Improving Practice Efficiency With Convenience Applications

Computerized practice management systems appeared about thirty years ago. Their major selling point? To automate humans out of as many processes as possible to reduce error and improve efficiency. Medical practices are attempting to achieve those same goals through the use of  electronic medical records (EMR) systems. But trying to eliminate humans entirely from the practice of medicine is a fool’s errand. Relying increasingly on technology without acknowledging the human element is a recipe for failure.

People will always be an integral part of the practice of medicine but there are ways that technology can leverage their effort for the better. Known as ‘convenience applications,’ these software programs range from free to under a couple of thousand dollars – compared to tens of thousands of dollars for your typical EMR or practice management system. And in contrast to the latter, convenience apps are specifically designed to assist humans to be more productive and profitable doing those tasks which can’t be completely automated. They help your staff do the right things (effectiveness) and do the things right (efficiency).

Due in large part to the ubiquity of such devices as mobile devices, these apps can be found in a multitude of areas from time and task management to collaboration and communication. If you own an iPhone or other smart phone, you’re probably using several of these already.

So how can these help you in your practice, you may ask? Let’s just take two areas of interest as an example, process documentation and project management.

Process documentation

Your medical practice is nothing but a bunch of processes. But, as W. Edward Deming, a pioneer in quality management, once said, ” If you can’t describe your process you don’t know what you’re doing.” Simply having well-trained, knowledgeable employees doesn’t help you very much if these employees leave and take their knowledge with them. By documenting all of your processes, you can standardize them, squeeze the variability out of their execution, and ‘clone’ your A-teams by ensuring the transfer of that knowledge.

If you are a solo practitioner with a handful of employees, you may think this is overkill. You are constantly teaching your staff how to do various tasks, so what’s the use of writing things down? But what happens when employees leave and you find yourself repeating this process ad nauseum?

A slightly bigger practice is more likely to document things (once) in a written employee training manual, but this is of little use in the middle of a busy clinic day. This is what is known as “just-in-case” learning, and it relies on filling workers’ minds with tons of information that they may or may not ever need to use. It also requires constant retraining and reinforcement so that, should that knowledge ever be needed, the employee will hopefully remember it.

On the other hand, documenting your processes, ideally in a digital format, employs “just-in-time” learning. All that a new or temporary worker would need to know is how to access your process flow maps and follow the specific steps as illustrated. And an existing worker could fill in for an absent one without having to formally cross-train for that position – she can merely consult the documented processes and get the job done. Another great feature of digital process documentation is the ability to use employee feedback to constantly tweak processes for improvement. In contrast, an employee manual merely tells workers what to do but not necessarily how to do it better, and is only updated infrequently.

Examples of Process Apps: SmartDraw, Google Docs, Microsoft Visio, Gliffy.

Project management

Anything that takes two or more steps and has a beginning and an end is called a project. This can be anything from a simple remodeling of an exam room to something as complex as implementing electronic medical records in your practice. Keeping true to the concept of knowledge sharing, project management should not take place in someone’s head but in a tool specifically designed to promote collaboration.

Project management apps can display timelines with dependencies, task staff members with automated reminders, and allow managers to display the progress of the project at a glance. They keep everyone on the same page at all times. And they are more flexible than calendars. Just try scheduling a multi-step project in a calendar and see what happens if one of those steps has to be postponed: chaos.

Examples of Project Management apps: MindManager, Basecamp HQ, Microsoft Project, ProjectPlace.

Smart practices are efficient ones. By using “convenience” apps, your practice can match the productivity and profitability gains an EMR system gives you at a fraction of the cost.

EMR and the Generation Gap

What is the quickest way to figure out how to use a new electronic device? Read the manual? No – hand it to a child and let them play with it for a few minutes and show you how it works. But the converse is true as well: if you hand it to an older person and expect them to use it without proper planning, you may be asking for trouble.

Previously I have written on the pitfalls of naysayers on your EMR implementation project. These are typically partners in your group who have already decided that the practice cannot afford EMR, the incentives the government promised will never materialize, and the whole thing is just an expensive boondoggle that will bring the business to its knees. Then there are those doctors who say they are willing to go along but in reality become withdrawn or drag their feet.

Most often the cause of this behavior is their anxiety over the new technology as well as the unknown effects it might have on their practice. The majority of people over the age of forty have limited exposure to computers and the like, particularly if they are only high school graduates. But even middle-aged individuals with higher education, such as physicians, may not feel completely facile with the latest gadgets.

If this technology is complex – like an electronic medical records system – and has a significant impact on that individual’s ability to perform his or her job – seeing patients – and make a living, be prepared for downright resistance. It only takes one major stakeholder such as a partner to bring down a project of this magnitude if he or she is not fully on board, so it is best to be proactive when it comes to push-back from doctors.

Katzen Eye Group had to deal with this very issue when they went paperless with NextGen in January, 2004. Janna Mullaney, their Chief Operating Officer, says, “I usually find that older docs fight EMR because they aren’t comfortable with it; they think it’s going to slow them down and it’s just too much of a change in the way they have practiced for several decades.  The trick is to make the transition easier and to get them involved early, to show them that they are going to have some input.”

