Switching gears a bit: I was honored to be a co-presenter this year, on the final day of User Group.

My colleague and I were curious about who would show up on the last conference day, especially after the late night festivities the night prior (Huey Lewis And The News, and KC And The Sunshine Band).

Thankfully, folks did show for the 9 AM session, and didn’t leave in droves, either.

Good Cop, Bad Cop

Our talk focused on the importance of cooperation at the upper levels of the management team, if you want a successful EMR roll-out. As alluded to in The Leadership Secrets Of Joseph Stalin, inspired by Dr. Cephus Allin, this means melding “physician champions” and “practice administrators” into a cohesive, irresistible team.

The administrator-realist role…is a full-time occupation, like herding toddlers.

No matter what size organization you have, from 2 to 200+, if you want a smooth adoption of an EMR system, you need someone who can play hardball, and someone who can encourage: bad cop/good cop, Stalin/Mother Teresa, administrator/physician champion.

This is more an observation of human nature, and what has transpired in many implementations I’ve observed:

• Some physicians and staff will be all for the transition
• Some will be undecided
• Some will be either hostile or passive aggressively against it

The administrator-realist wears the project manager hat, and cracks the whip to get that last group squarely behind — or out of the way of — the EMR adoption train. That role is absolutely necessary, whether referring to the office manager in a small group office, or the COO of an MSO. It is also a full-time occupation, like herding toddlers.

But guess what? We physicians have an individualist streak a mile wide, and instinctively resent heavy handed tactics, even while we privately admit the need for them.

Enter The Physician Champeen

It’s not a new idea, designating a physician in the organization to champion the cause of the EMR. What follows is our take on why having one isn’t just a good idea, it’s critical to the success of your EMR endeavor:

1) Physicians Are Social Creatures, Individualism To The Contrary

You’ve seen this time and time again: when a company rep explains an EMR to a doctor, he gets a skeptical response, but when an EMR-using physician explains the same points to the doctor, it’s a revelation! It’s miraculous! Where do I sign?

This is even true if the EMR physician gives a less-than-perfect presentation. The company rep is often an IT person, and knows the system better than the doctor.

Why is the EMR physician’s presentation so much better received than the rep’s?

Because before they became individualist practitioners, doctors had already been socialized into a professional social structure: the medical profession, itself. They may have entered med school as God’s gift to the world, but they left it as part of the medical establishment, stripped down and built back up in a health sciences boot camp.

An organization gets only so many catastrophes before the doctors lose faith…Head off even one of them, and the champion has earned his keep for the year.

And what do you do, once you’ve been socialized? You listen real good to thems what have gone before you. Snarling surgical residents quake in their clogs when the senior attending stares at them.

An EMR-using physician, who has survived a system adoption process with all its struggles, has immediate street cred with his or her colleagues. Doctors will listen to a member of the fellowship, because that’s how professionally socialized members have been trained to act.

2. The Physician Champion Stays In And Acts Out

An organization should only need to have its head handed to it on a platter once…before it realizes the value of a physician champion.

The conventional idea of a champion sallying forth with The Flag Of EMR Truth overlooks another, key role: advising internally, amongst the IT and EMR administrative staff.

The external role is fairly clear:

• You demonstrate the software, preferably live in your busy office
• You educate patients, doctors, and organizations about it
• You help new users “get up to speed”
  • in person
  • by writing teaching material
  • by creating AV tutorials, like Camtasia instructional videos

In essence, you show and expound upon the product, with the incomparable credibility of a colleague who’s been there, done that, and still is.

But the internal advisory role is arguable even more critical, especially from an organizational standpoint:

• Testing designs for viability, before release
• QA checks for glitches that only a doctor would appreciate
• Suggesting new features that would make doctors’ lives easier

Going back to the drawing board is a royal pain. An organization should only need to have its head handed to it on a platter once, by a group of irate docs, before it realizes the value of a physician champion who can save endless hours of software rewrites.

God forbid your docs utter that ultimate phrase of damnation:

Take it offline and give us back the last version until you fix it and get it right.

An organization gets only so many catastrophes before the doctors lose faith, and wander off in all directions into the dark. Head off even one of them, and the champion has earned his keep for the year, in user good will and saved IT staff headaches.

Another nifty tip from the NextGen Users Group Meeting.

Dr. Cephus Allin spoke in some detail about it, as did at least one other presenter; I’m pretty sure this is passing into the NextGen cannon of “Successful Practices Do THIS — So Should You.”

It sounds so simple, but I can attest to its profound effects on reclaimed time — and best of all, it works regardless of your EMR platform. And with a sensible use of technology, it will work regardless of your office size.

