Regardless of whether or not you use an EMR system, you may already have computerized billing and scheduling. And if you have multiple computers at your practice, most likely these computers operate on some sort of network. Even if you are not the ‘technical’ person in your practice, you should understand the designs and capabilities of computer networks, especially when a complex, multi-user EMR system is finally put into place.

Below are some basic principles of computer network design you should be familiar with:

Networking Basics (WAN, LAN, or MAN?)

Certain network hardware and system software may be incompatible with some EMR and EPM systems. Obviously, you should know this in advance. If you plan on adding users to your network at a later time, it’s often better to buy multi-user licenses rather than individual retail software packages. You can connect computers and printers in a practice on a Local-Area Network, or LAN. The LAN can link up with other local area networks via wireless connectivity. But be sure to check with the vendor of the EMR software to insure that it can operate on a wireless network.

A Wide-Area Network (WAN) can connect other smaller LANs, or Metro-Area Networks (MANs). Large practices can use these WANs to connect multiple satellite offices over a wide geographic area, for example.

The most recognized WAN is the Internet. The Internet can also create the possibility of an Intranet, or a private Internet, on which employees can communicate and collaborate with each other, regardless of where they are located. For such a system to function well between dispersed offices, a hi-bandwidth connection is a must in order to maintain smooth operations. We use an Intranet for such things as employee manuals, a practice Wiki, staff newsletters, photo sharing, and educational materials.

Bandwidth and Topology

Data capacity, or network Bandwidth, is often measured in bits-per-second (bps). In most cases connection rates range from 56kbps to millions of bits per second. Even so, the rates achievable may be limited by the hardware or sometimes even the software used. Overall speed on the network can be drastically reduced when many users are trying to use the system at the same time. If network speeds are slow because the hardware is underpowered or the network design is bad, ‘fast’ connection speed rates promised by the internet service provider won’t really mean much.

Network Topology is also important. Topology is the ‘shape’ of the network, as in the wiring between a series of computers. This topology should have a clean, intelligent design and not simply daisy-chaining PCs in a random, haphazard way. Optimal topography may mean more wires, but this can contribute to overall system resilience from failure due to a weak spot. Otherwise, if one part of the network fails, the entire network could collapse as a result. Proper topography protects against this sort of situation with redundancies. A network consultant should recommend a good balance between expandability and redundancy.

Wiring

In most cases, a practice running an EMR system will employ hard-wired computers connected to a server. However,  some physicians may prefer to input data via a wireless device, as this can be carried throughout the areas in a practice. However, wireless networks present some new points to address:

Signal

Wireless devices have less-than-expected ranges when functioning in an office with many walls. Many consumer-level devices may be inadequate for the needs of a medical practice network. And they may suffer from interference due to common appliances such as microwave ovens or cordless telephones.

Bandwidth

The useful speed on your local network can be limited by the speed of your wireless connection, even if your LAN has good bandwidth rates.

Wireless Security

A hacker can destroy your network if it isn’t protected. Even simple wireless access points need to have built-in security. This is especially important in the age of HIPAA compliance.

Firewall

And speaking of security, you can protect yourself further by having what is know as a firewall. These are software programs, either stand-alone or as part of a hardware device, which protect private networks against intrusion from the outside world. These have become relatively inexpensive for the small business, especially compared to the cost of a successful network attack.

Fat or Thin Clients?

Should you employ laptops (fat clients) that directly run software and connect to your network via a wireless connection? Or, should you run the software virtually with a network appliance (thin client) via a remote connection? With wireless networks, disconnects are an unavoidable reality. In this case, the thin client lets the software continue to run, and you can later pick up where you left off. A broken connection on a fat client may cause a software crash. On the other hand, the latter has certain other capabilities such as running video programs.

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There are many benefits associated with having a computer office network, regardless of whether you are ready to implement electronic medical records (EMR) or not. For example, what may begin as a helpful suggestion from an employee can blossom into a practice-wide tool which can improve overall productivity.

