2 Secrets to Successful EMR Implementation

In my informal survey of Successful EMR Software implementations, I have found 2 very important factors that make EMR Software implementation and Adoption successful. I have used two words:

  • EMR Implementation
  • EMR Adoption

Let me distinguish between the two.

EMR Implementation is just about usage of the system. It implies that you are putting a layer on top of your practice workflow, trying to automate and speed up some of the tasks everyone does. It does not talk about improving practice and workflow efficiency. In other words, you are just doing things better. If your practice workflow is inefficient, with technology, you just make that inefficiency better.

EMR Adoption indicates that your practice uses and depends on the EMR system to help you become better and more efficient. It forces you to examine your processes and weed out inefficiencies.

What are the Two Secrets of Successful EMR Implementation?

  1. Continuous Training
  2. Focus on Adoption versus Implementation - Focus on Processes

Continuous Training

There must be a good plan for training with the right trainers. Sometimes training is done by IT people and that is ok, they know the application, and can show you what buttons to press, but they don't always understand the practice workflow. It is always better to be trained by clinicians that know the system or by consultants that are experts in practice workflow. It is not important to learn every trick in the book, every intricate aspect of the EMR software to prepare for every possible workflow scenario.

Good training enforces, over time, simulations of workflows, 'what-if' situations.

Another important aspect of training is Continuous training and reinforcement training - not to different in philosophies from CME.

Too many practices and provides underestimate the importance of training. In the process, they over estimate their (and their staff's) ability to learn the EMR system, however easy it may seem. Part of it is driven by the motivation to try to reduce costs.

Training is precisely the Wrong place to cut costs. It actually costs you more in the long run to cut training costs. I wrote an article in February 2013 about this.

EMR Software Adoption - Process 're-engineering'

After EMR software implementation, one mistake practices make is to assume that everything will stay the same day-to-day. You are investing in EMR technology to become better and more efficient. You should not just assume that by 'implementing' and 'installing' EMR Software, it is going to solve all your problems.

Again, distinguish between Implementation and Adoption. Strive to examine your workflows and how EMR software can help improve them - re-engineer them.


Once EMR Software is implemented and Adopted, it is a process of continuous improvement. It must be a sustained effort to stay on top with changes - staff turnover, software updates, regulatory updates (MU, ICD-10), etc. It takes continual effort to constantly strive for improvement to get results of increased efficiency.

CareCloud Next Step: Sale? Appoints R. Scott Lentz as Chief Financial Officer

CareCloud announced the appointment of R. Scott Lentz as Chief Financial Officer. What does this mean for CareCloud and for the rest of the EHR industry? Scott has a history of working with Healthcare IT companies - Aprima, PracticeOne - among others. So, what is common among those companies?

Chop! Chop! Chop!

I see him as a Chop Financial Officer. He's been great for the company share holders and investors, but bad news for customers. I'm sure some may not like this bold statement.

  • Look at what happened with Aprima. Product sold to Allscripts. Allscripts botches it up because the entire financial model did not work out, decided to kill the product.
  • PracticeOne - is now AdvancedMD, which was sold to ADP. Clients of PracticeOne complain they lost the support they used to get.

Two things are clear to me.

  1. EHR Industry is financially over rated, over valued. Yet, investors keep ploughing money into companies like CareCloud and Practice Fusion. I've written many times on my blogs, there is just not enough return on investment from organic sales. Everyone is banking on sales of 'big data' or being acquired.
  2. When someone starts pumping too much money into an EHR company, and hires a high powered CFO, I run away from it. What you need as a provider, is a company that believes in providing great product and service rather than doing financial engineering. I don't see high profile announcements - 'we hired a CCO - Chief Client Officer', that will focus on providing the best product and services to our clients.

If I am considering buying an EHR, I'd be skeptical of CareCloud. If I am a client of CareCloud already, I would watch very closely and have a Plan B in place, just in case.

