By Eric S. Fishman, MD

Deciding to adopt an electronic medical record (EMR) is one of the most important decisions made by any practice. The transition to an EMR from a paper system can be challenging because it changes the way everyone works. Changes can include documentation, workflows, billing practices, scheduling, patient follow-up methods, and communication/messaging. EMR adoption usually requires reengineering current systems and can dramatically change the way a practice runs. Considering the vast changes that EMR adoption requires, extensive planning must occur for a successful implementation.

Below I describe recommendations and common pitfalls identified by experts in the field. Use this information to help plan your implementation and to avoid common errors that can occur during the transition to an EMR system.

Planning Phase
As the saying goes, "Fail to plan; plan to fail." The planning phase is the most extensive and time-consuming phase of the implementation process. The planning phase provides a great opportunity to map out the entire EMR process, which may include the following: conversion of data from the paper charts and deciding what information to convert; current workflow analysis; designing new workflows for the EMR; deciding on methods of documentation (template creation, voice recognition, voice capture, partial dictation); staff training strategies; software testing; hardware testing (whether to consider using mobile devices and wireless technology); security rights; authorized access; and system piloting.

• Identify goals and base your planning strategies around these goals. First identify broad goals for the EMR and then develop more refined goals. Examples of broad goals may be to identify and follow-up all patients who are not meeting the preventive health maintenance guidelines; analyze patient profiles based on demographics; create a referral tracking system; create tight security controls to reduce the risk of compromising the integrity of the chart.

• Decide what data needs to be retrievable. Identify what data will be useful for reporting purposes such as certain diagnoses and medications prescribed per physician; graph of BMI in a pediatric population after a pediatric exercise program was introduced; incidence of tobacco use within the patient population; diabetic patients who have not received a HbgA1c in a specified period of time; etc.

• Create timelines but be flexible. Timelines are great tools for project planning, but be aware that they must constantly be re-evaluated — especially if you are designing timelines for phased implementation. Entire implementations including training can span a couple of weeks for small practices (1 or 2 physicians) to several months for larger practices.

• Perform a workflow analysis. Analyze existing work processes while looking for opportunities for improved productivity and efficiency. Design new workflows that can be accomplished with the tools available in the EMR and develop a transition plan.

Staff Considerations and Planning
• Appoint a physician champion. A physician champion can be instrumental in the success of the EMR adoption. This person should be motivating, enthusiastic, have a good workingknowedge of the EMR, and be able to articulate the specific benefits that the EMR will provide.

• Appoint an in-house project manager. Most vendors will supply a project manager for large group installations, but in addition, have a key person on staff to oversee the entire project. This person should have extensive knowledge of all areas of the EMR as well as how the EMR will interact with each type of provider and support staff.

• Communicate to the staff the practice's desire to acquire an EMR before the purchase. Better yet, include them in the process of choosing an EMR vendor. The staff will more likely embrace a system that they have had input in choosing and will be more accepting of the adoption.

• Map out current workflows on paper and bring in the end-users who perform the current work flows to help design new workflows for the EMR. No one knows a job better than the person who does it everyday, but often practices do not go to the source for crucial input.

• Learning curves are usually underestimated. Even if productivity is not affected initially during the go-live phase, most providers do report an increase in the length of time necessary for documentation, especially if templates are used and the provider's are not familiar with them. Most providers will spend additional time at the end of the day documenting notes after a go-live. Utilize the vendor's knowledge for benchmark learning curve estimates.

Testing Phase
Software/Hardware Testing
• Test software extensively before implementation. Never assume that the software functions the way you think it should. Set-up a test database for software testing and for staff training. Thoroughly and completely test all areas of the software and have the end-users test applicable specific functions.

• Perform volume testing, if possible. Take a typical day and do a dry run in a test database. This step is often overlooked but can provide important information regarding the time it takes to enter data with typical volume or increased volume.

Hardware Testing
• Prepare the infrastructure. A crucial part of the success of implementation relies on the success of the hardware infrastructure readiness. The hardware testing will be much more extensive if a client/server environment exists or is chosen as opposed to a Web-based or ASP environment where the software and server is hosted by a vendor off-site.

Staff and Testing
• Pilot systems before implementation. Pilot workflows, procedures, modules, templates, and documentation time in a live environment utilizing a small group of staff long before "go-live." This is critical to identifying issues that are unforeseen during the planning phase.

Training Phase
• Not allocating enough time for training is a very common error made by most practices. Keep in mind that not only are staff required to learn the EMR but also new workflows and procedures. Training sessions are best if kept short and scheduled in increments. Small groups are beneficial for more personalized training. Allow staff to practice what they have learned using a hands-on approach before introducing new information. Trust the vendor's experience with training time but be willing to alter the recommendation for your individual practice.

• Training should be performed outside of clinical work sessions. Practice administrators, in their concern to not adversely affect productivity, may attempt to train staff as they try to perform their clinical duties. This leads to poor understanding of the software as well as to frustration. Train users correctly the first time. Several methods can be utilized to effectively train staff such as reducing or blocking schedules, hiring temporary employees, training outside of clinical time, etc. Staff should also be paid if they are being trained outside of their usual work schedule.

• Give staff time and a quiet location to practice. This can lead to a comfort level with the software and lessen the apprehension of "go-live."

• Appoint "super users." The role of a "super user" is to provide immediate, first line response to staff with questions and issues during "go-live." Designate a super user for each type of clinical role (MA, nurse, receptionist, provider). Super users should have extensive knowledge of the software and workflows. Providing immediate support to staff during a go-live situation will help ensure that productivity is not interrupted.

• Evaluate staff's readiness for go-live. Assess staff's knowledge of the software and workflows. Create mock live situations and walk-through the workflows considering all possible scenarios. Be prepared to delay go-live if staff is not sufficiently prepared.

Go-Live Phase
• Schedule the go-live soon after the end of the training sessions. Try to avoid a long delay — no more than a week — between the training sessions and the go-live. This will ensure better retention of the information.

• Reduce provider schedules. Reduce the number of patients a provider is required to see during the go-live phase. Learning an EMR can be a difficult process, especially for providers. By reducing schedules for some period of time, pressure reduces significantly. Many practices reduce schedules by 50% for 1 or 2 weeks after the go-live and then 25% for several additional weeks. Or add 15 minutes to comprehensive examinations and 5 minutes to follow-up visits. This method may involve some planning ahead to accommodate the scheduling templates.

• Provide adequate resources. Be certain to supply the staff with well-trained individuals such as vendor trainers, super users, and in-house project managers during the go-live phase. Create a help desk hotline in case trained personnel are not immediately available. Communicate the chain of support method to all users before go-live. Put a label on each computer with the help desk hotline phone number. Have systems in place in case bugs or issues are discovered.

Summary
In summary, spend enough time in the planning stages to determine exactly what goals you have for your new technology purchase. Armed with this information, a proper decision can be made regarding the specific program to acquire.

Similarly, planning the implementation schedule, including allowing for adequate workflow analysis, training time, and days of diminished productivity immediately after implementation should allow for a smooth transition to a well functioning paperless office.