The Conversion to Electronic Medical Records: Implementation and Potential Pitfalls

JUDITH BIBLE, AuD · ANDREW N. ANTOSZYK, MD

In parts 1 through 3 of this series, we discussed laying the groundwork for implementing an electronic medical record (EMR) software system in a vitreoretinal practice. These steps included:

► how to plan for an EMR system

► how to purchase new computers

► how to purchase and install servers

► how to create an electronic office network

► criteria for selecting an EMR software system.

With these steps in place, it is time to transition to a paperless environment. This process will test your months of planning and purchasing decisions. Depending on the practice size, the transition can take a few days (a small, single-facility practice), weeks (a small- to mid-size practice), or months (a very large, multisatellite group practice).

EMR SYSTEM INSTALLATION

Unfortunately, the installation of an EMR system is not a "plug and play" process. The process requires information technology (IT) expertise. Installation groundwork should be in place, ie, Citrix remote servers vs full-client software on each PC. Full-client installations may be time consuming, as each PC will need to be accessed and touched for installation of the software. The vendor will be instrumental in assisting with the installation process; however, there will be additional costs for the necessary IT support and after-hours work required. The cost can be estimated by the number of servers and PCs being touched. Following the installation, access and passwords and security levels will need to be assigned for all staff members and physicians.

It will be essential that security and privacy regulations be reviewed and adhered to throughout this process. This will be the time that evaluation of interfacing with retinal equipment should begin. Vitreoretinal practices utilize a variety of equipment for diagnostic purposes. Imaging, optical coherence tomography, b-scans, ultrasound biomicroscopy, and many others test results will need to be imported and stored in the new EMR system. The cost and time required to interface this equipment is often not included in the initial installation costs or vendor support. Having these test results at your fingertips is one of the most beneficial EMR uses.

However, making it happen will take coordination between the EMR and equipment vendors, as well as onsite IT support, which can be costly if not monitored. The amount, age, and type of equipment utilized will affect the success and cost of the interfacing endeavor. A complete list of equipment to be interfaced, including manufacturers, serial numbers, and age, should be reviewed with the EMR vendor and a plan (including costs) developed for each interface prior to training. Cost/benefit analysis can then be run for each interface. In some instances, it may be worthwhile to investigate new equipment, scanning options, etc. Plans should also be developed for instances when interfaces may be interrupted or nonfunctional for short periods of time. These plans should include whom to call (EMR vendor or equipment vendor), the cost of the call and resulting service, and a backup for providing test results to the physician so as not to interrupt clinic flow.

PRODUCT DEVELOPMENT

The efforts devoted to choosing the appropriate software package for a retina practice will make product development and refining a fairly easy and inexpensive process. Your software package should come with a set of defined retina-based templates and screens that provide a starting point for the physician exam documents. These templates will need to be evaluated, revised, and the options or pick lists created and organized for each physician. Dedicating the time and resources to this process will assure maximum efficiency of the system once you "go live" in the clinic.

The highly specialized nature of a retina practice will require extra attention to the pick list and documentation details by the physicians, technicians and scribes. The technicians and scribes understand the Physicians' current charting procedures and flow and can, therefore, develop pick lists and descriptors necessary for accurate, efficient charting. The time commitment for this process will vary, depending on the charting practices of each physician. A minimum of 10 hours will be necessary to assure that the development process is successful.

STAFF TRAINING

Creating the backbone of your system is the perfect time to introduce the software to the staff, allow them to give input, and begin the training and flow process. Training will be ongoing through the development and implementation. It is important to intimately know your technology skill level. It is worthwhile to do a staff survey early in the process. The survey should be quick and easy, and give you the information you need to identify the levels of computer skills among your staff. This will allow you to develop the appropriate training, training groups, training timeline, and recruiting plan. All staff (both clinical and administrative) should be included in the survey process. Future recruiting and hiring decisions can be made on the needs identified through the survey process.

The key to training is to make it fun and exciting for all skill levels and to set up an internal support system within your staff. Training is included with the purchase of any system. However, it is never enough, and often the training focuses on the organizational and operational flow changes and not the hands-on staff training required to be successful. A group of "super-users" (individuals who have extensive computer experience) should be identified within the clinic to assist with the training process. These people should have a flexible work schedule and a positive, willing "cheerleader" attitude. They do not need to be purely technical or clinical staff.

Training for the super-user group will encompass 10 to 40 hours of direct instruction. Choosing people with flexible work schedules will allow for both clinic and after-hours instruction so as not to interrupt clinic flow. However, the practice cost for this process should be calculated on each super-user's hourly overtime rate for the maximum amount of 40 training hours, assuming that training will be done after clinic hours. It may be possible to shift workloads to allow training during clinic hours, which will reduce costs but may affect overall productivity and morale of the clinic staff. An initial classroom training session should then be developed to allow all staff a general introduction to the software, development of security levels/passwords, and for outlining the implementation process with clear expectations for each staff member. Training on the software should encompass 4 to 6 hours of direct instruction, with opportunities for break time and lunchtime training review. The cost of this training should also be calculated based on overtime hours to determine the maximum cost to the practice. Once again, if duties can be shifted or reassigned to allow for training during clinic hours, you may have decreased staff expenses but will face a resultant cost in lost productivity.

Technical staff members should be encouraged to utilize the system as much as possible following training by inputting historical information for upcoming appointments. Physician training should be scheduled with and without the technical staff and follow the scheduling of the technical staff training. Physician training with the technical staff should include the exam documents and data input. Further training should focus on the physician sections of the EMR such as: signing of charts, notes, and procedures; faxing; letter generation; chart, image, and lab review; and physician options. This training should be completed in a classroom setting, followed by homework, which could include things such as inputting 5 to 10 patients scheduled for rechecks in the coming months, picklist organization, and a patient-flow analysis for each physician. The training should culminate in one-on-one training after homework assignments are completed. Physician training will add hours to the physicians' day, as it should be done after clinic hours to ensure a minimum of interruptions and adequate time for comprehension and questions.

