The fact that you are reading this chapter indicates that you are seriously

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1 SECTION IV E LECTRONIC H EALTH R ECORDS S ELECTION 14 Starting the Electronic Health Record Selection Process Jerome H. Carter, MD The fact that you are reading this chapter indicates that you are seriously interested in implementing an electronic health record (EHR) system. A survey conducted in solo and small group practices revealed an estimated initial cost of up to $44,000 per fulltime FTE and with on-going costs of about $8500 per year for a typical installation (1). Aside from the dollar cost, there is a price to be paid in lost income, low morale, and simple frustration when an implementation goes sour. Getting your EHR system successfully implemented requires planning and attention to detail. This chapter offers an easy to follow plan and a few words of advice. Take Your Time and Study Your Practice There is no rush. You do not have to worry about being the last on your block to have an EHR. Prudence dictates that you assess your short- and long-term practice goals, current economic situation, employee skills and attitudes, and your ability to deal with fear, uncertainty, and doubt. Talk to your accountant in order to determine how much you can afford to spend and what overall economic benefit you may expect from your EHR. Increased productivity does not necessarily mean fewer staff FTEs. Along the same lines, how will you manage the slow-down that frequently occurs after a new system is installed? How do your employees feel about an EHR? Will their fears of being replaced lead to destabilizing resignations? Finally, do you have the patience to see this through to the end? Addressing these issues takes time and thought. Don t rush. 329

2 330 ELECTRONIC HEALTH RECORDS What Worked in a Friend s Practice Will Not Automatically Work in Yours EHRs are not one size fits all. Your practice environment (patient mix, employee skills, and specialty) will play a substantial role in determining the type of EHR product that best meets your needs. What works for surgeons may not work for family physicians, and what works for a solo practitioner may not work for a large multi-specialty group. Remember, when viewing demonstrations or conducting site visits, your mileage may vary. Keep this in mind. When comparing your practice to another, always match as many practice variables as possible to ensure that the respective practices are similar. Your colleague is a touch typist; are you? On the Surface Most Products Are Similar EHR products have come a long way over the last five years. Most are the products of professional developers, are technically sound and offer similar features. However, the way that features are implemented may lead to significant differences in ease-of-use or utility. Consider a feature as basic as automatic drug interaction checking. Most EHRs offer this feature. However, all do not allow you to turn off the feature easily, adjust the number or type of interactions which are flagged, or check for food-drug interactions. You would be surprised to find how much the ability to adjust any of these features affects your comfort in using a product. Also, you may find that accomplishing the same task such as writing a prescription takes more steps in one product as compared to another. The Vendor Is as Important as the Product Quality, service, and continued existence count whether you are buying an EHR or an automobile. New vendors may have great products, but will they be around next year? Vendors may tout the fact that they have been in business for 10 years, but how often have they updated their products? Does the vendor offer interfaces to other important types of software found in medical offices (i.e., practice management systems, outside labs). How do they handle upgrades? Do they have a local office? Can they provide service during all hours that your practice site operates? Another key issue is market focus. Few vendors have a service model that allows them to handle solo practices and large multi-specialty groups with equal aplomb. The same is true of specialty practices. Unfortunately, many vendors will sell to anyone who wishes to buy their product even when they know the practice is not typical for their customer base. The result of these mismatches is usually bad service from the vendor if the prac-

3 STARTING THE ELECTRONIC HEALTH RECORD SELECTION PROCESS 331 tice is too far removed from their usual customer base. Always check the market focus; you really don t want to be the five-person group that buys an EHR from a vendor that sells mostly to hospitals. Do Not Confuse Quality with Price When you research products you will notice a significant variability in price. This should not be used to determine the quality of the product. Quality should be determined by independent reviews, speaking to current users, length of time the product has been on the market, de-installation rate (removal of the EHR from the practice), and other factors. Quality and price are not synonymous. After pondering the above points, if you still feel that you are ready to plunge ahead, then the next step is to draw up a plan for selecting and implementing a system. Success depends upon your willingness create a plan and stick to it. Please take planning seriously. Developing Your Plan Your EHR project will occur in two major phases: product selection and implementation. Each phase should be conducted using a formal plan. Product selection should begin with a focus on practice issues: goals, budget constraints, information needs (reporting and querying), employee skills, and process analysis (understanding the key tasks that must be performed in your practice). This will lead quite naturally to an RFP that truly reflects practice needs. Once a product has been selected the implementation phase begins. Here attention must be directed to fitting the practice to the EHR product. This entails workflow analysis (how each task is performed by each staff member) and reengineering (refitting the practice to achieve identified goals and to complement the EHR s features and functions). Table 14-1 presents an EHR project plan outline with suggested steps. The suggested completion times assume a practice at a single site with three or four physicians. It also assumes that an EHR Team (Chapter 21) consisting of key practice staff has been formed. Solo practices will have much shorter timelines. Notice the time allotted for setting goals/objectives and for practice analysis steps. These steps, which are dedicated to understanding the fine points of how your practice operates, are the most important of the group. It is in these steps that you develop the vision and define the outcomes that, once realized, will result in the practice improvements that initially led to you consider implementing an EHR. The remainder of this book is dedicated to helping you to both understand and carry out each step of your plan.

