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Beginning your EHR implementation

Selecting and implementing an electronic health record (EHR) system is one of the most significant changes to a medical practice that a physician can make. Daunting as the task may seem in a marketplace filled with products of varying quality and functionality, careful planning for decisions both immediate and long-term will give one’s practice the best chance at an easy change.

Assessing readiness

Even prior to vendor selection, managing partners of a practice should make a careful audit of the office’s current workflow practices and management function, according to practice management consultant Margret Amatayakul, who has given presentations on EHR adoption at the Academy’s Annual and Summer Meetings.

“The first thing to do is take a look at your practice and make sure that it’s running smoothly, that you’ve got good management, and that your billing is functioning efficiently. One of the things we’re finding is that if the practice leadership is broken, the EHR is much more difficult to implement,” Amatayakul said. “It represents such a big change and is already difficult to cope with before any existing problems are factored in. I’ve heard a lot of physicians say that they wish they’d attended to their practice issues before taking on EHR.”

In addressing management, Amatayakul said it’s important to have managers who are not only able to deal with the day-to-day functions of the practice, but who are also able to command a top-level view of the current business. Ideally, effective managers should be able to have data such as the denial rate at their fingertips, to be better able to streamline the system and address potential problems before they are exacerbated.

Additionally, the workflow process should be as smooth as it can possibly be heading into EHR adoption. The naturally slower pace of a newly adopted EHR system can be brought to a halt if inefficiencies exist in the system.

“In EHR adoption, one of the biggest barriers is an office’s procedures not being streamlined. I’ll go into an office and sometimes I’ll see staff yelling out to someone in another part of the office, or shouting for the patients to come to the desk, or they won’t be able to find a document they were handed five minutes ago. You want to take care of things like that, which are so fundamentally dysfunctional,” Amatayakul said. “Start thinking about standardization; talk to one another. You don’t have to standardize how you practice medicine, but your billing practices, your workflow, your appointment scheduling these should all be streamlined throughout the practice.”

Choosing a system

While certification of EHR through the Certification Commission for Healthcare Information Technology (CCHIT) and the Office of the National Coordinator for Healthcare Information Technology’s Authorized Testing and Certification Bodies (ONC-ATCB) offer a rough guide to product functionality, it’s important for dermatologists to find out which products best serve their specialty.

When judging vendors, according to Fairmont, W. Va. dermatologist Beth Santmyire-Rosenberger, MD, PhD, it’s important to assess the size and stability of the company. Not only will it increase the likelihood that the company has worked with physicians in one’s specialty, it also ensures a meaningful use-qualified product with better long-term functionality. (See also “Lessons learned”.)[pagebreak]

“A great way to get started is to use the EHR certification body websites. That can narrow down the product search quickly,” Dr. Santmyire-Rosenberger said. “Only the top companies and programs get that certification year after year. Less stable companies will forgo it, so you can narrow down to a handful of products pretty quickly. You’re more likely to start out looking at products whose companies have long-term stability and whose product is going to allow you to achieve meaningful use.”

Amatayakul also emphasized that it’s important to keep an open mind regarding product features.

“The sheer number of products, even those that are certified, is mind-boggling. I think one should go into the selection process without preconceived notions. Don’t go in thinking I can only have server-based EHR,’ for example. Keep your mind open, so that you really understand the different options available to you and the pros and cons of each,” she said. “Find out what your colleagues are using, what they like, what they dislike. Go to shows and speak to vendors. Talk to dermatologists in other types of practices, like those who work in multispecialty practices. It gives you an idea of what people in your community are using. Find out as much as you can.”

Practice management consultant Bruce Kleaveland said that after navigating the marketplace it’s important to cut down to a shortlist of vendors. He suggests physicians explore each program’s functionality, the upfront hardware and software costs, and the cost of upgrades down the road. The latter, according to Dr. Santmyire-Rosenberger, can be especially perilous if overlooked.

“I have a colleague with an EHR, and her practice has to pay a large fee every time there is an upgrade. Every time they implemented little fixes here and there, they would get another bill for the software upgrade. That’s something I didn’t realize was an issue when I started looking at systems, but it soon became something I really looked at with vendors,” Dr. Santmyire-Rosenberger said. “You need to look at not just upfront cost, but hardware that you have to replace eventually, and potential upgrade and support costs going forward. I ended up with a system where I pay quarterly for upgrades and maintenance, which for me is a much better system.” (See also “Exploring the costs.”)