The concept is “Having everyone in the office practice to the top of their licensure.” It basically means this: docs should do doc level tasks, MAs should do MA level tasks, and clerical/phone staff should do clerical and phone intake tasks.

Or more bluntly:

• Do you really want the $100/hr physician spending 5 minutes per encounter rooming a patient (an MA level task)?

• Should the MA spend 3 minutes per chart entering lab values (a clerical level – or better yet, automatable – task)?

Many tasks that physicians now assume they need to do can be handled by staff empowered to do so, within the upper but acceptable limits of what they’re supposed to do.

Make Your MA Your Faithful Scribe

HPIs and Systems Reviews are usually taken by the physician, but often can be done just as well — and much more consistently — by the MA.

Common HPIs can be filled out by the MA as he or she rooms the patient by clicking through a template, then reviewed in seconds by the physician upon entering the room. Same for a Review of Systems during an annual physical. These two tasks alone can free up minutes per visit – and even 3 minutes per visit over 20 patients a day means an extra hour of free time.

Concerned about the defensibility of that “all normal” ROS button, or the “past medical history reviewed – unchanged” button? Not if your customary practice is to have your MA read, verbatim, each line or question, and click the appropriate box.

This isn’t about shoving the scut onto your support staff – that would be suicidal. Ultimately, it’s about improving the workflow for everybody in the office, by having them sensibly do what they’re best trained for, and not burning gears doing other folks’ busywork while their own duties get put off.

If you’re a physician and you’re updating the meds lists, or an MA and you’re abstracting paper chart info, your office needs to step back and rethink your duties.

Trim The Fat And Snap To In 3 Steps

The basic mechanism goes like this:

1) ASSUME from the beginning that each team member in the office has a finite set of doable, key tasks, that if performed well, will have the EMR enabled office running smoothly. This is actually a reasonably safe assumption to make, for a perversely inverted reason: you’re screwed if this isn’t true, so you might as well start off on a positive note.

2) EXAMINE those tasks, and group them into categories appropriate to the particular team member: physician level tasks to the docs (needing higher level decision making, training, or “the boss” factor), clinical assisting and communicating tasks to the MAs, and clerical or phone duties to the front office or phone staff. Those meds lists should be updated by the front office or the MA, not the MD.

3) AUTOMATE whenever possible to reduce each team member’s tasks to manageable levels — something that an EMR enabled office can excel at.

Not sure where your MA is going to magically find the extra time to do data entry of all those incoming lab values? Push for that interface with the lab, so the results are automatically entered electronically into the chart, for your review and approval – MA properly out of the loop, saving her hours per day.

Have access to a secure email communication portal with your patients? Run, don’t walk, to get it incorporated into your EMR. Especially if it allows boilerplate text macros for commonly given instructions or responses to frequent questions, it will save tons of time that your staff now spends on simple patient notifications.

• Example: time yourself typing the instruction to adopt a low fat diet and regular exercise in response to that most common of primary care lab abnormalities, the elevated cholesterol result.

• Then time your MA re-transcribing that, putting it in an envelope, stamping it, and putting it in the outgoing mail pile, or worse, calling a patient, finally getting the patient on the phone, having to chat about it, then documenting it.

• THEN compare that total time to 2 mouse clicks — one on the “exercise and diet” instruction button, the other on the SEND EMAIL TO PATIENT button. Multiply that by the dozens of times daily a typical PCP gets abnormal cholesterol values, and you begin to see how supposedly itty bitty efficiencies can reclaim hours of lost time.

Me Scan? I Thought You Scanned?

What about abstracting and scanning old charts — who decides what’s important, and who feeds the sheets through the scanner? This is a whole topic in and of itself, but the same rules apply:

While docs are arguably the best arbiters of key chart info, it’s not an efficient use of their time to have them abstract or scan (see $100/hr, above). Everyone needs to have a pitch-in whenever needed attitude, yes, but do the math: if you fit in just ONE extra patient per day, that’s 23 extra patients in an average month, or an extra day of income. That’s enough to hire an extra scanning staffer who can even do the abstracting, if you give clear and simple directions on pulling info from a patient chart.

And with the increased efficiencies throughout the office, you should be able to squeeze in more than one extra patient, in addition to the cumulative savings of all those other process improvements (better billing and coding, less time wasted, etc).

Share The Wealth

The examples are almost limitless where practice life can be made better all the way around — that most desirable win-win-win situation for everyone in the office including the patient.

