By John Carruthers, staff writer, March 01, 2011
Preparing for a switch to electronic health records (EHR) can be a potent source of stress for dermatologists. Evaluating vendors, interpreting the implications of the new health care law, and deciphering the meaningful use requirements can trigger a full day’s worth of headaches before the first patient of the day even checks in. Yet a number of health care experts — be they a dermatologist in private practice, a practice manager who oversaw a gradual switch, or the coordinator of a regional health IT extension center — posit that physicians can reduce their stress and more efficiently implement EHR technology by evaluating staff readiness before making such a drastic workflow change. Doing so, and later working closely with staff and involving them in the EHR selection and implementation process, can lead to a better outcome for patients, employees, and the practice overall.
Preparing for implementation
When her Fort Myers, Fla., dermatology practice began the switch to EHR, practice administrator Kimberly Munn, MBA, said that the practice decided to form a physician-led group that included office staff to determine the best way to adapt staff and implement the new electronic system.
“We phased in electronic records five or six years ago. We made sure to have a good core group of people as the implementation team. Our core group who made the decisions included me, a physician, the clinical supervisor, and the billing and collections supervisor. The EHR works in tandem with the practice management system, so you have to be able to look at it from all directions,” Munn said. “We reviewed the system, made sure the vendor structured it to mimic what was being done on paper. And we implemented slowly, chipping away at it a little bit at a time.”
The broad spectrum of practice employees participating in the entire process, Munn said, ensured that employees from all sections of the practice — be they front office, billing, or medical staff — would have an understanding of how to use the new hardware and software. This allowed employees with questions about EHR to approach someone in their department, which was a much more relatable proposition for many of them. [pagebreak]
A large part of the pre-launch preparation, according to Munn, dealt with familiarizing a number of staff with not only the practice management system, but with computers in general. Having a long lead time, she said, proved especially prudent.
“As far as our personnel readiness, we had a year prior to the actual adoption to prepare. Some of our staff still didn’t have e-mail or access to the practice management system, so we got them started on that, reading e-mail, familiarizing them with the practice management system and learning how to maneuver around the screen, schedule a patient, and other basic operations. We made sure that all of the staff who weren’t familiar with computers in their personal lives became comfortable with them in the office,” Munn said.
In addition, Munn’s work group was operating at a time when more EHR vendors offered comprehensive hands-on training. According to Munn, who chairs the professional resource committee of the Association of Dermatology Administrators and Managers (ADA/M), many vendors currently encourage online tutorial offerings over the more expensive in-person option. Preparing staff members who need extra training may require choosing a vendor that makes such an option possible or creative planning on the part of the administrator or managing partner.
“We allowed more one-on-one time with the trainers for those who really needed the extra training, but this was a few years ago. Now a lot of the systems have online training,” Munn said. “But we found it important to have a champion’ physically in the office, a person who is very comfortable with computers and your system, someone to go to when people aren’t comfortable using the system. If your vendor doesn’t offer much hands-on training, then it can be someone who works in your office.” An in-house trainer may need more time due to competing priorities, she noted. [pagebreak]
To cut down on the total time needed for training — which can add considerable expense — physicians and practice managers should formulate a plan for in-house training that prioritizes the members of staff whose training will bring the greatest efficiency to the adoption process. Staff or department “champions,” involved in the process and invested in its success, maybe able to better relate the lessons of hands-on training to their colleagues. Prioritizing staff not only gets the necessary information in the hands of the most affected members of the practice, but supplements the “one size fits all” approach to training that many practices use.
Opportunity to improve
Bill O’Byrne, the executive director for the New Jersey Health Information Technology Extension Center (NJ-HITECH) at the New Jersey Institute of Information Technology, pursues a similar line of inquiry with the physician offices his organization advises. O’Byrne, whose office works closely with physician practices to efficiently integrate the data-capturing element of meaningful use into the standard workflow, said that the most important step in successful EHR implementation is to evaluate and modify the practice’s current workflow to make the best use of the new EHR system and capture the data necessary to achieve meaningful use. This includes a comprehensive evaluation of a practice’s current staff, workflow, and capacity to efficiently adapt to the altered workflow of a practice running EHR.
