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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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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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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Medical practices that are planning to get an electronic medical records (EMR) system in the near future will also need to consider whether they will be keeping their existing practice management software (EPM). Many factors come into play and we will discuss the pros and cons another time. For the purposes of our discussion, let’s assume you decided to upgrade to a new EPM that comes integrated with the new EMR system.

What do you do with all of the existing patient insurance and demographic data?

Keep it or throw it all away?

First, a little background. It is the year 1998 and businesses around the world are beginning to panic about the impending specter of the Y2K (year 2000) crisis. You remember – all computers will stop working because nobody thought to put the year in four digits instead of ‘19’ followed by two digits. (more…)

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Ask any doctor,  what is the first thing you should buy for an EMR implementation and the response will be, “The EMR Software, of course.”

Wrong! Ask any non-medical person involved with EMR implementation and his or her opinion would be that the EMR software is the last (or one of the last things) to choose.

But let’s assume that you already know that there are some basics that must be set up first, such as your building’s infrastructure, your network design, determining staff skill sets, etc. (If not, then check out this blog for previous posts on these topics before proceeding).

In this article, I¹ll discuss how to decide on both an EMR software vendor and the actual EMR software. (more…)

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