Bringing physicians on board and creating culture change are keys to your success.
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| Lori Yackanicz | |
Moving the electronic medical record (EMR) into physician practices offers the potential of bringing all aspects of the patient's clinical record online. The outpatient EMR promises workflow improvements and greater efficiencies plus improved patient safety and quality of care. Despite the potential, successful EMR implementation requires strong leadership and careful planning, clinical and technical cooperation, and physician buy-in.
With more than 25 ambulatory EMR implementations under its belt, Lehigh Valley Health Network has learned many lessons about what works and what doesn't.
Our earliest venture into the ambulatory EMR dates back to 1998 with implementation of an EMR in a 25-physician family practice. Four years later, we implemented a different EMR product for a 60-provider psychiatric practice. Over the next four years, the information services (IS) EMR teams expanded existing stand-alone products to meet the demands of users and to extend the product into other clinical areas. At the same time, physicians started pushing for interoperability between the EMR office application and the hospital's inpatient systems.
To meet those demands and move toward our ultimate goal of an enterprisewide patient record, Lehigh brought in a new EMR vendor, one that also was supplying the hospital information system, as well as the radiology management and practice management systems. We embarked on a fast track interoperability implementation and EMR rollout to the rest of the 65 network-owned practices. As of October 2009, 25 practices with 170 physicians have gone live. The remaining practices are scheduled to be up and running by the beginning of 2012.
For us, the initiative is more than just putting patient clinical records online in outpatient settings. It's about making technology work for physicians and improving clinical and administrative efficiency and the quality of patient care. Toward that end, we're providing interoperability for many hospital-based systems and we've added e-prescribing, voice recognition software and a patient portal to the EMR. We're also adding a feature that lets patients sign their consent forms online in the office and are developing a quality reporting enhancement as well as further system interfaces.
While our enhancements help make the case for implementing an EMR in physician practices, gaining physician buy-in has been a challenge. The degree and ease of buy-in often is a function of the type of practice (primary care or specialized medicine) and the size or position of the practice (part of a large division within a hospital-owned entity or a Lehigh-affiliated private office practice).
Simple things like a physician's typing skills also can be an issue. While EMR templates can make input faster and easier, doctors lose the option of dictating or handwriting notes. This can be particularly challenging for physicians uncomfortable at the keyboard. Our new voice recognition software, however, enables providers to once again dictate their notes. The physicians who piloted the voice recognition software give it rave reviews. While they still have to proofread, one physician reports that the EMR has reduced the time spent completing his notes by 30 to 35 percent.
To gain and maintain physician buy-in, we need to manage expectations. The physician must understand that his or her practice will undergo a major transformation—in workflows, patient interactions, communications and office practices. While we continue to work on lost productivity issues, implementation takes time and patience, and physicians will lose a degree of control and autonomy.
EMR implementations have a tendency to highlight inefficiencies within a practice, so a major indicator of success is how much time is spent evaluating and redesigning the workflow. EMR teams and office staff invest substantial time identifying and refining clinical workflow and tailoring the EMR application to streamline workflows. In some cases, our EMR teams have spent as much as 80 percent of their time working with the practice on office workflow.
Physicians will need to allocate funds for added staff time during implementation. And since patient visits will drop dramatically while accommodating cultural and workflow changes in the practice, physicians need to expect a short-term negative financial impact. For practices where revenue is the main focus, physician buy-in is harder to gain. Once the patient load is re-established after implementation, it takes time for a practice to settle into the new routine.
Adequate time for training is crucial, and we revise the training plan for each new implementation. We continually modify training to meet the growing needs and expectations of our users. Currently, we break training into navigational and clinical scenarios, an approach that flows better for the doctors. We even have remedial training, which we offer two days into the overall implementation. This training helps solidify the workflow used with the new application.
In the past, doctors often complained that they didn't have time for training, but now physicians from these practices are becoming strong proponents of ongoing education, particularly for the clinical aspects of the EMR. As the EMR becomes an integral part of their practices, they are pushing to further improve efficiencies and provide even higher levels of patient care.
A successful implementation and positive long-term experience requires IS support and, as mentioned, physician buy-in. With our initial implementations, we tailored the clinical templates to the demands of our different physician groups. But it soon became apparent that over-customization was imposing a greater workload on the EMR teams trying to support and maintain the systems. It also was having a negative effect on the overall system response time and making it very difficult to pull clinical data.
We therefore shifted our focus from customization to standardization and took a divisional approach in which physicians helped tailor clinical templates for their divisions. This was particularly helpful with our specialty practices. We made sure that everyone was heard and had input into the final product. We worked together to balance standardization and customization. Making physicians an integral part of the solution went a long way toward gaining buy-in and ownership.
Initially we provided doctors with system navigation and in-office scenario training but found they also needed training in the use of the Pentab notebook computer that replaced the paper chart. Using the computer wasn't the issue as much as having to type and talk with the patient at the same time. This is a new skill that the physicians need to master.
We recruited strong physician champions who help with the overall culture change in the practice. A physician champion needs to understand and articulate the value proposition from the physician's viewpoint. He or she must be able to credibly articulate the benefits and help assuage the feeling physicians often have that they are losing control. Champions need to be cheerleaders and supporters who inspire trust and can hold hands and coach when necessary.
The EMR is a catalyst for quality improvement based on hard numbers. Physicians may think they're doing better but can't know for sure unless they're looking at quantitative quality indicators. With increased demands to produce quality reports from their ambulatory practices, physicians now, more than ever, need an online repository to produce these reports.
In addition to identifying a strong physician champion, managing expectations and providing adequate training, other techniques can help gain physician buy-in. Here are some added tips:
Implementing a successful outpatient EMR requires lasting cultural change and buy-in and support from senior managers, IS, clinicians and administrative staff. The greatest challenge and the most critical aspect, however, is getting the physicians on board.
Physician buy-in demands realistically defining and managing expectations. Not only must physicians realize benefits and look beyond the short-term negative financial impact, they also must be willing to relinquish some degree of control and autonomy. They need to see short-term gains, such as the time saved with e-prescribing. And they need to develop a true appreciation of the long-range potential gains—in improved clinical decision-making, readily accessible records, enhanced compliance with government regulatory standards of care, and improved patient safety.
Over the course of our many EMR implementations, we've learned that redesign of workflow, involvement of a strong physician champion and participation of physicians as a group in the design of the clinical templates all play major roles in a successful EMR implementation. This is a work in progress. We will continue to modify our plans and processes with each new implementation and continue to move toward better overall implementation in search of best practices.
Lori Yackanicz is director of IS clinical applications at Lehigh Valley Health Network in Allentown, Pa.
This article 1st appeared on February 8, 2010 in HHN Magazine online site.
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