When the EMR alerts you when patient is overdue for something like a mammogram or a diabetes lab, any of the support staff should be able to generate the order and contact the patient to do it. Empowering them to automatically do so de-pressurizes the MD’s and frees them up for higher level tasks. And EMR automation can make the generating and contacting processes quicker than ever for the MA or front office staff.

Just remember to combine the proper delegation of “top licensure” with workflow changes that will make that delegation possible. Delegate down, but pull staff up, so to speak.

Okay, so maybe that’s gutting inefficiency in TWO moves.

There’s a fascinating article on the EMR and HIPAA blog that I couldn’t pass up.

It addresses one governmental (i.e. Medicare) solution to the traditionally low adoption rates of physicians of EMR’s: lower the upfront costs to essentially zero with the VistA system built by the Veterans Administration.

The clincher for me was the following observation:

While Medicare’s plan is to offer the software for free, one must ask what free is. Currently, free is software but not training, installation, and ongoing support.

My commented response, heavily informed by the collective wisdom garnered from the recent NextGen Users Group Meeting, is reproduced below:

Interesting development.

The issue with support and adoption rates are key, and intertwined.

If you want an EMR to do several, fairly high-level tasks, it is going to be a relatively complex beast, and you will HAVE to have IT/customer support. That’s as much a given as water being wet.

At a minimum, an EMR will need a database to organize patient data, and enable data actions like checking to see how certain populations are doing by certain criteria, for just one example of tons (the exception being a word processor, which is not what I’d consider an EMR). Most docs want it to also do prescriptions, which means a fax or electronic prescribing capacity, another drug database (constantly updated), ideally with formulary checking, and interactions alerts.

EMR’s should, in my opinion, enable phone messaging and intra-office tasking, notifications of when patients are due or overdue for key health maintenance tasks, forward looking reminders on past tasks not yet confirmed to be done, remote log-on/work from home capability, airtight data backup, and incorporation of paper info (old chart and new notes from outside).

ANY of these tasks will require tech support. ANY combination of these, to function smoothly…it’s mind boggling to think it even possible to work smoothly without tech support and maintenance — which the physicians cannot possibly do on their own, unless they become full time IT folks, at which point they’re not practicing medicine anymore.

The answer to adopting an EMR isn’t to make it cheaper.

The key is educating physicians and their offices: this can absolutely be done, but it WILL be the toughest transition a practicing doctor will ever make. It is NOT about a training session or two to get acquainted with a fancier word processing program, tied to a snazzier billing software for the front desk.

In tech terms, EMR is not a “kludge”; it is a fundamentally different way of doing what a doctor used to do, that will enable doing 10 times more eye-popping and productivity enhancing and patient safety increasing activities than ever before.

A vague sense of it being an new wrinkle on an old way of documenting…will result in the emotional equivalent of walking into a harvesting machine. An hour or two with the manual — like what you might do with a new word processing program — is nowhere near enough. 10-12 physician training sessions, about an hour each, of progressively more challenging practice cases, is more like it.

Until doctors and their offices realize this isn’t a step up from a Ford Focus to a Mercedes, it’s a leap up from driving a car to flying a jet, successful adoption rates will remain low. And price of the product will have very little to do with it.

Any thoughts on the matter one way or another? Add a Comment below, or click here to Contact Me!

I’ve never read anything by Joseph Stalin, but I gather he’d be much in demand for implementing EMR’s. From the management side, not the physicians.’

Dr. Cephus Allin’s presentation today, which referenced the late Soviet dictator, was titled How To Go From Paper To An EMR. It totally rocked; I wish I’d attended his other session, Why Everyone Needs An EMR. But that’s what happens when you have awesome content hidden behind modest titles.

Major take home points:

• shunt work more efficiently away from physicians onto support staff when possible
• less MD time/task = more patients scheduled/day
• abstracting the chart is much more important than scanning it
• limit the abstracting to absolutely necessary items (like problem list w/ICD-9’s, allergies, meds)
• limit the scanning to 10 pages per physician pass, and 3 passes, max, before bye-bye chart (ekg, last CPE, critical study reports/consults)
• when staff are limited and already multitasked-out, extend the go-live timeline, and adopt more incrementally and slowly

And that, indubitably, there are practices that just ain’t suited for EMR.

It’s not easy, defining the 6 Deadly Features, or whatever, Of Practices That Are Destined To Fail Implementing An EMR. There are too many ways for such a complex endeavor to go south, in what Dr. Allin termed “the toughest transition a doctor will ever do.”

Plus, it’s understandable that an EMR vendor isn’t going to dwell too long about clients it won’t be selling to. That’s a matter for the MSO’s that implement the setups, which must budget enormous but finite time and manpower resources to making things work.

