Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I met someone at a conference who commented that they liked this series of posts. I hope you’re all enjoying the series as well.

30. Remember that the EMR is only part of the safety problem
Remember that the EMR is just a tool. How you use that tool still matters. How you manage that tool matters. How you implement that tool matters. Safety is a result of great processes and that doesn’t change when you implement an EMR. In fact, I’d say it’s even more important. The same applies to bad clinical workflows. EMR won’t solve those bad workflows either. You can try to do a redesign of the workflows with the EMR implementation, but that often doesn’t go over well.

29. Errors should be easily reportable
To be honest, I’m not sure exactly which errors Shawn is talking about. I think I’ll take a different spin on it than what he intended and talk about the errors or issues that someone has using an EMR. This is particularly important when you first implement an EMR. You should want to know the errors that are occurring regularly so you can fix them. Make it easy for them to report them and provide proper encouragement and/or rewards for reporting errors they have with the system. Ignorance is not bliss…it always catches up to you eventually.

28. Use data to show both individual and system safety metrics
The key component that Shawn is describing here is the ability to report on various cross sections of data (individual vs system). If you can’t chop up your data to really know what’s going on in your system, then you’re not going to be able to really pinpoint the issues that users are having. Maybe it’s only one person who’s bringing down the average for the entire hospital. You don’t want to make sweeping changes to the system that annoy the majority of users when all you really needed to do was address the issues of an individual or small group of individuals.

27. Record management in the EMR is just as important as in paper
You thought HIM was done when you got the EMR. Wrong! Their role is still very important. Granted, it changes pretty dramatically, but in the clinics I’ve worked in the records management people were able to do a much more effective job improving the patient record in the EMR. Many of the things they did they never had time to do cause they were too busy pulling and filing paper charts.

26. Evaluate decision support tools for a fit to your needs
I believe that the clinical decision support tools are going to be the thing that changes the most over the next 5-10 years. You should definitely see how the clinical decision support tools they have available fit into your environment, but also spend as much time seeing what they’ve implemented and what their road map and method of implementing new clinical decision support tools is so you know where they’re going to be with their tools and product in five years.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

On my far-too-frequent visits to my younger daughter’s pediatrician, I’ve noticed pristine new monitors and keyboards wrapped up and sitting in the corner of the exam rooms. Over the last six months, there they’ve sat, waiting patiently to be unwrapped and plugged in. “What’s the hold up,” I think? As a parent, I’m hoping this new system will offer the doctors e-prescribing capabilities. As a healthcare IT observer, I’m wondering why what I presume to be an electronic health record (EHR) is taking so long to come out of the box and into operation. Is it a question of resources? Is the facility waiting for a training team to be made available? Is there back-end infrastructure that has yet to be put in place? These are the things I think about while dealing with low-grade fevers and scheduled immunizations.

Needless to say, my interest is always piqued when I come across stories of pediatricians adopting EHRs and/or realizing the benefits of that technology. So when I came across news that Sandhills Pediatrics had received $184,000 in EHR incentives, I was intrigued. The Columbia, S.C.-based practice has been using an EHR from SRS since 2010.

“Even our initially most skeptical physicians became committed SRS EHR users in a very short period of time,” said Kevin O. Wessinger, M.D., president of Sandhills Pediatrics, in the release announcing the pay out. “All fourteen physicians and their staff value the efficiencies that SRS has delivered and the patient care and practice improvements that SRS has facilitated.”

I recently spoke with SRS CEO Evan Steele to learn more about how Sandhills implemented the EMR back in 2010, and the benefits they’ve realized from it.

This being the practice’s first EHR, what prompted them to make the move from paper to digital?
ES: “The driving force was the quality of care Sandhills was providing. With 4 locations and Saturday and Sunday office hours only at the central location, patient chart review was a big challenge. The patient charts that were housed at the satellite offices, because that’s where the patients were normally seen, and so were not available to review for weekend care. Additionally, the practice provides nurse triage in the evenings until 10:00pm and again, the satellite patients’ charts were not available.”

Did you, as the vendor, encounter any barriers to adoption from the Sandhills staff?
“No, we did not encounter any barriers to adoption. Our implementation plan is highly developed and assures 100% adoption. In addition, the Sandhills team’s dedication to success allowed them to achieve their EHR goals. Furthermore, the decision to implement the SRS EHR was driven from the top down. Sometimes the age of the physicians may impact adoptability. At Sandhills, 12 of the 14 physicians are under the age of 50 so they are more computer-savvy and willing to make the change.”

