Successful EHR Usage It s not about the bits and the bytes, nor the size of the practice. Practice culture drives EHR success. WHITE PAPER
Successful EHR Usage It s not about the bits and the bytes, nor the size of the practice. Practice culture drives EHR success. Electronic health record (EHR) adoption has increased dramatically during recent years due to several regulatory and industry initiatives. Drivers to adopt the solutions include the lure of Meaningful Use financial incentives, the need for greater patient information access to improve care quality, as well as the market s push to share patient information with health information exchanges (HIEs) and accountable care organizations (ACOs). Although more healthcare organizations than ever now have EHRs, there is great variation in how the solutions are actually used. According the the Centers for Disease Control and Prevention (CDC), 72% of office-based physicians were using EHRs in 2012. However, only 27% of those physicians had EHRs that were capable of supporting 13 of the Meaningful Use Stage 1 Core Set objectives, according to the CDC. Some organizations are struggling to realize the benefits of EHR usage due to a combination of factors, such as functionality limitations, poor physician adoption or an overall lack of commitment within their organizations to integrate the solutions within their workflows. Conversely, other organizations are reaping the benefits of EHR usage due to careful planning that leads to high physician adoption. Successful EHR usage can be found at practices of various sizes, whether it s a solo-physician practice or a large group with dozens of physicians. An evaluation of organizations that successfully use EHRs reveals that practice size whether large or small is not a primary factor influencing EHR adoption or usage. Instead, these organizations reported that the culture within their practices is the determining factor in successful EHR usage. Consistent among these practices was a culture that not only encouraged EHR adoption, but also strived to incrementally expand usage on an ongoing basis by taking advantage of new capabilities, features and workflow enhancements. The following information highlights the lessons learned and best practices from three orthopaedic practices that are successful EHR users. The practices range in size from 1 to 13 physicians. Key individuals at these practices were interviewed to discover how they achieved successful EHR usage. Regardless of practice size, all agreed that successful EHR usage starts with preparation. Preparing for Changes Setting Expectations Today s orthopaedic practices are fast paced, high volume and have patients throughout their offices receiving multiple levels of care, such as diagnostic imaging, physical therapy, appliance fittings and more. The thought of interrupting this busy workflow with an EHR implementation is likely to be met with some resistance even among the physicians who are proponents of the technology. Successful EHR implementations begin with candid discussions to help set expectations. Clinicians and staff need to realize that implementations are challenging, and that workflows are likely to be disrupted during Page 2
the process. Furthermore, some workflows may permanently change to take advantage of EHR functionality. EHR training will consume precious time that was previously spent focusing on patients. Productivity decreases (e.g., lower patient volumes and delays in documentation completion) should be planned for during implementation and in the weeks following go-live. These are some of the sacrifices that must be made for practices to realize the benefits of EHR usage. Candidly discussing these issues prior to implementation will help practices prepare for the changes, and plan interim strategies to maintain operations. Creating and Articulating Incentives In tandem with setting expectations, practices need to create and articulate incentives to encourage EHR usage following go-live. Fortunately, the stimulus dollars offered through the Meaningful Use program are providing a substantial incentive for practices to utilize their EHR solutions, once installed. Meeting the Meaningful Use requirements will require practices to educate their clinicians and staff about the data elements that need to be captured, and the specific features that must be used to qualify for the incentive dollars. Practices should plan to routinely monitor Meaningful Use metrics on an ongoing basis to identify areas where requirements are not being met. Practice executives and administrators will be held accountable by board members who will require status reports to ensure that practices will not incur penalties due to noncompliance with Meaningful Use requirements. Additional incentives to encourage EHR adoption include preparing for HIE participation and future ACO clinical data exchanges. Successful EHR usage creates a foundation for participating in these entities, and future reimbursement as well as Meaningful Use Stage 2 requirements will be dependent upon the ability to exchange clinical data electronically. Medicare penalties for non-ehr usage under Meaningful Use Stage 1 decrease reimbursement by 1% in 2015, and escalate up to 3% by 2017. In addition, reimbursement cuts under the currently proposed Meaningful Use Stage 2 regulations penalize organizations that do not demonstrate specific clinical information exchanges with other entities. These financial incentives encourage EHR adoption, but they must be communicated to clinicians and staff so they understand the reasons why EHR usage is important for practices to achieve long-term viability. Other financial incentives to encourage EHR usage include reductions or elimination of transcription costs, increased productivity that escalates revenue, and the potential to earn higher reimbursement due to improved clinical documentation. Five Steps for EHR Success Aligning Culture, Implementation and Usage 1. Preparing for changes XXSetting expectations XXCreating and articulating incentives for EHR usage 2. Pre-implementation strategy XXConducing workflow analysis XXDetermining access where and how the EHR will be used XXAssessing training needs 3. Implementation & go-live XXDetermining implementation approach big bang or incremental XX XX Deciding data conversion strategy Going live and initial usage 4. Post go-live XXEncouraging point-ofcare documenting XXDetermining imaging integration XXIntegrating scheduling XXBoosting patient engagement and satisfaction XX Engaging EHR vendor for periodic check-ups 5. Evolving EHR usage over time XXSuccessful EHR usage is a journey, not a destination Page 3