Integration is key

Between 70 and 75 percent of EHR users are using what William Underwood, MPH, senior associate for the Center for Practice Improvement and Innovation at the American College of Physicians (ACP) in Washington, D.C., calls “complete solutions,” or a fully integrated practice management (PM) system and EHR system. Underwood manages the health IT education efforts of the ACP and leads the research efforts of AmericanEHR Partners, which provides physicians, vendors and funding organizations with the necessary tools to identify, implement, and use EHRs and other health care technologies.

Some EHR systems can be added on to existing PM systems, which can remove the steep learning curve that completely new systems require. Adding an EHR program to existing PM software can also curb the time it takes support staff to learn new software. The software they use within the system would not change much, if at all.[pagebreak]

In order to avoid the hassle of incompatible electronic systems, dermatologists should confirm that the new EHR interface is compatible with other systems so they can be integrated without large expense. Experts agree that successful integration can both reduce practice costs and improve revenue. Another important facet of integration is the consideration of attesting for meaningful use, which must be done in order to receive the federal stimulus money. If this is a factor, make sure to verify whether the level of PM interface is sufficient for meaningful use reporting.

Spearhead your adoption, maximize efficiency

After signing a contract, a practice will need to immediately begin planning for workflow integration. According to Kleaveland, the vendor should act as a partner during the workflow integration stage, and the practice’s physicians should take a leadership role in spearheading adoption.

“You’re going to work very closely with your selected vendor to develop and implement a plan that will take several weeks before you go live. Physicians should be very involved in understanding how the tool is going to be employed, and be active and participating in training sessions provided by the EHR vendor,” he said. “They’ve got to be engaged in the whole implementation process, so when it’s time to go live, they’re familiar, prepared, and ready to go through the learning curve.”

In addition to learning the software inside and out, Dr. Santmyire-Rosenberger said that it’s also important to keep an eye out for ways to further improve the workflow and interact with the software. Much of this will depend on a practice’s unique idiosyncrasies.

“The joy of starting a new project is that you have the ups and downs of figuring out how best to do it. I looked at everything I could and asked, how can I make this work for me?’ And I feel like there isn’t necessarily a systematic or magic answer to that part,” Dr. Santmyire-Rosenberger said. “It just evolves and develops over time. There are lots of little things we change all the time. Sometimes it works, and sometimes we have to tweak further.”

Additionally, Amatayakul said, practitioners should resist the urge to make any changes that bring more of a burden to the workflow process in the name of technological convenience.

“I was recently in an office where they had decided to allow patients to email the physicians instead of dealing with phone calls,” she said. “Well, the email was a nightmare. It was not a good solution. You don’t want to be adding a burden to something new.”

Practices well into the process should measure their success not just on their speed of use, but with the level of integration. “The measure of success for any EHR project is that clinicians are using it as their primary form of clinical documentation,” Kleaveland said. “The first year is about making sure everyone is using the system on a regular basis and that you’re in the process of weaning yourself off of the paper record.” Kleaveland added, “The primary efficiencies derive from the fact that you have one electronic record available at all workstations. Once you’re there, you can use that to try some creative applications to improve practice function or efficiency. At the end, if you’re supporting the EHR and entering the data properly, you can use it to help improve patient care.”


The American Academy of Dermatology has a number of resources for physicians looking to incorporate electronic health record systems into their practices.


The Academy’s online resource at www.aad.org/hitkit features:

  • The dEHRm Manual (revised for 2011): an in-depth look at EHR implementation for dermatology practices
  • EHR FAQs: Answers to common questions regarding implementation, EHR use, and vendor contracting.
  • Information on government incentive programs: including details on meaningful use criteria and timelines for incentives for adoption

AmericanEHR Partners

Through the Academy’s partnership with this group, AAD members can get valuable implementation information at www.americanehr.com/

Member EHR user groups

Launching in 2012, these electronic communities will allow dermatologists to share experiences and learn about best practices.

AAD Annual Meeting education opportunities

Several sessions at the 70th Annual Meeting in San Diego in 2012 address a variety of EHR topics.

  • Friday, March 16: (U026) New Health Care Policies: Incentives and Penalties (including discusson of the Electronic Health Record (EHR) Incentive Program)
  • Saturday, March 17: (S016) Electronic Health Record (EHR) Physician Demonstration
  • Saturday, March 17: (F022) EHR Implementation, Maintenance, and Lessons Learned