ProtoQue is a program which was developed in response to a problem we were having with our phone triage: we noticed that many patients were not called back in a timely fashion. This program, which is web-based, lets operators register calls automatically. The patient is then subsequently passed off from there to either medical records or a medical assistant. This program manages the ‘chain of custody’ so that the patient doesn’t slip through the cracks. The issue remains open until the problem is resolved. Every time a patient receives a return phone call, a time stamp is created, so our attempts to contact them are documented. The supervisors can use this application to monitor information flow, delegating calls to additional staff if the team falls behind, regardless of where they are located. We no longer have patients waiting until the next day to have their concerns addressed by our staff. Even though our EMR system, like most, has a messaging feature, we still find this program to be more robust and have continued to use it for over three years.

In addition to the phone triage program, we have designed some in-house programs that help us manage specific tasks, and which would not be possible without our computer network:

• The first helps calculate our eyeglass prescription capture rate, which is broken down by location and individual doctor.
• We also have an optical lab tracker program, which tracks jobs in real time, so an optician can tell a patient precisely when their order will be ready.
• Another custom application completes work-orders, and is located on a network that is accessible by IT, Human Resources, and Facilities. If supplies are needed, or a piece of equipment is damaged, an employee can complete a work-order and send it on to the right person. This facilitates full accountability while the chain of custody among the departments is being managed.
• Our Human Resources staff is working on an application that will let new employees enroll using our own electronic interface.
• A new PQRI Tools program which resulted in a significant federal incentive bonus. It attaches to the practice management system and identifies missed reporting before billing.

If you have any comments, please post them here. You can also post any questions you might have about some of our software tools.

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In order to implement important changes at your practice, you must gain buy-in from the staff. The executive search firm Korn/Ferry International cites a lack of employee buy-in as one of the most common management mistakes a new executive makes when trying to implement any new strategies or changes. If this executive fails to take the existing culture into consideration, the initiatives often fail.

For example, consider the controlling manager who arrives at a business only to discover that the employees work collaboratively. This combination can lead to significant struggles. Alternately, let’s consider the savvy executive who approaches the situation with an ability to acclimate, and who discovers ways to work in harmony with the existing culture and style at the firm. The latter approach can significantly assist your efforts to gain cooperation from staff when implementing the transition from paper records to electronic medical records (EMR).

Proper planning and the ability to adjust during the process are two tools that can help you avoid the need to pull the plug on your EMR project, with a potentially disastrous economic effect on your practice. The ‘Change Management’ process, which touts navigating change in a careful and systematic way, is a great tool to employ during this time.

Change Management: 10 Key Factors

1. Be clear and concise in speaking to each individual. Everyone should understand what is happening and what is expected from each. As long as having confidence doesn’t mean being unrealistic, it can be good for morale when problems arise. Be prepared to calm the fears of some staff.
2. The need for change will not go unquestioned. Present your case in a formal, referenced way which proves the benefits of changing over to a paperless system. Users need an incentive to change their habits, and will actually resist using the new tool otherwise.
3. Maintain good communications by keeping a dialogue channel open, encouraging participation at each step. The plan should also include a time line of actions for completion. Make sure to give the staff all the required information in the implementation process.
4. Address the aspects of the culture with explicit intent and detail. People can be expected to learn new skills on a gradual basis, taking baby steps toward learning more about more basic technology (using a computer, using a mouse. etc.), then advancing to more complex systems such as EMR.
5. Problems are a given; expect the unexpected. These may push back the system go-live date, and the effects will reverberate throughout the organization. Use the correct degree of flexibility to manage these effects.
6. When gaining acceptance, start at the top. The top tier of staff members, especially physicians and administrators, should be on board with the program, including any champions for the cause. If you have strong allies with the right technological skill and without a naive level of optimism, that is especially helpful.Resistant doctors in particular can be detrimental to the project, so stay on top of the nay-sayers.
7. Always acknowledge the human aspects. Without acceptance from the staff, a change to a new system could ultimately fail. The prospect of change often adds anxiety to the mix of human emotions, and this should be acknowledged during the process.
8. People should get involved at every level, so that everyone feels they contributed to the outcome. A committee of staff members, formed to create a proposal for delivery to the physicians, is another excellent tool. This committee should be representative of those who will ultimately use the EMR: administrators, business staff, and medical assistants.
9. Always make identifications and assessments of core values and beliefs in a cultural assessment, including possible sources of conflict or resistance. People often become set in their ways, resisting change as a general rule.
10. The leaders of the group should take ownership over project elements. As these staff members have better credibility with their subordinates compared to the physicians, these people are crucial and should be the first trained in the new system (‘super-users’), then passing the info on through training.