What sort of “extras” do the pediatric practices look for when selecting an EMR?
“Unique to pediatrics are immunizations. The SRS development staff worked closely with Sandhills on immunizations and pediatric growth charts. SRS secured the integration between Sandhills and the World Health Organization, developed a table for displaying and storing vaccine information, and enabled Sandhills to provide this information to their patients in a usable format.

“With a patient population of 57,000, Sandhills had to provide every kindergarten, grade school, and day care with proof of immunization. In the past, the practice had to hand-write 20,000 immunization certificates each year. SRS was readily available to provide a solution to this issue and saved the Sandhills staff many hours of aggravation. SRS created a form that auto-populates the immunization information so now the Sandhills staff no longer needs to hand-write each certificate.

The same process and benefits were developed for growth charts. The SRS EHR provides the patient’s age, and the Sandhills staff only has to enter height and weight, and this information auto-populates on the growth charts.

SRS created efficiencies, which coupled with our uniqueness in allowing physicians to continue to document notes as they are accustomed, has led to a successful implementation and positive EHR experience.”

How have clinical outcomes and patient satisfaction been improved since the EMR was installed?
“Clinical outcomes have improved as the physicians have access to pertinent clinical data at any time from any place. Additionally, the staff is quicker to respond to patient inquiries. They’ve experienced tremendous improvements in efficiencies and patient outcomes as a direct result of using SRS Order Management. Sandhills used to have manual paper tracking of lab tests and now with the SRS EHR, an expected date pops up in the system and if a test is not back by then, an alert is shown calling attention to the fact that it needs to be addressed.

“The patients, especially those seen on the weekends and evenings, have commented that they appreciate the improved and quick service. When they call in to the office with questions and concerns, they are comforted and given peace of mind knowing that the Sandhills’ staff is completely familiar and up-to-date with their situation.”

What do you think will be the next evolution of EHRs for pediatrics?
SRS Development recently unveiled vaccine inventory control. This process is entirely manual now, but the new enhancements will automatically track down the vaccine to the lot number. It’s also a double-check for safety that the lot numbers they have match what’s in computer. This is a double benefit – quality control and inventory control. This new development will especially find favor with the nurses, who are so happy that a daily occurrence that used to take 2 hours will now take 2 minutes.”

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

35. CPOE is important, but every EMR will have it.
I think that the CPOE discussion hit a head for me when I saw the CPOE requirements that were baked into meaningful use. Then, I heard someone from the often lauded (appropriately so) IHC in Utah who said that IHC didn’t have CPOE and it would be hard for them to meet that benchmark. Ok, so I’m more of an ambulatory guy than I am hospital, but this surprised me. In the clinics I’ve helped with EHR, CPOE is one of the first things we implemented. No doubt that every EMR has CPOE capabilities.

34. Make sure adverse drug events reporting is comprehensive
Yes, not all drug to drug, drug to allergy, etc databases are created equal. Not to mention some EHR vendors haven’t actually implemented these features (although, MU is changing that). I’d really love for a doctor and an EMR company to go through and rate the various drug database companies. How comprehensive are they? How good can you integrate them into your EHR? etc etc etc.

33. Make certain drug interactions are easy to manage for the physician
I won’t go into all the details of alert fatigue in detail. Let’s just summarize it this way: You must find the balance between when to alert, what to alert, how to alert and how to ignore the alert. Plus, all of the opposites of when not to alert, what not to alert, and how to not ignore the alert.

32. Ensure integration to other products is possible
Is it possible that you could buy an EMR with no integration? Possibly, but I have yet to see it. At a bare minimum clinics are going to want to have integration with lab software and ePrescribing (pharmacies). That doesn’t include many of the other common interfaces such as integration with practice management systems, hospitals, radiology, etc. How well your EMR handles these integration situations can really impact the enjoyment of your EHR.

31. Ensure information sharing is easy
This tip could definitely be argued, but I believe we’re headed down the road of information sharing. It’s going to still take a while to get to the nirvana of information sharing, but we’ve started down the road and there’s no turning back. Kind of reminds me of Splash Mountain at Disneyland where the rabbit has a sign that says there’s no turning back now. My son didn’t like that sign so much and I’m sure many people won’t like that there’s no turning back on data sharing either. However, it’s going to happen.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Anne Zieger over on EHR Outlook just posted an article talking about the need of training on an EHR. In the article, she quotes Dr. Bertman, CEO of EMR company Amazing Charts (Full Disclosure: They’re a sponsor of this site). Here’s one excerpt from the article:

According to Dr Jonathan Bertman, if you need extensive training to use an EHR, you shouldn’t buy it. “Doctors know how to be doctors,” he says. “They shouldn’t have to be trained to be software technicians – if they need training than it’s not a good thing.”

