EHR

Riding the EHR Roller Coaster

Here's how one practice's EHR “go-live” date went smoothly… even in the face of four daunting challenges.

Lisa Shaw, COE, Brookville, Pa.

“It's like riding on a rollercoaster, with no way to get off!”

That's how one provider described his EHR experience to me. I was at my doctor's office a year before our planned go-live; he was one month into his go-live. Was I nervous hearing him say this? You bet, but I was also curious as to what his biggest complaints were. I listened as he listed them… counting them on both hands. I learned a lot from his experience and applied what I learned to our implementation plan, hoping to avoid some of the pitfalls he encountered. Six months later, I was back for another appointment, and interested to see how things were going. I was pleasantly surprised to hear him say he loved it and would never go back to paper.

As I write this, we have been live for five weeks. Would our providers say they would never go back to paper yet? Maybe some of them, but some are still feeling the ill effects of the roller coaster ride. Implementation of electronic health records is one of the biggest changes many staff and doctors will ever experience.

What I have found from speaking with others is, even though we may have different sized practices and staff, the challenges are the same. I have identified our four biggest challenges and how we, as a team, were able to overcome them.

1 Staff trepidation

Regardless of how much you reassure staff and doctors, there will always be the fear of the unknown. The anxiety of taking away pen and paper and using a computer is something that is not easy to overcome. We began a year prior to our go-live by testing staff on basic computer skills, typing, email, and Microsoft Word. All staff were required to take the test and those who did not meet the competency requirements were scheduled to attend an in-house computer class. The staff then retested until they acquired the predetermined proficiency in all areas. This was key for us in identifying staff who were stronger and those who would require more intensive EHR training. We then used that information when forming EHR training classes. The computer training and classes also gave us the opportunity to talk about EHR with the staff and reassure them we would provide the tools they needed to succeed.

We have a unified management team that took every opportunity to provide feedback to the staff when they would ask questions or express concern over the coming changes. Seeing the management team's enthusiasm and confidence in the product was extremely helpful to dispel fears.

But, the most valuable assurance came from the doctors in our practice. They were committed to the project and reassured staff that, together, we would successfully incorporate EHR. The doctors' attitude was invaluable to the success of the project.

2 Training

We have more than 100 staff members working in our practice, so training was a formidable challenge for us. What is the best way to train that number of staff efficiently but be certain the classes were small enough so that the staff members felt comfortable participating? For our practice, we decided that we would schedule no more than five staff per class. We also felt it was important for the staff to receive a consistent message, so it was decided that one person would do the training.

Training took approximately three months and staff was divided into two groups. The Super User Group would be provided with three days of training and would be trained on all templates. The End User Group was trained on only templates that applied to their job and received two days of training. The physicians received one-on-one training.

We also chose to abstract certain key pieces of information from our paper chart:, medications, allergies, ocular histories, etc. The abstracting of this information was also used as a training tool. The staff was performing a beneficial task, and was learning from actually using the system prior to go-live.

I personally believe the time we invested in training was one of the best decisions we made as a group. The staff and doctors were well prepared when the date for our go-live arrived.

3 Workflow

Dissecting every step in the process that will be affected by EHR is key to a smooth go-live. All processes will need to be identified and discussion held on how EHR will affect that process. Workflow discussions can be incredibly brutal and detail oriented, but doing so will pay big dividends in the end. It will be impossible to anticipate every scenario, but the more thorough you can be with the process, the less time you will have to spend troubleshooting during and after your go-live. I was told that EHR implementation will magnify every workflow inefficiency in your practice… and it does. If you are able to correct those inefficiencies before you go-live, you will be much more successful.

4 Customizing your EHR

Customization of templates is a much-debated topic. We were advised in the early stages of our implementation that we should not make customizations until after our go-live in order to allow the users to become comfortable with the system and then make changes that will provide the most benefit. It didn't take us long to realize the templates were not designed specifically for our practice. We faced the choice of changing our workflow or changing the templates. We preferred to commit the time to modifying our templates so that our users could continue to use a workflow that was comfortable for them.

Customization is not for everyone, nor is it an option for all EHR systems. It is time-consuming to modify templates initially and will continue to be when we are planning an upgrade. It can also be a frustrating exercise when you are not able to please all providers with changes you make. In our practice, we have implemented a template approval committee. Any proposed template changes must be approved by the committee prior to implementation.

Four more tips for success

Throughout all the challenges, we found some things that were very helpful to us. These are the tips that we have either discovered the hard way or were fortunate enough that someone shared them with us:

■ The best tip that I can give is to network. You will find invaluable resources through other practices that have already implemented EHR. Attending national meetings is a wonderful way to connect with others that are sharing your experience or can give you helpful tips to make your go-live smoother.

One of the greatest resources I have found is a listserv of other users of our software. When I have a question, I often turn to this group instead of the software support staff. They are knowledgeable and always willing to help.

■ When you are negotiating your contract, stipulate that you would like a proven project manager and trainer. Through our networking resources, we asked for feedback and found a project manager and trainer that had prior ophthalmology experience and came highly recommended. We requested these both by name and made that a condition of the contract. We were happy with both choices and felt it was a contributing factor to our success.

■ We took a staged approach to our implementation. Approximately three years ago we implemented e-prescribing, knowing that EHR would be an eventuality. This was a way to familiarize our providers with the software system and allow them the opportunity to become comfortable with using a computer. We then implemented a patient portal approximately six months prior to our go-live. In using this staged approach, we were able to expose the staff and providers to aspects of EHR so they were familiar with the product before they were using it to document visits.

■ We also required staff to attend one of two mock go-live Saturdays scheduled prior to go-live. Staff was divided into two groups. The first group would be patients with fake identities. They were given a cheat-sheet of medications, allergies and problems. The second group was doing the workup on the fake patients. We involved the front desk staff and had the first group check in just as if they were patients. Someone from the second group would then take them back to the lane and do a workup. Our doctors also participated, so they would then see the “patients.” The staff would switch roles halfway through the day.

Many of the staff expressed how valuable that was to them. They were able to sit at a computer in the lane and do a workup before seeing an actual patient. It made them more comfortable on the go-live day. The staff was only required to attend one mock go-live, but many staff chose to attend both.

These are just a few of the things that were beneficial to us. Due to the dedication of the staff and the advanced preparation, our go-live went very smoothly. Our next challenge: meaningful use. As soon as we think we have that mastered, we will be looking at Stage 2. EHR is a constantly evolving process that will require continuous training, education and modification. OP

Lisa Shaw is the Information Technology Manager at the Laurel Eye Clinic, which serves western and central Pennsylvania. She manages computer security and maintenance as well as the systems that collect and store patient information.