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The Five Phases of EMR Implementations

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03oct, 2014
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The Five Phases of EMR Implementations

Also during this initial phase, the provider should develop a request for proposal (RFP) based on specific criteria and determine the total cost of ownership and the impact on your revenue cycle and collections. Below are 10 elements that should be included in your EMR RFP to make sure you and your team get a good sense of the vendors and what kinds of services they provide:

System Functionality and Scalability- This one might be a no-brainer, but making sure the vendor has the system features and functionality your organization requires isn’t as simple as it sounds. You might not even think about a function you need until you see a demo of the product and realize something might be lacking. Make sure to do a complete workflow analysis before the RFP to identify the functional and technical requirements necessary for your organization. You also need a solution that has scalability and will grow with your organization.

Interoperability- You want to make sure the solution fits the needs of your organization and that it interoperates with current clinical information systems. Ask the vendor to spell out the groundwork that’s going to have to be laid to link all those systems so there won’t be any chaos when the vendor comes onboard.

Customization- If being able to customize your electronic health record is important for clinician workflow, make sure to ask that question in the RFP. Many companies won’t offer much customization, while others are more open to tailoring the product to your organization.

Price- There’s no denying that price is a major deciding factor to any organization. You want to get a complete summary of costs beyond the hardware and software, including support, training, implementation, and consulting. What could be key is to try what NYC Regional Electronic Adoption Center for Health (REACH), New York City’s REC, did with their compatriot New York State REC, the New York eHealth Collaborative (NYeC), and do a joint RFP to get some economies of scale and group purchasing power.

Customer Support- Does the vendor provide 24/7 customer support? Will the vendor do onsite support at your practice or hospital? What kind and how in-depth are training sessions?

Privacy and Security- Privacy and security practices are a huge concern with new stricter regulations resulting from the HITECH Act and recent revisions to HIPAA. Experts on legal issues regarding healthcare IT and data privacy, strongly recommends vetting vendors on their security practices, especially when data storage in a cloud is concerned.

Standards Compliance- This is as basic requirement, but also necessary especially if you’re considering smaller vendors. You want to make sure they adhere to the following EMR standards: ICD9/10, LOINC, CPT, SNOMED, and other nationally available medication terminology.

System Technical Architecture- In AHIMA’s resource library, there is a fantastic RFP template that has a very good technical section. All types of architecture questions need to be asked: like do the communication components include TCP/IP, is CCITT Group III, IV used for compression schemes, does the system support standard HL7 record formatting for all input and output, does the system support SQL for communication?

Meaningful Use- Does the vendor have the functionality or at least a clear plan to help your organization meet meaningful use requirements for Stage 1, as well as Stages 2 and beyond?

Health Information Exchange- You should also consider the way you are currently sharing information outside your organization or how you envision doing it in the future? Are you involved in a statewide HIE or a RHIO? Make sure the system will enable participation in local health information exchange initiatives.

Phase 2: Negotiating & Executing the Agreement
Negotiating a contract with the vendor(s) of choice is nearly the last step and every bit as important as the vendor choice for which an organization has arrived. Following are some final, integral EMR services that should be assessed, if not determined before final vendor choice, but revisited and thoroughly addressed during EMR contract negotiations:

Does the vendor offer system upgrade inclusion such that it doesn't affect initial package cost? Is this included in the maintenance fees (as should be standard practice)? Generally speaking, or otherwise, when do system updates normally occur?

At what pace will the new EMR system be implemented? Can it happen gradually, and can the vendor and users propose a mutual time line (thereby adding flexibility in budgeting and payment processes)?

Is there an extra charge for round-the-clock vendor support, if, in fact, it is provided? Consider vendor service penalties be added into contract due to any non-delivery of services. Note: If a vendor does not provide adequate after-hours support, shop elsewhere.

Is there a system test that can be utilized by all staff before going live? Can the vendor host a dry run in order to show system functions?

Can specific system features and user-friendly improvements requested by users be enabled by the vendor? Note: If not, it is unlikely users' efforts in defining system specifications and/or system improvements can or will be tailored by the vendor to meet organizational needs.

Can vendors provide reporting functions within their products and other data aggregation platforms? What type of performance measure evaluation processes do they offer? What type of data backups does the vendor enlist, or is this up to the organization?

Phase 3: System Installation and Build
Nobody ever said implementing your EMR system would be easy or quick. In fact, most implementations run 3-4 months based on a variety of factors including the size of your practice, the EMR selected, and the number of third party integrations and interfaces that need to be established. However, the following seven tips can help you alleviate some of the implementation headaches often associated with these implementations all while keeping the project on track:

Analyze your current workflow and re-engineer the same in the light of how EMR will be implemented. Work closely with the vendor’s implementation team to define new workflows including prescription refills, lab results, phone triage, etc.

Get adequate training for all the providers and staff. This should be arranged just before go-live date (which itself may be a phased implementation). Work with the select vendor to create a sandbox environment so that everyone can get a hands-on training environment to play about.

Get key data into EMR. This process can be manual or it can be partly automated by creating an extract from your Practice Management System, scanning in required documents and attaching scanned images to encounter records created in the EMR System. You only want to enter data for established or current patients to manage the workload. Remember that this needs to be done ‘before’ go-live.

Buy, install and configure the required hardware. All the providers and staff must have the right level of access to the software and hardware so that they can get their work done.

