From The NextGen Users Group Meeting, Day 2: Implementation Secrets Of Joseph Stalin

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.