“Some doctors have strictly paper-based systems, others have already invested in their EHR systems and we do more of an involved assessment, which is more along the lines of a gap assessment. In either case, we come up with a boilerplate of what we believe the doctor needs in his or her office to become a meaningful user,” O’Byrne said. “So after we evaluate what the doctors need, we go back to the office and do a workflow redesign. We come up with our proposals regarding what they need to implement with the new system in their office. That, obviously, is a significant issue. Once we come up with a recommendation, we go back out to their office, present our findings and recommendations, and the doctor makes a choice.” [pagebreak]
In preparing for the EHR switch, Daniel M. Siegel, MD, the American Academy of Dermatology’s president-elect, who moderates the annual EHR vendor demonstration at the Academy’s Annual Meeting, said that it’s important to consider that such a massive change to a practice’s operation style may lead to a modest amount of staff turnover — usually voluntary, but possibly otherwise.
“The question is how willing is the person who looks at the EHR system and has never touched a keyboard? That person may not survive this paradigm shift. On the other hand, if someone is afraid to change systems, it may take some persuasion, some demonstration to convince them that this new system is better,” Dr. Siegel said. “You have to get them engaged in the decision process. You move to a better system with a reason — discussing with the front office people that they might see a scheduling system that makes more sense is helpful.”
Munn has also considered the issue, and found that turnover is more likely to come from voluntary retirement than termination.
“I’ve heard of a few people deciding that it was time to retire rather than spend the time learning and adapting to the new system,” she said.
While Munn’s practice was able to successfully train all existing employees on the basics of computers and the operation of the new system, she said that her work group had planned to address the issue of any employee unwilling or unable to remain productive in the new system. [pagebreak]
“We never really experienced an employee failing to adapt to a new practice system. The expectation from the beginning was that using EHR was going to become part of your job description, an expectation of your performance in the organization,” Munn said. “We allowed for a year’s time to become acclimated, but if any of our employees would have failed to perform after that period, we would have gone down the road of disciplinary action. There was coaching and training, and we felt that we had been fair.”
Offering continuing support to staff following the EHR conversion, Munn said, is as important as involving them in the selection and implementation process. Even the best-laid plans need to be altered following EHR adoption — it’s simply too drastic a change to successfully predict every hurdle.
Much as hands-on staff training can be vital to staff comfort with a new EHR, offering continuing education to members of staff — local computer classes, further EHR training, or even just online tutorials of basic system functionality — will make staff not just comfortable, but confident in their abilities.
Once physicians and staff are acclimated to electronic records, O’Byrne advises taking a fresh look at practice workflow and hardware preferences. Minor changes in the duties of different staff members may allow the practice to operate more efficiently while gathering a greater amount of patient and visit information. In addition, evaluating the placement of workstations and tablet computers can lead to greater efficiency through solicitation of staff input and preferences. Medical assistants may operate better with tablet computers, which can go from one room to the next without requiring multiple log-ins. On a related note, placement of networked printers is vital for practices that print patient lab reports onsite. Those printers must be placed in a convenient location for staff — but must also be far enough removed from other patients to eliminate the possibility of patients seeing one another’s medical records or results.
In addition to considering the impact upon current staff, it’s important to note that immediately following the decision to make the conversion to EHR, hiring practices must be re-evaluated. While many of the desirable traits for a candidate will remain unchanged, it’s important to recognize that you’re recruiting for a much wider skill set. As Dr. Siegel points out, however, practices seeking to recruit younger candidates are likely to find this an advantageous position. [pagebreak]
“I think that recruiting staff might be easier in that you’ve got an entire generation of young staff that might be hired as medical assistants or front desk people. They’ve been more exposed to technology, and may see EHR as a plus, rather than dreading it,” Dr. Siegel said. “I think it’ll actually get easier in recruiting new partners. Most people coming out of residency are being exposed to EHRs. They’re going to half a dozen hospitals in some cases, and are exposed to half a dozen EHRs. They have conceptions of what they like and don’t like in an EHR and bring experience on a number of different systems.”
While considering the impact of the EHR conversion on one’s staff and office is important, it’s also vital to recognize that a new set of communication tools can make for a new set of personnel issues. While Munn’s practice prepared itself for employee inability to utilize the Internet and EHR communication tools, the practice instead found that some employees made themselves a bit too familiar with Internet usage.
“We implemented policies and procedures about appropriate use of the system and the Internet,” Munn said. “While I didn’t have a problem getting them educated and onboard, our problems started when the pendulum swung the other way. Unfortunately we did have some terminations related to non-compliance with the new policies. Once people saw that we meant what we’d said and that our policies were live and effectual, we didn’t have any additional issues.”
