Three Dozen Essential Constituents
For Effective EMR Implementation In a large Medical Practice
Introduction
“The Health Information Technology for Economic and Clinical Health (HITECH) Act,
enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law
on February 17, 2009, to promote the adoption and meaningful use of health information
technology.”1 One of the primary goals of the act was to accelerate the uptake of
implementation of health information technology for the purpose of improving healthcare
delivery.
“The Health Information Technology for Economic and Clinical Health (HITECH) Act seeks
to improve American health care delivery and patient care through an unprecedented investment
in Health IT (HIT).”2 The investment included a number of financial incentives for physician
practices for effectively implementing EMR and achieving “Meaningful Use” goals and objectives.
In the broader context, “The provisions of the HITECH Act are specifically designed to
work together to provide the necessary assistance and technical support to providers, enable
coordination and alignment within and among states, establish connectivity to the public health
community in case of emergencies, and assure the workforce is properly trained and equipped to
be meaningful users of certified Electronic Health Records (EHRs). These programs collaboratively
build the foundation for every American to benefit from an EHR as part of a modernized,
interconnected, and vastly improved system of care delivery.”3
Purpose of this Paper
During a ten year period from 2001-2011 a significant number of large medical clinics
migrated to electronic medical records (EMR). The purpose of this paper is to:
•
To evaluate and articulate the transformation of the medical industry via information
technology.
•
To demonstrate a comparative context for this transformation.
•
To explore the best practices from some clinics that successfully implemented EMR
•
Glean insights useful to those practices that are about to implement EMR
•
To assist practices that have had shortcomings in implementing EMR
•
To provide a roadmap to EMR implementation success
•
To summarize and articulate the essential constituents necessary for successful
implementation of an EMR in a large practice
Process
A partial literature review of the overview of the history of the use of information
technology was conducted. This included a comparative history of the financial services
industry – an industry that aggressively made the transition to computer platforms in the
1950’s, 60’s, & 70’s (and the ongoing early adoption since that time frame).
In addition, there are a number of correlative lessons that can be gleaned from the early
phases of the US Manned Space Program, particularly from the Mercury, Gemini, and Apollo
programs. These apply to various essential constituents of EMR implementation.
In addition, firsthand participation in the endeavor of EMR implementation occurred.
This process was comprehensive and included exposure to multiple facets of assessment,
decision making, implementation, training, and ongoing process improvement.
A number of site visits, interviews (both formal and informal), and ongoing interactions
were conducted as part of the paper development process. In total, input from nearly four
dozen clinics was evaluated. More than a dozen of these clinics provided substantial insights
for solid input and conclusions in effective EMR implementation. These included: Georgia
Cancer Specialists (Atlanta, GA), The West Clinic (Memphis, TN), Gastro One (Memphis, TN),
Mark Zangmeister Clinic (Columbus, OH), Wilshire Oncology (Los Angeles, CA), Campbell Clinic
(Memphis, TN), Memphis Children’s Clinic (Memphis, TN), Pediatrics East (Memphis, TN), South
Carolina Oncology Associates (Columbia, SC), Memphis Heart Clinic (Memphis, TN), Atlanta
Cancer Care (Atlanta, GA), North Georgia Oncology Centers (Northwest, GA), Florida Cancer
Specialists (West Coast & Central Florida), Montgomery Cancer Center (Montgomery, AL),
Consolidated Medical (Memphis, TN), Tennessee Oncology (Nashville, TN), Memphis Gastro
(Memphis, TN), Mid-South Pulmonary Specialists (Memphis, TN).
The specialties included in these practices are Medical Oncology, Hematology,
Gynecologic Oncology, Radiation Oncology, Cardiology, Radiology, Internal Medicine, Family
Medicine, Pediatrics, Gastroenterology, Orthopedics, Pain Medicine, Pulmonology,
Endocrinology, & Rheumatology. The number of providers in these practices ranges from 12 to
190 and the total number of employees from 75 to over 700. All of these practices have more
multiple sites ranging from 2 to 30 locations. A number of these practices have large flagship
locations. Some are more decentralized – including a few with offices geographically separated
by 200 miles or in multiple states. Some of the practices are mostly office based and some are
mostly hospital based – with all having some mix in their primary place of service.
Most of the practices have physicians and some mid-level providers; either Nurse
Practitioners, Physician Assistants, or both.
An example of the diversity included in the research is the juxtaposition of South
Carolina Oncology Associates (SCOA) and the Mark Zangmeister Clinic (Zangmeister) with
Georgia Cancer Specialists (GCS), Tennessee Oncology, and Florida Cancer Specialists. SCOA
and Zangmeister both have one large facility (120,000 square feet) and one or two small
satellite offices. Interestingly, they have the same flagship building design. In the flagship there
are over 15 medical oncologists and gynecologic oncologists practicing along with advanced
radiology services, radiation oncology, two very large chemotherapy rooms, pharmacy, the
business office, and an extensively developed patient friendly facility and well landscaped
campus. Georgia Cancer, Tennessee Oncology, and Florida Cancer Specialists have two to three
dozen small offices (Florida Cancer just recently opened one larger facility – approximately
35,000 square feet). Most of the offices of these three oncology groups house 3 or fewer
physicians.
Another contrast is Mid-South Pulmonary that has a heavily weighted hospital practice,
while Memphis Gastro has a heavily weighted office practice. Some of the clinics cover only
one hospital, others cover many hospitals. Some have business offices within active patient
clinics, others have separate and distinct business offices.
Sample Assessment
Each of these practices had a clearly defined scope of practice and an intent and process
to implement an EMR. Here is one example:
The West Clinic is a cancer clinic based in Memphis, Tennessee that has specialists in
Oncology, Hematology, Gynecologic Oncology, Diagnostic Radiology, Interventional Radiology,
Radiation Oncology, Endocrinology, Internal Medicine, Hospitalists, and Pain & Palliative Care.
There are over 300 employees at 6 locations including the billing office. In 2002, the clinic
made a strategic decision to fully implement an oncology oriented EMR. In the spring of 2004
implementation began. Within 12 months, it was fully implemented in every aspect of the
clinic and housed within a new IT center contained at the flagship clinic site.
Here is another example:
Memphis Children’s Clinic and Pediatrics East have 32 physicians and six offices and 22
physicians and four offices, respectively. They are the pillars of the Memphis based Pediatric
Independent Practice Association (PIPA). They are widely regarded as the leaders of their
specialty in the greater Mid-south. As part of a commitment to internal transformation both
groups, together, set out to implement EMR around 2004. A multi-year endeavor led to a
generally successful implementation using an Alternative Service Provider (ASP) model. After
running EMR for a half-dozen years, both made decisions to migrate their platforms to ensure
greater support for their systems.
Another example is Georgia Cancer Specialists. This group had a very focused strategy
for EMR implementation. The emphasis was based upon establishing clearly defined clinical
pathways. Under the leadership of Dr. Bruce Feinberg, this group achieved its primary goal –
ensuring that the best evidenced based practice of medicine was “hardcoded” into the clinical
decision making guidance of the EMR. This objective was accomplished by not using a specialty
specific EMR but designing the templates of a widely deployed non-specialty specific EMR.
The successful implementation of the EMR at The West Clinic, Memphis Children’s
Clinic, Pediatrics East, and Georgia Cancer Specialists demonstrates a unique challenge with
tailored solutions. With each of the practices explored (all four dozen practices, with special
emphasis on those listed) there were significant unique challenges and many commonalities.
The common factors and differences provide insights into broader understandings that are
valuable to effective implementation of EMR. This paper looks at three dozen of these
constituents. In addition, it provides examples and related insights that should assist others
who are embarking upon this endeavor or these who need to correct or tweak their present
situations.
The essential constituents will now be explored. Please note that their order of
importance will vary depending upon the group and its situation.
ESSENTIAL CONSTITUENT #1: VISION & MISSION
Vision and mission are critical components to the success of any endeavor. Without a
vision one arrives at their destination by default rather than by design. With a vision the
prospects of reaching objectives are exponentially increased. In the context of the cold war,
President Kennedy summoned a nation “to achieve the goal, before this decade it out, of
landing a man on the moon and returning him safely to the earth.”4 National Aeronautic and
Space Administration (NASA) flight director, Gene Kranz indicated this vision and mission gave
the team a confidence boost to overcome all obstacles – even before achieving the most basic
objectives. He said, “This guy trusts us, when we haven't been able to put a man in orbit”5
Implementing an EMR requires a vision and leadership that exudes confidence in the team. This
gives them the “want to” and a belief that they can achieve something new and big.
Those practices most successful in implementing EMR demonstrated a clear vision and
mission – for their practice’s existence and purpose as well as the objectives associated with
EMR.
It is noteworthy that many medical practices do not have a stated vision and mission.
Without a vision and mission, the decisions of an organization are made apart from a focused
trajectory. This is likely to result in disjointed decisions that undermine desired goals and
objectives. When an entire organization is being transformed from paper to electronic health
information, the organization must be guided by a clearly stated vision and mission.
In the case of the West Clinic, the organization’s vision and mission were clearly stated
and widely known. The Vision is, “No Stone Unturned.”6 The Mission is, “The West Clinic is
World-class center for Oncology, Hematology, Radiology, and other Advanced Medical Care.”7
This vision and this mission were not arrived at without careful assessment and
consideration. A three month process was set in motion during 2001 to distill down the
essential nature of the vision and mission of the organization. This included several extended
board meetings and significant input from the management, staff, and patients. The clinic
wanted to embrace a vision and mission that truly reflected its culture – where it stood, what it
stood for, and where it intended to remain.
Everyone in the organization was expected to know this vision and mission, recite them
on a moment’s notice, and function in accordance with these. Doctors are recruited to fit this
mission and vision. Nurses are hired in accordance with these priorities. All employees are
vetted through a selection process governed by the vision and mission. They were then put
through a rigorous orientation framed in this context. If an individual brought into the
organization turns out to not be an appropriate fit, it usually comes to light very quickly.
Every major decision and determination the organization undertook was consistent with
this vision and mission. Thus, the commitment, selection, implementation, and role of an EMR
should be completely consistent with the vision and mission of the practice.
Campbell Clinic’s mission is undergirded by the storied history, national reputation, and
renowned textbook on Orthopedics (used by many medical schools and residency programs).
The stated written mission is, “The Purpose of the Campbell Clinic is to Provide Unsurpassed
Patient Care while being Recognized as the Leader in Teaching and Research in the Profession
of Orthopedic Surgery.”8 The clinic’s medical information infrastructure is designed to support
this commitment to excellence.
The Mission Statement of the Mark Zangmeister Cancer Center is a traditional kind of
healthcare organizational mission statement, which is stated on its web site:
“The Mark H. Zangmeister Center is dedicated to providing the best quality care
for our patients and families. We adhere to a holistic approach to patient care.
We provide the most advanced technological care while meeting the physical,
social, emotional, economic and spiritual needs of each individual we serve.
We are committed to providing a friendly, relaxed and confidential environment.
We are our patients’ advocates. We promote patient education. We serve as a
liaison between our patients, the community and all healthcare services. We
help patients meet their health goals throughout the duration of their care,
which includes prevention, treatment, rehabilitation and symptom management.
The Mark H. Zangmeister Center believes in teamwork. Our team is committed
to excellence in staff education and quality care. We understand the necessity
for trust, compassion and humor in the patient-healthcare provider relationship.
We work together to uphold our reputation as a leader in the field of oncology.”9
This mission statement, does reflect the center’s commitment to excellence, is embraced by the
entire team and is expressed by the staff, the facility, and the reality of an implemented EMR.
Memphis Children’s Clinic has a simple mission statement that reflects its leadership in
the community, “Providing Excellent Care to the Children of the Mid-south for Over 60 Years.”10
(as of this writing, the practice is in its 62nd year). Thus, the implementation of an EMR was
very consistent with the stated mission of the organization.