Beyond the financial incentives, practices need to articulate how EHRs can benefit individuals by communicating what s in it for them. The challenges of EHR implementation are more easily swallowed when individuals realize that the solution will benefit them on a daily basis by: XXEliminating the searches for lost patient records XXEnabling them to access patient mis-filed histories and test results quickly and easily X X Allowing them secure and HIPAA-compliant access to patient records and test results from home or via mobile devices Pre-Implementation Strategy Workflow Analysis Practices interviewed for this white paper strongly advised organizations to conduct a workflow analysis prior to implementation. This is especially important for orthopaedic practices that have sub-specialists who have unique documentation requirements, which impacts how patient data is collected, input and stored in the EHR. The analysis should evaluate how patients flow between different levels of care within the clinic (e.g., physician consultations, physical therapy, imaging, etc.), including how and when information is documented. This analysis also uncovers the types of information that is collected and how the EHR will accommodate those needs, or if templates and fields need to be configured differently before the system goes live. Interviews with clinicians and staff can help identify potential problems and areas where workflow improvements efforts should focus. Additionally, it is wise to engage an experienced third party, such as an EHR vendor or consultant, to conduct a workflow analysis to identify inefficiencies or habits that impact workflow. Skipping the workflow audit may result in unexpected increases in implementation timelines, and certainly elevates frustration levels among users. Access Another component of the workflow analysis is to determine where the EHR will be accessed. Orthopaedic practices that offer multiple levels of care may require additional desktop or laptop computers as well as handheld devices to conveniently access information during normal workflows. Plus, some physicians may plan on documenting encounters at the point of care, while others may perform that task from their individual offices. EHR access is one area where practice size makes a substantial difference in how the EHR is used. Successful EHR usage in large practices may require additional computers to complement workflows. Training There are several levels of training that need to take place prior to implementation. Practices interviewed for this white paper all said that it is easy for provider organizations to underestimate their training needs. Their advice is to first confer with internal staff to carefully calculate how much training time is necessary then double it. Second, work closely with the EHR vendor to once again calculate training times. Vendor training estimates are often higher than a practice s estimates, since the vendor is experienced with the realities and nuances of implementing their solutions. Additional time and training costs are a small investment to prevent issues that cause delays and productivity losses during implementation and go-live. Larger practices will need to coordinate groups that rotate through training while others maintain operations. Page 4
Training typically starts with online interactive training, which helps future users get acquainted with the EHR prior to go live. Although online training usually takes place before hands-on classroom training, practices interviewed for this white paper recommend users to revisit online training after having some hands-on experience. Additional functionality and system navigation tricks will be more easily absorbed during online training once they have some familiarity with the system. Classroom training at the vendor s office, or onsite at the practice, is where the bulk of learning takes place under the guidance of an experienced instructor. Prior to engaging in classroom training, it s highly recommended that practices have all changes resulting from their workflow analyses implemented in the system. This will prevent the need to change templates and screens during classroom training, and will provide a consistent training experience for all users. Implementation and Go-Live Big Bang, or Incremental Implementation Practices have a choice of implementing their EHR all at once, known as a big bang implementation, or incrementally rolling out the solution. Although the big bang approach is a whirlwind of activity and stress, many practices choose the approach to minimize implementation time and distractions. Having the EHR vendor onsite during go live for support and guidance is vital to the success of a big bang implementation. Incremental implementations roll out functionality gradually over time in an attempt to minimize distractions and lost productivity. The incremental approach is often used by large practices with multiple locations. Practices should consider whether the big bang or incremental approach will most encourage successful EHR usage. Data Conversion Data conversion decisions have a big impact on successful EHR usage, whether the practice is converting from paper-based processes or migrating from another EHR. Should practices populate the EHR with patient histories and demographic data, or should they start from scratch and enter each patient as a new patient in the system upon their first office visit after go-live? The size of a practice can have an impact on this decision. Large