Choosing EHR / EMR Vendor - Importance of Claims Processing Stability

I got an email this morning from someone that complained about an issue that never comes up during the EMR selection process. Here's what he wrote, 'current practice management solution has switched who it uses for claims processing many times because of contract issues. '

When you research your system, you generally don't ask these questions. At the best, you (of your biller) may ask who is the Clearing house, just to make sure it is a good reputable company.

The EMR industry is under so much pressure that all kinds of things are happening. Vendors are cutting costs, cutting services and you will notice 'shortcuts' that can affect you. Here are some situations that can have prompted this -

  • A complete system is quite often built with partnerships. One such partnership is with a Clearinghouse to process your claims. Vendors strike deals and negotiate pricing. In doing so, sometimes promises are made that EMR companies cannot keep in terms of volume sales. When that happens, clearinghouse wants to raise prices, renegotiates contracts that can have direct repercussions on client pricing.
  • A worse case scenario is one where your vendors switch partners. If they bring in a less than desirable partner for claims processing, your cash flow can be severely affected. Just as there are 'Free EMR' companies, there are 'Free Clearinghouses'. Even paid EMR vendors sometimes use Free Clearinghouses because of pricing pressures.

Two quick questions can resolve that.

  1. Who is the clearinghouse partner? Make sure it is someone like Gateway EDI, or similar company that is stable and has been around, and has a good reputation.
  2. How long has the EMR company been in partnership with them? Is this the only clearinghouse they use, or do they partner with others also? If so, who are the others?

In short, unfortunately, this is one more thing you must have on your list to ask your EMR vendor.

An Eye Opener for EHR Incentives Ignorance

Imagine my surprise when yesterday, September 27th, 2013, few years after the EHR Incentive program was launched with tremendous fanfare, two (not one, two) Specialists told me "Oh, but I'm a Specialist", when I asked them why they are not signing up for EHR before October 1? I was talking to two specialists that have done their homework, finalized the vendor and their EHR system. But they said, they will sign soon. Both are starting a new practice October 1.

So, I asked, 'if you have decided and it is just a matter of signing the agreement, why aren't you signing before October 1? Don't you want the benefit of EHR incentive?'

Even after so much education, information published and even vendors trying to 'educate' providers of the incentive benefits, somehow, somewhere, misinformation seems to have crept in.

$1 Billion EHR Crashes

A very expensive EHR installation crashed with major implications as reported by HealthcareIT News. These are huge systems for large Organizations such as Sutter Health of Northern California. But there is a lesson for small practices, even solo docs.

It is, that don't try to do everything in-house, don't try to be technologists, don't buy a 'Client Server' system. Fortunately, there are really good Web based EMR system.

If you are concerned about 'what is my internet connection goes down', I can tell you, there are plenty backup options out there, but if your server goes down, you are sc#$@%^.

Balancing Act with EMR - Attention focused on Screen or Patient?

Who is not struggling with finding a balance between using technology to research and document versus the perception that 'I'm not listening'. The problem that all providers face is not how good you are at handling technology, but how do patients react? Technology is a double-edge sword. You want it (other than CMS mandating it), because it is supposed to make you more efficient, you don't want to take charts home. On the other hand, it can be a distraction if you don't pay attention to patients. Even worse, you are paying attention, but patients feel they are not being heard. Consequently, you don't want these patients to stop coming to you.

Let me first focus on the technology itself. There are multiple ways of using technology to chart in an EMR.

  1. Templates - point and click
  2. Typing
  3. Dictation
  4. Transcription services

Every individual is different. Some are good typists, some are fluent with 'point-n-click', some just love dictation. Majority of you fall somewhere in between. You must find your own sweet spot. Find a method that works well with you.

When I interact with providers, I actually help them find a way that works well for them. For example, here's a scenario:

"Dr. Smith is an OK technology user. She can google, use internet to search, use email quite effectively, and overall use a windows system quite well. On the other hand, her typing skills are not good. She actually hates typing. When she emails, she hunts and pecks the keyboard."

Armed with this information, the first thing I did is have her take a test of a dictation software like Dragon Medical. She did pretty good. Achieved almost 98% accuracy without any training at all.