Large medical practices have a culture and should have a written vision and/or mission.
These realities are keys to undergirding the transformational and sentinel event that
accompanies the implementation and migration to EMR. This helps the organization arrive at
its destination not by default, but by design.
Lastly, the key element of any vision or mission statement and its impact upon EMR
implementation should be utterly related to a patient centric commitment to excellence.
ESSENTIAL CONSTITUENT #2: UNDERSTANDING OPERATIVE REALITIES
Every organization has an operative culture that reflects the personality of the
organization. Effective implementation of an EMR requires a clear understanding of those
operative realities. At one of the large practices there were three operative realities of the
organizational culture. These realities were very simple:
1. “We don’t have to be the biggest, but we must be the best”
2. “More”
3. “Change”
Every aspect of the organization embraced the necessity of being the best. It was often said,
“We are treating cancer patients – we cannot be second best.” Being the best, involved:
•
Best Clinical Care
•
Best Care & Compassion
•
Best Character & Integrity
•
Best Patient Experience
•
Best Organizational Process
“More” involved:
•
A recognition that a quality cancer care experience requires doing more than routine
•
Staff performance expectations of both quality and quantity of work performed
•
Facilities that exceeded the expectations of patients
•
Human Contact expressing special warmth, care, and compassion
“Change” involved:
•
The recognition of ongoing self-improvement
•
Values are timeless, processes are not
•
Change is driven by external realities and internal realities
•
Change means we have never arrived and, thus, can always be better
Implementation of EMR fulfills the reality of these three organizational characteristics – to be
the best, to embrace more for the patient, and to acknowledge the necessity of change to
ensure that the organization moves forward rather than plateaus. The recognized operative
realities are well aligned with the implementation of an EMR.
Perhaps implementing EMR can borrow from NASA Flight Director Gene Kranz’s motto,
“Failure is not an option.”11 Encased in this simple, yet profound, statement is the commitment
to resourcefulness, calm determination, passion, vision, enthusiasm, and bottom-line gut check.
Effective EMR implementation really does tap into these character qualities.
ESSENTIAL CONSITUTENT #3: GOVERNANCE COMMITMENT
Getting the Board of the Clinic to embrace the first level of commitment is vital to the
progress of the endeavor. This is a key element to the due diligence phase. During this phase
both the internal organizational assessment and external EMR opportunities are fully reviewed
to ensure that there is:
A. A genuine opportunity to move forward
B. Assessing the internal and external competitive advantage to proceed
C. It is in the best interest of the organization to proceed
D. Proceeding is reasonably executable
E. Proceeding is cost effective
Organizational transformation is best accomplished when the time is right or when external
realities necessitate newness. An assessment of the organization embraced by the board
included:
-
An inward leaning to proceed due to the positive experience with the patient
assessment technology called the patient care monitor.
-
A commitment to being a leader in adopting technology – both for excellence in patient
care and the competitive advantage is provided for the group.
-
A strong desire to have an enhanced data repository to be mined to enhance patient
care.
-
Strong enough organizational finances to support implementation as well as a clear
assessment that cost savings and efficiencies will emerge after full implementation.
-
The external incentives considered by CMS for physicians who embrace the adoption of
EMR/HER technologies.
-
The fundamental reality that the future of healthcare will be saturated in health
information technology.
Boards of large medical practices have both a formal and informal leadership component.
Successful navigation of both is necessary when fundamentally transforming a large
organization.
The formal leadership component – the lead physician(s) must be energetic leaders in
this endeavor. This is substantially accentuated when there is a close and effective physicianadministrator leadership team. At every practice assessed, the successful complement of the
physician-administrator team proved to be one of the most vital aspects of their success in
effectual EMR implementation. The most salient examples were Pediatrics East, The Mark
Zangmeister Clinic, South Carolina Oncology Associates, Memphis Gastro, Mid-South
Pulmonary, Atlanta Cancer Care, Northwest Georgia Oncology, and The West Clinic. In each of
these cases the lead physician(s) and administrator made EMR such a priority that their
testimony is one where they were “hand-in-glove” in their cooperative efforts.
The informal aspect of leadership is also critical. There are often key opinion leaders
within a practice that must supportive of the EMR effort. Without the support of these
individuals, the entire effort can be derailed or, at a minimum, slowed like a road with speed
bumps. A number of administrators referred to specific physicians (by name) that were
essential in their efforts. In addition, a number of administrators cited those physicians who
were not on board who hindered the efforts.
The key elements to winning the support of these informal but key opinion leaders
within the group are:
 Time: Making the time and effort to include them in the process
 Communication: Maintaining regular updates, including face-to-face
 Clear & Concise Information: Generally keeping updates brief and to the point
 Inclusion in decision making: This is critical, even if the informal physician leader
is not in full agreement, they are still part of this important process and will
often state their appreciation when issues arise from other quarters.
These key elements will both move the process forward in a positive manner and help
minimize “back channeling” disruptions. Lastly, these will help reduce the ability of later
dissenters or objectors to have credibility when (not if) issues arise when the EMR is
implemented.
ESSENTIAL CONSTITUENT #4: PREPARATION, PREPARTION, PREPARATION
In the world of real estate it is often said the key to success is “location, location, location.” In
business the key is “people, people, people.” In the realm of EMR implementation the
operative phrase is “preparation, preparation, preparation.” Effective implementation requires
an enormous planning – even simulation and trial runs.
The core responsibility of preparation plans falls upon an implementation team. This
team should be led by a director. This director should be empowered like a “NASA flight
director – with all the power of go/no go – with the priority being very simple – mission success
and organization safety.”12 The implementation team must have comprehensive depth and
breadth.
One essential preparation component is the dispelling of the many myths around EMR.
Often EMR is oversold as a panacea to the practice. In addition, lack of planning could lead to
near paralysis for the group. Many clinics have had major downturns in their patient volume as
the practice is overwhelmed during EMR implementation.
Steve Waldren, MD, director of the American Academy of Family Physicians Center for
Health IT and Rosemarie Nelson, principal of the MGMA Consulting Group gave the following
list of major mistakes providers can commit in EMR implementation. It is noteworthy that all of
these issues are related to preparation:
“ 1. Not doing your homework: Avoiding supplier problems means background research and
thorough evaluations of vendors and products. And beware: vendors tend to make promises
they can't keep. According to Waldren, it's important to get the specifics down on paper.
"Often, a doctor will ask if [an EMR] can do this or that, and a vendor will say yes. Then, they're
surprised when in reality, it doesn't. Doctors need to make sure all expectations are met in
writing."
2. Assuming the EMR is a magic bullet: It's important to remember the EMR is a conversion,
not an upgrade. Although the system will save you time and money in the long run, Waldren
warns it isn't an instant fix to issues in the workplace. "Most people think an EMR solves
problems," he said. "But an EMR will only amplify problems that already exist in the practice."
3. Not including nurses in the planning stages: Nelson says doctors tend to think a new EMR is
all about them. "They don't think about how much the nurse preps the chart, how often the
nurse presents information to them, and how much the nurse handles patients over the
phone," she said. Having nurses involved from the beginning avoids future conflicts, and
considering their thoughts on product selection and implementation will only help with
workflow. "[The implementation] needs to be done with the support of staff; everyone needs
to be involved," added Waldren.
4. Not participating in training: Don't undervalue the importance of training, since failure to
provide and partake in it will only allow chaos to ensue come go-live time. Nelson said if a
vendor suggests a nurse spend six hours on training and a doctor four, then do it. "Microsoft
made us think everything is plug and play; the same with a MacBook," she said. "They think 'I
can do the same thing with an EMR.' The difference is, it's a complicated environment with a lot
of regulation, coding, and documentation. You have to dedicate the time for training."
5. Thinking you can implement the same processes as paper: Just as the EMR won't be a quick
fix to problems in the practice, it will also require different processes than paper. "EMRs require
process reengineering," said Waldren. The two ways of documenting data may seem similar,
but they are based on considerably different workflows.
6. Not asking for extra help: A detrimental mistake Nelson often sees is groups thinking they
can implement an EMR without asking for help. According to her, staff is already burdened with
work. Thinking they can take on a conversion, along with learning a new product and dealing
with a change in workflow, could lead to a disaster. "To do the whole thing without having
extra people is just creating an opportunity to burn out staff or hamper your productivity," she
said. "It becomes a self-fulfilling prophecy because we're less productive, and we don't have
nursing staff to support us." Nelson suggests bringing in temporary medical assistants to help
during the transitional period.
7. Being short sighted: According to Waldren, it's important to find an EMR that supports not
just the current healthcare industry, but what the industry will soon become. "You can't be
shortsighted [when implementing an EMR]," he said. "It needs to measure quality
improvements and populations, like those with diabetes, for example. It can't just measure
today -- it has to measure tomorrow."”13
It is this writer’s strong opinion that no issue that faces a medical clinic should be a
surprise to those responsible for its operations. In addition, there should be no adverse
situation that arises that does not involve the execution of contingency plans. These plans
should already be in place – in writing, training, and discussion.
All of this planning and preparation can and should ensure that a large medical clinic has
a mostly seamless implementation of EMR. Effective preparation strategies take an extensive
amount of time and a willingness to have significant plans in place before proceeding. The
organization should not fly by the seat of the pants – but should have briefing, detailed
understanding, and debriefing mechanisms.
Much can be learned from the processes established in the first dozen years of the
American manned space program. Particular lessons from the flights of:
-
Gemini 6 & 7 – the first rendezvous in space (precise tracking of simultaneous critical
events)14
-
Gemini 8 – with a thruster malfunction threatening the spacecraft and crew
(contingency decision making at critical junctures by those on the front-line)15
-
Gemini 12 – with the first long-term, task oriented spacewalk after severe trouble on
the previous three flights (recognizing that basic assumptions may need to be jettisoned
and a new paradigm embraced)16
-
Apollo 8 – the first manned flight into deep space, outside of the earth’s gravitational
pull (pioneering risk amidst the known, the unknown, and the known unknowns)17
-
Apollo 11 – the first lunar landing with the actual descent to the moon full of one huge
challenge after another (delegated decision making teamwork in a multifaceted
interconnected environment)18
-
Apollo 12 – a rocket struck by lightning on liftoff with all systems completely disoriented
on the spacecraft (commitment to learning additional nuanced and unorthodox
solutions that may come into play in the most unexpected and unplanned
circumstances)19
-
Apollo 13 – and the explosion aboard the spacecraft service module on the way to the
moon (grit, determination, proper assessment, and improvisation amidst the most
challenging system failures)20
-
Apollo 16 – critical pitch and yaw thumbwheel control indicators sending inaccurate
information.21
-
Friendship 7 – the first manned orbital flight in February, 1962 – when on board signals
falsely reported a heat shield risk) to learn to wisely trust instincts (when the foundation
of knowledge and experience may contradict the key indicator(s) – demonstrating
something is wrong with the diagnostic tool rather than the process or system).22
These are some salient examples that are helpful in demonstrating how preparation,
planning, contingencies, and other plans are elements of essential constituents to the
successful execution and minimizing risk of failure should the worst disaster occur.
A very important reality to healthcare issues is to learn how to simply plow through
challenges, understanding that there will be doubters as well as highly intelligent skeptics all of
which can paralyze progress. In an environment where physicians are owners of an enterprise,
the leader must know when concerns and complaints need addressing or when they can be
ignored as background buzz that accompanies the environment. Solid preparation helps bring
assurance to those who may have their doubts or insight into the implementation of a complex
process.