Ultimately, every employee needs to buy-in to the change, and for this to occur successfully, a helpful framework is known as the ADKAR model (Prosci):

• A = Awareness of why the change is needed
• D = Desire to support and participate in the change
• K = Knowledge of how to change
• A = Ability to implement new skills and behaviors
• R = Reinforcement to sustain the change

Have you already implemented EMR in your practice? Did you have issues related to the Change Management? Post a comment below and let us know.

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Do you plan on implementing electronic medical records (EMR) at your medical practice? If so, you’re taking on a sizable project. Something this large must stay on a time-line or it may never reach completion. At our practice we experienced some setbacks including back-to-back hurricanes, construction of two new buildings, and hiring of a couple of partners - all of these events pushed the date of launch back over a year. Even so, having a firm date to ‘go live’ helps get everyone on board, allowing them to team together to engage in what could be one of the more challenging changes in their career.

Choose someone to be the project manager in charge of implementing the project. It could either be someone from staff such as an IT person or supervisor, or you could hire an outside consultant. Next, you want a comprehensive plan which covers the how, who, what, where, when, and why of the project from start to finish. Before going forward on your EMR plans, be sure your assets are ready. It just takes one poorly-prepared component to send well-laid plans down the path to failure.

Regardless of the practice, physicians’ attitudes towards EMR will range from gung-ho optimistic to downright resistant. Whoever is in charge of leading the project must decide when all of the physicians will roll-out on EMR, whether in unison or staggered on various launch dates or locations.

Some doctors may be quite comfortable allowing colleagues to test the waters first; but this may lead to more work and stress for the staff. If one doctor sees a patient using EMR, and the patient returns on a follow-up visit with another doctor using a paper chart, how will the patient’s chart be reconciled?

If there are multiple locations at your practice, you may want to implement EMR at one office before going on to the others. However, if your employees rotate between locations, your training plan must take this into account; if too much time passes between the launches at different locations, training may suffer.

Again, a project this large requires a firm commitment from the top authority at your practice, typically a physician ‘champion’, along with buy-in at all levels. One single voice of negativity from someone in a power position can drag down the entire campaign. A managing partner may have to intervene if the practice discovers that a doctor is actively working against the project – your administrator should not be put in this no-win situation. It’s also important that patients are well-informed of  the practice’s goals, so that they are more likely to tolerate the expected delays and hiccups while your team is working out the kinks in the system.

If you’d rather not make the big switch to digital all in one day, you may prefer to see only some patients using EMR. At our practice, we began with new patients requiring complete exams only, to prevent our clinics from grinding to a halt. As these patients gradually return for follow-ups, they continue to be seen using the EMR system. In this way, we were able to launch all locations simultaneously so clinics would not suffer from disparities in employee training and skills. This has also allowed us to gradually ramp up EMR with little effect on productivity.

Other items which shouldn’t be left to the last minute:

• Are your desktop machines or wireless tablets configured correctly?
• Has the software been installed and tested?
• Is there a proper disaster recovery plan in use?
• Is your infrastructure (wiring and wireless networks) ready to go? Adequate bandwidth?

Your schedule should include at least a month of intensive training for staff, which concludes well before the launch date. You may have to rotate staff during the day, or train people after hours at the usual overtime rate. Supervisors must have the ultimate word to ensure that the employees are trained to work with the EMR system in a live clinical setting. Naturally, they will need to practice to keep their skills sharp.

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Although written two years ago, a post by Vince Kuraitis on the e-CareManagement blog seems timely:

“Google Health promises to simutaneously create and dominate the market for next generation personal health records (PHRs). There is nothing else in our solar system or in the entire universe like it.”

What follows is an extensive analysis on the impact that Google could have on not only the individual patient but also on health system reform itself.

So, has anything changed since then? Well, there is still no central repository for PHRs. But with the heated debate about health system reform, Google, Microsoft, and their ilk are trying to stay in the fray. In fact, they aren’t too happy with what they are hearing from the Obama administration regarding health information technology (Health IT).

They would like to see Health IT information rolled out on web-based platforms (theirs, of course) instead of the network of “outdated database systems” that they feel the government is proposing.

What do you think? Do Google and Microsoft have our best interests in mind?

Is your personal health information fair game for free market capitalism?

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In order to implement an electronic medical records (EMR) system, you must have ‘buy-in” from your staff. This means you’ll need firm commitments from the influencers at your medical practice, along with cooperation at all organizational levels.

One Bad Apple

Since one single naysayer can drag down everyone else down, it is important to intervene early. A managing partner may have to interject if it turns our that another physician is working to prevent project implementation. It’s also a good idea to tell your patients about the practice’s upcoming move to electronic records; they’ll be more patient when the practice hits the expected little bumps along the road.

The majority of project managers would cite the ‘people factor’ as the primary cause of project failures, particularly those of the scope and magnitude of electronic medical records implementation. Usually the causes are traceable to ineffective planning and training.

A transition over to EMR can be a stressful situation for some people – this is particularly true if they’re having to learn the system while caring for patients in a live work setting. It’s usually a good idea to specify some key personnel as the go-to people, and these should always be available at the different locations and within the various departments.

Audit Your Training Process

One way to determine if your staff is ready for EMR is to conduct training audits. For example, one practice asked the office coordinator to conduct a course which taught employees to use the upcoming EMR system. These training sessions were held each week. Everything seemed to be flowing well. However, when the launch day arrived it became obvious that some employees didn’t have much skill using the new system.

Unfortunately, their training process didn’t include an audit or a way to evaluate effectiveness on the individual employees. Sending employees to EMR ‘class’ is a good idea in general, but this doesn’t guarantee they’ll understand how to use the new EMR system afterward. Tests should be conducted, and grades issued based on performance. Also bear in mind that skills fade after long periods of inactivity.

Ideally there are ample opportunities for staff to develop and practice new skills during the workday. It’s a good idea to offer after-work tutorial classes as well. Remind your staff that successful implementation is a team effort, and you understand how hard everyone is working to reach this aim. Bottom line: trust, but verify, that everyone is prepared to make the big switch to EMR, with an effective training audit process.

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According to an article by Lou Agosta in B-Eye-Network.com, 80% of healthcare is delivered by medical practices consisting of only 1 to 5 doctors. And most big players in the EMR software system arena are marketing to larger clinics and multi-specialty institutions.

Even existing and proposed open-source systems such as OpenVistA still require significant investments in infrastructure on the part of the clients. And the government seems to be pushing for more open-source solutions, catching the attention of proprietary vendors like GE Healthcare, who may be offering some less-expensive options.

Still, there is a a lot of potential for EMR vendors who can target small medical practices, possibly with the SaaS (software as a service) or ASP (application-service provider) models.

Click here to read the entire article.

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There is a very interesting blog post by Steve Brown that gives us a novel way of approaching the massive challenge that is healthcare reform. While politicians and pundits are arguing about how to spend stimulus bill money, nobody is thinking about how to improve the dissemination of information. This, after all, is the holy grail of EMRs (electronic medical records). Not just the reduction of medical errors but also the great benefits of EHR (electronic health records) which promise greater efficiencies in the delivery of medicine.

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In order for your electronic medical records (EMR) implementation to be successful, you need to get buy-in from your employees. And for that to happen you need some key personnel involved from the get-go. It’s not possible for just one person to handle this task alone, no matter how talented he or she is.

