One of the goals of meaningful use and all the related federal spending of health IT is for EMRs to improve care coordination. But the current reimbursement system that’s heavy on fee-for-service encourages software developers and users alike to focus on documentation of billable events rather than coordination of care, a new study finds.

Read more on EMRs and care coordination

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The Centers for Medicare and Medicaid Services (CMS) announced today a proposed outline for Meaningful Use criteria, in accordance with EMR implementation provisions under the Health Information Technology for Clinical and Economic Health (HITECH) Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009. These specify some of the guidelines by which physicians can receive incentives of up to $44,000 per provider, over 5 years, beginning as early as 2011.

Stage 1 criteria (the first of 3 total) would cover 25 meaningful use objectives (and 23 for hospitals). These are listed under modules known as Health Outcomes Policy Priorities such as Improving quality and patient safety (use of drug-allergy interaction checks, use of ePrescribing, maintaining active medication list, etc.), Engaging patients and their families in their health care (e.g., provide patients with a copy of their health information), Improving care coordination (e.g., exchanging key clinical information among authorized entities), Improving population and public health (e.g., capability to submit data to immunization registries), and Ensuring adequate privacy and security for personal health information (through the use of appropriate EMR technology).

The implementation of Stage 1 meaningful use standards would begin in 2011. Stage 2 (which would essentially expand upon certain aspects of Stage 1) and Stage 3 (which would deal with achieving improvements in conditions of a national high-priority nature and population health outcomes) would follow later.

While this certainly doesn’t clear things up completely for the individual physician, every piece of information that trickles down from Washington is eventually analyzed and translated for all parties which have a vested interest in the process. Hopefully, resources such as this can help doctors stay informed and as up-to-date as possible.

If you have any comments or questions, please post them here. If we don’t know the answer we’ll certainly try to find someone who does.

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EMR Implementation – How do you stack up against your colleagues?
We’ll post the results in a week or so.
Click the Next button after you answer each question

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Previously, I described some of the benefits gained from having an office computer network, even if you haven’t yet implemented an electronic medical records system. At our practice, even as we prepared for EMR, we began to see unexpected benefits. At that time, the thought that a computer network could help improve overall efficiency in the practice was met with skepticism from staff, especially some of the doctors. Over a year later, I was pleasantly surprised at the variety of ways that the office network makes our practice work smarter.

Emailing Documents Instead of Printing

Any forms that have to be distributed throughout the practice are ‘printed’ as PDF files and emailed, instead of printing memos and physically handing them out. This also allows the sender to keep a record of what has been sent. I have also used this to scan and email important documents to myself, which can then be shredded, so I don’t have to drag paperwork home from the office.

Document Repository

The redundancy and security of our servers makes them ideal to store private (for an individual’s use only) and public (for use by all staff members) documents. Some of the doctors use these to backup important personal or financial information. Large documents that are frequently updated, like employee manuals, can be accessed electronically without the need for wasting massive amounts of paper at the slightest change. It can also be used for important timely documents such as a practice-wide Influenza Pandemic plan.

‘All Hands’ Alerts

Previously, someone would have to call the satellite offices to try to locate a missing chart or document. Now an alert is sent to everyone in the practice via the network. This has significantly cut down on hours spent on this process.

Security Issues

Prior to setting up our practice-wide network, we had a rag-tag collection of PCs which were unsupervised. Any employee could send email or access the Internet with impunity. Now that the amount of bandwidth needed for our EPM and EMR is critical, unauthorized use of this resource is a problem. Our administrator can access email or Internet usage and determine its appropriateness. It is important to note that employees should be instructed that use of practice computers is not considered personal and is subject to scrutiny.

Batch Scanning of Paper Documents

Temporary workers help handle the load of documents which need to be scanned into the EMR system – these include laboratory data, personal documents, or medical records from other physicians. The batches are then processed by clinical techs, from whatever location they may be at, and placed in the appropriate patient files.

