1 GOING ELECTRONIC NO-TEARS, NO-FEARS EMR PLANNING, SELECTION, AND IMPLEMENTATION
2 FREE MEDICAL CLINIC OF OAK RIDGE In Oak Ridge, TN, home of Oak Ridge National Lab; very data-driven Serve three-county area, primarily rural Opened January, 2010; 1-1/2 days per week Now open Monday Friday Primary care, women s health, physical therapy, behavioral health, wellness Average 140 patient visits per week (all services) 3 FT staff Exec. Director, Office Manager, Dir. of Nursing 4 PT staff 2 nurse practioners, 2 nurses Lots of volunteers! 5 MD s, 2 nurse practitioners, 17 nurses, 28 office volunteers plus volunteer physical therapists, massage therapists, behavioral health counselors, substance abuse counselors, nutritionists, and diabetic educators $350K annual budget
3 WHY EMR?... It s not a fad EMR s are here to stay!
4 WHY EMR? THE FMCOR EVOLUTION January May 2010: Paper charts spreadsheets to track basic demographic data May 2010: Awarded grant required to track distinct patients and number of primary care MD/NP/PA visits per quarter. How? June 2010: Began using Medkind for scheduling, demographics, broad category diagnoses, report generation. Only office staff and nurses used program. Providers still used paper charts. Spring 2012: Hired a part-time nurse practitioner; expanded from 2 to 5 days per week. Soon drowning in paper and looking at how to improve efficiency and reduce errors without adding paid staff. An EMR system might be the answer. We started the evaluation process. January 2013: Clinic-wide implementation of EMR/Practice Management System. Almost everyone at FMCOR uses this EMR!
5 FMCOR BEFORE... AND AFTER
6 PAPER CHARTING VS. EMR THE BASICS Paper Charts Easy to misfile Take lots of space Handwritten notes can be difficult to read Difficult to locate information in chart Lack drug interaction alerts No integration with billing systems Can create security/privacy issues Doctors are very comfortable with paper charts especially retired MD s Paper charts don t require much infrastructure just chart racks EMR System No worries about misfiled charts Just need desk space for computers Typed notes are always legible Information is readily visible and easy to find Includes drug interaction alerts Integrated billing module Data is secure and HIPAA compliant Doctors generally range from ambivalent to very negative about EMR systems EMR systems require computers, servers, networks, good Internet connection
7 WHAT DO ELECTRONIC CHARTS LOOK LIKE? EMR systems have multiple, integrated components, including front office/practice management functions Scheduling Patient Demographics
8 WHAT DO ELECTRONIC CHARTS LOOK LIKE? easy-to-access clinical components Patient Dashboard SOAP Notes
9 WHAT DO ELECTRONIC CHARTS LOOK LIKE? integrated procedure orders and prescription modules Lab/Imaging/Test Order Modules Prescription Module
10 WHAT DO ELECTRONIC CHARTS LOOK LIKE? and simple tools that improve patient care and tracking. Assessment/ICD-9 Tools Pop-Up Reminders
11 WHY USE AN EMR SYSTEM? Data Searchable retrievable trackable - extractable facts How many patients smoke? How many patients have diabetes? How many patients fall under the Federal Poverty Level? How many patients graduated from high school? These are types of information you can easily access if you have a good, workable EMR system. AND--This is exactly the kind of data you need for grant applications and for reports to your funders and donors.
12 Patients on Lisinopril 40 mg (exported into Excel) Number of Patients by Poverty Level (as shown in EMR)
13 Diagnosis Analysis Report (as shown in EMR) Smoking Status Report (exported into Excel)
14 WHY USE AN EMR SYSTEM? Easy Access to Patient Records Everything you need to know about a patient right at your fingertips Lab and imaging results Current prescriptions Previous visit notes Previous diagnoses Patient demographic data No need to thumb through pages of paper; just click the mouse a few times to pull up the information you need. And no searching for misfiled charts!
