Warning: Have You Doomed Your EMR To Fail?

Nobody wants to crash and burn their EMR.

It’s supposed to be pretty hard to do that, thanks to the built-in redundancy of most large scale systems. Your patient data isn’t going anywhere — in NextGen, for example, it’s backed up automatically on multiple servers. And while I’m more a fan of the nearly crashproof Unix-based operating system, 98% of the software industry finds Windows solid enough to design their EMR’s around. Short of a meteor strike or Armageddon, your EMR should function just fine, if used as designed.

What you do to it, however, is another matter entirely.

The IT Mantra: There’s No Accounting For Protoplasm

“There’s no more guaranteed way to doom your EMR implementation, than to dump it into the laps of not-ready users.”

As noted in the prior post, EMR’s are a conglomeration of tightly linked applications: databases, word processors, faxing and e-prescribing utilities, spreadsheets, graphics programs, etc. ad nauseum. The closest thing at your local computer store is project management software, which you can use to plot your timeline of world domination, or plan the next Superbowl half time show, while sending proposals, videos, and emails to all your cronies.

That’s for a few projects, using a package with an IT and design staff the size of Rhode Island. Your EMR manages thousands of patients, each a multi-year “project,” and your local tech support will likely to number a dozen or less.

There’s no more guaranteed way to doom your EMR implementation, than to dump it into the laps of not-ready users. Silicon vs. jelly-nailed-to-a-tree? The silicon always loses.

Principle #1: Don’t Even Start Without Improving Your Workflow

Maybe that’s an overstatement.

But if your office is barely scraping by, due to clashing personalities, non-team players, or too slow or too few support staff, throwing EMR into the mix is NOT likely to engender Kumbaya hip-hugging.

You will never attain that theoretical state where everything works perfectly, finally “ready” to accept EMR. But going from paper to electrons is a transition, no question, requiring more patience, more effort, and fewer patients on the schedule until the proverbial dust settles. If you’ve made the decision to commit, things need to be running “smoothly enough” as opposed to “this close to tanking.”

Otherwise, your foray into a better tomorrow could sink your practice (or at least this implementation of your EMR).

Principle #2: When Ready, Plan Out The Pre-EMR Months

“Having the busiest doctor in the office as your IT guy will NOT work, don’t even think about asking.”

When you think you’re ready, you’re still not ready for at least 6 months.

Why?

1. You’ll need to find your support staff, and have it trained.
   You probably won’t be calling your EMR vendor for support; rather, your vendor should train some local people to handle the most common issues. These are the folks you’ll have on speed-dial, usually in practice management at the office manager or upper support staff level. They need to be friendly, tech competent, and service oriented — and must do tech support full time. Having the busiest doctor in the office as your IT guy will NOT work, don’t even think about asking.
2. Next: You must set up an EMR Committee.
   Unless you’re in solo practice, you need a buffer between the providers and the tech folk. Tech support/IT will know how to fix problems and customize your EMR, but not what works best under busy clinical conditions; the medical providers know what would be unworkable if you had to repeat it 50 times a day, but not what the limits are of the system. An EMR Committee comprised of both is vital to the compromising that both sides must learn to do.
3. You should plan on reducing your patient responsibilities.
   Try to ease into your EMR, especially if there are skeptics among your group. Start with the easy and obviously time saving components, like in-house messaging and prescription refills. And once you’ve picked a start date, schedule half your normal patients during the first 2-4 weeks. No matter how well you think you know the system, there will be the inevitable goofs and the unexpected. Pad your schedule and you can always add more folks if things go smoothly; unpacking an overbooked schedule while simultaneously struggling with an EMR is impossibly stressful.
4. You must arrange for on-site tech support for the first 1-2 weeks, every other day for 1-2 more weeks, and then on-call 24/7 thereafter.
   You did your best medical learning “live” on the wards; your most critical questions will only occur when seeing actual patients. Have your IT support seconds away at all times, and at your elbow when you first go live.
5. And for the majority of the months, you’ve got to Scan, Scan, Scan.

Principle #3: Don’t Skimp On The Scanning

You will want your paper charts for the first several months, it’s comforting, like Linus’ blanket. But you want to go all-electron as soon as possible, or you’ll have piles of charts on your desks AND less desk space with your EMR hardware.

“After about half a year, you will have enough visits, EMR notes, and test results at your fingertips to no longer rely on the old scanned chart; the EMR by that point is the new chart.”

Scanning is necessary to have in-EMR access to your previous notes, as well as future access to other non-EMR info sources (like other specialists’ consult notes). You need to settle on a sufficiently reassuring protocol and start scanning as early as possible. If most of your patients’ charts are not accessible by go-live, your office staff will have to be diverted to scan the day or so before a patient’s appointment, and your staff WILL have other things on their minds at that point.

My mid-sized family medicine group decided to scan the last 2 years of the paper chart, with the info categorized as it was scanned: progress notes, consultations, labs, images, EKG’s. That was a simple, one sentence instruction for the scanning staff, with sufficiently comprehensive results for the providers

Whatever your needs and protocol, keep it as simple as possible and NEVER be tempted to save time by scanning charts as a single massive ream. You’ll hate life clicking through charts one page at a time to find the MRI report buried 39 pages down — and knowing the next chart will be just as bad.

Principle #4: Remember — It’s All Temporary

After about half a year, you will have enough visits, EMR notes, and test results at your fingertips to no longer rely on the old scanned chart; the EMR by that point is the new chart.

And it’s a new chart with legs. The biggest source of exasperation — digging through scanned documents, often imperfectly indexed by scanning staff — eases dramatically once your EMR notes become your primary database. Scanned documents are pictures, and graphics files take time to load on the screen; your EMR notes are text files, much smaller, and load nearly instantaneously.

More importantly, these files are automatically indexed and rapidly searchable by your EMR itself. Notes are in Notes, labs are in Results, phone messages are under Messages, and refills are under Meds — and all displayable at your preference, chronologically, alphabetically, by category, or searchable via wildcard characters or Boolean logic (e.g. all your patients named Fred born in 1957, or all your male patients over 40 with diabetes who haven’t had their PSA drawn in the last 63 days).

It’s a difference in access speed between finding a song on an old cassette tape — fast forwarding an inch at a time — or on a CD — jumping anywhere from track to track in an instant. Except your EMR “CD” includes a search function that indexes every word of every song, plus the artist, date of performance, and backup musician bios, as the songs are being recorded.

Your job at the onset of EMR is to keep everyone happy long enough to build a self-sutaining library of “music,” so folks can reap the benefits of a cleaner, deeper, quicker to access and search, body of work.

And for that, you’ve got to PLAN.