The employees will well understand that a new EMR system will have a profound effect on the practice. They’ll also realize the pressures they are facing at work, and some anxiety is to be expected. Administrators and doctors should understand the top concerns which staff will raise when discussing EMR implementation. And sometimes staff will present with some resistance to the plan.

In our practice we use an integrated EPM/EMR platform but we didn’t switch on the EMR module until we were humming along with the EPM system. Only after the staff were well trained and we had converted all of our useful data from our old EPM system did we attempt to go live with EMR.

We created a group of ‘super-users’; these people were the first trained on elements of the new system, and had the responsibility to bring  the rest of the staff up to speed. Peer-to-peer learning is the most effective, even among physicians. Your super-users should be representative of the various departments, including IT, office staff, compliance, front desk, administration, and clinical.

At our practice we also created an EMR committee that was authorized to hold meetings when necessary – these individuals had run with the project since its inception, and some had put in long days and weekends. They ended up with some decision-making power, as well as the added responsibility that comes along with it. Confidence in the project began to grow from that point on.

Some of the most important staff players include:

Coding/Billing Specialist

This person should have a voice in the initial software selection process. Having their expertise helped to minimize the hiccups we experienced when we switched from our old practice management (EPM) system to the new one. On their recommendation, we performed a trial run on the new system prior to completely abandoning our old system. This allowed our IT specialist to verify that the posting and billing were being performed correctly. Someone technically proficient with coding and compliance issues will be invaluable when your EMR  system goes live – to prevent under- or over-coding and ensure HIPAA compliance.

Clinical Staff

Although not as vital during conversion of your EPM system (unless you are using an integrated system), their participation will be key to the success of the integration of the EMR into the practice. Therefore, it is important to for them to be involved in the early stages of planning; it is helpful for them to have an appreciation for what the non-clinical staff does on the EPM side and how the EMR will fit into the scheme of things.

IT Specialist

This person should be involved from the beginning, even prior to choosing the EMR software. If a practice cannot initially justify the expense of a full-time IT specialist, at the very least an IT consultant should be retained. Because we knew that conversion to EMR was just part of our overall strategic technology plan, we felt we could easily justify hiring a full-time IT specialist. In fact, due to this person’s expertise in such areas as software licensing, internet communications, and hardware networking, the changes that were incorporated into the practice saved enough to cover part of his salary.

Front Desk Staff

They provide valuable input from the perspective of the end-users of the EPM. Their tasks include check-in, check-out, posting of charges, and scheduling. Their critical job prior to the EMR rollout was to help test the design of the posting process at the time of patient check-out. Once we went live with EMR, they had to learn to post the charges electronically in real-time. Having time to get the bugs out of this process helped support our decision to postpone implementation of EMR until the staff was well acclimated to our EPM system.

At our practice the doctors empowered the EMR committee with authority to manage and plan the EPM/EMR integration. Managing partners continue to meet regularly with the administrator for status reports. They also meet with IT to continually tweak the system to improve efficiency. Bottom line: the overall success of the project will depend on the cooperation and involvement of everyone at the organization.

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A recent article in the AMA news discussed some of the continued ambiguities of the “Meaningful Use” prerequisites handed down by the Health IT Policy Committee. Nevertheless, it does give everyone an idea of where they are headed. Generally speaking, meaningful users are defined as healthcare-providers who are using E-Prescribing, that their EMR technology is connected in such a way that there is an electronic exchange of health information, and that clinical quality measures are submitted to the government via electronic means.

For practices that fail to have meaningful use by the end of the set timelines, not only would there not be incentives, there would actually be penalties in the form of reductions in Medicare reimbursements – unless the practice could demonstrate some type of financial hardship that would prevent adoption of EMR.

If you don’t think the financial incentives are worthwhile, thing again. SoftwareAdvice.com has a nice explanation of what medical practices have to gain by getting the ball rolling and not waiting until the perfect EMR solution falls out of the sky and hits them in the heads (note: it ain’t gonna happen).

To give you an idea of the timeline we are talking about, here is a graphic from a committee report (courtesy of Digitized Medicine). So, what are you waiting for?

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