4 332 ELECTRONIC HEALTH RECORDS Table 14-1 EHR IMPLEMENTATION PLAN OUTLINE Product Selection Set Goals and Objectives (be specific) Practice Analysis: Process Identification Process Analysis Requirements Specification Product Evaluation Vendor Analysis Create and submit Request For Proposal (RFP) Contract Negotiation Implementation Workflow Analysis and matching to EHR Re-engineering Hardware/Software Installation & Testing Training Go-live until normal patient flow returns Suggested Time for Completion 1 month 1 month 2-3 months 1 month 1-2 months 1 month 1-2 months 1 month or less 1-2 months 1-2 months 1 month or less 1 week 2-3 months Goals and Objectives What problems are you trying to solve? Frame your answers in the most concrete terms possible. Are you hoping to increase productivity, reduce staff FTEs, improve access to patient data, improve safety, participate in pay-for-performance programs, or improve quality? These are a few of the reasons most often given for investigating EHR systems. Unfortunately, the next step is frequently a call to an EHR vendor. The more appropriate action would be to look at each problem more closely and determine what exactly would be required to address it. A good way to start is with staff interviews. Have each person create a list of common problems that they regularly encounter or how they would like to see the practice improve and then group them by type (goals, problems, wish list, etc.). Typical goals/ objectives and problems are discussed below. We would like to increase productivity Productivity is a fairly vague concept in many practice situations. If increased productivity is the goal, it would be very helpful to know what is currently impeding an increase in productivity. If you wish to increase productivity, you must first define it in terms of what happens on a daily basis in your practice. Let us assume that in your practice productivity is defined as the number of patients seen per day. The obvious next step is to determine why more patients cannot be seen each day.

5 STARTING THE ELECTRONIC HEALTH RECORD SELECTION PROCESS 333 If a good deal of time is spent looking for charts or if needed information is frequently unavailable when seeing patients, then you have identified a common cause of decreased productivity. Assuming that locating charts during patient visits is an issue, it would be helpful to categorize this as a chart access problem. Once chart access issues are on the table, try to determine if there are other chart access problems. Remote access to patient data, especially while on-call, is a well recognized access issue. Similarly, concurrent access (multiple users at the same time) may be an issue in large practices where more than one provider may need access to the paper chart at the same time. Finally the simple, but very common, problem of temporarily misplaced charts is one that many practices deal with daily. Once you are satisfied that you have a fairly complete issue list, turn your attention to understanding why they exist. At this point you are trying to determine which issues may be addressed by changes in administrative policy and procedures as opposed to those that can only be solved by an EHR. Consider the example of an office where there is a thirty-minute lag-time between patient sign-in and placement in an examining room. If the delay is due to problems locating the patient s chart, then an EHR might help. However, if the delay is due to poorly trained staff, an EHR may actually result in a decrease in productivity. Table 14-2 contains a list of causes of low productivity that an EHR will not improve. Make sure that none are present in your practice before purchasing an EHR. No amount of technology will resolve these issues; sound administrative policies are required. We would like to implement quality improvement, safety, and pay-for-performance programs Quality improvement starts with the implementation of best practices for common ailments. The key is ensuring that all patients receive the proper interventions at the proper times. EHRs support quality improvement by Table 14-2 COMMON ISSUES THAT AFFECT PRODUCTIVITY Poor staff training Poorly defined staff duties Lack of formal administrative policy Ineffective process for handling telephone calls Ineffective process for managing charts Ineffective process for managing information flow into the practice (labs, x-rays, referrals, etc.) Poor resource scheduling (e.g., procedure suites)

