This, the third article in a series on electronic medical record systems (EMRs) for the office, addresses the basic concepts of Change Management and Process Redesign.
The first topic to consider has already been alluded to in the prior articles: change management. As part of the readiness assessment that was conducted at the onset of the project, the office should already have an idea of how receptive the staff members are to change. That includes the full complement of staff, from the physician, office nurse, medical assistant, lab technician, front office receptionist, and office manager. Obviously, in some practices, these roles are combined into single individuals. One person may fulfill all of the front office functions in a solo physician office, while in larger practices there may be more than one receptionist.
Human nature often supports Newton’s Laws of Physics; First Law: “A body at rest tends to remain at rest” and Third Law: “For every action there is an equal and opposite reaction." Thus, change management is crucial in achieving a successful implementation of a new work paradigm, and rest assured, the electronic medical record is a new paradigm.
The second topic for this article is process redesign. The use of computers to increase the throughput of tasks should be well known, and abundant examples of how good workflows can improve efficiency should also be easily found. Look, for example, at the purchase of an airline ticket today: visit the web site of the airline, select the originating point of the flight and the destination, the date and time of travel desired, select the seat desired from a real-time list of available seats, confirm the itinerary, purchase the ticket with a credit card, and, within 24 hours of the flight departure, print the boarding pass at home (or even have it sent to your cell phone or PDA). The speed, efficiency and cost to the airline for this process are far better than the prior paper-based one. Similarly, with proper design of new workflows enabled by current technology solutions, an enhanced process will result in improved speed, efficiency, and reduced costs to the practice, and improved patient safety and quality of outcomes.
Thus, it is amazing to still hear intelligent people insisting on replicating their exact current workflows with the electronic system they are looking to install. That is akin to insisting that an automobile have a buggy whip in the passenger compartment because horse-drawn carriages needed one available to motivate the “engine”. Some processes are deeply flawed, and should be eliminated, though others may only need “tweaking” to make them fit in the new workflow. Process redesign and change management needs should be evaluated with the goal of optimizing the process, not replicating existing processes. That concept must also be kept in mind during the vendor selection process. Think again of someone touting their electric typewriter’s ability to have correction tape in the typewriter versus a modern word processor program with the ability to spell check or delete misspellings before finalizing the document (much less the fact that it may never be printed on paper, but be sent or stored electronically!).
“Suburban OB/GYN, P.C.”, a two-physician practice near a large metropolitan area, is interested in implementing an electronic medical records system in their two office practice. In their existing workflow, obstetrical records are copied at various points in the pregnancy (at 28 weeks, 36 weeks, and on admission to L&D). Each office must also copy or fax records between the two offices if patients arrive in the other office, either due to patient preference or coverage issues. Records must be retrieved, copied, and/or faxed between offices for medication refills, and for after-hours notes that need to be transmitted from the current office location of the physician providing services while on call.
In their existing workflow, patients are mailed a questionnaire regarding their reason for visit, the patient’s medical history including medications, family history, etc. When patients arrive at the practice, the paper form is collected, or for those patients who either did not receive the form or forgot it, a new form is provided and completed. The patient is called back to the lab area, where additional questions are asked, vital signs are taken, and the nurse records the information in the chart. Paper forms for lab requisitions are prepared, and on receipt of the completed labs, the nurse must match the results with a paper chart, and manually log abnormal results in a follow-up journal. Calls or letters to patients must also be completed to follow abnormal results, and phone calls for new medications or refills requires pulling charts to confirm the appropriateness of the prescription or refill, possibly confirming with the physician (and waiting until not in with a patient) as well as a subsequent call to the pharmacy.
In the workflow after a new electronic medical records system is deployed, the patient’s current obstetrical records are available in L&D electronically. There are no chart pulls, no updating, copying, or mailing of records to the hospital or between offices, as all clinical information is available at home, hospital, or either office.
Patients are given the option of completing the same type of questions through an on-line patient portal in the comfort of their home and in advance of their arrival to the office. For those patients that arrive without having completed the questions in advance, a kiosk or a Tablet-PC is provided for completion in the waiting room prior to being seen by the staff. Any supporting documents are scanned into the EMR, and the original document is either returned to the patient or shredded as appropriate. As the answers to the patient questionnaire flow forward into the electronic system, the nurse needs only to confirm certain information, rather than re-enter it, speeding the process. Lab requisitions are electronically sent and specimen labels created, and an electronic log of results can be refined to display abnormal results only. Workflows to handle phone calls (or now electronic patient messaging, and electronic prescribing requests) is now needed, and should be much more efficient, with the physician able to see and respond to the electronic requests without being otherwise interrupted.