practices may have several hundred thousand patient records. Converting these whether they are scanned from paper or imported from another EHR can be costly and time consuming. Furthermore, converting data from some antiquated EHRs can be particularly troublesome. However, having some historical patient data in the EHR speeds up physician adoption and utilization. To address these issues, many practices choose one of the two following options: Selective Conversion Practices have the records from their recurring patients either scanned (for paperbased systems) or converted and uploaded into their new EHR. Since this is done on an as-needed basis, a relatively small number of records get converted. With today s EHRs, this is a much more viable option than it was in the past, since EHR migration and data mapping techniques have greatly improved over the past several years. Dual Systems Practices may choose to keep their old EHR running for an interim time period so users can access patient histories when needed. This is an expensive option, since a practice is essentially paying maintenance on both solutions to run simultaneously. In many situations, organizations choose to implement an integrated EHR and Practice Management solution. Under this scenario, practices can convert the patient demographic data from the old practice management system and have it populate the database in the new solution. Since the integrated practice Page 5
management and EHR solutions share a database, the EHR will also have access to the demographic information, which reduces data entry needs. Of course, practices will still need to decide whether they will convert patient histories to populate their new EHR. Although time and finances are a consideration, practices should make their conversion decisions based upon which choice will provide the best user experience and information access options to drive successful EHR adoption and usage. Go-Live and Initial Usage To prevent EHR go-live from being an overwhelming experience, most practices have their users start off by focusing on basic EHR functionality, such as electronic charging, or e-charging. Additional functionality and documentation entry is added as users become comfortable with the system. At this early stage, it s important to demonstrate the benefits of their efforts to encourage higher levels of usage that delivers even greater benefits. Ultimately, the goal is to have clinicians document their patient encounters at the point of care, which leverages the power and benefits of EHR usage. Post Go-Live Point-of-Care Documenting Successful EHR use doesn t happen overnight. It typically evolves through stages. Therefore, it s important to allow for some flexibility in how the EHR is used during the weeks and months following go-live to accommodate the needs and preferences of users. With the proper support and incentives, usage of the solution will evolve over time. For example, many physicians still prefer to dictate their notes during the early stages of EHR usage, and the use of voice-recognition software can be a good compromise especially when it is integrated in the EHR. As they become more comfortable with the solution and transcription costs continue to mount they will be encouraged to enter their documentation directly into the EHR. Initially, they may have a scribe or a nurse enter the information for them, or they may enter the information themselves from their office instead of at the point-of-care. The goal is to guide them toward efficient EHR use. For physicians who are forever committed to using paper to document encounters, there are still ways to increase efficiency. For example, forms can be created that mirror the fields of the EHR. When physicians complete these forms for an encounter, they are essentially placing the right information in the right place for easy entry into the EHR by another person. Eventually, they may find it easier to simply enter the information into the EHR to avoid the interim step. Surgery Scheduling Surgery scheduling, which is vital to orthopaedic practices, is another incremental improvement that is easily added after go-live. Practices with integrated EHR and Practice Management solutions can enable electronic surgery scheduling to improve efficiency and the visibility of schedules. Handheld devices, with applications to access the schedule, help physicians stay on top of their workloads, and further increases usage of the solutions. Boost Patient Engagement and Satisfaction Patient portals and kiosks are additional add-on solutions that can further extend EHR functionality while also improving patient satisfaction. Portals provide a secure method for clinicians and patients to communicate, exchange test results, and schedule appointments, while also meeting the requirements of Meaningful Use Stage 2 with the portal. Kiosks allow patients to electronically check in upon their office visits, as well as input or verify insurance and demographic information. These solutions reduce front-office data entry tasks, and add valuable functionality that further increases EHR usage. Page 6
Periodic Check-Ups It s valuable for practices to engage their EHR vendor for periodic check-ups to evaluate usage. The frequency of the check-ups can be quarterly or annually, based on the practice s needs. These check-ups allow vendors to fine tune the solution, suggest workflow modifications to take advantage of functionality, and discuss upgrades or add-on solutions that could benefit the practice. Evolving EHR Usage Successful EHR usage is a journey, and not a destination. The practices that realize the most benefits from their EHRs are the ones that are continually looking for ways to evolve how they use their solutions. These practices cultivate and promote a culture that is always on the lookout to find a better way to do things, get them done faster, and more accurately. In the end, it s not about the bits and bytes, nor the size of the practice. Successful EHR usage is an attitude, and it s contagious. Page 7
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