HISTORIC DATA INPUT

The retinal physicians will need to arrive at a consensus on how the practice wishes to handle current and old paper records. The choices are many and must be weighed through a complete cost/benefit analysis. Retina practices historically have a high volume of return/chronic patients, who may require different procedures from a high-volume cataract, laser-assisted in situ keratomileusis (LASIK), or routine vision practice. Retina practices often have multiple locations and are faced with high costs of transportation or storage of records at multiple locations. Such practices may find it beneficial to scan their old records into an easily accessible imaging section of an EMR to avoid a costly 2-chart system.

Scanning of records creates its own set of issues, however, such as what should be scanned and what process should be used. Scanning the complete chart can be done in many ways, each of which has its own set of cost-to-benefit ratios. Scanning the chart in its entirety gives the physicians the ability to have all information at their fingertips without the associated costs of chart pulls and delivery. However, the cost of electronic storage space and the person-hours for scanning must be evaluated, as well as the scanning process. For example, the cost and time figures increase greatly when complete chars are scanned in sections, or the original charts are in disarray (multiple paper sizes, colors, and legibility).

An alternative is to scan the initial encounter note and the last office visit note into the EMR for easy reference. The old chart can then be kept offsite and be readily accessed if needed. The pros and cons and resulting costs of each option — including person-hours, electronic storage, and paper storage and retrieval — should be included in the evaluation.

HISTORIC DATA INPUT

It is now "Go Live" day. All staff members have been primed, and preparation has been done for a successful transition. Starting with new patients may be a good way to let the staff "put a toe in the water" without drowning on the first day. Two weeks of using the EMR for new patients allows for the discontinuation of paper records, gives the staff a taste for the process, and allows the ability to work through operational bugs. Beginning to input historical information (past medical history, past surgical history, medications) on return patients with upcoming appointments allows for improved flow, minimal stress, and continued training opportunities as you completely transition to EMR. Minor schedule modifications may be necessary for high-volume physicians during the full implementation week. Those physicians seeing more than 50 patients may reduce the number of patients per morning and afternoon sessions by 4 for the first week, 2 the second, and back to normal volume the third week. Those seeing 30 to 50 patients per day may reduce their encounters by 2 to 3 per session the first week and 1 to 2 the second. Those seeing fewer than 25 patients per day should keep their normal schedule.

Setting this expectation and timeline prior to the implementation day ensures that the physicians and staff do not get comfortable with a lighter schedule and the revenue stream does not slow to a trickle during an expensive implementation. Notifying patients of your new and improved system through signage and snacks in the waiting rooms helps to reduce complaints and makes them a part of the process. The focus of any "Go Live" implementation should be the examination and resulting exam document. Requiring physicians and staff to complete the patient examination within the EMR improves their understanding of the basics and provides a good foundation for return visits. Letters, educational materials, prescriptions, and all other bells and whistles can be added 1 to 2 months after implementation, as familiarity and speed with the system improves. Many EMR systems have an associated practice management component. Although these systems allow for integration and efficiency, it will be worthwhile to determine your practice's ability to deal with both clinical and administrative changes in a short period of time. Evaluating your practice's risk and change tolerance will also be necessary, as you may run the risk of interruption to the accounts receivable collection during a practice management conversion. Both EMR and practice management are integral parts of the practice. Therefore, thorough independent implementation plans will be necessary. While it is possible to change both systems concurrently, it may not be wise and should be fully evaluated.

Adding the bells and whistles, interfacing equipment, retraining, and training new hires will encompass the next few weeks and months. The process of implementing an EMR does not have a clear start and stop date. The system will change and grow, requiring ongoing training and implementation plans as you move forward. The EMR tool will assist in coding improvements, patient care and documentation improvements, billing interfaces, quality measure reporting, and interactions with referring physicians. The list goes on. Once you begin the process, it takes on a life of its own and will require ongoing care and oversight from the physicians, the technicians, IT, administration, trainers, and human resources. The great benefits of EMR can easily be offset by poor utilization, lack of ongoing training, and neglect of practice standards and consequences.

Now that you have addressed all the implementation aspects, you will need to face the inevitable question: "What if the system goes down?" Having a plan in place and the staff well trained will mediate any interruption that may occur. Although a good IT plan and setup will keep interruptions to a minimum, glitches will happen. Your plan will need to include short- and long-term interruption scenarios. Short-term interruptions (a few hours) can be handled by completing exams on paper as if everyone were a new patient and providing overtime to staff to input the data into the system as its function returns.

Longer-term downtime of a day or longer should be rare. However, it must be anticipated as well. A disaster-recovery plan must include manufacturer support, remote access to backup data, and staff access to historical information to allow for patient care and follow-up during the outage. Long-term outages may require scanning of the paper exam documents into the system when recovery is completed. However, scanning of exam documents will limit the search and historical efficiencies built into any EMR. A minimum of daily back-ups should be done of all EMR documents. In larger practices, routine backups may be scheduled throughout the day to keep data loss to a minimum should an outage occur.

CONCLUSION

Your EMR is now part of your practice and your life. The benefits have far exceeded the risks due to your diligent planning, development, and training. Your partnership with your manufacturer will be cultivated over the coming years to ensure that your practice's needs are met as newer versions of the software are developed. This relationship will also ensure that your ongoing costs and resulting response time for support are reasonable for your level of need. RP