The initial readiness assessment will have provided areas that need the most attention for acceptance and understanding of the changes that will be needed in the new environment. Engaging those that are reluctant to consider an EMR, not just those that are eager to have the new electronic medical records system implemented, will ensure that their voices are heard and considered in the process. Communication during the entire process needs to be constant, consistent, and expansive.
Clinical transformation: a structured, culturally sensitive process to redesign work flows, implement best practices, and adopt technologies that integrate resources and standardize operations in support of specified improvements in clinical, operational, and economic objectives. Using a process mapping tool such as Microsoft Visio allows existing workflows to be examined, and with the assistance of consultants or vendors, the new workflows expected can also be mapped (see examples below).
Remember that some existing workflows will not be needed at all in the future state, and all existing workflows should be evaluated for applicability, need for modification, or elimination!
How is value to the practice and to physicians achieved with electronic medical records? Significant improvement in patient safety and clinical effectiveness leads to reduced medical malpractice risks (cost avoidance), and improved clinician productivity leads to greater revenues. Reduced administrative and indirect care costs also are accrued, along with improvements in patient and provider satisfaction.
Be diligent in looking for the reduction in steps in the workflow, as the efficiencies achieved help increase productivity and financial gain. Achieving a 10% greater throughput in patient volume will increase financial gain far more than 10%, as the marginal costs of providing care to the added numbers is substantially less than for the existing volume.
Risk and Barriers
Failure to understand and incorporate the psychology of change management will lead to real problems in the organization. For example, implementing the project before preparing the organizational culture will result in stress arising from differences in capacity and willingness to change. There may be a significant mismatch between the required effort and the expected outcome, with unrealistic expectations in either the work effort or the capabilities of the system leading to patient or provider dissatisfaction. Finally, failure to recognize the differences in innovation behavior (early adopter « laggard) and the way to effectively engage all the user types can lead to a schism in the practice.
When categorizing barriers to adoption, one of the most prominent problem areas encompasses miscommunication, with unclear rationale for system implementation, unrealistic expectations communicated for system capabilities, and knowledge and support deficits being prime examples. An issue that is becoming a less prominent problem with continued expansion of the computer-savvy population is an inadequate baseline technical knowledge, for both computer skills and ability to use the internet. A problem that does continue, though, relates to inadequate training, often caused from inconvenient location or times for training, insufficient time prior to the implementation for an understanding of and trying new workflows, and inadequate resources available for help on-site after go-live.
Understanding the workflow processes and how the above barriers and risks impact the process redesign will result in an improved delivered product and acceptance by the practice. Most projects fail not because the software itself is incapable of delivering value, but because the leadership failed to communicate the value, support the project, or understand fully the new environment that would result from a fully implemented project.
Projects such as electronic medical records selection and implementation can stress the strongest of organizations, and sink those unprepared and/or unwilling to prepare and respond to the challenges presented. The future of medicine in the U.S. will undoubtedly include widespread use of EMRs: the American Recovery and Reinvestment Act of 2009 (ARRA) includes provisions entitled the “Health Information Technology for Economic and Clinical Health Act” (HITECH) which provides stimulus support for physicians and hospitals that utilize certified EMRs, including payments of up to $45,000 per physician beginning in 2011, with both Medicaid and Medicare payments having incentives for use, and disincentives for non-use of EMRs.
It will be incumbent on each and every physician office to evaluate its own readiness, its culture and ability to adapt to change, and then move forward to find and implement the system that best meets the current and future needs of the practice. Some practices may have the internal resources to accomplish all of these tasks. Others will be better served seeking guidance from experts in the field, those having successfully undergone the journey, to let someone else who has already made the mistakes and learned the hard lessons ease their transition into the world of electronic medical records.
--Michael J. McCoy, M.D.
Example #1:Chart Pull with Current State (paper) records :
Example #2:Chart Access in Future State (electronic) :
Example #3:Current state access to L&D records :
Example #4:Future state access to L&D records :