EMR Implementation – How do you stack up against your colleagues?
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It doesn’t matter if your practice is just a single doctor at one location, or numerous physicians across multiple satellite offices. Either way, even before you can implement an EMR system, you’ll need to start by developing your system infrastructure. Although typically a contractor will take care of the network wiring for your office network, it is still a good idea to be familiar with some issues related to network wiring as well as terminology so you don’t get taken advantage of. Consider using a contractor who has been certified by the Building Industry Consulting Service International (BICSI), as this certification is the standard for contractors who deal with complex data and voice cable installations.

Some of the specific issues with which you should be familiar include:

Wiring: Typical Cat5e network wires have either a T568A or T568B standard. Select either, and be sure everything is wired to the same standard. The Cat6 wire standard is newer and more expensive, possibly a bit much for most medical practices. Copper wires between telephone communications closets shouldn’t contain segments over one hundred meters. Consider using fiberoptic cable for wiring over longer distances, as these cables can move more information and aren’t as vulnerable to interference and lightning. Fiberoptic, however, is more expensive.

Wireless: Are you considering wireless networking, also known as WiFi? If so, you will have to select a standard: either 802.11a, 802.11b, 802.11g, or 802.11h. Some newer standards provide higher data transfer speeds, but cost significantly more. The wireless standard that you choose should depend on whether you’re running a thin or fat client ( see Designing the Office Network for more about thin vs fat clients. Also, beware of interference from such common devices as cordless phones and microwave ovens.

Overwire: Most existing buildings are wired above the ceiling. Wiring is then dropped down the walls. When wiring, I would recommend ‘double drops,’ as the largest cost of wire installation is the labor. You will thank yourself later when you want to add more network devices (scanners, printers, diagnostic equipment, etc.), as these additional network connections will already be there.

Cooling: Network and server equipment create heat, and tend to shut down when over-heated. Plan for this by being sure that you have adequate cooling – you may want to consider installing a small, dedicated air-conditioning unit.

Electrical connections: It’s a  standard IT practice to have a certified electrician install isolated circuits for your network and servers – usually the outlets are orange so you can tell them apart.

Security: Don’t forget about security! Make the wiring closet secure, and remember that anyone with access to this closet can dismantle your network at any time.

Multiple locations: You’ll have to create a WAN, or wide-area network, to make a connection between remote office locations, so do your research and check out all your options. Larger metropolitan areas will generally have more options available for wide-area networks.

Fiber Backbones: Local utilities commonly maintain a fiber backbone which they allow businesses to access. These fiber backbones allow for high bandwidth rates between office locations (10-100Mbps) at a reasonable cost.

Local Phone Service: Meet with your local telephone sales people and service technicians. They understand the offerings in your geographic area. Some of the key points to discuss are:

• T1 lines: would a Metropolitan Area Network (MAN) or a Point to Point (PTP) be better?
• Inquire about both burst and committed information rates. A fast T1 connection may not cut it if the maximum isn’t available when you need it most.
• Will the phone company supply you with and maintain your router hardware, or will you need to take on this task yourself?

The costs of network infrastructure are much lower in new buildings. Apart from easier (and less costly) installation, the ability to oversee the network wiring in a building under construction is an advantage for clear design. Unfortunately, the majority of practices are located within existing buildings, so sound design and forethought in planning will help save your practice excessive costs and headaches later.

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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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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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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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EMR Update 4 – follow along as Ocala Eye implements its EMR system

This Issue:

• The importance of running an EMR simulation
• Evaluating the effectiveness of your staff training

Podcast: Download (Duration: 8:15 — 1.4MB)

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As I wrote in previous posts, the technical side  of the electronic medical records (EMR) implementation process, namely which EMR system to use, is probably the least critical component.

The most important things are ultimately related to the people side or what is known as ‘change management’. For EMR, this boils down to the implementation plan (which we discussed earlier) and the training plan.

The EMR training plan can be broken down into three steps:

1) Identify current skill levels. Many of your employees are probably recent high school graduates andhave grown up making cell-phone calls, emailing, and texting. These are the people you need to worry the least about.

(more…)

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We’ve all heard the proverb, “He who fails to plan, plans to fail.”

This is certainly the case in the majority of failed electronic medical records (EMR) implementations, and usually the physicians/ administrators/ owners (circle your choice) bear the responsibility. Since this may well be the most difficult (and expensive) project your medical practice will undertake, it literally pays to have a good plan in place.

Implementation of an EMR system is truly a formidable task and the logistics can be overwhelming. We realized that we would need an integrated plan that would tie together both the technical side of the project with training in order to maximize efficiency, making the best time and use of our staff and contracted help.

So we worked with a project manager to break our EMR implementation project down into major processes and then (more…)

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EMR Update – follow along as Ocala Eye implements its EMR system

This Issue:

• Train the Trainers
• Utilize the “Gee Whiz” Factor
• The Who, What, Where, and How of Scanning Old Paper Records

Podcast: Download (Duration: 13:07 — 2.3MB)

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