Betty S. Chu, MD, FACOG
If you’ve made the decision to invest in an electronic health record, you’ve probably spent many hours contemplating the “bells and whistles” of different systems. Once the hardware begins to arrive at your office, the nagging question in the pit of your stomach slowly makes itself known… how am I going to integrate a new way of practicing into a dynamic office?
Two years ago, my five person, single specialty OB/GYN practice invested $50,000 per doctor in an EMR product. I volunteered to be the “computer specialist” in our office even though my experience was no more than the average person; I use my computer to check email, buy books from Amazon and download pictures of my son. We made the decision to purchase EMR because we were looking for a way to improve communication between our two offices, to decrease paper documentation and to improve billing. We were also concerned about new mandates such as pay for performance that will require data to support incentives. We have yet to see a financial benefit to this application, but I do see improved communication and documentation in our office. Although I think the effort is worthwhile, implementation is challenging, so I offer the follow advice.
1. Consider hiring additional staff
We did not change our electronic billing system (it was the same product as our EMR) as we thought our staff would be able to handle the added workload. We decided to scan pertinent patient records as they came in for each visit instead of the entire old chart. We didn’t, however, take into account the volume of paper generated on a daily basis such as lab studies, old records and notes from consultants. Our staff became quickly overwhelmed with trying to electronically file the incoming data. Hiring an entry-level staff position to assist with this data entry would have made the transition to electronic records more seamless.
2. Establish office email on your EMR system
On a daily basis office staff communicates with patients and these messages usually require a response from a physician. The electronic messaging system is also connected to the patient record and leads to a more seamless accounting of phone calls and problems. The electronic record allows these messages to be documented more completely if time is taken to enter the data. It also allows us to communicate with our office staff and other colleagues. The staff and physicians found that sometimes this method of communication was less efficient than handwriting a note and needed to be encouraged to use the computer for documentation. Also, it is important for everyone to develop the habit of checking email messages two to three times a day to avoid missing messages. A paperless world will only be effective if people take the time to document.
3. Examine office workflow
Each office has a unique workflow that needs to be examined prior to implementing an EMR. Work flow includes: patient scheduling, registration, intake by a nurse or medical assistant, evaluation and examination by a physician, documentation, ordering tests, performing procedures or tests and check out with collection of payment and scheduling future appointments. These items will usually uniformly be addressed by whatever EMR system you choose. Other workflow items may be individualized for your office and will require you to develop specific algorithms and templates. These may include: reviewing test results over the phone, following abnormal labs (“tickler” file), refilling prescriptions, surgical scheduling, management of immunizations and referral letters.
Prior to implementation, I would recommend meeting with your staff and reviewing specific scenarios that occur in the office routinely (such as sending a consult letter) and practice using the EMR to perform these tasks. You may consider electronic implementation of some tasks gradually (such as the tickler file) if you are concerned about loss of data due to your staff being overwhelmed with this new method. I don’t think this is necessary but it may add to your comfort level with implementation.
4. Minimize your templates
In our office, the medical assistant who admits the patient chooses the template that will be used and they enter data such as vitals and medications/allergies. These templates are the outline for the office visit and will be unique to your practice. Although it may seem convenient to have many problem specific templates (such as AUB, UTI, etc), we found that a generic ‘progress note’ template reduced confusion. It also felt more familiar to physicians who could then tailor the note to their liking. Also remember that templates need to be universally accepted by all physicians. This is no different than adopting the same standard ACOG form in your office- everyone will adapt to the change. Take time to review the templates with your providers and explain to them that the final template cannot be too specific and will represent a consensus amongst all the users.
5. Expect resistance from physicians and staff
This is a painful process. It will slow down your ability to see patients and every individual has a different comfort level with technology. Take time to train your doctors and staff on a continual basis. I would suggest implementing the electronic health record in stages. In our office we began with New patient – Gyn exams, then added all annual exams and E&M visits. We chose to add our New OB and OB visits last due to our volume of OB patients. Given the average OB visit of 10 minutes, we were concerned that learning the system on these patients would be too disruptive and too time consuming. We were also concerned lack of data entry. If you are able to schedule fewer patients during the first week of implementation this may reduce staff and provider frustration. Designate and train a staff person to answer questions and compile problems to discuss with your vendor. Communication and correction of problems will increase user confidence and prevent your staff from feeling overwhelmed.
6. Establish a laboratory interface
Because we were one of the first systems in our area to purchase from this EMR vendor, a link between our largest provider of laboratory services, Quest, and our electronic record had not been established. Approximately one year after we purchased the system, we were able to receive lab data directly from Quest and place orders. Once the labs are signed electronically, they are automatically filed in the patient record. This function has reduced paper significantly in the office and also reduces the need for staff to pull charts. It is a tangible way that we have seen the benefit of increased efficiency in the office. This positive reinforcement has kept the staff interested in continuing to use EMR to it’s full potential. Continuing to motivate staff and physicians to embrace change is difficult and is made easier if there are recognizable improvements.
Much of the excitement about electronic records has been by those who have not had to pay the price tag and endure the implementation process. In a small office, planning for implementation is as important as choosing a system. If you have or are considering purchasing an EMR, you already realize that a legible, complete computerized patient record is a necessity and that healthcare of the future will demand us to provide data. Hopefully you can integrate electronic records in an efficient and painless way.