After discussing a bit more, here is what we concluded. For Dr. Smith, the recommendation was -

Use templates (point and click) to chart important elements of the note while in the exam room with the patient.

  • Diagnosis
  • Orders/Procedures
  • Meds ePrescription

As soon as the patient leaves the exam room, she dictates her finding in detail under HPI and/or Plan.

Regarding other parts of documentation such as review of systems, physical finding, she chose to point and click after the patient left.

So, we found that in her case, this was the most effective method. It took her less than 5 minutes between patients to finish the encounter completely.

Will this work for you also? Maybe, maybe not. We have to figure out a way that works for you. But I know for sure that there are ways that will make YOU more efficient and effective.

Now, the second part. Managing Patient Perception and Expectation.

There are few things you can do to make sure that Patients know you are paying full attention to what they are saying, including their body language.

  1. Let me 'show' you. Immediately involve patients in the use of technology. Sharing a screen with past results, past prescriptions, and then asking them about it, engages them right away. Asking questions - 'Is that clear?', etc. makes them comfortable with the new you - you and technology together.
  2. You know you can multitask, but patients think they deserve and want your full attention. So, after that initial encounter with technology, turn around, face the patient and give them 100% of your attention. Let them know you care with thoughtful words and compassionate attitude.
  3. Now is the time to 'document', and so with patient's consent - 'let me make sure I document that' - turn your attention back to the computer, while talking all the time with the patient. If you are 'clicking' on a template and documenting a diagnosis code, say what you are doing, relating to and repeating what the patient told you. That way, as you are clicking, you are doing what good listeners do - feed it back - 'let me make sure I heard that right'.

Just this 1-2-3 step approach takes the fear of technology from your mind as well as that of your patients. If your software allows, use diagrams to draw and show patients what is going on. In other words, anything that you can do to make the computer part of the conversation rather than an adversary.

By examining your use of technology, we can ensure an even more professional human bond with your patients and increase efficiency for you at the same time.

Can we automate E&M coding in EMR systems?

Another thought provoking article by my friend John - here. E&M Coding guidelines are so old. They're from 1995 and 1997. If we look at what the guidelines say, it starts with the basics - whether the patient encounter was Brief (1-3 elements)or Extended (4 or more elements). This is just for the History of Present illness, where HPI Elements include: location, quality, severity, during, timing, context, modifying factors and associated signs/symptoms.

This is the easy part.

Then you look into 'complexity', data reviewed, and 'risk of complications'.

We are not at a point where 'systems' can evaluate risk and complexity. Also, as doctors frequently tell me, it may not be a complex case or may not be that high of a risk, but if the patient is talkative, and I spend more than 30 minutes with the patient, my level of coding may jump up.

Secondly and more important, these guidelines may be rendered totally obsolete if healthcare reform progresses where reimbursements would be tied to 'continuum of care' rather than pure 'episodic'.

Just additional food for thought.

Continuous EMR Training

This is a must Read Blog - Click here. John is always very inspirational. But this time, he touched on something that just happened yesterday.

A very good client (a Wonderful Physician in Florida) of mine called me couple of days ago. They had been a good EMR user for a couple of years, but thought they can do better. Thought they needed to ‘graduate’. So, we spent half an hour online, and ‘discovered’ he can save at least 45 minutes per day just by tweaking things.

Spot on John – - Continuous Training - Continuous Improvement

I've seen too many EMR users try to cut corners, cut costs by avoiding one of the most important elements of a successful EMR software implementation.

It is my humble appeal to all EMR users - Web based EMR, or Client Server EMR; Please don't compromise not only on ample initial training, but also ongoing training.

All EMR Are The Same

"I've looked at so many systems, they're all the same - just tell me how much is yours..."
I hear this every day. So many of my colleagues at various EMR vendor companies echo this.
So, are they really the same? Yes and No. Let me break it down.
Yes they are the same, if... All you need is a 'vehicle' to go from here to there, then all cars are the same, without taking into consideration quality, manufacturer, long term value, resell value, comfort and so on. When it comes to EMR, they are all the same if -
  • the only reason you are getting an EMR is to get the incentive money from CMS
  • you believe your practice is so efficient, there is no scope or room for improvement
  • you think of EMR as just an 'island of automation' without consideration of other moving parts of your practice
  • you think of your Practice as a center for patient care, which is great; however you don't run it as a true 'business' trying to bring efficiency, increase productivity and therefore profitability.
  • you fail to recognize the benefit of ROI. Unfortunately, most practices run on a weekly/monthly cash basis rather than as an 'enterprise' that looks at return on investment
  • you fail to ask a critical question to your prospective vendor - 'tell me the background of this company/product'.
I will elaborate on the last bullet point - "Tell me the background of this company/product" a little bit later.
No, not all EMR software companies are the same.

  • Who is the founder of the company?
  • Does that person have an IT background.
  • If the founder is a physician what is the role of the physician - just an investor, or, an active designer of the system?
  • Does the company have a physician as a partner or owns 90% or majority off the company?
  • Where is the support based?
  • Who are the people that provide the support? Is it clinical people or information technology people? What are the credentials off the support people?
Now let me talk about why it is important to find out about the background of the company/product.
If you look at the history of EMR software, it is clear that originally medical record software was created just to record clinical charts. Billing software was the first piece of technology for healthcare. They did not talk to each other in the beginning. Then everyone realized that clinical charting software and billing software need to talk to each other to become efficient. However they were on different database platforms. They were then ultimately 'interfaced' - NOT - 'integrated on one platform'. May not matter to you, but there is a huge difference.

If a vendor started off as an EMR company and then added or merged a billing component to it, that shows that the emphasis is more on clinical documentation, and vice versa. It would be ideal to find a vendor who had the vision to create a system with a common database trying to optimize the business off a medical practice to begin with.

What would you call such a system? Practice Management System? I would call it Practice Business System. It sounds like a new term, but if you keep it in your mind it will allow you to focus on what you need and how to approach vendors when considering a 'system' for your Business; not just clinical charting.

Can Electronic Medical Record Systems Transform Health Care?

I just read a paper written by R. Hillestead et.al in 2005  and I was intrigued by the topic and it's relevance today. http://content.healthaffairs.org/content/24/5/1103.long

I'm not focusing on the title, although it has relevance - 'Electronic Medical Record (EMR)' versus 'Electronic Health Record (EHR)'. The context is still very relevant today.

I do believe Healthcare IT can significantly transform the landscape, but we are not there yet. What has started is the 'foundation'. Adoption of EMR is the broad groundwork; primarily because the first goal is to enable change. Change in Providers mindsets about the use of technology.

There is one reason why I believe in 'Web based EMR' or 'Cloud EMR' or 'SaaS EMR'. That reason has to do with the ultimate goal of transforming healthcare costs. Web based EMR makes sharing of data and therefore reducing costs possible.

I leave it to you to decide if we've made progress.

ACO Model, reimbursements and Web based EMR

We've been reading about ACO and there's a debate going on about its pros and cons related to its benefits. There was a great post this morning I want you all to read. http://www.emrandhipaa.com/emr-and-hipaa/2012/02/29/aco-model-risks-and-rewards/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+EmrAndHipaa+%28EMR+and+HIPAA%29

Irrespective of the outcome all providers, physicians, doctors, care takers need to be read.

One way to be ready is to adopt technology that can ensure two things:

  1. Good Patient Care
  2. Reimbursement for that care

For the second part, current systems - EMR (Electronic Medical Record systems) and PM (Practice Management systems) seem to be quite adequate. I'm not so sure about their readiness related to the ACO model of reimbursement, i.e. incorporating risks and benefits related to quality of care provided to a community. As the article says, bad care = less reimbursement, good care = more reimbursement.

How does one measure good care vs. bad care? These models will emerge and change over time.

It is clear that the pace of change is rapid. Technology needs to adapt.

I think only Web based EMR systems will be able to keep pace with the rapid change. The reason is that web based EMR systems can make quick changes, and the benefit of these changes will be available to providers instantly. One more reason for adopting web based EMR systems.