Here was my response in the comments of the article (and a little additional commentary for this post):
I have a feeling Dr. Bertman and I agree about training, but I think it’s over the top for him to say, “if they need training than it’s not a good thing.” Certainly many EHR software vendors require far too much training. I think that’s the point he’s trying to make and I agree 100%. However, the reality is that there are a whole lot of people that get training even on Office. In fact, there’s a whole entire industry around training on Office products. So, EHR is going to have training as well.

Another excerpt from the article:

“Compare them to Microsoft Office,” Dr. Bertman suggests. “It’s a powerful tool, but you usually don’t need special training to use it. An EHR is not more complicated than Office, and that’s how we should be looking at them.”

I’d generally disagree that an EHR is not more complicated than Office. The reality is that what you want to do in an EHR is more complicated than Office. Sure, if all I want to do is type a little bit and maybe click bold, then I’m fine. Most EHR you don’t need any training to login, browse their appointment grid, browse patients, and even create notes.

The reason for the EHR training that’s out there isn’t for these simple features. It’s for the more advanced features like is done in most Office trainings. I could be wrong, but I believe Dr. Bertman generally agrees with me on this, but it wasn’t expressed in a short quote from him.

One other interesting point is that I think a lot of people call it EHR training when in fact it’s about EHR workflow planning and training. You’re a brave person to implement an EHR without planning out your current workflows and how they’ll map to an EHR workflow. I often see this workflow planning and training covered under the broad definition of EHR training.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

40. Do NOT let the finance department drive the EMR choice or deployment
I’m far too much of a physician advocate to even imagine a finance department driving the EMR choice and deployment plan. Ok, I understand that it happens, but it’s a travesty when it does. Considering the finance department will almost never use the system, it should make sense to everyone to have the users of the system help drive the EMR choice and deployment. After all, they will have to use the system once deployed.

Let’s not confuse what I’m saying. I’m not saying that finance shouldn’t be involved in the EMR choice. I’m not saying that finance can’t provide some great insights and an outside perspective. I also am not saying that users of the EMR should hold the hospital hostage with crazy demands that could never be met. It’s definitely a balance, but focus on the users of the EMR will lead to happy results.

39. Ensure work flow can be hard coded when necessary, and not hard coded when necessary
Related to this EHR tip is understanding when the EHR company has chosen to hard code certain fields or work flows. You’ll be surprised how many EHR have hard coded work flows with no way to change them. In some cases, that’s fine and even beneficial. However, in many other cases, it could really cause you pain in dealing with their hard coded work flows.

Realize which parts of the EHR can be changed/modified and which ones you’re stuck with (at least until the next release..or the next release….or the next release…).

38. You can move to population based medicine
You’re brave to do population based medicine on paper. Computers are great at crunching and displaying the data for this.

37. Safety is created by design
Just because you use an EHR doesn’t mean you don’t need great procedures that ensure safety. Sure, EHRs have some things built in to help with safety, but more often than not it’s a mixture of EHR functionality and design that results in safety. Don’t throw out all your principles of safety when you implement your EHR.

36. Medication Reconciliation should be a simple process
I’m not sure we’ve hit the holy grail of medication reconciliation in an EHR yet, but we’re getting closer. It’s worth the time to make this happen and will likely be required in the future.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

45. Think about ICD-10 compliance sooner than later
ICD-10 goes into effect October 1, 2013. (barring them postponing it again). Can you imagine if you’ve implemented an EHR and then find out that the EHR isn’t ready to support ICD-10? Sure, we’re still a little ways out, but ICD-10 has been on the docket for a long time coming.

44. Make sure your revenue cycle process is as clean as possible
Cleaner processes are easier to implement. Your revenue is going to take a hit when you first implement an EHR in your office just based on the learning curve of EHR. You don’t want to add to the changes by having to change any issues with revenue cycle at the same time.

43. Don’t underestimate the time necessary to be compliant with 5010
This won’t be as bad as ICD-10 for most practices, but you want to be ready for it.