Public Outlook Folders

Our executive secretary posts the doctors’ social schedule, meeting schedule, and on-call schedules. The clinical supervisor posts announcements, memos, and meeting minutes. The doctors have also posted any articles of interest to others for viewing. Our marketing director posts ad tracking data, as well as advertising proofs for review. Our EMR committee has a shared task-list folder for sharing progress on template changes or other projects.

Confidential Documents

Our bookkeeper and business office personnel can send certain critical documents electronically with password-protection.

Computerized HVAC Control

We installed this system at our ambulatory surgery center. It tracks temperature and humidity throughout the building and plots these on a graph. Our nurse administrator can optimize the system depending on the use of the facility, and can even remotely monitor the system from home if there is a problem at night or over the weekend. We have been able to run the building much more efficiently, recouping half of the system cost already from energy savings.

Networked Devices

Expensive peripheral devices such as color laser printers can be shared among employees, making them more cost-effective. Newer diagnostic equipment is frequently network-ready, so reports can be accessed from anywhere in the practice without having to print and fax, saving paper costs on both ends. Cameras are also networked so images can also be seen electronically instead of using expensive photo paper.

Employee Intranet Portal

This is basically an internal website for staff members only. What started out as a simple way of communicating within the practice has grown into a myriad of tools, from critical ones to fun ones:

• Practice Wiki – from the Hawaiian word wiki meaning ‘fast’, a wiki is a simple website that can be easily edited by many different users. We use this to post manuals and how-to’s for every kind of task or project.
• Employee blog – this is a website managed by our marketing director and keeps the staff up to date on practice news. Employees can also post news of interest to their colleagues which makes it a great morale booster.
• Security cameras – these networked cameras can be accessed by physicians and supervisors. Buildings can be checked on remotely during off-hours or during periods of bad weather. They can also be used for theft deterrence.
• Doctor scheduler tool – supervisors can check all the doctors’ schedules at a glance to determine optimal staff scheduling.
• Work order system – our staff utilizes an online work order system for department-specific issues. Examples include printer cartridges needed at a particular location, a leaky faucet at a satellite office, or a new employee who needs orientation, security codes, or time card access. These ‘orders’ would then be distributed to the appropriate department (physical plant, clinical supervisor, IT staff, HR staff, etc.). In the past, this required phone calls or paper messages which would invariably get lost.
• EMR Bug Tracker – this is a tool used to post problems or ‘bugs’ with the EMR system. These can range from misspelled words to a template that crashes to a wish list item. Our IT department can prioritize these on the fly.
• Various auditor tools – these are used by different supervisors to monitor things such as schedule changes, use of the EMR medication module, coding audits, or triage workflow, to name a few.

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One of my partners asked if our practice could use free GMail instead of replacing our old and failing mail server (not free) and having to purchase the licensing for the Microsoft software (definitely not free). When I looked into it, it turned out to be a bit more complicated than just deciding between a free mail service or one that has recurring expenses.

You see, with the advent of recent privacy regulations, there are increasing responsibilities being placed on the shoulders of medical practitioners to insure the protection of patient medical information. Before we get down to the details, let’s discuss some terminology:

Privacy vs. confidentiality. According to Gary Kurtz, in an article in the Journal of Healthcare Information Management, privacy is the right of an individual to control disclosure of his or her medical information. Confidentiality is the understanding that the information will only be disclosed to authorized personnel. This is what is known as a “need to know” basis.

Information Security. Since patient information will be increasingly common in a digital-only format, loss of electronic medical records could have an adverse impact on patient care. So it is up to the guardian of that information, typically the physician, to ensure that there are proper procedures for protecting both the safety and the integrity of that data.

The data safety relates to such issues as access to the information with minimal downtime, proper backup of the data with redundancy, and a disaster recovery plan which is regularly tested.

