| Implementing an EHR: Preparing for Launch |
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 } Ever wonder just what it's like going through the process of implementing an EHR? What would you and your staff really have to contend with?To give you more than an academic answer to these questions, The Connected Physician has begun following three small and medium-sized practices through the process of installing and learning how to use an EHR. Throughout the year, we'll take you behind the scenes—up close and personal, as they say—to monitor what's going on and how everyone in the practice is reacting to the changes. In this article, we'll look at how the practices are preparing for implementation and what their expectations are. In the next TCP issue, we'll revisit the same offices to see what problems they encountered during the "go-live" phase and how they addressed them. And in one of our fall supplements, we'll see how the practices are coping with and benefiting from their EHRs six to eight months after they turned them on. These practices have all acquired systems in which the EHR is integrated or closely interfaced with the practice management system, and all are replacing older PM software. While each practice bought its EHR from a different vendor, and each has very different needs, their implementation plans have some similarities: For example, they're all planning to scan charts or key chart documents into the EHR as patients come in to be seen. All have already arranged interfaces with reference and hospital labs beforehand. They're all having their computer systems installed and serviced by local, independent technicians. And they all expect to do more business with the same staff, rather than lay anyone off as their offices become more efficient. Now that we've seen what characteristics these practices share, let's take a close look at what makes them different, and how that affects their approaches. Barnegat, NJ Internist and geriatrician Harjinder S. Bedi of Barnegat has decided to plunge into his new Practice Partner system with both feet. On Feb. 12, this intrepid older physician and his equally courageous staff will turn on both sides of their integrated EHR/practice management system, and Bedi will begin documenting most patient visits electronically from Day One. One reason why Bedi is so confident is that he's been on the cutting edge of technology for years. He accesses his medication lists online from the OnCallData e-prescribing service; he views hospital reports online; and he has a vital signs machine and a digital ECG device, both of which will be interfaced with the EHR. Another reason: he's just hired a young physician who used an EHR in her residency, and he expects to lean on her expertise. Bedi's office manager, Pat Cea, also knows her way around computers and is working closely with Practice Partner to prepare for the launch. During November and December, she spoke weekly with a vendor representative who guided her through the configuration and the use of the system via telephone and web tutorials. Practice Partner trained Bedi and the staff on site for three days in January. (During that period, the office shut down completely.) Bedi isn't worried about losing productivity during the launch phase. For one thing, he points out, his new doctor won't be too busy, so she can take up the slack while he learns the system. But his real ace in the hole are his three unusually helpful medical assistants, who, he says, "are ready for change." These MAs already go far beyond their job description, taking patient histories that go deeper than a simple statement of the chief complaint. But Bedi wants the MAs to go even further and enter most of the patient history in the EHR so that he can just come in, ask a few questions, and make the necessary decisions. Since this will help him see more patients, he's willing to pay his assistants extra for that. "This will reflect how efficient they are in getting the patients ready for me." While Bedi is very pleased with the computer system that a local technician selected and installed, Cea foresees problems with the decision to put PCs in each exam room, rather than using portable computers. She points out that the doctors and their assistants move from one room to another. If each MA has to log on to each PC every time she goes into a room, and the physicians have to do the same, it will slow down the process. She's hoping the vendor will come up with a solution. Despite these technical obstacles, Bedi is eagerly looking forward to having an EHR. "I sincerely believe that with an EHR, whatever I do, I'll do much better," he says. "I spend a lot of my energy now just shuffling paper. When I have the electronic record in front of me, I'll have everything I need in a flash. I'll be a better physician, and it won't take too much of my energy." Tewksbury, MA Caution is the watchword at Merrimack Family Medicine. The practice took eight months to look for an EHR before settling on eClinicalWorks (ECW), a modestly priced but robust system that has won several awards. Besides the fact that the doctors liked the EHR, the PHO affiliated with nearby Lowell (MA) General Hospital was offering incentives of up to $10,000 per physician to member practices that chose either ECW or one of the two other EHRs that the PHO has endorsed. According to FP Frank E. Osborn of Merrimack, that incentive has encouraged his practice and many others in the vicinity to adopt an EHR, and it's covering nearly half the cost of Merrimack's system. The practice's approach to implementation has been just as pragmatic. Following the advice of Masspro, the state Quality Improvement Organization (QIO) that's been helping Merrimack with its project, the physicians and midlevel providers will gradually phase in electronic documentation. Each provider will start with just a few patients per day and work up to documenting all visits in the EHR over four to six