All of the groups that contributed substantially to this article laid an extensive
groundwork of preparation. For example:
•
The Memphis Heart Clinic demonstrated the value of preparation in contingencies and
improvisation as new roll outs of GEMMS empowered opportunities to improve
operational processes
•
Georgia Cancer Specialists demonstrated the value and opportunity of pioneering risk
into the unknown as it implemented a total plan on for comprehensive protocols and
pathways with its EMR implementation.
•
SCOA exemplified the simultaneous tracking of critical events as it implemented its EMR
coupled with its new facility in a multi-specialty oncology environment
•
Memphis Children’s Clinic sought to solve the integration of a large Pediatric practice
with the challenges of having up to date clinical data for patients admitted into a large
Children’s Hospital (LeBonheur). This required the jettisoning of many of the previously
conceived notions…
•
Wilshire Oncology effectively executed a contingency plan to migrate to a new product
when their primary EMR ended up being purchased by a company that had threatening
implications to the future of their support and data security.
ESSENTIAL CONSTITUENT #5: BASIC CONFIGURATION
Configuration relates to a fundamental question – how much will the system conform to
the practice and how much will the practice have to conform to the system? Thus, how much
will the system configuration conform to the practice and how much will the practice need to
reconfigure to conform to the EMR. Individuals and organizations are often averse to change,
preferring well-worn paths and routines. Migration from the 19th century model of health
information to the 21st century model means significant transformation calling for forsaking the
old methods and embracing the new. The best model for progress considers the reality of
effective, existing front-line patient processes while opening the door to new processes
enabled by technology. There are at least a dozen matters to consider when addressing issues
of configuration:
1. The WHO of the workload – for example: regarding the entry of demographic, clinical,
and other health information. What are the change points from the existing processes?
2. What changes or improvements can occur in the patient flow process? Some EMR’s
have patient navigation capacity to help facilitate flow to multiple stations within a
larger clinic.
3. How can the clinical decision making process be enhanced with the technology? Some
practices demonstrated the ability to establish clearly defined clinical pathways to
reduce variation and ensure best evidenced-based practice.
4. What transformational elements exist in the system’s options? Several oncology clinics
were able to interface with technology that obtained patient quality of life outcomes
data and use this data in the EMR to elevate the quality of patient care and the ability of
the provider to document and code at the appropriate level.
5. What existing processes can be made more standardized/consistent during the
transition? Nearly all practices were able to standardize a number of directives that had
previously been tailored depending upon the physician. This saved an enormous
amount of time and brought about huge realignment of consistency of the
administrative overlay of the clinics.
6. What aspects of the practice structure can be phased out? A number of practices were
able to completely phase out medical records and were able to right size dictation.
7. What new elements need to be created? Some practices were able to embrace a whole
new scheme of internal chart audit for documentation, coding, and other compliance
concerns.
8. Are there useful data repository and data mining opportunities that heretofore were
unattainable? This is perhaps the largest untapped area. For those practices involved in
managing diseases, clinical research, publishing papers, providing epidemiological data,
and other relevant information, this opened the door to a whole new realm of
opportunities.
9. Which “What-ifs?” need to be effectively assessed so that contingencies are sufficiently
covered?
10. Which “Whys” need to be evaluated? – particularly those that heretofore have been
considered “untouchable”.
11. Are the usual time-lines (the Whens) of a patient encounter needing to be reconfigured
– for example can patient demographics and insurance be entered into the system prior
to the patient’s first visit to the office?
12. Where should the previous medical records live and what should be accessible and what
should be discarded?
Effective engagement in the configuration process can utterly transform an organization.
During the 1970’s and early 1980’s the commercial banking industry adopted a whole new
technology for worldwide interbank fund transfers. This system, called SWIFT, stimulated an
entire era of re-engineering bank operations to empower the technologies and create
remarkable efficiencies and data security. One of the key components of configuration was
completed in 1975 when, “Rules defining responsibility and liability are written, operational
practices put in place. Fundamental principles behind SWIFT are established at an early
stage.”23 During my participation on Wall Street (in the early 1980s), the SWIFT system gained
rapid uptake due to the proper foundations laid in the 1970s. “SWIFT went live in 1977 and had
10 million wire messages by 1978. By 1983, the 1,000th member financial institution joined as
the worldwide network for interbank fund transfers took hold.”24
A number of practices seized the EMR migration to reinvent themselves on many levels.
Some of the more dramatic transformations occurred at SCOA, The West Clinic, and Georgia
Cancer Specialists.
SCOA’s transformation occurred as their new facility (120,000 square feet) and new EMR
(IMPAC) were implemented on a common timeline. Thus, SCOA went through a
metamorphosis similar to a caterpillar becoming a butterfly. Other than the same friendly
faces, the new organization was hardly recognizable.
The West Clinic used the migration to EMR to reassess every process in the organization.
Using an outside consultant – Engineering Innovations – a comprehensive process map (see
exhibit 1, 2, 3 on subsequent pages) and a computerized simulation model was created. This
empowered the organization to reinvent itself using a real-time dynamic model of “what-if”
scenarios. Key elements such as the use of pre-meds and mixing of chemotherapy drugs, new
sub-wait rooms, admissions and discharge processes, chemo order forms, and hundreds of
details were modified to transform the organization – the quality of care, patient safety,
efficiency, consistency, and resource allocation.
Georgia Cancer Specialists used the migration to set in motion a pathway of consistent
clinical protocols so that the entire organization was transfixed on best clinical practices
regardless of the medical provider. The EMR was the essential vehicle to execute a change that
was previously too onerous to implement.
In all of these cases, the front-end configuration, the questions and answers, the solutions,
and the ways and means were essential. At such a moment, origin determines destiny – in this
case the origin of change empowered the destiny of transformation. Thus, it is essential that a
significant amount of time and talent devote themselves to the essential constituent –
configuration.
Exhibit 1
Process Map of
activities to care
for one cancer
patient in a full
service…
…Community Oncology Cancer Center
Exhibit 2
Chemotherapy Treatment Component of the Process Map for a
Cancer Patient in a Community Oncology Cancer Center
Exhibit 3
Radiology Component of Process Map for Cancer Patients in a
Comprehensive Service Community Oncology Clinic
ESSENTIAL CONSTITUENT #6: SOFTWARE DECISION(S)
The software decision is another constituent that requires an enormous amount of due
diligence coupled with that perspiring moment of decision. There are so many key components
to making this decision. These include:
1. Determining the scope of the practice’s commitment. There are multiple elements to
an EMR and practice management system. These include:
a. Billing
b. Scheduling
c. Medical Records
d. Data Repository & Security
“In the 1950’s the financial industry made its first major foray into computerization via
the check processing automation.”25 In medical practices, the equivalent was the
massive migration to automated billing in the 1980’s and 90’s. Phase I in this process
was the basic billing and accounts receivables and scheduling. Phase 2, was the
electronic filing of health insurance claims.
In the 1960’s & 70’s Banks began to gobble up the accessible technology for enhancing
all of their operations. The goal was to reduce cost, increase efficiency, reduce
transaction errors, standardize processes, create interconnectivity (internal and
external), and truly modernize and decrease paper data storage.26 The present state of
physician practices is now at this point.
“The strategic objectives guiding the EMR/HER implementation during Project Infocare were
fairly typical. They included:
• Enhance access to care
• Improve continuity of care
• Provide physician connectivity
• Gain operational efficiency
• Support facility and services expansion
• Push quality and performance improvement”27
2. Given these options the practice must determine if it is going through a total platform
transformation or will it retain some of its existing platforms and integrate them. This is
a very arduous and complex decision that calls for substantial input from physicians to
front-line users.
3. There needs to be an internal brain trust of individuals who really understand computer
systems, medical systems. These individuals need to know more than the nomenclature
but need to understand all aspects of software and hardware architecture, operations,
and integration. The practice administrator (CEO) needs real knowledge in this area to
ensure that goals and needs are actually met.
4. Are there solid specialty specific software solutions? Will a generic solution work? This
is a huge issue that requires much investigation and thought. In the area of Cardiology
the software GEMMS has proven to be successful. In Oncology, there were several wellknown solutions (IMPAC, Optx, I Know Med, etc.). There are solid generic solutions that
have worked across specialties (e.g. Next Gen, Greenway, Athena, Misys, etc.). It is
imperative to become proficient in understanding these systems (beyond their sales
material and trade show demos and slick testimonials).
5. Strengths & Weaknesses and their relevance to the specific practice and installation.
For example, the strength of an oncology specific program was embraced by SCOA,
Zangmeister, and West Clinic, but was found to be a hindrance (in its flexibility) to
Tennessee Oncology, Georgia Cancer Specialists, and Florida Cancer Specialists.
6. Integration with other existing systems is important. Some practices only want the
medical record component of an EMR and are satisfied with the billing and scheduling
that they already have operational.
7. Clinical Pathways are more salient as Medicare and commercial payers are looking at
measurable performance, reduced variation, and defined outcomes. “Before you can
implement a best practice, you need to know what is best practice,” says Janet Porter,
PhD, former COO and vice president of Boston’s Dana-Farber Cancer Institute and now a
health care administration consultant. “You need to first gather evidence that supports
what the best practice is.”28
8. Data – Accessible, useable, and replicable – both within the practice and across the
specialty (locally, regionally, and nationally).
9. HIPAA compliance is essential, including a number of the data sets that were being
rolled out during the time period of many of the installations.
10. Complexity/Friendly – from a user’s perspective, friendliness goes a long way to
enhance the adoption and uptake.
11. Flexibility – many practices have complex patient encounters with multiple actionable
events during the patient visit. The ability of a system to apprehend the contiguous
nature of a patient encounter or a treatment episode can be critical.
12. Transitional Realities – there are numerous concerns on this front. Perhaps the most
substantial concern is the downturn in patient volume that often accompanies the
migration to EMR. This is usually the result of the time consuming process of reentering patient data and the slowdown of patient processing as the staff grows
accustomed to the new system. This is a huge concern that can adversely impact the
group’s finances and referral patterns and requires a proactive approach. One group
CEO insisted that there be zero change in patient volumes during the transition. This
approach was unconventional. However, the group achieved this goal by excessive
training and preparation before implementing EMR.
13. Data Migration – Some practices may want to maximally migrate the existing data
(patient information, demographics, billing data, etc.) to the new system. Usually, this
kind of migration requires an additional effort, time, and cost for most vendors.
14. Parallel utilization – it is common for two systems to run parallel. This can be the paper
and electronic record and/or the old billing and new billing system. There should be
clear timelines for parallel utilization with an absolute commitment to cutoff the old
system on a fixed date.
ESSENTIAL CONSTITUENT #7: HARDWARE DECISION(S)
The hardware decisions were to be governed by twelve major factors:
A. What are the system requirements? The particular emphasis will be on the system
capacity, speed, and configuration.
B. What are the long-term needs and expectations of the organization? The growth of the
organization and patient volume must be realistically understood and not
underestimated.
C. What was the experience of other comparable organizations? This is helpful to ensure
that the system does not bog down or fill up due to underestimating the demand that
will be put on the system due to number of users, volume of patients, storage capacity,
and more.
D. What real efficiencies can be achieved? This may be an opportunity to centralize certain
hardware or more effectively manage backups or off site redundancies.
E. What related matters needed to be addressed? If there are other hardware needs, this
may be the time to bundle purchases or reconfigure systems that are less than ideal.
F. What Opportunities can be simultaneously embraced during EMR implementation? Are
their legacy systems that can be phased out? Are their operational efficiencies to be
implemented?
G. What new technologies are on the horizon? It is important to have a pulse on the future
to ensure that the organization does not find itself cornered with a dinosaur or
technology that does not enable a bridge to the future.
H. What are the real cost issues? This includes short-term and long-term, fixed and
variable, main hardware and supportive components, maintenance and upgrades, and
present needs vs. growth demands and opportunities.
