Nationwide, hospitals aggressively are acquiring physicians and creating tighter affiliations with physician groups. Building a strong physician network is always difficult, but the challenge is even greater when it is combined with an electronic health record rollout — a necessary move that will allow the partners to share information and take advantage of new payment initiatives.
Implementing a new ambulatory EHR system often will disrupt practice workflow, impair physician productivity and affect physician income. But when a hospital is providing the system, cultural and political issues come into play that can damage or kill relationships. For many hospitals, the EHR rollout creates a physician backlash just when the integration strategy is getting off the ground.
How can a hospital mitigate the risks of implementing an ambulatory EHR system? The following seven steps will help minimize conflict, contain costs and increase your chance of a successful rollout.
1. Form a Multistakeholder Governance Team
Some hospitals treat an EHR implementation as just another information technology project. Information technology staff members lead the system selection and installation process, executives take a hands-off approach, and physicians are relegated to the role of "receivers." This approach does not work well with electronic health records.
EHR use has a huge impact on physician practice as well as hospital strategy and finance. For that reason, a governance team that includes hospital executives and physician leaders must direct the EHR implementation.
Multidisciplinary governance is key to helping physicians transition from independence to collaboration. For example, physicians once "owned" the patient chart. With the move to EHRs, they need to adapt to a system in which the patient owns his or her medical information and physicians share charting responsibilities with many others. Who will maintain the list of complaints? Who can modify diagnoses? What are the documentation standards? These decisions can be made only with physician participation.
2. Get Agreement on Objectives and Be Honest About Differences
Conflicts arise during an EHR implementation that easily can derail the project. For instance, physicians often request electronic connections to independent labs. But this undercuts the goal of clinical integration. To avoid such distractions, the governance body needs to establish agreements on the strategy and core objectives.
Hospital culture tends to be methodical and risk-averse, while physicians are used to making quick decisions, with little need to consider the impact on others. Agreeing on the basics will help smooth out these cultural differences. A common understanding of strategy and core objectives can help:
- physicians focus on the needs of the system and the importance of careful planning;
- hospital administrators make faster decisions and allow stakeholders to proceed more independently;
- both parties understand how to pick their battles by delineating what is open to debate and what is not, what is a critical concern and what is a side issue.
3. Hire Medical Practice Expertise
Hospital administrators who have not worked in a medical practice usually do not understand medical office processes and needs. This is true in every hospital department, and IT is no exception. The problem: EHR implementation teams that do not grasp ambulatory workflows often create needless disruptions.
The solution is to hire an expert who understands medical practice workflows, management processes and culture. The ideal expert is someone with direct experience working in a small practice setting — for example, a former practice manager who has been through an EHR implementation.
An implementer with medical practice expertise will understand how to interact with physicians and office staff. He or she will be able to foresee implementation problems and configure the EHR system to meet individual practice needs.
4. Form Collaborative Task Forces
Even with medical practice experts on the implementation team, hospitals need a way to learn from medical practice staff members about what will — and will not — work in their office. The solution is to create implementation task forces that include key individuals.
Nurses, practice administrators, medical records staff, billers, even receptionists all should be represented. Establish an overall task force to plan EHR configuration and processes, and break out smaller groups to tackle specific issues like template design and process metrics.
Collaborative task forces can anticipate user problems that hospital IT staff would never see coming. They also build a sense of shared ownership for the EHR system. In addition, task force members are able to support their coworkers after implementation, reducing the practice's reliance on hospital IT.
5. Build a System, Not an Assembly Line
Implementing an EHR system for a physician network will require medical practices to adopt some standard workflows and clinical protocols. While standardization is necessary, it can create problems in individual situations and for certain medical specialties. A rigid approach to workflow design will breed resentment and result in a poorly functioning system.
Here's a rule of thumb for EHR implementation decisions: Don't force any changes that won't improve care quality or bottom-line results.
Say a group of family physicians wants to use voice recognition software to create referral notes. Some hospital-led implementation teams oppose voice recognition technology on the grounds that it does not generate discrete data within the EHR system. But meaningful use regulations and quality initiatives do not require all documentation to be formatted as discrete data. Since voice recognition technology may improve quality of care and make life easier for physicians, the best decision is to allow its use in the proper place within an EHR environment.
6. Rip Off the Band-Aid®
Even with good planning and risk mitigation, an EHR implementation is expensive and resource-intensive. The issue before hospitals and physicians is this: Do you want it to be quick and expensive or slow and expensive?
Both parties must devote resources up front to ensure a prompt and efficient EHR rollout. Physicians need to set aside time to learn the system, which means temporarily cutting back their schedules. Hospitals need to provide additional support to soften the impact on physician productivity. Some hospitals provide physicians with medical scribes to assist with the transition to electronic charting, while other hospitals supply temporary nursing support to help practices maintain patient flow.
These moves add expense to an implementation project, but they are a small investment when weighed against the risks of a failed rollout.
Here again, agreement on core objectives (see Step 2) is important. Both hospital administrators and physicians must be able to understand why they are making the change if they are to maintain commitment to the implementation and make needed investments.
7. Share Accountability
While the system rollout requires a big push, the work does not end there. All stakeholders must have ongoing accountability for creating high-performance electronic health records.
The hospital, of course, is responsible for maintaining the system and providing training. Physicians are responsible for using the system well. Ultimately, successful EHR adoption and meaningful use depend on what happens at the practice level.
While physicians need to make time to learn the new system, they also need to attend training sessions (you might be surprised by how many do not). Medical practice staff should participate in planning and implementation. Practice representatives also should take part in EHR user groups — collaborative learning groups that allow staff to share best practices and solve system problems, ultimately reducing their long-term reliance on hospital support.
Hospital administrators and physicians need to work together on continuous improvement. This is where the governance structure is still important, because there needs to be a body that identifies improvement goals and enforces behavior change for the sake of the entire system.
Best Chance for Success
Each of these steps will minimize the problems that can arise during a hospital-led EHR implementation. Together they allow hospital leaders to ensure the best chance of success for an electronically connected physician network.
Robert Tennant is a managing associate of Health Directions LLC, a national consulting firm based in Chicago that provides business solutions for health care organizations. Tina Wardrop is a vice president of Health Directions.