Integrity refers to processes which insure a true, uncorrupted and legal record. Most EMR systems maintain what is known as an audit trail, which tracks every change made to a record, when and by whom. Without an audit trail, it would be nearly impossible to tell if a patient’s record had been altered. Imagine a physical chart written on a dry-erase whiteboard – changes could be made at any time without discovery.

That said, the two main issues of information security relate to Who is controlling the information and Who has access to the information.

Who controls the information. Previously we discussed the two main types of EMR systems available: server-based and web-based. In server-based systems, the patient data is typically located on a computer or server in the doctor’s office. The upside: the doctor has ultimate control over the information. The downside: the practice is responsible for maintaining the security of the patient records, something which most medical practices have little experience with.

In a web-based system, the doctor accesses the EMR system via the internet, and the data is located off-site, usually on the server of the EMR vendor or a third party. The upside: these entities usually have a lot of experience with information technology security processes as well as the resources to implement them. The downside: the information may be stored on the same server as information from other medical practices; there is the potential for the information to be accessed by someone other than an authorized party. In addition, loss of the internet connection means loss of access to your patient files.

Who has access to the information. As stated above, access to patient information should be on a “need to know“ basis. There may also need to be additional provisions for restricted types of visits such as patients with HIV, mental health issues, or those undergoing drug treatment.

HIPAA (the Health Information Portability and Accountability Act) determines how patient health information may be shared electronically. So a medical practice would need, according to HIPAA language, to insure the confidentiality of the patient information not only within its domain, but would also need to take any steps necessary to make sure that third parties who have access to the same information (outside vendors, laboratories, consultants, etc.) maintain confidentiality as well. This could even be carried, in the extreme perhaps, to anyone who potentially has access to patient records, such as cleaning service companies or maintenance contractors. A practice would be well-advised to sign Business/Vendor Associate Agreements for HIPAA compliance with these companies. You can find many examples of these online that you can use.

Other potential gaps in information access include:

• computer monitors within sight of other patients (these should be locked if an employee leaves her station)
• printers or faxes located in ‘public’ locations
• lost or misplaced laptops or thumbdrives with critical information and without password protection
• passwords taped on monitors (you should have a strict password policy including passwords which expire periodically)
• doctor or staff smart-phones or PDAs which are not password-protected
• a wireless network in the office with inadequate security encryption
• unattended EMR workstations (these should automatically lock after a short period of inactivity)
• unauthorized software downloads which could allow breach of the network

So, going back to our story about GMail…for a medical practice to use GMail for its email service, it would need to enter into a Vendor Associate agreement with Google Inc. and require Google to adhere to the practice’s procedures and policies for privacy of patient information (and every medical practice that used GMail would have to do the same). Needless to say, Google is highly unlikely to agree to signing these types of agreements with possibly thousands of doctors, and be potentially exposed to significant liability.

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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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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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If you talk to anyone who is involved in the electronic medical records (EMR) industry, one of the biggest points of discussion is what is known as “Meaningful Use of EMR.” What started as a well-intentioned (by some) effort to establish standards for EMR software systems has morphed into political jockeying by corporations, consumer watchdogs, and others.

The US Dept of Health and Human Services (HHS) outlined these criteria for Meaningful Use of EMR:
1)    Improve quality, safety, efficiency, and reduce health disparities
2)    Engage patients and families
3)    Improve care coordination
4)    Improve population and public health
5)    Ensure adequate privacy and security protections for personal health information

And although each of these has defined goals followed by specific objectives and measures for the years 2011, 2013, and 2015, these still sound a bit ambiguous. Many industry experts, however, expect these to be more fine-tuned as the dates approach, but medical practices will have to stay informed to keep ahead of the curve.

Financial Incentives

As part of the ARRA (American Recovery and Reinvestment Act of 2009), financial incentives will be given to those physicians whose practices demonstrate “meaningful use” beginning January, 2011.