Dr. Siegel also recognizes the potential for harm to the practice, and stresses that even seemingly innocuous online activities can have a detrimental effect on network security. [pagebreak]
“The downside to tech-savvy employees is that you have to develop a more secure practice. There are instances where people post a Facebook photo that might have a patient in view. That’s not acceptable from a practice perspective, and you’re going to have more of this to worry about,” Dr. Siegel said. “Think about anyone sitting in front of a workstation right now. Taking notes on something, probably with at least two social networking options open at any time. That’s something that one of your long-tenured employees working part-time likely won’t be interested in doing,” he said.
“It’s really hard to think of a person under the age of 40 who isn’t thinking of social networking as a way to spend some of their time. Every time someone opens up an instant messenger window, you create a conduit to put malware on the system that goes around your security,” Dr. Siegel added. “You can shut out all that Instant messaging and social networking sites along with strict filtration of inappropriate sites and just allow access to specified parts of the Web, since we need that in the practices — checking patient insurance and so forth — and you get more and more clever people who work their way around it.”
EHR incentives available
On July 13, 2010, the Centers for Medicare and Medicaid Services (CMS) released the final rule detailing how eligible physicians and hospitals can qualify for EHR adoption incentives. The incentive program offers significant financial incentives to physicians who satisfy a series of 15 core measures to prove they are meaningful users of an EHR. Incentive payments will be made through 2016, paid out over the course of five years, with penalties of a percentage of all Medicare charges beginning in 2015.
Adoption in 2011 - $44,000
2012 - $44,000
2013 - $39,000
2014 - $24,000
2015 - $0 (1 percent penalty for non-adoption)
2016 - $0 (2 percent penalty)
2017 onward - $0 (3 percent penalty)
Readiness in brief
- Assess the computer-readiness of your staff. Are they proficient in basic functions like e-mail and Internet usage? Do they show familiarity with the basic functions of your practice management system?
- Raise the topic of switching to an EHR system with your staff and solicit feedback. For medium-sized practices or larger, it may help to form a physician-led workgroup of employees from different areas of the practice.
- Plan for hands-on training in basic computer functions (for employees who need it) and using your new EHR system. Many vendors push online training rather than in-person, so either make arrangements with your EHR vendor or plan for an alternate source of training for your staff.
- Evaluate your network security and consider disabling Internet functionality that could potentially bring harm to the system, like social networking and outside instant messenger programs.
- Plan to start slowly once the new system launches to give employees time to acclimate themselves to the new work flow. Munn’s practice (discussed above) started by launching EHR for new patients, then spent two years incorporating 14 years of existing patients and records into the system.
- Change job descriptions to include computer and technological literacy, and institute disciplinary policies for employees who violate the terms of Internet or technology usage.
EHR adoption and meaningful use
Bill O’Byrne runs an independent non-profit that receives government funding to consult physicians on how to meet the requirements for earning federal meaningful use incentives. He oversees 50 full-time employees and 25 independent HIT contractors. He believes that successful meeting of the meaningful use measures can be greatly aided by steps taken during EHR adoption.
Dermatologists should consider the impact of EHR adoption on staff — but Bill O’Byrne’s team knows they are also concerned with the bottom line. “All our work is directed toward satisfying meaningful use,” he said. “Otherwise, the physicians we consult won’t get the incentive funds they’re entitled to. It’s our job to help them get the incentive funds, and the feds have hired us to do that,” O’Byrne said.
“Simply using EHR doesn’t really mean the same as documenting it, from the federal point of view,” he added. “The biggest thread is to focus on what the Office of the National Coordinator for Health Information Technology requires in the three stages of meaningful usage. The first stage is the yardstick for qualifying for the incentive funds. A lot of doctors lose sight of the 15 required items and the five from the menu set. That’s what you’re measuring yourself against.”
Choosing from the menu set is vital. “One of our other biggest common threads is to sit with the doctor, decide what items of the menu set to choose from, and go for it,” O’Byrne said. “Different things are easier or more relevant for different doctors. We make sure that they get those items done first so that they qualify for the incentive funds right away,” he added.
“When you’re playing football, you know down and distance,” O’Byrne said. “It’s important to keep the same measurement and goals in mind when targeting meaningful use. What’s the most efficient and effective way to get where you need to go?”
More information on the meaningful use criteria is available in the Academy’s online HIT Kit at www.aad.org/hitkit.