concerns about who owns the data and cost of monthly cable fees; slower speeds compared to a client-server model; need a fast internet connection, preferably a cable modem, DSL or T1 line.
- Decide on an inputting strategy. Different types of inputting are necessary because clinicians have different specialties, personal preferences and document requirements:
- Dictation. In spite of the desire by most people who purchase an EHR to avoid dictation, many physicians will not want to give this up because it is part of their routine or they practice in a specialty where the historical narrative is best told with a dictation. Besides cost (10 to 20 cents per line), the disadvantages are the fact it is non-structured data, the physician must proof read and someone must cut and paste the narrative into the EHR, thus causing some delay.
- Speech recognition. Speech recognition is an attractive alternative to standard dictation for many but not all physicians. The cost to purchase, example Dragon Naturally Speaking (DNS) 12®, is approximately $1,600 per physician (on-site training not included) and includes a choice of multiple medical specialty vocabularies. DNS is available for the iPhone and wireless platforms.204 There is preliminary evidence to suggest speech recognition improves the patient narrative and has a reasonable return on investment.205 While it is true that speech recognition has improved dramatically in the last few years, it will not be satisfactory for all users. In 2010, Hoyt and Yoshihashi reported a failure rate of 31% in a large scale implementation of voice recognition in a military treatment facility.206
- Handwriting recognition. A few EHRs utilizing the tablet PC platform will allow a clinician to write on the tablet and have the information converted to text.
- Digital Pens. Smart (digital) pens are being used as another means of inputting that fits physician workflow.
- Templates. Most EHRs offer a template or point and click option to facilitate inputting history and physical exam data into the EHR. In addition to saving time, templates input data as structured data so it is machine and human readable. Practices can create templates ahead of time before going live and thereby, try to standardize care within a practice. Multiple template designs are available. With MEDCIN every phrase must be located and selected for inputting. Others document-by-exception which means there is standard language for most exams; if verbiage does not pertain to a patient, it can be deleted. Most templates can be customized (some on the fly) and shared. Many are disease specific such as low back pain or headache templates. One concern with templates, besides a potential robotic note, is the over use of options such as auto-negative where the review of systems can be performed rapidly with the potential for false documentation. Clicking history or physical exam choices that the clinician did not ask or examine is considered fraud. Conversely, submitting an overly detailed history or physical exam that is not justified by the diagnosis could be considered abuse.207
- Typing. A minority of physicians will be happy to input their data by typing, particularly if they are tech savvy and excellent typists. Most physicians, however, will complain that typing notes is not why they went to medical school.
- Scribes. Emergency rooms were the first hospital area to hire scribes to shadow physicians and in addition to multiple duties were responsible for inputting information into the EHR by typing, templates, dictation or transcription.208
- A blended approach. Medical practices would be wise to offer multiple means to input patient data. As an example, for simple patient encounters for flu, templates may be adequate. For more complex visits dictation or voice recognition may be necessary. Organizations will have to balance the need for productivity by finding better ways to input into an EHR with the needs to have discrete or structured data. As an example, hospitals rated as stage 6 by HIMSS used templates 35%, dictation/transcription 62% and speech recognition 4% for inputting into EHRs. Newer software, using natural language processing, will extract discrete data known as narradata from dictations that can be used secondarily for decision support, reporting and billing. This approach is known as discrete reportable transcription (DRT) and may be important for Meaningful Use of EHRs.209
- Discuss mobility. Will clinicians need to be wireless? Will they benefit from access of the EHR remotely using a smart phone? Multiple vendors, like Epic, offer their software on, example an iPhone or iPad.
- Decide on EHR / PM Approach. Is a combined EHR and Practice Management System needed? Will a combined EHR and practice management system be purchased or will there be a need for an interface to be created?
- Survey hardware and network needs. How many more computers are needed for purchase? What about a network and/or wireless? Is the plan to use an in-house server with its dedicated closet, air conditioning and backup? What about a network switch and commercial grade firewall? Will the practice require short term or long term IT staff? What is the data back up and disaster plan. Plan for a commercial grade uninterruptible power supply. Also, plan for a service level agreement if the practice opts for the ASP model.
- What interfaces are needed? What about interfaces to external laboratory, pharmacy and radiology services or is that part of the package purchased?
- Will the practice need third party software? As an example: patient education material, ICD-9 codes, CPT codes, HCPCS database, SNOMED, drug database, voice recognition, etc. Ask if that is part of the purchased package.
- Develop your vendor strategy.
- Write a simple Request for Proposal (RFP) or Request for Information (RFI). This will cause the practice to put on paper all of your requirements and will provide the vendor with all of the important details regarding your practice. This formal request will standardize the responses from vendors as they will need to respond in writing how they plan to address your EHR requirements. Exact pricing should be part of the RFP. Sample RFPs are available on the Web.210
- Consider using a web tool to compare EHR vendors. One free web site offers EHR resources, readiness assessments, detailed search engine and vendor comparisons, vendor profiles, EHR top 10 ratings (11 categories).211
- Obtain several references from each vendor and visit each practice if possible. Be sure to select similar practices to yours.
- The following comprehensive reference by Adler provides an EHR demonstration rating form, questions to ask vendors, RFP advice, EHR references and a vendor rating tool.212 Create a scoring matrix to compare vendors.
- The following reference also has a scoring sheet with sections for vendor software, interfaces, third party software, conversion services, implementation services, training services, data recovery services, annual support and maintenance, financing alternatives and terms. It also includes red flags and FAQ’s. This reference is intended to compare costs and not EHR functionality between candidate vendors.213
- Obtain in writing commitments for implementation and technical support, including data conversion from paper records; interfacing with practice management (PM) software; exact schedule and time line for training.
- Look for funding:
- The most obvious choice is Medicare or Medicaid reimbursement under the HITECH Act.
- As noted before, hospitals can donate EHR systems to physician offices under the safe harbor with physicians having to pay 15% of costs.
- Physician Quality Reporting System (PQRS) will reward physicians for quality reports that can be generated by an EHR. This will be covered in more detail in the chapter on quality improvement strategies.214
- Check to see if your state has incentive programs
- Select a vendor and develop a contract. Most practices will need to create a contract with legal help. This will ensure the vendor meets their obligations and will define the contract period, duties and obligations, license stipulations, scope of license, payment schedules, termination clauses, upgrades, support, warranties, liabilities, downtime clauses, etc. ONC developed a 2013 Guide to EHR contracts so adopters could better understand contract terms and pitfalls.215
- Decide on a strategy to convert paper encounters to electronic format. Most experts advise that key information (medications, allergies, major illnesses, immunizations, lab results, etc.) be keyed in by staff on active patients several months before going live. Decide what documents such as prior encounters, consultations, discharge summaries, etc., will be needed to upload into the EHR. Several resources will help the practice develop a strategy.216-218 One vendor posts an approximate charge of 15 cents per page for less than 30,000 pages to scan in paper forms. As an example, for 5000 pages this would amount to a charge of $825.219
- Training. It can be said that one cannot train too much. Determine if your vendor has an electronic training database clinicians and staff can use before going live. Assess IT competencies of the clinicians and staff and train for gaps in knowledge.
- Implementation. Consider a phased in approach where clinicians and staff begin with processes such as e-prescribing, internal messages and laboratory retrieval before tackling patient encounters. Develop a go-live plan to determine reduced schedules and frequent debriefs. For more information about roll out and turnover strategies readers are referred to these references.187,220
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