months. That way, Osborn says, they'll minimize the loss of productivity that occurs during an EHR's start-up period. Because of its need to maintain revenues, Merrimack didn't close or reduce its schedule during training, as Bedi did in Barnegat. Instead, it trained half of the staff in the morning and half in the afternoon, and it had physicians come in on their days off. After the system is implemented, the doctors might also have to put in some extra time at first to make sure that all patients are seen, says Osborn. The providers will have portable tablet PCs that allow them to type or write free text outside of the point-and-click templates; in addition, all but one of the doctors will use Dragon Naturally Speaking, a voice recognition program that interfaces with ECW. Providers can use whichever mode they feel most comfortable with, Osborn says. The practice and the EHR vendor have created a detailed timetable for implementation. Staff members were trained in January, and eCW's billing and scheduling modules were slated to go live a week later. The physicians and the NPs will learn the EHR this month, and that part of the system is scheduled to be turned on Feb. 19. The time lag has allowed the staff to get experience on the practice management system before the providers start using the EHR. While the billing staff received more hours of training than the receptionists did, Beverly Winslow, the practice manager, doesn't expect the billing work to change much. She also doubts that the front-office staff will see a big change. For example, she says, they won't use eCW's messaging system a great deal, because theirs isn't a big office; they'll continue using a light system to tell doctors when a patient has been roomed. Similarly, phone calls will continue to be routed to a triage nurse; the only difference is that she'll document the calls in the EHR and send phone messages to providers' inboxes. Physicians and nurse practitioners already do electronic prescribing, but Osborn says they'll switch from the PocketScript system to eCW's e-prescribing module. Osborn admits that "cultural and social change doesn't come without its twists, turns, and frustrations. But the fact that we know where we want to get to means we can continue to work toward those goals. And within our practice, we've always prided ourselves on having a good structure that can accomplish whatever we want." Plainfield, NJ The practice of cardiologist Saleem Husain, who employs two internists and a nurse practitioner, differs from the other practices in several respects. Not only is it a multispecialty practice, but the group has three offices, in Plainfield, Watchung, and Dunellen. The Plainfield office, where Husain is based, is across the road from Muhlenberg Regional Medical Center, part of the Solaris Health System. That proximity had a direct effect on the practice's choice of EHR. While Husain and internist Kumar K. Ramaswamy looked at several leading systems, including eClinicalWorks, Allscripts and NextGen, they decided on GE Centricity in part because Solaris had installed that brand in its two hospitals and its affiliated primary care practices. That means that Husain's group will be able to import hospital labs and other reports directly into their EHR. In addition, the MSO that's running the hospital group will service Husain's GE software, providing the practice with a local help desk. There were other reasons for picking Centricity, though. One big one, according to Ramaswamy, was that the GE system had better integration between cardiology and general internal medicine than the other products they looked at. He and Husain also preferred to go with a big company like GE that would be around for a while. Both physicians say they expect the EHR to tie their multiple practice sites together. Ramaswamy, who practices in all three offices, points out that the EHR will let him see any patient's chart wherever he happens to be. Similarly, Husain notes that the EHR will give him access to patient records whether he's in the office, in the hospital, or at home—a big plus when patients are admitted at night. Since billing and scheduling are already centralized, it has been relatively easy to add the EHR to the same network, he adds. The practice implemented its EHR during Christmas week—always a slow period in the practice—and will phase in the PM system over several months. "We're trying to do it in a slow transition so the office won't be overwhelmed and there isn't too much chaos," says Husain. "The office can still keep running the way it is." GE Centricity made that choice easier by including a scheduling module in the EHR. The practice dumped its patient demographic data from the current PM system into the EHR and is currently entering data on new patients on both systems. The plan is to gradually move the scheduling to Centricity, with the billing work to follow. To save on transcription, Husain is starting to use Dragon voice recognition software to dictate reports and letters in the EHR. Ramaswamy, who dictates few letters, is documenting mainly on the templates while typing in free text. Both physicians decided to document most visits electronically from Day One, even though they knew it would affect productivity. "If a patient took 15 minutes before, it'll take half an hour to see that patient initially," predicted Husain before the EHR went live. "It'll take us double the amount of time it took before. But as time goes on, that should shorten, and we should be back to the same level we're at now." In any case, Husain was confident that he and his colleagues could maintain their current patient loads. "To do that, you might have to increase your hours a little bit initially, just to keep up the same volume of patients," he said. "But I see that only as a short-term issue." By Ken Terry The Connected Physician Source: Medical Economics Magazine |
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