15 Patient Dashboard the first screen we see when opening an electronic chart
16 WHY USE AN EMR SYSTEM? Access When You re Not at the Clinic For most EMR systems, you will have a username and password that allow you to access the system remotely from your home, while you re on vacation, etc. So without physically being at the clinic: Providers can check patient lab, imaging, and test results Doctors can do chart review (e.g., of charts for patients seen by a nurse practitioner) Office staff can contact and reschedule patients when there is a weather-related closure
17 WHY USE AN EMR SYSTEM? Improved Quality of Care Prior diagnoses and treatments are easy to locate Current, accurate prescription information Drug interaction alerts Pop-up reminder notes of tests that need to be done Tracking for patients with chronic diseases Preventive care tracking Online educational materials
18 Diabetic Flowsheet Educational Material Drug Interaction Alert Pop-Up Reminder
19 HOW DO WE SELECT AN EMR SYSTEM? Evaluate How You Will Use the System An EMR is a tool for you. It should make your clinic operate more smoothly and efficiently. Establish a team to spearhead the process include a provider, preferably an MD. Talk to your staff and volunteers What would make having EMR worthwhile to them? Are they playing phone tag with patients because they don t have the information in front of them when the patient calls back? Are there questions about a patient s current medications because the charting is unclear? Think about the reports you generate and the data you need to collect for those reports What could simplify the reporting task? Make a list of reports and data you need.
20 HOW DO WE SELECT AN EMR SYSTEM? Evaluate How You Will Use the System (cont.) Look at workflow/patient flow through your clinic What is working well? What could be improved with an EMR? If you already use Practice Management software, find out what EMR systems are compatible. Talk to your providers and other staff about how they want to access the EMR. Desktop computers? Laptops? Tablets? Not all systems have a tablet version. Not all systems are Mac compatible. Prioritize your needs and wants!
21 HOW DO WE SELECT AN EMR SYSTEM? Determine Your Budget Parameters and Other Financial Considerations Hardware: How many computers? What type? (We have 18 Windows 7 desktops) Printers? (In exam rooms for prescription printing) Scanners? (In patient registration and check-in for photo ID, etc.) Software: Local server version server cost, plus installation, maintenance, and someone to troubleshoot at the clinic level. May have one-time upfront fee for software or monthly/quarterly/annual fee. Remote server/cloud based may need to upgrade to better, more costly Internet connection. Typically charged for software and data storage on ongoing monthly/quarterly/annual basis. LAN: Local Area Network connects all the devices in a clinic to a single network, including laptops, printers, etc.
22 HOW DO WE SELECT AN EMR SYSTEM? Determine Your Budget Parameters and Other Financial Considerations (cont.) Training and Support: What training is included in the purchase price? Are there extra charges for on-site training sessions? Travel? Is all tech support free? What hours is free tech support available? Is after-hours support available for an extra charge? Data Transfer: Costs to transfer data from existing system? Extra staff needed to scan paper charts? Clinic Tech Support: Who will provide IT support at the clinic? Staff or volunteer? Future Costs: Additional software licenses/users as clinic expands? Additional workstations? Lifespan of computers and other hardware?
23 HOW DO WE SELECT AN EMR SYSTEM? Involve People Who Will Use the System Welcome anyone who wants to be involved in evaluating the systems under consideration! Physicians Nurse Practitioners Nurses Office Staff Office Volunteers Your Tech/IT Staff and Volunteers The more people involved on the front end, the fewer complaints there will be during implementation.
24 HOW DO WE SELECT AN EMR SYSTEM? Check Out As Many Systems As Possible Sit in on EMR demonstrations at conferences. Sign up for webinars and other online presentations. Ask other clinics/practices if you can visit and see their system at work. Focus on practices that are close to your size and your business model. Find out if there are particular EMR s that interface well with your partners and vendors your local hospital, LabCorp, Quest, etc. Think about remote server vs. local server: Talk to clinics who use each type; find out what they like, what they don t like, what works well, what doesn t work well.
25 HOW DO WE SELECT AN EMR SYSTEM? Eliminate Systems That Obviously Won t Work Well for You X Not compatible with your existing practice management software X Will not interface with your partners and vendors (hospital, LabCorp, etc.) X Will not easily generate the reports and other data you need X Out of your budget range You will be able to eliminate some systems early on by simply doing these three things!
