Our practice went live with our own EMR system in late 2008. For the most part, this was uneventful. The reason for this was mainly due to proper planning. And credit for our implementation plan goes primarily to our administrator, our IT director, and staff members of our appointed EMR committee. Although some of the physicians were an integral part of the committee, we tried our best not to micromanage the process. We also made the decision to gradually roll out EMR, instead of trying to convert all our patients overnight. As a result, there was no loss of productivity for the entire practice. And these days especially, every dollar counts.

It is estimated that no more than 20 to 25% of medical practices in the US are using EMR as of this writing. Why? Practices site cost, waiting for the right EHR, and concerns about recouping their investment as some of the reasons why they’re holding off on their decision. For practices that are not yet using EHR, here are some words of advice that hopefully will guide you along the way.

Doctors tend to like gadgets so their inclination is to focus on the software. This is usually a mistake. As in many technology implementations, sometimes the who is more important than the what. The following is a list of implementation steps from a guide I wrote, Navigating the EMR Jungle. Notice that the software itself is not mentioned until step 5.

1. Decide you need to do something. Why are you doing this? The financial incentives? That’s very nice, but you need more than that to motivate your organization and see the project through to its successful end. Some other good reasons would include improving patient care, improving coding and reimbursement, improving practice efficiency.
2. Assess your needs. What kind of system you need? Does it have to be wireless? Does it have to work between multiple offices? Other things to consider: how much you want to spend, whether or not have an in-house IT person, whether or not you want to control your own data or let it be hosted elsewhere, and what your timeline is.
3. Form an EMR committee. This should include key members from different departments including billing, clinical, and administrative. You should also involve an IT specialist early in the process, even if it means hiring someone from the outside. Just make sure it’s someone with medical IT experience, not your nephew the tech geek.
4. Involve the doctors. All of the doctors, especially those who are resistant to change. I’ve written previously on the dangers of naysayers; it only takes one person in a position of power to scuttle your entire project. Bottom line: grease the squeaky wheels first. This means spending extra time with them on training, answering concerns, and getting their templates up and running first.
5. Create a short list of vendors. By this point, your EMR committee should have whittled down the plethora of software vendors to some key players. Now is the time to get the key decision-makers involved in performing demos, checking references and interviewing the companies on the short list before you ask for proposals and ultimately purchase one. Don’t rush this decision.
6. Plan your implementation. This is a critical step in the one where many practices fail. You must find a balance between easing into a new way of doing things and not disrupting your revenue cycle unnecessarily. It’s best to allow for a gradual rollout so that the clinic and the billing office can work out the kinks. Converting all patients to EMR overnight is usually ill advised yours is a very small practice (and you only have yourself to yell at if things go bad).
7. Organize a training schedule. With about 150 employees, it wasn’t practical for us to train everyone at the same time. We put a dozen old computers in a spare workspace and created a classroom. Staff members were rotated through training as their schedules permitted and after hours (yes, this was an overtime expense). Supervisors were tasked to audit their training and send any employee back to the process if they needed to improve upon certain skills.
8. Run a simulation day. We credit this for uncovering some key problems that otherwise would not have been detected until we went live. We brought all of the doctors and clinical staff in on a Saturday and ran other employees through simulated check-in, work up, exam, and check out. Everyone complained about having to do this, but was thankful when the big day finally came.
9. Go live! If you’ve done everything right up until this point, this should be anti-climactic. Nevertheless, it still stressful, especially when there is a hiccup (and hiccups should be expected).
10. Assess current set up and plan next steps. EMR in your practice is not so much a project as a process, so constant assessment and feedback is critical. As such, there is a huge potential for improving the way you practice medicine.

I recently had the opportunity of asking members of the Large Practice Interest Group (LPIG), a workgroup comprised of 18 large ophthalmology practices that are early adopters of new technology and  management trends, for their words of wisdom for practices considering the EHR. Here’s what they had to say:

Keith Casebolt, CEO of Medical Eye Center of Medford Oregon, advises practices to “plan for training, more training, then add 25% !” His practice adopted Medflow’s electronic medical records system about six years ago. Another word of advice: there must be a specific person who “owns” the EHR, someone to stay on top of upcoming changes and who has the authority to make decisions. “Essentially [the project manager is] a new job and you need to recognize and budget for that.” He also stresses the importance of spending a lot of time in due diligence, making site visits, and attending user meetings. Lastly, make sure that you have properly assessed the level of support for this important project. “You need a lot of people rowing in the same direction, with no anchors.”

Andersen Eye Associates, in Saginaw, Michigan, is a NextGen EHR user. Kurt Beuthin, the practice CEO, says practices should get their EMR vendor to project what IT expenses are expected to cost given the size of your organization and the scope of the implementation. “Ongoing IT support costs have been more than anticipated,” he says, “and it would have been nice to have had this information from the beginning.”