In the case of our own implementation, we also chose NextGen’s EMR solution because it is fully customizable. This gave us the ability to ensure that the transition would have the least impact on individual physicians’ work schedules and productivity. Those EMR systems that are the easiest to use ‘out of the box’ may be the least flexible regarding customization and their apparent simplicity may in fact hamper the long-term success of your project [read Choosing EMR Software and get our Free EMR Software Checklist].

So what are some ways to stave off a potential mutiny when it comes to your EMR implementation? Ms. Mullaney adds the following pointers for those practices dealing with ‘buy-in’ issues from older physician partners:

  • Provide screen shots early in the process to get them familiar with the fields on each template even before training
  • Make sure that the project manager spends some one-on-one time with them for training to ensure their comfort level
  • Appoint a ‘super-user’ to each older doctor to provide support [n.b. - and each location should have at least one super-user at all times]
  • Start the EMR transition with new patients at first (more established physicians usually have fewer new patients so this eases them into the process at a slightly slower pace)
  • Since older providers tend to remember their patients by personal tidbits, use a system like notes to continue to identify with their patients when they don’t have the thick paper chart in front of them, or use digital “sticky notes” within the EMR system
  • Put patient pictures in the template as a visual reminder of the patient
  • Keep a paper patient router so that they have that last vestige of paper
  • Scribes, scribes, scribes (if they aren’t already using them) – while they can add to implementation costs, these can usually be offset by cutting back on transcription, adding more patients per hour and, because the documentation may be better, you can support a higher exam code

Now, I realize that this is somewhat of a generalization; the issue of resistance is not strictly a generational one. There are younger physicians who are less technologically adept and therefore may balk on EMR and, conversely, there are older doctors who wholeheartedly embrace it. But regardless of whom you are dealing with, it is a good strategy to involve these individuals early in the process to allay their anxieties and to address their concerns before the situation deteriorates to an impasse.

Designing an Effective Strategic Training Plan to Improve EMR Adoption

Guest Post
By Dr. Greg Forzley and Mr. Tony Onorad

As health care organizations of all sizes struggle to meet the challenge of electronic health record adoption and meaningful use, one recurring theme is common: How to effectively educate learners on both the new and / or adapted processes resulting from the implementation of the new system and the necessary skills to use the new technologies in order to efficiently execute those processes. Physicians in particular may feel challenged to learn how to use a particular EHR or EMR with the skill and finesse needed to balance patient care activities with the capture of information in the electronic record.

As Dr. David Blumenthal, National Coordinator for Health Information Technology (ONC), succinctly surmised in an April 2009 interview:

“Simply having an EMR system isn’t enough. We need to ensure that physicians can actually use it.”

It is important to understand the distinction between an EMR and an EHR. A clearer definition can be found in the April 28, 2008, report to the Office of the National Coordinator for HIT, “Defining Key Health Information Technology Terms:”

With the recent Federal legislation, it is clear that the focus will be on EHRs and their ability to share information securely across health organizations. In order to meet meaningful use standards and, more importantly, in order to provide more efficient and safer patient care, EHR users must be equipped with the knowledge that they need to successfully use any system they be required to use for patient care.

A key component to an EHR’s success is a clearly defined, measurable, and effective strategic knowledge improvement plan. This is not just an important component of the initial implementation, but critical to the long-term success and vibrant use of EMR technology.

Five major pieces to successful strategic knowledge improvement plans include:

I. Successfully Managing Change
a.  Answer “Why are we doing this?”
b.  Answer “What’s in it for me?”
c.  Articulate the benefits and features.
d.  Purposefully review and communicate the process, including timelines.
e.  Set realistic expectations (we’re not flying to the Moon on Day One).

II. Implementing Readiness and Skills Assessments
a.  Assess current, basic PC and Windows skill levels (not everyone knows what a radio button or a “right” click are). Don’t take the learner’s report of skill level without an assessment verification tool.
b.  Ensure that all learners’ basic skill sets (i.e., Windows and PC) meet a minimum proficiency level prior to go-live training.

III. Designing Knowledge Improvement Approach
a.  Key concept: Implement role-based training – you’re not training your users to be EMR experts; you’re training your learners to provide safer, more efficient patient care using a new system.
b.  Think long term: What is a sustainable model that will yield the most for a diverse set of learners?
c.  Evaluate your options carefully, understanding the cost, implications, and necessary support.
d.  Be prepared to stay in the game: Learning doesn’t stop at go-live. Now what?
e.  How are you going to determine the level of support and communication needed for new processes, system “fixes,” upgrade training, etc.?

IV. Assembling Your Knowledge Improvement Team
a.  Who will train your end users?
b.  What adult learning facilitation skills do they have?
c.  Who will design your knowledge improvement tools (classroom curriculum, eLearning, Knowledge Banks, mLearning, etc.)?
d.  Think long-term: Do you need a full EHR training team, comprised of full-time employees? Is relying solely upon consulting talent wise? A blended approach?

V. Evaluate, Measure, and Realign Your Strategy and Tools
a.  Evaluate training strategy, curriculum, etc., against real-life results.
b.  Address the “pain points” quickly.
c.  Always seek to learn from every encounter and adopt an attitude of continuous improvement.

We’ll explore each component of a strategic knowledge improvement plan in detail in subsequent articles.

****

Dr. Greg Forzley (forzleyg@trinity-health.org) is the Director of Informatics for St. Mary’s Health Care in Grand Rapids, Michigan, and serves as Chairman of the Michigan Medical Society. Dr. Forzley has been instrumental in improving physician adoption of EMR systems and is a champion of improving patient care through meaningful use concepts.

Mr. Tony Onorad (TonyOnorad@OnoradSolutions.com) is the founder of OnoradSolutions, a knowledge improvement consulting firm and has been an innovator in the adult learning field for over fifteen years.

Change Management: Preparing Staff Members for EMR

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.changes sign.jpg

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.

How to Keep Your EMR Project Nimble

How long do you think it would take you to implement an EMR system in your practice?

3 months? 6 months? A year?business-juggler.jpg

Of course, this is a trick question. First, you have to define when the actual project starts. Is it as soon as you make the decision to go paperless? Is it as soon as you have purchased the software? The hardware?

If you aren’t already using EMR, you are no doubt feeling some pressure from Washington to get with the program. After all, there is some serious money coming in the form of incentives in the next couple of years. Although, you can most certainly spend some serious money on the endeavor, especially if you don’t plan properly. With a reported failure rate of 30-50%, EMR implementation will be one of the biggest jobs your practice will tackle.

In our case, the timeline was more like three years. Granted, we could have pushed to meet the original goal of eighteen months. But, the arrival of two new partners – and two hurricanes – pushed this back. In subsequent articles, we will discuss the mechanics of the actual rollout. But for now, we will stick with the planning process. That’s the part that most practices fail to do, and which ultimately is the main cause of failure.

Some of these things may have been mentioned before, but I will summarize all the steps of a proper implementation of your EMR project:

  1. Perform a needs/wants assessment. What exactly are you looking for in an EMR system?
  2. Set up an EMR committee. This should include key players from different aspects of the practice: doctors, nurses, medical assistants, administration, billing, and of course information technology (IT).
  3. The EMR committee should come up with a check list for an ideal EMR system based on #1. What are ‘must-haves’, ‘would-like-to-haves’, and ‘neato-cool-wish-list’ features?
  4. Based on #3, come up with a short list of EMR systems, interview and demo them, check references, perform due diligence, and then make your choice.
  5. Consult with a certified project manager. Check out the Project Management Institute . You may think you can’t afford one, but the truth is you probably can’t afford not to. Alternatively, ask your EMR vendor for some recommendations. The last option is to have your IT person or consultant to run the project – but this person should have some experience with project implementation, not just IT.

The project manager, or your staff member who has been trained to be one, will set up your project in a dynamic timeline known as a Work Breakdown Structure (WBS). This tool has the ability to adapt to changes in your schedule which will undoubtedly occur. By contrast, a schedule set up on a traditionally rigid calendar can easily be scuttled by a minor setback – this is a perfect opportunity for the naysayers to voice their “I told you so’s”.

For the do-it-yourselfers, use the tool the professionals use for producing your own WBS, mind-mapping software. The gold standard is MindJet’s MindManager. Although there are some less expensive or even free products out there, this is the most robust and the files are ubiquitous.

However you do it, don’t do it alone. And take the time up front to plan properly. This way, your project can roll with the punches instead of rolling over dead.

Planning Your Electronic Medical Records Implementation

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 [Read more...]

Preparing the Staff for EMR

Perhaps one of the most challenging aspects of implementing an electronic medical records system (EMR) is managing its effect on the staff.

According to a study by executive search firm Korn/Ferry International, one of the most common mistakes that executives make when joining a company or mannequins-plan.jpgmaking changes is failing to properly read the existing corporate or office culture. An example would be a control-oriented manager coming into a company with a collaborative culture, leading to tension and resistance.

In this column, I’ll explain how to adapt the existing office culture to facilitate the staff’s acceptance of a switch from paper records to EMR.

[Read more...]

Managing Your EMR Project

In the late summer of 2004 our city of Ocala, located in the center of Florida, was directly hit by two of the four major hurricanes which made landfall. Due to a combination of lengthy power outages and significant damage to buildings, including the homes of many employees and patients, many medical practices were forced to close (some practices along the coasts were unable to perform surgery for up to several weeks).

Our original timeline placed our EMR implementation around the late summer of 2005, but the domino effect from the storms forced us to push this back a couple of months.

Unfortunately, this would coincide with a couple of other major events in our practice: the addition of two new associates, the departure of another, and the construction of two new satellite offices. [Read more...]