26 HOW DO WE SELECT AN EMR SYSTEM? Eliminate Systems That Aren t Working Well for Other Clinics Get a list of other users for any EMR you are considering then contact those users to find out how the EMR is working for them. Be sure to ask the EMR reps about the types and level of training and support available then ask other users about their experiences with training and support. You will be able to eliminate even more systems early on by simply doing these two things!
27 HOW DO WE SELECT AN EMR SYSTEM? Exercise Due Diligence Regarding Potential EMR Systems How long has the EMR company been in business? How many practices use their system? How many of those have a business model similar to your clinic s? Does it have staff in place to support new users? What is the response time for tech support?
28 HOW DO WE SELECT AN EMR SYSTEM? Narrow Your Choices Based on Staff Input and Clinic Needs Which systems seem to work best with your patient flow? Which ones are less intimidating to your staff and volunteers? Which ones function in a way that seems more intuitive to your clinic staff. Here s how we did it: Initial inquiries: Medical Director, Director of Nursing, Executive Director--almost 20 EMR systems Critical to have physician input from the outset! First cut: Eight systems worth further review and evaluation Review of these eight: Staff nurses, nurse practitioner, and office manager selected four for additional review Final four: Invited more people to help us make the selection--volunteer MD s, volunteer nurses, and office volunteers Final selection: A unanimous decision by everyone involved Hooray! It s user friendly, creating SOAP notes is easy, and we can access the reports and patient data we need.
29 HOW DO WE IMPLEMENT AN EMR SYSTEM? Slowly-- Implementing your new system in stages will lessen (but not eliminate!) stress and frustration.
30 HOW DO WE IMPLEMENT AN EMR SYSTEM? One Step at a Time Phase in one function at a time, with lots of staff and volunteer training before and during each stage. Do not phase in the next function until the current one is working well. Here s the plan we followed: 1. Scheduling and patient demographics 2. Triage and SOAP notes 3. Lab, test, and imaging orders and results 4. Prescriptions 5. Flowsheets, macros, templates all the extras And almost two years later, we re still learning about features in our system! Scanning of paper charts happened throughout this process--office volunteers spent nine months scanning 2400 paper charts.
31 HOW DO WE IMPLEMENT AN EMR SYSTEM? Be Realistic in Your Expectations 1. Expect stress and frustration. My IT guy says, We have computers, so we have computer problems. Plan end-of-day or end-of-week gatherings where staff and volunteers can communicate their problems and concerns and their successes! 2. Encourage everyone to use the system, but acknowledge that not everyone will. Make adjustments accordingly: Plan for scribes and transcriptionists for volunteer MD s who can t or won t use the computer Use volunteer nurses where they feel most comfortable some may prefer drawing blood to using the computer Find other ways to use office volunteers who don t adapt to the new system
32 HOW DO WE IMPLEMENT AN EMR SYSTEM? Be Realistic in Your Expectations 3. Understand that problems will continue to occur: Programming updates to one area of the EMR sometimes have an unforeseen impact on other areas. 4. Report problems to the EMR company when they occur, preferably with a screen shot to clearly show the problem. Be able to explain, to the best of your ability, what you were doing when the problem occurred. Contacting your EMR company days after you had the problem, with only a vague recollection of what was going on when it occurred, does not provide a good starting point for assessing the problem. Which brings us to.
33 HOW DO WE IMPLEMENT AN EMR SYSTEM? Build a Good Relationship With Your EMR Company Tech and sales support people are you new best friends. They have answers and solutions though maybe not immediately. Understand that except for true emergencies, system-wide issues will be resolved quicker than issues that impact just your clinic. Find out the best way to communicate with the support people at the company Phone? ? Designate a limited number of contact people at your clinic who will work with the EMR company and make sure everyone on both ends knows who the contacts are. Ask whom to contact for what Training issues? Report problems? Error messages? Be sure the problem isn t on your end before you contact tech support!
34 THE END RESULT.. Less Paper and Clutter Scheduling and Practice Management Electronic Clinical Records
35 PLEASE FEEL FREE TO CONTACT ME..
36 CHECK OUT THESE ONLINE RESOURCES (good article on how to select an EHR system, including a functionality checklist and a demonstration rating form) AAFP-Landing.aspx (free, but requires registration)