I. What is the best primary location for the key hardware components? One that is safe,
secure, has backup power, and is best for the entire organization. It may require the
creation of a whole new data center.
J. What are the ancillary infrastructure and costs (e.g. wiring, T-1s)? The internal cabling
and the external connectivity are essential – especially to ensure real-time speed and
access.
K. What are the offsite backup hardware requirements? For mirrored systems, backups,
and contingencies.
L. What are the business interruption contingency plans? Having off site backups (both
local and outside the immediate geography are critical).
ESSENTIAL CONSITUTENT #8: VENDOR INTERACTION & SITE VISITS
Visiting comparable sites where EMR has been implemented is essential to the process. Each of
the groups had a multi-tiered approach to “test driving” systems before making their final
decision. This included:
A. Examining systems at various meetings and trade shows. This created an informal
atmosphere to explore options and press the vendors with difficult questions. It also
allows the potential purchaser to be insulated as they, themselves, are unable to make a
final decision.
B. Visiting sites that have installed and operationalized the product is essential. For
example one of the large groups visited three sites to review the same product and
found three different results – one where a product was completely and successfully
installed, one where there were huge issues, and one where the other practice clearly
dropped the ball. This gave the practice the encouragement to know that success was
possible and the reality to apprehend that either the vendor or the practice can cause a
less than optimal migration. A typical site visit should be at least 4 hours – preferably
longer.
C. Several practices went to the vendor’s home office to examine the product, ask the hard
questions, and set the table for potential negotiations. One practice CEO showed up at
the headquarters of a vendor unannounced and in an innocuous fashion just to see
what kind of customer experience they would encounter. The experience was very
enlightening and had an impact upon the group’s decision making.
D. Nearly all the groups had a video conference demo. Some groups had multiple demos
with the same product (to accommodate questions and include key stakeholders).
These demos should last 2 to 4 hours minimum and should be repeated more than once
to ensure all stakeholders and broad array of staff are sufficiently exposed to the
product.
E. It is essential to call other practice physicians and administrators to get the whole story
on their experiences. Prepare an extensive check list of questions on the soup to nuts
issues raised in this paper.
F. As a large practice, the group should leverage its size and importance to make sure it
has regular interaction with the leadership of the vendor (the CEO, COO, etc.). One
group CEO routinely sent the message to their prospective vendor, “We will be your
greatest customer or your worst nightmare.” In other words, we will help you sell your
product again and again or you will find us ensuring that your poor reputation is known.
G. It is good to ask vendors about their competitors and their competitors’ products and
then listen closely to what they say.
ESSENTIAL CONSTITUENT #9: INTELLIGENT PROCESS
There is a plethora of information about the advantages and disadvantages (challenges of
EMR). For example the Mayo Clinic reports,
“The electronic medical record (EMR) is critical to Mayo's ability to provide
efficient, coordinated, safe and high-quality care.
"I can quickly and easily pull up test results in the exam room to review with my
patients," says Sandhya Pruthi, M.D., of Mayo Clinic in Minnesota. "I also can
verify when they had past exams or procedures. I can even show them results of
their imaging tests on the screen."
Multiple care providers, in different locations, can simultaneously view a
patient's medical record on their computers and get up-to-the-minute
information on test results and other doctors' recommendations. This
collaboration enables care providers to work more efficiently in determining if
further consultation or testing is required.”29
Many report that the transition is quite painful with everyone having to learn a new
system, organizational processes bog down, patient flow slows, and frustration sets in. Some
of these concerns are summed up as follows:
•
•
Lack of Quality Patient Time: When doctors, nurses, and administrative staff are
unfamiliar with the technology and how a new system works, they often spend more
time on it. Or, they may be uncomfortable using it so it will take them longer to execute
a task. All this lost time could be potentially spent servicing patients or tending to other
mission critical matters.
Paging Standards, Where are You: Since electronic medical records, as an industry, is
still in its infancy, we have yet to see a standardization of EMR requirements and
utilization across healthcare organizations, insurance companies, pharmacies, etc. The
problem is when these disparate systems do not synchronize, it results in errors,
duplication of efforts, or a lag in time in service. 30
Therefore the process for determination, implementation, and execution of an EMR in a
large medical practice had some common elements that are summarized by the following
sequential routine:
1. PLAN: The EMR Implementation team would plan each step in the process
2. ACTION: The group would then take appropriate action based upon the plan
3. ASSESS: Each action item would be assessed upon implementation
4. DEBRIEF: A debrief session would follow the assessment
5. IMPROVEMENT: Necessary improvements in processes or systems would then
be considered.
6. IMPLEMENT: The improvements would be implemented.
7. EXECUTE: The updates in processes or systems would then be executed
8. CYCLE: The cycle would continuously repeat to ensure that the implementation
was maximally achieved.
This mechanism effectively assisted the Memphis Heart Clinic to better manage the staff
resource allocation in the office clinics. The way patient care was documented and how the
patient encounter was managed were improved through a series of on-site assessments and
changes that helped the group move past hurdles of how it was always done.
One group was committed to maintaining its existing Lab Information System (LIS) and
having that data populate the EMR through an HL-7 interface. This delivered a very busy lab
staff from having to transition to an entirely new system just a few years after the LIS was
implemented. The process to ensure that the data was migrating timely and accurately
required a series of cycles of the process methodology described above.
Many of the groups had in-house or outside radiology data that needed to integrate
with their systems. Given the wide array of equipment and vendors each had to go through
many cycles of this process management experience to accomplish the goals for their group.
All of the groups had some very engaged physician champions who not only beta tested
processes but provided an ongoing role in this process. One group had the mindset, if we can
make it work for Dr. X, then we can make it work for the entire clinic. This approach, though
intensive proved highly successful in achieving 100% migration to EMR on schedule.
ESSENTIAL CONSTITUENT #10: BUDGET
Finances are one of the primary constraints of any EMR implementation plan. Large
groups can afford the investment, particularly when they consider the potential downstream
benefits of revenue enhancement and cost savings. “Implementation of an electronic medical
record system can result in a positive financial return on investment to the health care
organization.”31
Typically a large group will spend 0.5% to 1.5% of their annual gross revenue for a
comprehensive EMR system. Thus, a sizeable oncology group with $100 million of revenue may
spend $500,000 to $1,500,000 in hardware, software, and related costs (cabling,
communications, networks, off site backup, training, support) as an initial investment to make
the transformation. A $50 million per year cardiology group will probably spend $250,000 to
$500,000 as the major initial investment.
Several groups were able to validate substantial revenue recovered by migrating to
EMR. In a paper world, fee tickets (super bills) would disappear like socks in a dryer. In the
EMR world the patient on the schedule, the EKG, the nuclear test, the CT, the expensive
oncology drug, everything was captured in the process and closing the encounter. It was not
embellished to say that the entire investment in EMR was recovered through revenue capture
in one to three years.
Some groups encountered substantial savings. There were instances of staff savings of
6 to 12 FTEs since the old paper chart system was unwound. In addition, the number of
transcriptionists declined in some practices as the physicians documented their encounter or
used a voice recognition system.
Several groups such as SCOA and Zangmeister experienced real savings as their new
facilities coupled with the EMR empowered a plug and play cross trained model of staffing –
where each pod had such consistent processes that the flexibility of the staff to cover each
other allowed for fewer staff overall.
When it comes to the financial aspect of the investment, all the groups that successfully
implemented EMR stated that the result was a positive financial return on investment.
ESSENTIAL CONSTITUENT 11: ASSESSMENT GRID
A unique practice tool used by a number of the groups was the creation of a
comprehensive grid to assess all the components of each EMR. These were juxtaposed to one
another in a report card fashion. The most valuable asset of these report cards is the process to
develop them – one that requires serious thought and an ability to explain the assessment.
Inside of oncology a number of clinics faced at least 5 to 8 viable options – several specialty
specific and several non-specialty specific. In addition, the groups also faced the challenge of a
full on-site system or one that would be housed elsewhere via an ASP model or a hybrid shared
resource configuration.
Another component to the grid is an extensive narrative that accompanies the
assessment of each option. The narrative helps put operational realities to the features,
benchmarks, and costs. In addition, various site visits help move the consideration from virtual
and theoretical to tangible and pragmatic.
In interviewing members of one team that were involved in developing a comparative
grid and narrative – one could glean that hundreds of hours of in depth and balanced thought
went into the process to compare system options.
Ultimately, the grid is a very useful tool – even when it is comparing apples to oranges –
because it can help the decision makers assess the value proposition by seeing the cost
juxtaposed to the actual deliverables. It also helps clarify real expectations compared the
optimistic claims that vendors.
A sample grid is exhibited on the next three pages.
Sample EMR Assessment Grid, Page 1
PLATFORM & DESCRIPTION
-Location
-Data Storage
-Specialty Specific
COMPONENTS
-Scheduling
-Billing
-Medical Records
-Other (1)
-Other (2)
USER FRIENDLINESS - Scale of 0 to 100
-Scheduling
-Billing
-Medical Records
-Other (1)
-Other (2)
HARDWARE DEMAND - Anticipated
Expense
-Server(s)
-Network(s)
-Integration/Interfaces
-Cabling
-Data Communications
-Mirror System
-Off Site Backup (1)
-Off Site Backup (2)
-Off Site Backup (3)
-Additional Annual
-TOTAL
INTEGRATION
-With Existing PMS
-With Existing LIS
-With RIS
-With Data Repository
-With Other Systems
EMR Product 1
EMR Product 2
EMR Product 3
EMR Product 4
In-House
Multiple InterActive Drives
Yes
In-House
Multiple InterActive Drives
Yes
ASP
Sufficient
Shared Resource
Sufficient
Yes
No
Yes
Yes
Yes
LIS
Radiology
Yes
Yes
Yes
LIS
Radiology & PACS
No
Yes
Yes
None
None
Yes
Yes
Yes
None
None
90
85
90
90
95
90
90
95
90
90
85
85
-
85
85
85
-
65,000.00
25,000.00
25,000.00
12,500.00
7,500.00
25,000.00
10,000.00
8,000.00
8,000.00
35,000.00
221,000.00
55,000.00
15,000.00
28,000.00
7,500.00
7,500.00
18,000.00
12,000.00
5,000.00
5,000.00
27,500.00
180,500.00
8,500.00
12,500.00
7,500.00
5,000.00
12,500.00
0.00
0.00
0.00
0.00
9,600.00
55,600.00
22,500.00
15,500.00
15,500.00
4,500.00
6,500.00
7,500.00
8,500.00
5,500.00
0.00
8,400.00
94,400.00
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Sample EMR Assessment Grid, Page 2
DATA & REPORTS
-Routine Billing & A/R
-Patient Demographics
-Routine Lists
-Business Development
-Clinical Oriented
-Clinical Pathways
-Patient Outcomes
-Clinical Research
Yes
Yes
Yes
Yes
Yes
Yes
Limited
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Limited
Yes
Yes
Yes
Yes
Limited
Limited
Limited
No
Limited
Yes
Yes
Yes
Limited
Limited
Limited
No
Limited
Established
Import or New
User Defined
All, Part, or
None
Established
Import or New
User Defined
All, Part, or
None
Floating
New Only
None
Floating
New Only
None
None
None
120 Hours
$1,000 day
Train off site
160 Hours
$1,200 day
Train off site
40 Hours
Negotiable
none
40 Hours
$1,000 day
None
GO-LIVE
-By Module
-Support during go-live
Cust Defined
Intense On-site
Cust Defined
Intense On-Site
No Flex
Remote
No Flex
Remote
CUSTOMER SUPPORT
-Phone
-After Hours
-Weekends & Holidays
Unlimited
Unlimited
Limited
Unlimited
Unlimited
Unlimited
Unlimited
Limited
Addl Cost
Unlimited
Limited
Addl Cost
UPGRADES & Enhancements
-Normal
-Migration to New System
Free
Contingent
Free
Contingent
Free
Not Specified
Fee
Contingent
On-Site
Applic & Data
Data
Yes
On-Site
Applic & Data
Data
Yes
At Host
Data
None
None
At Host
Data
None
None
INSTALLATION
-Timeline
-Transition Model
-Test Period
-Data Importation
TRAINING
-On Site Hours
-Addl Cost
-Other Options
BACKUP & RECOVERY
-Mirror Server
-In-town Off Site Backup
-Out of Town Backup
-Crisis Hardened Backup
Sample EMR Assessment Grid Page 3
COST
-Front End Prep
275,000
185,000
13,200
96,000
569,200
109,200
1,028,500
120,120
9,500
$800
Provider/Mo
55,600
8,500
12,000
100,100
44,500
287,600
48,950
12,500/yr
94,400
8,500
18,000
133,400
39,000
297,900
42,900
B
B+
B
B
22
750+
Private
$90M+
None
45
1250+
Public
$320M+
Radiation Equip
3
75+
Private
$1M+
None
9
350+
Private
$5M+
None
REPUTATION
-Other Customers Exper
B+
A-
B
B
OVERALL ASSESSMENT (1-100)
86
92
80
80
-Software
-Hardware
-Communications (Annual)
-License & Support (Annual)
-Total Year 1 Costs
-Year 2-5 Costs/Per Year
-Total Install through Year 5
-Year 5+ Costs/per year
SITE VISITS
-Site Visit Report Card
COMPANY STATUS
-Years in Business
-Total Customers
-Public/Private
-Total Revenue
-Other
17,500
22,500
195,000
221,000
13,200
75,000
504,200
85,200
862,500
93,720
8,500
ESSENTIAL CONSTITUENT # 12: FINAL DECISION TO PROCEED
The decision to proceed with an EMR [after the extensive due diligence phase]
essentially follows the routine pathway that each group has grown accustomed to when they
are making major strategic decisions. Typically the CEO and lead physician(s) will make a
presentation to the board. The presentation will include the recommendation. Perhaps the
most effective way to do this is to create a relatively brief power point (approximately 24
slides). This presentation should hit the high points of goals, the due diligence, some key
salient conclusions, and the recommendation.
The CEO and lead physician(s) recommendation to proceed should in a normal manner
with a written and roll call vote. The objective should be unanimous approval. This is best
accomplished by an open and informative process leading up to the presentation and vote.
Of course the final decision to proceed should be contingent upon completion of
contract terms that are in accordance with the group’s stated interests. The matter of the
written agreement could precede the vote – however, the nature of the lawyering process may
be used to lower legal costs or to leverage final terms depending upon the group. Some groups
have lawyers that are very transactional oriented and will expedite the final deal. Other groups
have attorneys who seek to inject themselves into the final deal. Each group has to function
according to its orientation in this regard.
ESSENTIAL CONSTITUENT #13: CONTRACT TERMS
The purchase, implementation, and support for an EMR in a large medical practice is a
major transaction. It is imperative that the group have the written terms of its agreement
enumerated and clear. The use of solid legal counsel for this process is an imperative to protect
the interest of the group – particularly when matters go awry. It is important to not accept the
boiler plate terms of the vendor’s contract. Negotiate the terms to ensure that there is a level
playing field in this large, expensive, long-term relationship. The key components of the
transactional terms requiring consideration include:
1. Price: The price of the system needs to be clear and understood. Pricing in the world of
software and hardware, often has so many contingencies and “what-ifs” and unforeseen
circumstances. A detailed articulation of what it takes to have the system “turnkey” in
reality is necessary. This includes all of the hardware components, all of the software
modules, all of the operating system costs, all of the wiring, communications, and
backup expectations. It also involves data transfer between other operating systems in
the office. For example, several groups used the Orchard Lab Information System quite
successfully and wanted the data to seamlessly migrate from one system to the other.
Another matter for a number of groups was information flow the PACS (imaging) system
in radiology. Every imaginable cost related matter needs to be articulated in the
agreement. Two good means to ensure that everything is covered are:
a. Call as many clinics as possible that were involved in implementing the same
system to find out their cost experience and how the vendor defines pricing. A
number of groups were looking at a similar vendor and found the pricing models
were completely different from one group to the other. The model for one
group was based upon sites, another was based on users, another based on
licenses, and another based on modules. Of course the bottom line is key, but it
is important to know how the vendor got to the bottom line.
b. Have the entire implementation team spend a day considering all that is
required to implement the system. Diagram the whole process on a white board
and place a dollar sign everywhere there is a cost (both internal and external).
The financial team should then determine what each of these costs are and
present it in a spread sheet – including costs that are not part of the transaction
but are a result of the transaction (i.e. internal labor, T-1 lines, scanning charts).
2. Payment Terms:
a. Benchmark definition of installation, training, and utilization should be part of
the definition of when payments are made and how much is paid during the
purchase and installation of the product.
b. Reasonable expectations on a transition should have some definition in the
contract.
c. Some groups have successfully inserted language that leaves an open ended
element concerning an unwind and recoupment should they not be satisfied
with the installation or the ongoing product, service, or support.
3. Implementation:
a. It is important to define successful implementation. The practice and the vendor
will have disparate expectations and clarification of these terms will save a lot of
angst and conflict.
b. Stated timelines and benchmarks for implementation are most helpful. For
example a group may have a stated date for the billing to be fully implemented
and then release funds accordingly. The subsequent implementation of the
medical record will release further funds to the vendor.
4. Training:
a. Sufficient training is an essential. It is important to milk as much training as
possible – preferably on-site training. A group is spending hundreds of
thousands of dollars for a product. One consultant said, “Insist on lots of training
and then horse trade for more.”
b. Make sure training is specific and has stated goals and benchmarks to ensure
these goals are achieved. Training is often defined in “hours”. This works well
for the vendor. However, the user should define training in terms of who, how
many, and what capabilities have been mastered.
c. The group should insist that the vendor succeed in training the trainer. In short,
several people within the group should master the program before the training is
considered successful.
5. Support:
a. Support is that element that tells the customer that they are not left hanging
amidst that which would disrupt their operations.
b. Support terms should include response time, level of support, hours of support,
and fast track support during a crisis.
c. The group should concede points that avoid frivolous support issues landing on
the vendors lap. It should demonstrate a strong in-house IT team that can
handle the basic issues that often cause users to have unneeded palpitations
(generally issues that are related to hardware or operating systems rather than
the vendor product).
d. The customer should internally control who, what, and when should precipitate
a support call. This is best kept to the IT team and the EMR Director. This does
not have to be in the terms of the agreement – but an internal decision to
ensure that support is properly used and leveraged for real needs rather than
perceived needs. One of the big challenges that can occur is when a physician or
one of their key staff routinely hounds the vendor support team about an issue
rather than working through a well-orchestrated internally managed process.
This can waste time and dilute the group’s effectiveness and credibility for the
bigger issues where it will need leverage.
6. Resources: It is important to have vendor defined resources for training, support, and
other issues (e.g. hardware, systems operations) for when matters go awry.
7. Written Specifications: System specs are critical to get in writing – particularly to
support hardware purchase decisions as well as parallel operational functions. A
number of practices found that the system overloaded and slowed down well below
their peak demand expectations. Having the specifications in writing can force
monetary or other concessions when additional capacity or system processors need to
be expanded
8. Upgrades: Clear pathways for routine upgrades, new releases, and whole new systems
should be discussed, negotiated, and enumerated. Most systems will have regular
patches and upgrades released without charge. A new release or new base system
(using the same data set) may have some cost associated with it. These matters should
be addressed in writing in the initial agreement.
9. Back-ups, Redundancy, Disaster Recovery: This is a critical component that needs
definition. At minimum, there should be on-site redundancy and backups, local off-site
backups, and remote (distant) backups (at least 200 miles away). In addition, there
should be a clear pathway and methodology to restore the system should there be a
major crash or data issue. Also, a defined way to ensure a mirrored remote system to
engage on-line in case of a facility disaster or some other unforeseen circumstance (e.g.
natural disaster).
10. Lost Productivity: Defined issues of lost productivity during installation, upgrades, down
time, or disasters can be in an agreement – with potential economic damages. Most
vendors will resist such language – however, it is worth pursuing since the nature of the
business enterprise of a large medical practice cannot afford business interruption.
ESSENTIAL CONSTUENT # 14: CLINICAL PATHWAYS & PROTOCOLS
Many specialties can use EMR to effectively implement clinical pathways and protocols.
“"Mayo's integrated medical record has long helped to maintain high standards
of quality because the 'open book' serves as an excellent means of peer review,"
says George B. Bartley, M.D., an ophthalmologist at Mayo Clinic in Minnesota.
"It's harder for a single doctor to get too far off the track when others can
carefully scrutinize the thinking that led to the diagnosis and treatment plan."
He says that the next advances in quality improvement likely will come from the
ability of the computer to offer diagnostic possibilities for a certain combination
of signs, symptoms and test results, or to recommend various therapeutic
options for a problem, such as the best antibiotics for a particular infection. "This
should save money, too, because the software can identify a less expensive drug
that is equally effective," he says.”32
Oncology, Cardiology, Endocrinology, Nephrology, Pulmonology, and Pediatrics are
among those that can implement protocols for effective management of chronic diseases –
cancer, heart disease, diabetes, kidney failure, Chronic Obstructive Pulmonary Disease (COPD),
childhood asthma and more.
A foundational essential to the effective implementation of EMR was the formal
establishing of preferred clinical pathways for each type of cancer treated by the clinic. For
example, Cancer is hundreds of different diseases with thousands of clinical options. In
addition, those with cancer have additional medical issues – both from the disease, other comorbidities, and the treatment itself. Some cancers require multiple lines of therapy. Lastly,
many cancers have become a chronic disease requiring extensive ongoing management. Thus,
the clinical pathways are complex “Rubik’s cube” that requires an extensive process to ensure
excellence in care and treatment.
As preparation for EMR implementation once cancer clinic undertook a full year of
focused emphasis. It required an energetically engaged physician team, clinical research team,
clinical management, nurses, pharmacists, administration, billing staff, and others. The process
was continuous with weekly meetings to assess the progress, make decisions, and disseminate
additional tasks and responsibilities. The process also continued after implementation since
new treatments and evidence continue to flow from the broader community of researchers,
treatment centers, journals, meetings, and others contributing to the body of knowledge.
The result of the effort was that best evidenced-based choice first and second line
therapies for all major cancers were established in a priority order in the EMR. By using this
model, the group was able to participate in a transitional demonstration project with a large
national payer.
Another group was able to work with their local BC/BS to provide defined clinical
pathways for intensive care hospital service through extracting data and outcomes from their
EMR.
Several groups were able to integrate data from a supportive care technology tool that
assessed an array of quality of life data points from the technology into the EMR. Interestingly,
CMS established some reimbursed demonstration projects in these areas and these tools and
some others made the whole process of capturing and reporting the data quite simple.
There were groups that had a strong emphasis on ensuring that clinical trial options
were available for cancer, heart failure, and several other diseases. Busy physicians often
overlook these options (amidst their busy-ness). The EMR was able to refresh the physician
with these choices during the clinical decision making process.
ESSENTIAL CONSTITUENT # 15 : PHYSICIAN & CLINIC CONSISTENCY
Given the nature that physicians tend to see themselves with a solo mindset as captains
of their own ship, the groups that had the most successful implementation of EMR made a
concerted effort and commitment to bring about operational and administrative consistency
regarding its clinical operations.
For example, among the oncology groups, It was quite revealing to learn that the way
chemotherapy was ordered (the forms and methods) varied among the physicians. Thus, the
same chemo regimen could be written in multiple different formats or on one of several
existing or newly created forms. In addition, various test results, labs, functionality within the
physicians clinical area, scheduling, chemo administration processes, patient flow, and other
key areas all had variation from physician to physician.
Implementation of the EMR gave the group an opportunity to narrow these 12 lane
superhighway into four consistent lanes – this improved patient flow, patient satisfaction,
reduced the risk of medical error, and ensured that the staff was far more flexible in its ability
to serve any provider.
The key to succeeding in this effort was to enlist physicians to help lead the charge. In
one practice, this physician was a large producer, highly efficient, and had merged their solo
practice into the large group about 7 years earlier. Some of the unique elements of this
physician’s practice remained untouched by the merger. Before the process was completed,
chemo orders, test results, pod functionality, chemo administration functionality, scheduling
processes, billing processes, documentation processes, and dozens of other administrative
essentials were brought into far greater consistency.
This resulted in greater staff flexibility, improved operational efficiency, staff cost
savings, improved patient safety, potential reduction in medical, better communication and,
most importantly, a better environment for the effective overlay of EMR in the practice.
ESSENTIAL CONSTITUENT # 16: FULL VS. FAUX IMPLEMENTATION
One of the more extraordinary discoveries during the due diligence process was the fact
that many medical practices that indicated they were using and EMR had actually executed
more of a faux implementation. For example, there was a large practice in the southeast that
was well known for their implementation of an EMR. When a team from another practice
went to visit this site, it was found to be using the system for patient information and billing.
The medical records were still half sized paper charts that were handed to the patient to carry
with them when they were called to proceed into the clinical area. When asked about this
matter, the group conceded that the doctors were not ready to go “paperless”. In reality this
was a faux implementation. The primary purpose of EMR is to have the patient’s medical
record electronic – this large group was avoiding this critical objective. This was largely the
result of failed leadership.
In contrast a practice that was visited in the mid-west was found to be completely
paperless. The administrator who oversaw this practice – as part of an adjunct to a hospital
system – indicated that paper was banished on a fixed date. The entire practice was using the
EMR to its full capacity. The practice was a smaller group that had fewer obstacles to overcome
to achieve full implementation.
Another large practice in a city with two large cancer clinics had been on an EMR for two
years. However, as inquiries went to the group to understand the extent of the
implementation it was clear that the group was “in transition” regarding implementation. It
was evident that a number of obstacles – both personal and operational – were preventing the
group from jettisoning the paper charts. Thus, the group was doing everything on paper and
some things electronically. While this was not faux implementation, it was certainly not full
implementation.
Two large cancer clinics were interviewed at a national meeting. Both had boasted of
having implemented EMR. These clinics were well known to be pioneers in advancing medical
and information technologies in their centers. However, when they were scrutinized for
specific clarifications regarding their implementation it was evident that neither had fully
implemented the system.
One center had done an effective job determining their first-line clinical pathways and
had hardcoded this into their EMR. However, they were still working on second and
subsequent lines of therapy. Thus, implementation was in process but not fully executed. The
other center in the second city had spent quite a bit of money and effort in leveraging a
negotiation to essentially become the EMR model for oncology for a specific system. All the
back room work, however, was still in process and nothing had been implemented in their
centers. Interestingly, two years later the whole endeavor was scrubbed and the group went
ahead with a better known system for their specialty – after wasting too much time and too
much money.
Lastly, there were the sales stories that were evaluated. A number of centers who
bought the various products were called and evaluated for real implementation. It turns out
that less than 20% of those who purchased the products had arrived at “full implementation
status.”
Memphis Heart Clinic and Memphis Children’s Clinic are examples of groups that die
implement EMR but came short of ideal implementation. Even after using their systems for 3
to 5 years, many of the aspects of patient information and documentation remained on paper
or were inconsistent from one provider to the next or one office to the next.
Consolidated Medical also had wide variation in the level of installation – largely
because the group functions more as a federation with a single tax ID rather than a centralized
managed organization.
It takes real determination, motivation, leadership, and incentives to fully implement an
EMR; even in an atmosphere of government payments, younger techno savvy physicians, and
the many advantages of moving forward.
ESSENTIAL CONSTITUENT # 17: PHYSICIAN CHAMPIONS
Without question the most essential constituent to the successful implementation of an
EMR is the active role of physician champions. “Clinic C had a senior physician whose role was
the clinician champion for the EHR rollout. He led planning meetings and sent out weekly
communications to all clinic staff setting expectations for how the practice would change. The
clinician champion also engaged two other providers to endorse the EHR and assist with clinic
change management processes.”33 These champions set the overall tone for the expectations,
the process, and the execution of the EMR. Without these champions every obstacle is
magnified, every hindrance a potential shipwreck. It is essential that these champions be
leaders in the practice – those recognized by their peers. It takes only 2 or 3 physician
champions to lead the charge. However, all the physicians need to be on board. At the West
Clinic physician champions from each of the specialties were chosen to ensure that all aspects
of the clinic were covered. At Georgia Cancer Specialists, the physician CEO championed
change. At Pediatrics East a lead physician made their implementation more successful than
the other large Pediatric group in the community using the same software.
The best physician champion encountered [during this research] had an amazing
commitment. This physician came into the office by 7 am every Monday, Wednesday, and
Friday for over two years. The physician and his personal nurse and administrative assistant
met with the EMR Director and continually learned new features, tweaked shortcuts,
brainstormed through issues, and became the guinea pig for change and enhancements.
As the Chief of Staff for his large group, this physician set an example and expected the
rest of the group to follow. As a result, the group had a most effective full implementation of
EMR and demonstrated the success that can occur when physicians lead the effort.
At Florida Cancer Specialists – two key physician champions, Dr. Harwin (the group CEO)
and Dr. Rubin led the charge for EMR. On multiple occasions Dr. Rubin demonstrated the
means and methods to national meetings of oncologists and administrators. This set a solid
example for others to follow.
The physician champions should be empowered to impact the following:
•
CULTURE: The entire organization should know and sense that the physician leadership
is behind the implementation of EMR. This should be effectively communicated by the
physician champions.
•
CHEERLEADING: EMR is like implementing a whole new game plan. Like any good
coaching assignment the leaders much set the tone – even as cheerleaders for the team.
•
COMMITMENT: The entire organization must know that the transformation is going
straightly forward. The message of no turning back and the necessity of change must be
effectively conveyed.
•
CONSENSUS: Effective leadership helps build consensus – especially when fundamental
change is involved.
•
CHALLENGES: Obstacles, delays, speed bumps, inertia, et. al. are all part of the process
of wholesale organizational change. The physician champions are being watched by
their peers and all the staff. Any signs of wavering or waffling in the commitment to
change can be seized by those who by nature prefer the path of least resistance.
ESSENTIAL CONSTITUENT # 18: IMPLEMENTATION TEAM
One of the more critical decisions that can ensure success is the creation of a comprehensive
implementation team. The concept of an “EMR Implementation Team” resulted from those
observing those groups who did not effectively implement EMR.
One of the better EMR Implementation established the following goals:
1. Full Implementation
a. Replacing the current paper medical records completely
b. Replacing the current scheduling system completely
c. Replacing the current billing system completely
2. Timely Implementation
a. Phase I – Scheduling
b. Phase 2 – Billing
c. Phase 3 – Medical Records
3. Comprehensive Implementation
a. All Employees
b. All Locations
c. All Service Lines
d. No Exceptions
4. Ongoing Excellence
a. Super Users
b. Site Experts
c. Specialty Experts
d. Ongoing Training
e. Upgrades & Enhancements
f. Continuous Improvement
In order to accomplish these goals the implementation team had to include the following clinic
staff: The CEO, COO, CFO, CNO, Clinical Director(s), IT Director, EMR Director, Billing Director,
Pharmacy Director, Radiology Director, Chemo Managers, Site Managers, Reimbursement
Manager, Medical Records Manager, Scheduling Supervisor, and Front Desk Supervisors.
An effective implementation team:
 Ensures that all users are sufficiently trained
 Operationalizes everything
 Weaves the EMR into operational opportunities and vice versa
 Links all operational functions
 Creates parallel pathways for implementation
 Solves problems – and there are going to be scores and scores of problems needing to
be solved
 Reengineers the organization
 Champions the effort to entire staff
 Impresses the Board of the Group
 Impresses the Vendor
 Ensures the Vendor Exceeds Expectations
 Meets several times per week
 Continually maintains a dialogue via e-mail
 Communicates, Communicates, Communicates within itself and to the whole practice
 Maintains Optimism and a “can-do” spirit
ESSENTIAL CONSTITUENT # 19: DIRECTOR OF EMR
Given the size of the organization and the scope of implementation coupled with its
transformative effect, it is best for the organization to have a solid individual to lead and
oversee the efforts. In some groups a person is assigned the position of Director of EMR.
Some groups had there CEO or COO serve this role. This generally worked fairly well. This
position, however, really requires a full-time emphasis and is best served by someone who has
been an operational director within the clinic and who is IT savvy.
One of the more effective EMR Directors worked in a group that had over 350 users at
nine locations spanning nearly 120 miles of separation in two states. This person had
previously managed two of these locations and was fully aware of all the daily operational
issues facing the practice. They were also quite skilled in IT areas and had the advantage of
having a husband who was IT Director for a large clinic in the same community.
This individual literally worked 10 to 12 hours per day, often six days per week. Their
sole responsibility was EMR – thus, they kept the whole implementation steadily moving
forward. This person reported directly to the COO of the practice and gave multiple daily
updates to the CEO, COO, CFO, and CNO.
ESSENTIAL CONSTITUENT #20: FULL CEO SUPPORT
“Leadership at the highest level (e.g., CEO) is responsible for establishing
organizational aims for the EHR and assuring that the strategies to achieve those
aims are executed at the highest governance level. This requires articulating a
business case for clinical quality as well as allocating resources, removing
barriers and fully engaging providers and patients.”34
EMR implementation is a “sea change” for a medical practice. The CEO must be fully
supportive – yes, fully behind the implementation. It is one of those initiatives that require the
CEO to be boldly out front – leading the effort, like a football quarterback – knowing that
success will be to their credit and failure will be to their blame.
One of the best examples was Ann Embrey of Pediatrics East in Memphis. Her hands on
engagement accelerated the adoption of EMR. Bill Appling, the President of PIPA (Pediatric
IPA) and healthcare consultant remarked on her extraordinary efforts that made a huge
difference for the group – particularly as others in the community floundered in their efforts.
In short the CEO must take full responsibility for the success or failure of implementing
an EMR. Our research found no large practice with a successful implementation without a fully
engaged, supportive, cheerleading CEO.
ESSENTIAL CONSTITUENT #21: PRIORITY
The decision to proceed with an EMR makes it one of the organization’s top Strategic
Priorities. Thus, the board, all physicians, and all administration and managers are clear that
this is priority. Every meeting and routine communications should mention EMR and
underscore its significance to the whole group and everyone who works there.
ESSENTIAL COMMUNICATION #22: ENERGY, DEVOTION, & MOMENTUM
It is difficult to contemplate something more daunting for a large medical practice than
the migration to an electronic medical record. Whenever an organization faces a huge change
requiring heavy lifting, significant re-engineering, and substantial re-orienting few constituents
are more necessary than high energy and passionate devotion.
In nearly all endeavors in life, the principle of inertia casts an overwhelming shadow
upon the prospects of starting, maintaining, and completing a new course or challenge. In the
midst of a large medical practice, the tyranny of the urgent, the security of well-worn pathways,
the natural inclination to resist change, fear of the unknown, and many uncertainties provide
numerous obstacles to success.
There can be no more powerful energizer to overcome these obstacles than effective
leadership – optimistic, determined, communicative, energetic, devoted, and visionary to
ensure success. It is up to the CEO and the lead physicians to provide unwavering energy and
devotion to the endeavor. They must keep the message flowing – positive, achievable,
reassuring, confident, and committed to the cause.
This energy and devotion must become infectious. The organization must see itself as
pioneering a more excellent way.
The reality of this constituent is one that is both tangible and intangible. It summons
the leadership of the group to call the group to a higher way, a positive vision, and an important
and critical way forward. At those clinics that best implemented EMR, there was a common
and constant call towards excellence in this regard – in meetings, in conversations, in e-mails, in
videos, in encouragements, and more. The intangible element of true leadership must shine
through during this challenge – encouraging all to a better clinic – better for patients, better for
the physicians and staff, better for strategic positioning, better for the intrinsic value of a job
well done.
ESSENTIAL CONSTITUENT 23: TIMETABLES
Clear and concise timetables are an important constituent to success. The purpose of
timetables is quite simple – to press the organization to complete the larger task through the
accomplishment of valuable and critical smaller achievements. A well planned and specific
timetable for implementation, training, and go-live aid the group to fill in the micro details of
implementation such as set up, data tables, clinical pathways, how to schedule multiple
appointments, and dozens of other daily routines.
Timetables also enable the practice to maximize the vendor’s resources. Many of the
groups had 4 to 6 (or more) of the vendor’s best employees on site during critical go-live
events. This was made possible by effectively planning and managing key timelines of
preparation, training, and implementation. (sample timetable below)35
ESSENTIAL CONSTITUENT 24: TRAINING
Comprehensive and effective training are one of the common deficiencies of EMR
implementation.
“Clinics often underestimate the number of hours they need for training in
efforts to reduce costs, or they may opt for over-the-phone (versus in person)
training to avoid vendor travel costs. Providers often assume they can learn
anything on the spot, and may skip aspects of training altogether. These patterns
can all contribute to a dynamic in which clinics receive inadequate training,
forego a full dress rehearsal and end up going live unprepared.”36
During the process of EMR selection, The West Clinic leadership found only one cancer
clinic in the United States where the users were sufficiently trained to use the EMR. This was a
small clinic in Illinois where the limited staff could not afford to have any weak links among
their users.
It was astonishing how a number of large clinics had implemented EMR with so many
users deficient in their capacity to use the system. This deficiency can adversely impact patient
care, patient flow, staff morale, turnover of staff, and greatly increase the cost of the clinic’s
operations.
Thus, groups with the best implementation experience determined to have massive,
comprehensive training of all staff with the following parameters and goals:
1. Minimum Proficiencies to maintain employment
2. Cross Training to create flexible and valuable staff
3. Ongoing Training to ensure continuous improvement
4. User Levels to provide reward or discipline of staff
5. Testing to ensure that the skills are measurably attained
6. Rewards that are tangible and sufficient to motivate excellence
7. Employee Evaluations as an added component to the existing evaluation process
8. Expectations of the Vendor to ensure the vendor fulfills it obligation
ESSENTIAL CONSTITUENT 25: ONGOING EDUCATION
The best groups made sure that the minimalist mindset was not acceptable within their
practice. Using the most skilled staff to maintain honed skills for all staff, all employees must
continue an ongoing scheduled process of further training. This training really has three major
components:
1. To ensure that the existing skills of an employee are real. Groups often find that
employees help cover one another’s weaknesses in EMR by learning how to
discreetly get others to do certain tasks with some quid pro quo. All employees
must be able to continually demonstrate via a test the essential skills of the EMR
that all should know.
2. To ensure that new skills are added to each employee’s skill set. The EMR Director
should have specific, attainable, and measureable goals that are expected during a
normal quarterly rotation of having staff spend several hours of additional in-house
training.
3. To ensure that the group is maximally cross trained. This eliminates exposure in
employee absence and also creates an environment of flexibility, high expectation,
and determination for each employee to demonstrate their value – sort of a
competitive environment where no one wants to be perceived as the weak link who
is most dispensable to the group.
ESSENTIAL CONSTITUENT 26: CONTINGENCIES
Experience indicates there are two kinds of hard drives, those that have failed and those
that will fail – plan accordingly. Implementing EMR is far more complicated than maintaining a
hard drive and planning for its failure. There are so many areas where the prospects of
implementation can go wrong. Unfortunately, a number of these are not technological but
human. Thus, the challenge requires contingency planning on multiple levels is critical for
successful implementation of EMR – before transition, during transition, and after transition.
Some key areas of contingency planning include:
 Transferred data: When data is transferred during the migration or between existing
systems (such as a Lab Information System) it is critical that the data transfer be
reviewed and validated. One practice that had a very successful implementation
noticed, later on, that Lab Information was not properly populating the EMR. This had
major organizational risks for patient care, documentation, and billing. A team from the
practice and vendor came together and solved the problem. In addition, they
established monitoring protocols to ensure that future deficiencies were quickly
identified.
 Lost or Corrupted data: There is no substitute for multiple, frequent, restorable, on-site,
and off-site backups. There are no exceptions. One of the pediatric clinics experienced
a substantial data loss during an upgrade transition. Recovery was painful due to a less
than ideal backup matrix.
 Hardware Issues: The key is having a good IT team and sufficient back up technology. It
could be as simple as failed computer in a pod that needs to be quickly replaced or it
could be failure of the main system’s processor for which a backup needs to be
available.
 System or Software Failure: There are so many potential failures that can occur. Some
are in-house, others involve the vendor. It is important to manage these and avoid the
finger-pointing exercise that often accompanies some of the problems. EMR vendors
are regularly developing patches for system bugs that only show up when their larger
users push the system to the limits. These patches need to be quickly applied to the
system.
 Network Issues: These will occur and the IT team needs to monitor these issues and
resolve them quickly.
 Communication Issues: T-1 lines or other communication between sites. Many clinics
have reported failures due to construction in the road where expensive T-1 lines were
cut.
 Facility or Power Failure: This is a huge concern – especially for the site that houses the
central servers. Many of the large practices have expensive generators that can
maintain operations during power failures.
 Physician or User Issues: Some users have an incredible knack to derail a system or
cause a disruption by their shortcomings or their remarkable ability to uncover system
flaws. In addition, an impatient or angry physician can really disrupt established
processes through self-will, retaliation, or frustration. Unfortunately, these situations
usually spillover to others. For example, a radiologist in one practice was so angry about
the number of clicks required to e-mail a report that he insisted the entire system be
removed from Radiology and replaced with a Radiology Information System (RIS). This
derailed dozens of users and processes and cycled and recycled every 3 to 6 months
until the vendor’s CEO personally flew to the practice to address the physician’s
concerns.
ESSENTIAL CONSTITUENT #27: COMMUNICATION
Effective communication reinforces the expectations, goals, and objectives of any organization.
The practices determined to have a multifaceted communication strategy. This includes:
•
Preliminary education sessions with the entire staff.
•
A major Kick-off session to build enthusiasm.
•
One practice developed two videos on EMR – one humorous, one sober. All staff were
required to watch these videos. The videos remained on the practice’s intranet for
follow up viewing.
•
HR Orientation: EMR must be addressed during all the Human Resource orientations
and reorientation sessions.
•
CEO Lunches: In one group, all the staff (in groups of 15) had lunch with the CEO to
discuss the EMR implementation.
•
Site Kick-Offs: Groups often had the key players on the EMR implementation team go to
each location for kick-off meetings.
•
Routine e-mails: These should be sent out at least weekly to inform the staff about the
EMR implementation.
•
E-mail Training Tips: Regular training tips provided by the EMR implementation.
ESSENTIAL CONSTITUENT #28: SUPER USERS
To ensure clinic wide uptake on EMR it is essential to have a broad spectrum of super
users who are the in-house resource for the entire staff. Super users should be highly trained in
every aspect of the EMR. Every site and every department should have easy access to a super
user. It is recommended that there be at least one super user for every 20 employees. Super
users should receive a generous bonus for attaining super user status and, perhaps, an annual
modest bonus for serving that role. Candidates for super user should be determined by the
management of the clinic.
ESSENTIAL CONSTITUENT # 29 : MANAGEMENT ENGAGEMENT
Without the full and focused engagement of management, the endeavor will not
succeed. There can be no obstructers or naysayers among the organizational leaders. Some
groups use EMR as an opportunity to weed out management or staff who are not carrying the
load sufficient to justify their management role or their employment.
One large practice moved their Director of Billing Operations to a new role in
compliance in order to place someone better suited for the speed, demand, and efficiency
required by the new system.
ESSENTIAL CONSTITUENT # 30: MANAGING ORGANIZATION RISK
Migrating to an Electronic Medical Record is fraught with risks. These risks can
adversely impact clinic morale, patient flow, clinical quality, patient safety, financial solvency,
professional satisfaction of physicians, employee performance, and clinic competitive
advantage. Nothing can more undo the effort than the development of a significant problem.
Successful administrators oversee the management of their practices will full anticipation that
major problems could occur and implement proactive avoidance measures as well as
developing contingency strategies should they arise. Some of the major issues to proactively
address include:
Magnifying Existing Problems: EMR is not a cure all that makes problems go away. It has no
“magic wand” abilities per se. In fact, EMR is more likely to magnify existing problems and
exacerbate salient clinic issues. Some examples include:
1. Inconsistent methods for patient orders
2. Incomplete charts
3. Differing approaches to patient flow and scheduling
4. Billing processes requiring appropriate documentation for coding
5. Wide variations in how each physician runs their practice within the scope of the
larger practice.
6. Key Issues of data security including access, HIPAA transaction code sets, and PHI
access logs of documentation.
If these and scores of other matters are not consistently resolved prior to EMR
implementation these matters will be glaringly magnified – potentially slowing the billing,
enhancing legal risk, stifling scheduling and patient flow, along with other substantial concerns.
ESSENTIAL CONSTITUENT #31: CLINIC PROCESS ASSESSMENT & CLINICAL PROCESS REENGINEERING
It is quite extraordinary how many practices simply implement an EMR without really
conducting a comprehensive assessment of clinic processes. “Clinical personnel, including
providers, often have little insight into the clinic’s workflows and the roles others play in care
delivery. This blind spot results in inadequate planning for the most important determinant of
successful implementation.”37 When an EMR becomes an overlay to current clinic processes,
the flaws in those processes do not get fixed, they get magnified. The migration to EMR is the
perfect time to transform the entire organization.
Some examples of significant re-engineering include:
•
Wilshire Oncology’s migration from one EMR to another, setting the table for an
opportunity to hardwire better clinical decision making
•
GCS determination to create the templates for its non-specialty specific software. These
templates also hard wired clinical protocols for better care.
•
Memphis Heart Clinic had two outside consultants advise the group as it expanded in
size and number of locations. One of the consultants helped implement significant
operational changes to minimize administrative variation around the use of GEMMS
EMR.
•
The West Clinic comprehensively reorganized all of its processes to improve efficiency
and maximize the efficacy of its implementation of IMPAC EMR. An outside consulting
company, Engineering Innovations, worked with key in-house staff to model and
effectuate the changes.
•
One large practice in the southeast was actually running two EMRs and a paper based
system. It had a visit assistance from an outside consultant who helped diagnose key
issues to move forward with full implementation and reengineering.
ESSENTIAL CONSTITUENT #32: THE PATIENT FIRST, THE PATIENT LAST, THE PATIENT
EVERYWHERE IN BETWEEN
It is important that patients be informed about the EMR. Some groups provide patients
with updates well in advance. Implementation of EMR can cause clinic delays and it is
important for patients to know beforehand.
Patients should know that their medical records are becoming computerized and will no
longer be on paper. Most will take this change in stride, but some will need reassurance about
the change.
It is good to promote the advantage of EMR; how it will help patient care, patient flow,
their physician, and the entire team. Some groups even engaged patients in the process
through focus groups, town halls, and celebrations of success.