Donna Davis, administrator of Atlantic Eye Physicians, in Long Branch, New Jersey, is currently involved in her second EMR conversion (and fourth practice management system conversion). She stresses the importance of keeping entire staff motivated. “We brought all key staff into the selection process and at every meeting I made sure to state what benefits the new system would give us operationally.” In contrast to other practices that I spoke with, they are planning to convert 100% of their patients when they go live upon the recommendation of their EMR vendor, IO PracticeWare.

The importance of staff training was stressed by all of the administrators. Hayley Boling, administrator of Boling Vision Center, in Elkhart, Indiana, says, “ongoing training is essential, especially for your staff that is not computer-savvy. Having qualified staff members that are able to troubleshoot issues that arise along the way is imperative. These issues happen frequently.”

In our own practice, there was significant angst when we first proposed going paperless, but that quickly changed. Ann Hotaling, Director of ASC for Ocala Eye, says, “Rest assured that the staff and physicians will give you pushback when you start your EMR project. But within a year you will get pushback from trying to hand them a paper chart. They will adapt.” She also recommends cross training your key computer staff. It is not uncommon for a networking person to be unfamiliar with the EMR software; conversely, someone who is good with the program and templates may have trouble troubleshooting a hardware glitch. It also helps for the lead technical person to be fluent enough with the clinical aspects of the EMR program to be able to communicate effectively with the physicians.

Some practices have had major problems with their EMR implementations, but their advice can be especially valuable. One partner in a four-doctor practice, who wishes to remain anonymous, said that “Ours is a case study in how NOT to implement EMR.” Their previous practice administrator chose the software, no due diligence was performed, and the doctors did not demo it prior to going live. Over time they came to the realization that software was primarily designed for solo practices, and they have had to deal with numerous technical problems including frequent software crashes. “It has been a very frustrating endeavor.” He says the choice of this particular company was in large part to try to reduce their capital outlay, but in the end it has cost them more in the long run in terms of decreased productivity. They are more than a year out and the issues are still not fully addressed. In addition, they have noted a decrease in job satisfaction among their technicians.

Below are some more pointers from our administrators (as well as a few technical considerations thanks to Kathaliya Folds from our IT department):

Before Purchasing EHR

• Strongly consider an integrated EMR/EPM
• Make sure it fits your workflow – this is better than trying to adapt to the software
• Make sure can it interface with other systems you have – practice management as well as diagnostic
• Check references; do a site visit with the same software, preferably in a practice of similar size and in your same specialty
• The software doesn’t have to be specialty-only, but the company should have proven experience with your specialty
• Consider ditching an old legacy system if it is not working out/cut your losses early
• Consider software-as-a-service versus hosted locally if you are a small practice
• Get input early in the process from a technical person – someone needs to be able to speak the same language with the EMR vendor to avoid misunderstandings
• Make sure the specs you get from the EMR vendor are scalable and that the system will grow as your practice grows without difficulty
• Make sure your office infrastructure can support the EMR system you want the way you want to use it – wireless devices, video streaming, multiple locations, high-resolution imaging, etc.

Implementing EHR

• Keep your patients informed and ask for their patience
• Have a ‘point person’ or ‘super-user’ in each location who acts as trouble-shooter and motivator
• Use a “train the trainer” model. Have the EMR vendor train your key employees who then train the rest of your staff – these can then become your ‘super-users’ that others can turn to with their questions or problems
• You should definitely have an EMR ‘champion’ to see the project through to the end
• Consider having your own full-time IT person on staff
• If you can’t afford your own IT person, hire someone locally – the EMR vendor is usually too busy to give you rapid support on most issues
• Budget liberally for ongoing IT/EHR expenses
• Realize that you might have to spend a little more time with the less tech savvy doctors getting them up to speed with the software
• Take bite-sized chunks. Employee a phased rollout beginning with certain types of patients and adding other subsets as doctors and staff become acclimated.

Using EHR

• Get patient information into the records prior to the visit if possible
• Take advantage of template customization by doctor, by type, by type of test
• Use macros for quick plans – they take a little work to set up but can greatly increase your efficiency
• Take advantage of built-in capabilities such as printing out patient instructions and educational materials
• Realize that EHR is an ongoing process and constant tweaking is required
• Consider an audit process to ensure you are continuing to capture key exam elements, testing interpretation and history

The best advice from all of this is to seek counsel from those who have ‘been there and done that’ – don’t try to reinvent the wheel. Most practices who have been through EHR implementation are more than happy to share their experiences or host a site visit.

Peter J. Polack is an ophthalmologist who blogs on medical practice management and electronic medical records implementation on Medical Practice Trends.

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