EMR Implementation – How do you stack up against your colleagues?
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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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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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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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