42. Keep transcription in mind
Make sure you have a good understanding of the costs associated with cutting out transcription. Notice that I said costs and not savings. I already know that you’re aware of the savings of cutting transcription. What you might not have taken into account is the costs of ending transcription. If you’re doing voice recognition then you’re going to need the software, a great microphone, and possibly faster/newer computers. If you’re doing voice recognition there will be more manual corrections that you’ll have to do than in transcription. If you’re cutting out all voice input of data, then just be aware that you may hate “all the clicks” and want to go back to transcription in some form. Is your EMR conducive with that change if you decide to go back to transcription?

41. Watch your insurance claim denials
Of course, most clinics are doing this already. However, a whole new set of claim denials will happen because of how your EMR files those claims. You don’t want to miss out on the insurance money because you can’t handle the claim denials in a timely manner.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Everyone probably realizes by now that I love to read first hand experiences with EMR and EHR. I guess I’ve always loved stories and I’ve always loved to tell stories, so maybe that’s where that comes from. I guess this is why I loved Katherine Rourke’s post called “Would An EMR Have Improved My Son’s ED Care?” on the Hospital EMR and EHR website. It’s a great read if you love first hand experiences with EMR as I do.

Katherine does raise a challenging question, “Does an EMR improve patient care?”

In past presentations, I’ve always put the idea of an EMR improving patient care under the “possible EHR benefits.” (See a full list of EMR and EHR Benefits) As many things in life there’s a big “Depends!” that is the b est answer to that question. The answer to this question depends on what kind of care you were offering previously, the type of care you offer, the EMR you chose, the features you chose to employ in that EMR, the match between your workflow and the EMR workflow, and I’m sure another dozen other depends as well.

What’s more important to point out is that an EMR can improve patient care. I certainly can’t guarantee that an EMR will improve patient care in your clinic, but I’ve seen many cases where it has improved patient care and so I know it’s possible. The biggest determining factor in whether an EMR will improve patient care in your clinic is your desire to have it do so.

Many times in life, you get what you want. Do you want an EMR to improve your patient care? Or were you too focused on wanting to get the EHR Incentive money? Not that these and other benefits are mutually exclusive, but the focus of your EHR implementation matters a lot. Make sure you’re focused on the right things and your EMR selection and implementation will go 100 times better. In fact, it will even improve patient care if you want it to.

In celebration of National Health Information Technology Week –  proclaimed by President Obama earlier this week in an effort to “urge all Americans to learn more about the benefits of Health IT by visiting HealthIT.gov, take action to increase adoption and meaningful use of Health IT, and utilize the information Health IT provides to improve the quality, safety, and cost effectiveness of health care in the United States – I’m hitting the road and heading to North Carolina.

Actually, it’s pure coincidence that my annual Fall road trip to Charlotte and Chapel Hill coincides with this newly official week of celebratory activities. (You can view a list of events here.) But it did prompt me to ponder the state of North Carolina’s EMR and overall healthcare IT utilization. My first stop was the HIMSS State HIT Dashboard, a handy resource that provides an overview of all 50 states’ utilization of healthcare IT.

According to HIMSS, as of September, 2011, North Carolina has six Health Information Exchanges (HIEs):

•  NC Healthcare Information and Communications Alliance Inc. (NCHICA)
•  Carolina HIE
•  Coastal Connect
•  Western NC Health Network (WNCHN Data Link)
•  Southern Piedmont Partnership for Public Health (SoPHIE)
•  Sandhills Community Care Network

The state’s regional extension center, which assists the state’s physicians with selecting and implementing EMRs, has at this point recruited 50% of the providers in its target group of 3,500 priority primary care providers, according to the NCHICA website. The NCHICA seems to be the main governing/advisory body over the state’s HIT activities. Its 239 member organizations will converge in just over a week at the Grove Park Inn in Asheville for its annual conference and exhibit. The lineup of sessions looks pretty interesting, especially “So You’ve Decided to Implement an EHR, Now What?” I’m sure conference attendees will have a great time at the Brews Cruise as well.

My next stop was Google, where a quick search yielded the fact that North Carolina, and the Duke Center for Health Informatics in particular, is home to MindLinc, an EMR for behavioral health. It is now the world’s largest codified behavioral health database, and provides information for research and benchmarking purposes.