What was more widely agreed upon across the expo’s sessions were the features of implementations that succeeded. Not surprisingly, the most important of these starts at the top, with our good friend, Joe.

There Must Be Champions, And There Must Be Management

Or as Dr. Allin put it, Mother Teresa and Joseph Stalin.

Good Cop, Bad Cop.

In a small practice, these two hats may have to be worn by the same person: setting the positive, “We can do this” tone, and cracking the “Failure is not an option” whip. But ideally, this is done by folks dedicated to these separate duties, which also extends post implementation to balancing wish lists of new custom features (Doctor Teresa) and hard-nosed reality checks (Office Manager Stalin).

One audience member cited the extreme case of a large group that had to be coerced into EMR; the local organizing entity refused to renew the contracts of MD’s who did not adopt it. While not standard business practice, it was the second time I’d heard of things going that far.

Translation: There are a million ways that an implementation can fail, and ten thousand excuses. But it all starts and stops with the absolute commitment to success from the folks at the top. “Yeah! We can do this!” and “You had better believe we are gonna do this.”

You Have GOT To Be Serious

The key phrase, here, is absolute commitment.

Why does every talk about EMR implementation start with the requirement of having a “physician champion”? Even though the physician may not be the key to the smooth functioning of the office (whereas a good office manager always is)?

Because like the fighter jet examples that Dr. Allin used, it really is ultimately about the pilot, i.e. the physician. The fighter jock couldn’t get off the ground without a crew chief, team of mechanics, communications assist, etc. But in the end, nobody argues: it’s all about getting the pilot in the air.

And if the pilot’s attitude sucks, then everything is for naught.

It’s natural to be cautious when examining the prospect of change, and to chew your lip when contemplating a transitional drop in income, and resource allocation for training yourself and your staff. But once you make the choice to proceed, you must be positive, motivating and encouraging. Lead, and lead by example, that this will all work out, you’re all in this together, and everyone’s efforts during the transition are vastly appreciated. Your support crew, be they two or twenty, will take their cues from you.

Sometimes the physician champion isn’t you, it’s a colleague who years ago was standing exactly where you are now, and has successfully navigated the process. Take heart from that, but do your own due diligence: in addition to training arduously at navigating the system, go visit your colleague’s practice and learn how he or she works the workflow. Dr. Allin called this “double shadowing”: folks shadow you to teach you the EMR in your environment, then you shadow a successful adopter to appreciate how an efficient office can and should function.

If you can’t be King Arthur, no one should be seen working harder than you-as-Lancelot.

And Now…Back To Joe

It’s relatively easy playing Mother Teresa; what’s hard is saying “No.” Or, “No thank you, we won’t be needing your services any longer.”

This is hard in small offices, where a staff member may have been with you for years, but is obstructing your path to EMR, repeatedly, and seemingly immune to more training sessions. The nuclear option of letting someone go in a small office can mean losing 50% of the support staff. It can seem especially unthinkable when that support staff is family — an all too common scenario noted by presenters and implementers, especially in 1-2 MD practices.

“And for what — a new way of taking notes?”

This goes back to that squiggly target of What Will Sink An EMR Implementation, but you have GOT to have Joseph Stalin on your side. Or put another way, if your practice’s Joseph Stalin isn’t as committed to adopting EMR as you, the champion, are, and isn’t murmuring, “Failure is NOT an option; we’ll float this puppy, one way or another, never fear,” you are doomed, doomed, doomed.

The Round Table would’ve sunk — did sink — once Lancelot undermined Arthur; if the crew chief doesn’t sign on to the latest engine upgrade, the fighter jet stays on the ground.

This isn’t about taking something that’s a monumentally bad idea and cramming it down your throats — if that’s your conclusion after considering EMR, either of you, then stop right now.

It’s about adopting a technology that will in the foreseeable future be required to continue the practice of medicine in America, at one level or another. A technology that will in the near future post implementation, enable you to see at a minimum your same, pre-EMR patient volumes, with greater coding efficiency, accuracy, and therefore reimbursement.

A technology that if you persist in refining its use, will enable you to see more patients than before, with greater patient safety, fewer callbacks, and the capacity to do previously unimaginable things, like notifying all patients on a just-recalled medication, or checking what percentage of your diabetics really do have HbA1C’s less than 6.5, or sending letters to all your patients overdue for their last fill-in-the-blank test or visit.

It’s an adoption process that can be gotten through. If other staff is less than enthused, you can still get through it, if you’re leading from the front, and your Joe Stalin is pushing or yanking or replacing them from the rear.

Without Joe’s support, not even Mother Teresa and King Arthur combined will float your EMR.