6 334 ELECTRONIC HEALTH RECORDS making it much easier to identify patients who have specific diagnoses and to ensure that they receive the required interventions. This is often difficult to do with paper charts because of the time required for case finding and follow up. Not harming patients while providing care is at the heart of patient safety. The medication features of EHRs provide the most obvious example of patient safety features. Drug-drug interactions checking and automatic allergy checks during prescription writing are good examples. Creating a legible prescription contributes to patient safety in a less high-tech way. In addition to quality and safety issues, EHRs also help with other types of outcomes studies. Provider profiles, patient satisfaction, and simple performance studies are well within the capabilities of the average practice. Each may be done manually, but an EHR will certainly make things much easier. Of course, proper administrative policies must be in place to ensure that data are collected and entered in a systematic manner. Pay-for-performance is another side of the quality/safety coin having the same basic requirements for the use of standardized protocols. Participating in these programs requires submission of patient data. Therefore, one important feature required of an EHR for pay-for-performance is the ability to create and export data sets using common informatics standards (Chapter 6). Review your practice with an eye toward standardizing as many common activities as possible. You may, for example, reduce the number of laboratory service providers utilized. This will decrease the number of lab order forms that staff must use and remove the need for remembering multiple names for various combinations of common lab tests (e.g.; chem-7 vs. electrolyte panel). Do you have a process for ensuring that all diabetic patients receive yearly eye exams? Do you conduct chart reviews to determine if all required documentation is present? How are common interventions such as flu shots recorded? Do you have a special form or flow sheet for interventions or are these items included only in the provider s note? Table 14-3 list suggestions for preparing your practice for quality, safety and payfor-performance programs Table 14-3 STEPS FOR PREPARING FOR QUALITY, SAFETY, AND PAY-FOR-PERFORMANCE Implement standard preventive health measures Implement standard protocols for accepted clinical practices (ACE inhibitors for CHF, inhaled steroids for asthma, etc.) Standardize documentation (templates) for common procedures and interventions

7 STARTING THE ELECTRONIC HEALTH RECORD SELECTION PROCESS 335 We need to get a better handle on costs Cost control is a major issue for many practices, especially for those with significant numbers of capitated patients. An EHR can help in this area. However, an EHR alone is not enough; your practice management system is important as well. When dealing with capitation the costs generated from a patient encounter are derived from three main sources: diagnostic interventions (labs, x-rays, procedures), referrals, and therapeutic interventions (depending upon the amount of risk taken on by the practice). Begin your analysis by reviewing use of medications and diagnostic studies by diagnosis. For example, in managing patients with headaches, how often do you order CT scans or refer to neurologists? How often do providers order electrolyte studies for patients taking diuretics? Many common prescribing habits may confer little real benefit to the patient. An excellent example of this is the widespread use of antibiotics for common upper respiratory infections. Another cost saving measure that is also good medicine is the use of prophylactic medications for patient who suffer from migraine headaches. Effective prophylaxis may result in less use of expensive pain medications and fewer emergency room visits. Table 14-4 offers suggestions for reviewing practice patient care related costs. We need better access to patient information Timely access to information is a cornerstone of good patient care. Large practices and those with multiple sites are most likely to have problems with chart access. Remote access, while on call or simply away from the office, provides an additional example of the need for easy and rapid access to patient data. This is perhaps one of the clearest benefits of EHR technology. Table 14-4 COMMON ISSUES THAT AFFECT PRODUCTIVITY Review use of disposable supplies for unnecessary use/overuse Review practice guidelines for common diseases for suggestions for best use of diagnostic studies and interventions Look at antibiotic prescribing habits for over use Look at outside referral patterns for common procedures/diagnoses Review emergency room visits with particular emphasis patients with the following diagnoses: asthma, chest pain, headache, URI, UTI, abdominal pain Review use of patient educational materials/walk-out instructions

8 336 ELECTRONIC HEALTH RECORDS Access to patient data for internal care processes or for sharing with other providers is not a function of EHR technology alone. Data quality is important and has to be managed carefully. As with many other things in a practice, high quality data requires well-defined administrative policies that are adequately enforced. Proper respect for the importance of properly managing patient information for legal and regulatory reasons must be emphasized and reflected in practice policies. Take time to sit down with your medical records staff and review any issues they may have regarding current policies. Ask for suggestions for new policies or changes to current ones. Standardize forms placed on charts, look for redundant forms and practices, and optimize those procedures deemed worth keeping. Obviously, staff training is a major component of sound patient information management activities. Keep in mind that your EHR will become your legal record and must be treated accordingly. You must be able to demonstrate that the contents of your EHR are tamperproof and that all signatures are valid and cannot be forged. This is also a good time to look at communications with outside clinical consultants or facilities. Can paper-based reports be transmitted in electronic form? Would consulting providers be willing to send reports via disk, , or fax? Try polling consultants/groups with whom your practice has frequent interactions to determine if better ways of moving patient information can be agreed upon. Finally, when evaluating EHRs, look for systems that permit easy import of outside data and allow for remote access with good security protocols. Parting Advice You are about to start on a journey that will never really end. New technologies will appear, new reporting requirements will be mandated, your needs will evolve. Therefore, it is very important that you keep your goals firmly in mind. Monitor and evaluate your practice on a regular basis, look for inefficiencies and opportunities to improve. Remember, successful implementation of an EHR is very much dependent on your ability to identify and analyze your information needs. The remaining chapters of Section IV EHR Selection (Chapters 15-20) and Section V, EHR Implementation (21-25) will help you through each step. References 1. Miller RH, West C, Brown TM, et al. The value of electronic health records in solo or small group practices. Health Aff (Millwood). 2005;24: