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EMR Implementation from the User/Provider/Physician Perspective

By Marie Richards, M.Ed, PMP, CPEHR, CPHIT, CPHIE

The “meaningful use” journey can progress through various twists, turns, stalls, restarts,

frustrations, elations and finally relief and satisfaction from a job well done. Proof

abounds that project tenacity trumps despair and that early adopters are enthusiastic

about electronic health records (EHR), and even eagerly anticipate the next stages of

Meaningful Use objectives. For those who have adopted EHRs, there is no more tedious

page-turning to find specifics in a patient‟s medical history. They experience a dramatic

reduction in copying and faxing or couriering records to referral colleagues. The staff is

happy and, more importantly, providers can feel more confident in their care decisions

after having found and reviewed all of the patient‟s medical history. A healthier

community is the end result.

However, it is understandable that at the beginning of what appears to be a long journey

and with the other side of the mountain not yet visible, providers feel some trepidation.

There are many unfamiliar tasks and obstacles for providers and staff to navigate on this

journey. There are transformations of their practice workflows from paper to capturing

and processing electronic patient health information, along with numerous upgrades of

software. There are EHR vendors to be selected and vetted. There are EHR

demonstrations to be arranged, seen and evaluated, orchestrated using specialty specific

patient scenarios. There are EHR quotes to be solicited, compared, assessed and balanced

on the merits; all of that, while maintaining a smooth running, revenue generating

medical practice with satisfied employees and patients.

From a provider‟s initial perspective, they frequently decide on an EHR purchase to

achieve the greater aims of practice viabilities, practice efficiencies and program

incentives. Yet these attractive benefits are seldom sufficient to overcome the barriers to

EHR adoption and pervasive fear of change. Providers seek out their colleagues‟ opinions

and stories of their past journeys down this path. They hear experiences of an initial

reduction in productivity and sometimes limited support from EHR vendors. They envision

themselves at the mercy of post-implementation EHR vendor support staff in remote

places, with limited empathy for the impact to the practice of difficult-to-understand

error messages and frequent interruptions for upgrades.

Those providers who do take the plunge into the waters of EHR implementation generally

fall into a few categories. The providers who do best, near and long term, are those who

take the time to incorporate lessons learned and best practices from successful EHR

implementations. These practices identify a physician champion who sees the EHR

implementation as a means to an end and not the end in itself. These providers have

clearly defined outcomes they want to achieve, which affects the patients‟ quality of

care or practice efficiencies over the short and long term. These providers engage the

hearts of their staff in goals anticipated from the journey.

These objectives and outcomes, defined prior to EHR selection, are the focal point for

the entire EHR implementation, from the choice of EHR vendor options, interfaces,

productivity enhancing features, to the prioritizing of staff training, system validation and

post go-live workflow optimization.

One important best practice these providers implement is to select and abstract essential

elements of the paper chart, to entered by staff into the EHR prior to the patient seeing

the provider post go-live. They refine their choice of patient e-folders into which „only-

absolutely-necessary-documents‟ are scanned and filed, so the provider can easily think

where to retrieve these documents, e.g. vision screens or EKG tracings. This speeds the

doctors‟ ability to find relevant data, as structured data, and lessens dependency on

scrolling through pages and pages and pages of scanned documents.

There are providers who fall into the category of the minimalist. They specify the

minimal objectives, if any. They may select the EHR with the minimum of capabilities.

They may fall prey to consultants offering the minimum cost and suggesting the minimum

effort required. They end up with the minimum of services and spend minimum time

preparing for the transition in workflow. Often they spend the maximum time scanning a

plethora of practice records. This ends up costing them dearly in time and inefficient

workflows, post go-live. This approach prevents them from achieving the loftier goals of

enhanced patient care coordination, measurable quality of care and patient satisfaction

improvements. Sadly, some of these providers fall into the category of a failed

implementation, disconnecting their EHR and returning to the paper chart. Sometimes

these are the providers who get the ear of other providers who are just starting to plan

their journey.

At the conclusion of a successful EHR implementation and meaningful use achievements, I

ask the providers to reflect on the EHR software implementation process and offer their

perspective on the barriers to the journey, the early benefits realized, and their

anticipation for future benefits as health IT becomes more integrated in the processes of

healthcare delivery.

Summarized below are some barriers identified by the doctors who have achieved Stage I

meaningful use of their EHR:

The EHR vendors‟ help desk support staff struggle to understand the providers‟ concerns and struggle to communicate practical or accurate solutions.

The Federal and State level rules and instructions frequently frustrate due to specificity of supporting documentation requested.

Some certified EHR systems stubbornly refuse to cooperate in ensuring the accuracy of reports generated or creating ease or flexibility in producing that data, or even in demonstrating the capabilities for which they are certified.

Primary Care practices that lag behind in their adoption of EHR technology are beginning to frustrate early EHR adopters as they try to share health information data or coordinate care across their patients‟ care provider community.

The vast selection of certified EHR products frustrate the providers, although astute providers are beginning to notice critical mass forming within their specialty for specific EHRs.

The instability of the internet in certain rural locations frustrates providers who want to minimize the hardware footprint in their practice and who choose to access the EHR software via the internet.

Point-to-point interface is sometimes cost prohibitive, but the Health Information Exchange alternative is not yet the reality some providers are anticipating.

However, the list of barriers is offset by an equalizing list of EHR benefits realized early

in the implementation of the certified EHR solution, as well as in the future years.

Providers are pleasantly surprised when they successfully import a patient‟s electronic clinical summary file or „continuity of care document‟ into their EHR and see the test patient‟s medical history as structured data, readable, understandable, sans faxing and scanning and all ready for decision making. When the doctor realizes the potential for saving staff labor, a smile usually emerges.

EHR implementations allow a practice‟s staff to explore their skills in leading, persuading and creative problem solving.

Practices that adopt the EHR technology, using best practices, often increase staff satisfaction, as medical assistants learn new workplace skills and become more involved in documenting patient care observations and histories on the EHR.

Practices of multiple physicians find that the Clinical Quality Measurement reports are sufficient to motivate change in practice workflows and clinical actions necessary to improve patient care outcomes and perceived care quality. The numbers speak for themselves and often stimulate physician workflow changes aimed at improving their patient care outcomes.

Meaningful use objectives and the required actions to achieve them benefit the practice in ensuring that the EHR vendor completes the training on the software in adequate detail.

Physicians who use the services of their Regional Extension Center are frequently very pleased with the skilled consultants who help them focus on the important actions which keep them making forward progress, help them navigate the EHR vendor selections, assess the thoroughness of EHR implementations and optimize their medical practice workflows beyond the EHR implementation‟s go-live. Testimonials are flowing in at several Regional Extension Centers as practice owners get excited about the MUVer programs or becoming a Meaningful Use Vanguard.

Future health IT capabilities enthuse the early adopters of EHR technology. Provider

practices have been known to attest to Meaningful Use Stage I, and with the excitement

of the adrenaline rush, ask: “What‟s in Stage II?”

Physicians articulate their desire to collaborate as a community of healthcare providers

on behalf of their patients. Medical practices anticipate a lessening of the burdensome

referral processes, as health information exchange gateways come into their own. There

is particularly anticipation for access to clinical data about the patient, relevant to the

present illnesses, which providers will use for enhanced decision making, while

eliminating redundant and unnecessary tests. Technology refinements should reduce the

cost of interoperability of devices and more easily link data sources with data

destinations. Most importantly, physicians anticipate gains in personal freedoms with

improved mobile, yet increasingly secure access to patient information.

Marie Richards, Consultant at TMF® Health Quality Institute, working with the Regional

Extension Centers in Texas to assist physician practices to achieve meaningful use of

their EHR and reach the objectives specified by the Centers for Medicare & Medicaid

Services, an agency of the U.S. Department of Health and Human Services.