My last stop was YouTube, where I found an interesting video created by Janet Apter, an RN and member of the faculty at the Duke School of Nursing, for Duke’s Doctor of Nursing Practice Program. Entitled “Electronic Health Record – a Promising Solution,” the video shares the perspective of one nurse/patient’s frustration with a lack of interoperability between facilities in the same health system, and makes a simple case for the need for a nationwide EHR system.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

50. Determine how complete the financial reporting is
Don’t assume they have the reports that you want because they have other doctors using their EHR. Have your practice manager or business person figure out the types of financial reports your office will need to run and make sure that your EHR vendor does them out of the box. If they have develop new reports for you, it either won’t ever get done or is likely to cost you a bunch of money.

49. Take a close look at financing your EHR vs. paying straight cash for it
I’ll leave most of this conversation to your accountant. Plus, the decision is quite different in a hospital vs ambulatory setting. In the ambulatory setting we’re seeing a big shift to purchases that don’t require a huge up front fee and/or a bunch of financing. I think this is a healthy change for the EMR industry and one that more doctors should embrace. Also, get a good lawyer that’s knowledgeable of EMR contracts before you pay too.

48. Plan for a rollout gap
The idea of a rollout gap refers to the loss of productivity which is almost certain to come with the rollout of an EHR. The key is to plan for this loss of productivity. Ask other doctors that have implemented that EMR how long it took them to get back to full productivity However, you can also do things to minimize the loss of productivity by having a well thought out implementation plan and good training.

47. Plan for staffing surges
This suggestion is more apt for a hospital environment. In that case, you’re likely going to need a lot more staff during a go live. in the ambulatory setting, you might have a consultant or two around to help. You’ll also want your IT support somewhere close by, but otherwise you won’t have the same surge of staff as a hospital EMR implementation.

46 Know where your charges flow
Don’t underestimate the change in how charges will be captured and reconciled during an EHR implementation. EHR’s often significantly change your charging process. Much of the workflow planning that I do for an EHR implementation is around entering, collecting and billing the various charges. You’d think it would be easier than it is, but it always seems to be more work than we realize.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

I came across an article the other day about “10 of Today’s Hottest Jobs” and was not surprised to learn that five of the cited 10 had something to do with healthcare or IT. We’ve all been told time and again that healthcare reform and its incentivized plans for IT implementations will lead to a greater demand for healthcare information management and IT positions, including the much-coveted EMR implementation specialist. But as we’ve all realized, just because industry demand for these types of positions has risen, that doesn’t mean they are being filled quickly – or at all. The same article alludes to what is happening in the healthcare IT job space right now: “Believe it or not, even with the unemployment rate stubbornly high and many industries reluctant to staff up, there are employers out there who still can’t find enough qualified applicants.”

And there’s the rub. Many healthcare vendors and consulting firms, particularly those involved in healthcare IT implementations, are looking for “qualified applicants,” and completely overlooking the enormous pool of talent that newly graduated job seekers have to offer. This certainly isn’t a new observation, but as America – whose citizens are experiencing unemployment at record levels – sits down tomorrow night to watch President Obama address the nation’s employment situation in front of Congress, it certainly is a timely one.

Let’s take a look at two videos that highlight the employment disconnect between higher education in healthcare IT, and the types of firms that would seem to be hiring new graduates.

In the first, Kelly Patterson from Hinds Community College in Raymond, Mississippi, chats with a local news station about the Office of the National Coordinator for Health Information Technology’s (ONC) Community College Consortia Program, which trains individuals in healthcare IT workforce roles, including EMR implementation.

In the second, employees at Cerner Corp. chat about how happy they are to work at the company, and list many benefits of being a Cerner employee. Most are young – many could be recent college graduates – and seem enthusiastic about their careers.

So if national training programs abound, and vendors seem eager to hire fresh talent, where is the disconnect? Why do statements like the one below seem like a dime a dozen these days?

“Training and certification do not seem to be enough. As in all new fields, experience comes from experience.” – Nachum Greenspan via LinkedIn

EJ Fechenda at HIMSS JobMine gave her two cents on how to bridge this employment gap in a recent blog: “With federal deadlines looming, healthcare organizations need to get moving and there are a lot of job seekers out there ready for the challenge. Are there organizations or companies willing to extend opportunities to these candidates? Is there a training or job-shadowing program that can be used as a best practice for other organizations to implement? Who are the champions already doing this or willing to lead the charge?”

I’d love to hear from any recent healthcare IT graduates who have been hired recently and have an employer willing to help train and mentor them. It takes champions, of course, but every champion needs someone to fight for.