EHR Insights

Congratulations. You've made the decision to deploy an electronic health record (EHR) system in your practice. This is no small undertaking. As is the case with any workflow change in a busy office, your staff is understandably nervous about the potential decrease in productivity.

Presuming your technology needs have been sorted out, the real question is: How can my staff be prepared for the “go-live” moment when our practice has made a firm commitment to document all clinical notes on a daily and routine basis in the EHR system rather than on paper or some other legacy computer system? As both a developer of an EHR system and a practicing physician, I can offer a few pointers on these issues:

1. Organizational readiness starts at the top. If you as the physician do not take an interest in the deployment of the EHR system, it is unrealistic and probably a little unfair to expect your staff to do so. In many busy offices, the staff may find excuses to delay or avoid implementation of anything that causes a disruption in what they are used to doing. There can be many reasons for this: they may fear reprisal from you as the employer if they can't learn to be as efficient with the new system as they have been with the existing process. They may also assume, correctly or incorrectly, that bringing new technology into the office will result in earlier mornings and later nights and a general change in the office morale. As the physician, communicate that the implementation is not optional and that everybody needs to become adept at using the new system. This will require not only training staff, but also training all physicians and providers in the practice. Dedicate specific time for training sessions and support during the go live period. The degree to which this will involve on-site participation from a vendor will depend on which system you use. Your staff will be more apt to embrace the change rather than resist it depending on your level of genuine involvement. If you can't be bothered to learn the system yourself, what message do you think that sends to your staff? Another good message to communicate is that this is an exciting time for your practice, as these tools and technology will position you as a more state-of-the-art practice.

2. Ease into it. You should expect with most EHR systems to have a grace period where you can gradually shift from doing a few notes per day to completing all your notes in the system. Ideally, a well-designed EHR system should allow you to see at least the same volume of patients every day to which you are accustomed, while offering advantages including portability, automation, and reproducibility of information in your notes. I generally recommend that when a practice is making the transition, the staff and physician should identify together a few patients each day that will have their notes duplicated into the EHR system after completing them with the existing approach. For example, if you are currently using paper charts, perform all of your usual charting for the entire day and then, at the end of the day, attempt to re-create a note with the same clinical content that would serve the same documentation purpose within the EHR system. This will help you understand the way the EHR system organizes histories, diagnoses, examination findings, treatment plans, document management, bill generation, etc. Once you've gotten the hang of this with a few patients a day, you can then increase to approximately 20 percent of your clinical volume, then 50 percent, and eventually completely transition to full electronic documentation.

3. Training is a worthwhile investment. Understand that your staff will probably need to train during the workday, as well as after hours. Typically, a vendor's curriculum includes training sessions during the vendor's normal business hours (which may or may not coincide with yours, depending on time zones), and most vendors will also have homework assignments to complete between the daytime lesson plans. Also, it is difficult to train an entire large staff simultaneously, so your staff may need to train in shifts. This comprehensive training is a worthwhile investment.

4. Perform a dress rehearsal. Once you have completed initial training and curriculum assignments, you may want to spend a Saturday running some mock drills of patient flows. This can help you and your staff understand the workflow of chart generation. This begins with initial creation of the patient demographics, progresses through the addition of documents received via fax or brought by hand, may include establishment and communication with the patient through a portal and possibly even exchange of photographs and other images relevant to a consultation. Depending on your EHR system, this may involve scanning the paper documents and attaching them to the record or integrated inbound fax tools, which may differ fundamentally from your existing practice of photocopying the pathology report and adding it to a paper chart. You also need to decide how much of the data entry in the examination room is performed by an assistant or scribe versus the physician. Some physicians find electronic systems interfere with the face-to-face doctor-patient relationship. In such a situation, an iPad or other tablet-based EHR system may take the form factor of a chart that can sit in the doctor's lap while the doctor continues to make eye contact with the patient. I find this particularly important for the cosmetic patient, but it's certainly applicable for all encounters. Some practices may want to take a hybrid approach, whereby some documentation is transcribed on paper and then scanned and/or entered into the EHR system after the patient has left the office. As a team, you and your staff should make a concerted effort to decide how you wish to approach this. Mock patient set-ups can help you identify bottlenecks in your process flow.

5. Learn about process improvement. If you have the opportunity, read the book “The Goal: A Process of Ongoing Improvement” by Eliyahu M. Goldratt and Jeff Cox. Part of every business school curriculum, this book describes critical pathways and bottlenecks in process flows. It can greatly help you learn how to map out your processes to identify the bottlenecks on the critical path of efficiency. Delays in your existing workflow with paper charts may not be the same as those you encounter when using electronic systems.

6. Prioritize. Decide upfront which patient charts need to actually be re-created in electronic format and which can be archived in their paper form until they need to be recalled. For example, your routine toxin and filler patients probably should have their existing paper charts digitized (scanned) as you anticipate seeing them on a recurring basis. If you are not expecting recurring business from a patient, you may not need to import that patient's entire chart into your EHR system if you're not expecting recurring business. The cost and hassle of scanning all of these legacy charts may not be worth it. If you are switching systems, this may be even more important as data conversion can be a costly part of implementation.

7. Develop a process and communication plan. Have a plan for how you are going to process documents and pathology reports as well as sensitive information. Find out if your EHR system has a dedicated internal communication tool, then set clear guidelines for what types of information can and should be shared internally through the record system. Dovetail that into your strategy for how communications will be conducted with patients. To what extent will you use patient engagement tools, and how will correspondence be memorialized in your records? While not every phone call or communication needs to be entered into every patient's record, you should have a consistent approach to make sure any information that is critical to documenting your care plan and patient compliance shows up in the EHR system to provide as much value as it does when you use paper charts.

8. Be patient. As with any change, it's important to understand and accept that you will not get everything right on the first try. Make sure to discuss with the EHR vendor the support services it offers and make sure your office manager, medical assistant and other practice stakeholders know what their access rights, responsibilities and benefits are. Understand whether you will be billed per call to the vendor support system, on a monthly basis or with escalating fees year-by-year. One potential advantage of software as a service (SaaS) is that support fees may often be bundled into the monthly subscription. Lastly, go easy on your staff during the transition so that they will go easy on you, as well.

Tim A. Sayed, MD, FACS is Medical Director, EMA Plastic Surgery™ and EMA Cosmetic™ at Modernizing Medicine. He is also an Executive Committee Member of HIMSS EHR Association.