The most important voice in change in healthcare is often the most neglected – the
voice of the patient. When a group migrates to EMR, their patients can be the most informed
advocates of this change with some encouragement and communications.
Lastly, the entire staff should demonstrate the gladness that accompanies the
advantage of a fully implemented EMR. Some offices wore buttons that promoted the EMR
and how it was to the advantage of all – especially the patient.
The bottom line is simple, EMR will lead to better patient care, a better patient
experience, and better healthcare. This message must resonate in word and in deed.
ESSENTIAL CONSTITUENT # 33: PROBLEMS & MANAGING EXPECTATIONS
Problems and issues are certain during any fundamental transformation of an organization.
Thus it is critical to anticipate the nature, type, and depth of any issue that may arise and have
contingency plans in place for when (not if) they occur.
 Phase problems – these are problems associated with changing the wheels on the
wagon while it is moving. The team has to be fully able to change from one system to
another (and all of its administrative processes) through a process of preparation, brief,
execution, and debrief.
 System Problems – Systems (technological, administrative, and others) do fail.
Contingencies, backups, and alternative routes of execution must be established prior to
failure.
 Process Problems – By nature a process will be undermined by exogenous changes,
unforeseen circumstances, or better ideas. In the world of oncology, the methodology
for coding and billing changed substantially in 2004, 2005, 2006, and 2007. Each
required a whole new reorientation that impacted the execution of the routine
processes within the group. Those groups that had EMR needed upgrades, education,
and training.
 People Problems – one of the wisest sages who ever lived, Stephen Kaung, said, “Where
there are people there are problems, want no problems, have no people.” Sometimes
people problems are simply the wrong person in the wrong place. Many of the groups
that were explored indicated that EMR implementation afforded them the opportunity
to reshuffle staff in a manner that retained the employee but empowered a better fit for
them and the organization.
 Data Problems – This is the most critical concern and one that requires the most
intensive attention. Several key staff must daily monitor key benchmarks, trends, and
audit key components of the data to ensure integrity throughout the system.
 Attitude Problems – several of the practices that we reviewed had a similar outcome of
EMR implementation – 1/3 fully embraced the change, 1/3 were in process, and 1/3
were lagging behind. Often the latter third were obstructing due to unwillingness or
fear. Coaching and coming along side are key elements to overcome these hurdles.
ESSENTIAL COMPONENT #34 : EMPLOYEE INCENTIVES
Creating economic incentives for the employees proved to be very successful at a
number of clinics. One clinic had a very comprehensive model that truly incentivized and
achieved results. This group had four categories: Super Users, Gold, Silver, & Bronze.
The Super Users were selected by the management team and were expected to become
real “experts” in the system(s). The Super Users required substantial hours of training coupled
with proficiency tests. Super Users were rewarded with substantial bonuses – on the front
end, during the process, and after a period of time. The typical super user is as proficient as
someone who would come on-site to train the team. Thus, it can be expected that super user
status is achieved after a minimum of a year of intensive focused training and education. The
total typical bonus for a super user is between $1,000 and $1,500. Though this seems quite
substantial, the savings resulting from problem resolution and others learning from their skill
far outweighs the expense.
Bronze users were those that had the minimum requirements to retain their
employment. This is an incentive that is necessary to effectively make the transformation.
There can be no exceptions. Though this is the lowest hurdle but should be quite a substantial
requirement. The typical bronze user should be able to do all the tasks required for their job
and the job of another. In short, even the least trained user will be substantially proficient. The
typical bonus for a Bronze User (in addition to retaining their job) is about $100. Bronze
proficiency is demonstrated by management oversight – concurring proficiency and a test
measuring proficiency.
All who are Bronze users are encouraged to become Silver users. Silver users are
rewarded an additional $150 for enhancing their skills both in scope and depth. The typical
Silver User can do the job tasks of someone in several departments of a clinic. Typically 20% to
30% of the users in a clinic attain Silver status.
About 10% of the clinic staff should be selected to become a Gold user. Gold users are
rewarded an additional $200. The typical Gold user is capable of working the EMR in any area
of the clinic. As a team, the Gold users interact with each other to equip each other and others
in the clinic to enhance their skills.
A cadre of about 3% to 5% of the clinic staff should be selected to become Super Users
are rewarded an additional $500 to $1,000 (forfeited if they leave the group within a certain
time frame). These Super Users are as good as the typical trainer for the vendor. They are
highly proficient in nearly all aspects of the system.
The spread sheet below is for a group with 330 employees who retained their jobs and
received a $100 bonus by attaining to the Bronze level of proficiency in the new system. Of the
330 employees, 60 went on to attain the Silver level of proficiency and received another $150
bonus. Of the 60 employees who attained Silver level, 30 went on to Gold status and received
an additional $200 bonus. Of the 30 who went on to Gold status, 12 became Super Users and
received an additional $500 bonus. This bonus was to be forfeited if the employee left the
group within 36 months of attaining the bonus.
Bonus
# Employees
Total
Bronze
100
330
33,000
Silver
150
60
9,000
Gold
200
30
6,000
Super
User
500
12
6,000
Total
Cost
54,000
The total bonus pay outs were $54,000 – an investment well worth ensuring that the practice
can successfully implement and use the EMR. Typically these bonus payments are less than
10% of the total front end investment in the system and less than 0.5% of the practice’s overall
revenue for a year and less than 0.3% of the a practice’s operational expense and less than
0.15% of a practice’s non-provider labor expense.
ESSENTIAL CONSTITUENT #35: NOT GOING IT ALONE
Now that a plethora of practices have migrated to EMR, there is no need for any
practice to do so in isolation. It is most helpful to have contact and the morale boost of others
who have gone down the road. Establish some solid relationships that can be called at critical
junctures of the process. Even have a few people that you can vent to when circumstances
seem to have lost control or the pressures from within or without are overwhelming the team
or the leadership.
Five things proved helpful to a number of practices:
1. Be open to stepping off the accelerator if you sense the team is bearing too much.
Several practices delayed go-live dates after reasonable consideration and assessment
of where their group stood.
2. All the key people involved in the implementation should be able to have their normal
breaks – during the day, the evenings, the weekends, and vacations. Yes, there will be
times of sacrifice, but be careful to not sacrifice people for the sake of the organization.
3. Maintaining a sense of humor amidst the endeavor is most helpful. This can release
tension, sustain the humanity of the effort, and simply cause everyone to feel better.
4. Lead the team into some social (off site) experiences. Take them out for a meal. Rent a
box at a sporting event. Invite them to a special event in the community completely
unrelated to the job. Express appreciation every step of the way.
5. Commit all the details of activity to prayer. Several organizations conveyed that their
success was due largely to learning to pray through matters together that were much
larger than their ability to execute. This also built team confidence in a manner that few
exercises can.
ESSENTIAL CONSTITUENT #36: BECOMING A SHOWCASE SITE
A number of practices purposed to excel in such a manner that they would become a
showcase site for the effective implementation of EMR. This also caused the vendor to deploy
additional resources to ensure success. This symbiotic commitment resulted in significant
benefits for all involved.
CONCLUSION
With the advent of the HITECH Act and its rewards and penalties for EMR
Implementation (via meaningful use)38, medical practice management has crossed a threshold
similar to that faced by the financial services industry decades ago. Successful Implementation
of EMR for a large practice is an endeavor that draws upon all aspects of the MGMA/ACMPE
Body of Knowledge. The four competencies of the body of knowledge are critically brought to
bear in this effort:
Professionalism: The practice CEO must network with other professionals and exude the
character necessary to move the organization forward. In addition, the leader’s knowledge of
the broader healthcare system is essential for selecting, endorsing, and implementing EMR.
Leadership: Implementation of EMR requires an unparalleled cooperation of an entire
organization – both the clinical and administrative team. This endeavor must be sparked by
real vision and a creative focus to work outside former parameters. The key element of
leadership in this effort is to get all the parties rowing in the same direction at the same pace.
Communication Skills: The complexity of an effective communication matrix is critical for
implementation of EMR. The CEO, lead physician(s) and board must be fully informed. The
interaction with vendors must be clear and concise. The EMR implementation team must be on
the same page. The entire staff at all locations
Critical Thinking Skills: The volume and complexity of critical thinking regarding EMR
implementation is daunting. An openness to ideas is critical. Yet, decisiveness is also very
important. Key players on the staff need to be empowered to make decisions, yet know the
limit of their scope is equally as an important. EMR implementation will have the entire team
stuck in periods of information overload. The leadership must know how to cut through the
excess and stay focused on key tasks. There will be huge cause and effect realities that must be
clarified and understood. In addition, the team will become experts in learning from mistakes
and learning how to move forward.
In addition all the domains of the Body of Knowledge are used in EMR implementation
Business Operations: EMR Implementation is a business operation plan that requires
assessment, acquisition, and implementation of technology that impacts every aspect of the
business and every person who works there.
Financial Management: EMR implementation is one of the largest financial investments a
group will make in its infrastructure. A clear pathway to demonstrate the value of the
investment coupled with effective execution will prepare the group to thrive and survive in the
changing healthcare environment.
Human Resource Management: Every employee’s job description changes when EMR is
implemented. In addition, many employees may encounter a new organizational structure.
EMR implementation calls for new standards of excellence and measure within an organization.
Information Management: EMR Implementation is the fundamental transformation of the
managing of medical and other information. Many groups fail to understand the gravity of this
transformation and under commit time, money, people, and technology to the effort. The
organization’s leader must be savvy and engaged to ensure sufficient resources are deployed to
succeed.
Organizational Governance: EMR is ultimately a decision rendered by the owners and the
board of the organization. The dynamics of navigating wholesale change through the official
board and unofficial opinion leaders in the group to integrate the technology change into the
warp and woof of the organization’s mission and vision and then ensure that it is executed
accordingly requires a very engaged physician-administrator team.
Patient Care Systems: Effective EMR implementation can help revolutionize patient care
systems. There is unique opportunity to improve processes, flow, patient safety, physician
consistency, and have data and outcomes measures that heretofore were non-existent. It is
imperative that physicians, nurses, clinical team, and administration establish real goals and
objectives and ongoing processes and timelines to continually improve patient care.
Quality Management: EMR implementation will by its nature expose some of the weaknesses
within the practice. This is the time to end disparities and implement Six Sigma type
approaches to improve the ways and means of the group.
Risk Management: Facility Risk, information risk, HIPAA risk, and other areas will need to be
fully addressed by the entire team. As EMR weaves the group closer together, opportunities to
consider exposure from a clinical perspective and a business disruption perspective will emerge
and allow the group to minimize its overall risk.
36 Essential Constituents
This paper recommends 36 essential constituents for effectively implementing EMR in a
large medical practice. Ultimately, the CEO, COO, and lead physician(s) will be the vanguards of
the success or failure of the endeavor. These 36 essential constituents provide basic guidelines
and draw from real experience. The details of how to ensure that these areas are sufficiently
covered will be unique to every practice situation.
Ultimately, success in any endeavor involves the ability of leaders to convey a vision,
practically develop the means to achieve it, execute it, and keep the entire team confident in
the greater enterprise.
EMR implementation is not for the fainthearted. However, like the Irish poet of old who
with his friends as a child came to a wall and threw their hats over it as the means to ensure
that had to climb the wall – so it is with EMR. Amazingly over 4 decades after the United States
first put a man on the moon, our health system still struggles to achieve an obvious basic
component – widespread adoption of EMR.
May this paper help encourage those who are about to take the plunge, inspire those
who are still reluctant to wade in, and assist those who undertook the endeavor but came short
of their objectives. May the next decade bring medical groups into a whole new realm of
success in this important aspect of ensuring excellence in patient care and a more
contemporary health system.
References
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