The incentive payment, according to CMS, is equal to 75% of Medicare-allowable charges for covered services in a given year, and maxes out as follows:

• Year 1 – $15,000
• Year 2 – $12,000
• Year 3 – $8,000
• Year 4 – $4,000
• Year 5 – $2,000

For those practices who are early adopters of the technology and hit the threshold for meaningful use in 2011 or 2012, the first year payment would be $18,000. Note that this only applies to Medicare; there are additional incentives for healthcare providers who have a certain threshold of Medicaid patients and/or who practice in a rural area. The threshold for office-based pediatricians is lower, and so they would be more likely to qualify for those additional funds.

[table courtesy of SoftwareAdvice.com]

Even considering the fact that EMR implementation may cost anywhere from $10,000 to $50,000 per provider, these incentives would certainly make that investment more palatable.

Those practices that procrastinate, however, will be penalized with cuts in Medicare and Medicaid payments:

• 2015 – 1%
• 2016 – 2%
• 2017 – 3%
• 2020 – 5% (maximum reduction)

So, how do you know if you qualify? According to the health IT blog NetDoc, to be a “meaningful EHR user”, a physician must satisfy three criteria:

1. Must use “certified EHR [EMR] technology”
2. Must demonstrate that the certified EHR technology is connected in such a way that it provides for the electronic exchange of health  information to improve the quality of health care, such as promoting the coordination of care (using HL7 or XML standards)
3. Must submit information on clinical quality measures specified by HHS (such as PQRI)

Some physicians have told me that because there isn’t a final definition of what is considered “certified EHR technology” they are just going to wait. Big mistake. Most health care IT experts working on and advising on this issue feel fairly strongly that the Office of the National Coordinator for Health Information Technology (ONCHIT) will set CCHIT (Certification Commission for Health Information Technology) criteria as the standard for EMR certification.

CCHIT is a non-profit organization funded by various corporations and groups such as the American College of Physicians and the American Academy of Family Physicians, and was recognized by the US Dept of Health and Human Services (HHS) as a certifying body in 2006.

Some critics, however, charge that CCHIT is a shill for the Healthcare Information and Management Systems Society (HIMSS), the healthcare industry’s membership organization focused on healthcare IT. Although made up of both corporate and individual members, these critics feel that their goal is to corner the market for certain major EMR players. Nevertheless, unless or until there is an alternative, most EMR vendors are using CCHIT certification as the benchmark.

In addition to the EMR certification criteria, the ONCHIT is expected to adopt an initial set of standards and implementation specifications by the end of the year 2009.

Timeline

So, is too late to implement EMR in your practice and still qualify for the financial incentives? Well, that depends on the size of your practice, type of specialty, and how motivated your doctors and staff are to go paperless. Just don’t expect to run down to Office Depot, buy an EMR program and launch it the next day (although there is talk about WalMart getting into the EMR business, but we’ll leave that story for another day…)

According to MBA HealthGroup, these are some reasonable time frames to expect for EMR Implementation:

• Stage 1 – up to 6 months – researching vendors, getting buy-in, setting up an EMR committee, checking out demos, and making a final decision on the EMR system
• Stage 2 – up to 5 months –  time it will take to actually ‘go live’. In the meantime, adapting workflow to EMR system you chose, ordering hardware, and standardizing processes
• Stage 3 – between 6 and 12 months – amount of time it will likely take to achieve “meaningful use”, which includes ePrescribing, documenting electronically, and ability to report certain items (which are still being determined)

[timeline courtesy of MBA HealthBlog]

Smaller groups and solo doctors may be able to purchase a more basic, “out-of-the-box” EMR system and more quickly adapt their workflow to the system, rather than vice versa in the case of larger medical practices. But, the one thing you can count on with EMR implementation is that you can’t count on anything – that is why some sort of timeline is important [see EMR Implementation Rollout].

What this boils down to is that those practices that have already started implementing EMR will have a good shot at getting those higher financial incentives. On the other hand, physicians who have been wishing that the whole idea of EMR was just a fleeting fad may not only miss out on these incentives but may also face cuts in their reimbursement.

Questions? Comments? Post them below

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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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