Make sure that your Practice Management system works. This is a pre-requisite for successful implementation of the EMR System. If you are changing your Practice Management System at the same time as implementing a new EMR System, ensure that the Practice Management System is up and running for a couple of months before phasing in the EMR System.

Implement the EMR gradually. It may help to migrate simple clinical processes to EMR so that providers and staff become comfortable with the workflows and start seeing the benefits rather quickly. This might include lab orders, lab results, prescriptions, etc, which have external interfaces and consume a lot of time besides including plenty of document handling.

Customize templates. Typical EMR Systems come with hundreds of templates. Use the Pareto principle or the 80-20 rule to identify 20% of those templates which will handle 80% of your encounters. Customize these templates as part of getting ready for the implementation. Rest of the templates can be customized as your staff gathers more experience with the new System.

Phase 4: System Training and Going Live
This stage will typically take about a month, but will vary based on your commitment to completing training in a timely manner and the availability of your staff. Noting that training and change management is the most expensive component to your EMR implementation, there are eight mistakes that if made, can derail your implementation while wasting thousands of dollars that you may have to spend again to get back on track. Avoiding the following can be the key to a successful Go-Live:

Big time gap between training and 'go live' - Cases have been reported where the EMR vendor rushed ahead and trained staff on using EMR, even though the provider enrollment with various payers was far from complete. Big mistake! The training vendor went through the motions of training, collected a nice check, and went away. When the enrollment process was finally completed, 8-10 weeks later, and the clinic began using the EMR system - you guessed it, the provider and staff had forgotten how to use the application and were forced to purchase additional training days.

Training everyone on everything - In a larger clinic (including multiple locations), clinic staff often play widely different roles, and therefore need to know very different parts of the EMR application. Training every staff member on every feature of the EMR won't optimize their skills on the parts that are most relevant to them. For example, only a few staff members will have access to the sensitive areas of the EMR (e.g., security administration). Training plan must be based on roles. A better approach is to have the EMR vendor train a set of super-users ("Train the Trainer") who will have the responsibility to train and support the rest of the staff. They are the ‘go to' people when users have issues with using EMR (before someone makes a call to the Customer Support operations of the EMR vendor).

Assuming that training ends after implementation - Training doesn't end when the EMR system is up and running. Staff roles and responsibilities can change over time, and new employees will need training on the EMR software. Training never ends - but it's a lot cheaper to have one or more super-users on the staff who can train than others, than to bring back the training vendor each time.

Having the EMR vendor train staff in basic computer skills - Having the EMR vendor teach basic computer skills is a huge waste of money. If your staff members can't teach each other these simple skills, find an adult-education course, or hire a computer science student who'll do the job for a fraction of what the EMR vendor would charge. Plan to have the hardware installed well in advance, so that staff can be trained on basic skills before the EMR system arrives.

Assuming that training can be imparted remotely and effectively over Webex or other web conference media - Many EMR vendors offer remote training using remote Webex or GoToMeeting sessions over the Internet, without any on-site support during go-live. Remote training costs less but is never as effective as face-to-face training. Choose on-site setting, even if it means spending extra money. Also, insist on having an expert on-site during go-live. Not insisting on formal training material or not using desktop recording software to record the training session - Insist that the vendor provide formal training materials that can be used to train new staff. Ideally, the training materials will be tailored to your practice requirements. If no formal training material is available, have your staff capture snapshots and create a training binder for future reference. Better still, use a desktop recording software to record the video and audio (if possible).

Assuming that the training provided by EMR vendor will encompass all elements that are relevant to your medical practice - Most of the time, the EMR Vendor may adopt a ‘one size fits all' approach as far as EMR training is concerned. It is in your interest to work with the vendor in designing the training sessions customized to your specific requirements. You may find that some portions are not covered at all while some easy functionality hogs valuable training time.

Not validating the credentials of the trainer provided by the EMR vendor in the medical specialty of your Clinic - It is recommended that you confirm the trainer's credentials before he/she comes on-site. It's very important that the trainer understand the unique requirements of your medical specialty, so the trainer can offer relevant tips to help your staff optimize their use of the EMR system.

Phase 5: System Optimization
Planning for what you do after Go-Live is as important as the planning that went into the previous stages of your EMR implementation. Once your users are over the initial shock and settled in the EMR routine, they will be ready to learn the tips and tricks to make them faster and more efficient. Here are five low-cost optimization ideas:

Utilize super users: Super users can help end users become more efficient right away. Often, end users are more willing to take constructive feedback and ask questions when working with a colleague vs. responding to a management mandate. Super users are also on site and can be proactive by tackling minor issues before they become major. They can be eyes and the ears for the analyst team when problems arise and are extremely helpful when troubleshooting issues or explaining new functionality.

Create a monthly newsletter: Monthly newsletters are a helpful tool to communicate any changes within the EMR and to send tips and tricks for increased efficiency. Organize the newsletter by specialty so that users can quickly find information relevant to them. Include links to additional teaching documents.

Review provider encounters. Periodically, review provider encounters to allow coding and compliance departments to determine if documentation and charges are being entered correctly - and whether any charges are missing. This will help you avoid any insurance corrections, reduce billing compliance risk and improve the revenue cycle.

Conduct short, e-learning sessions. These sessions can be from five to 15 minutes long, and are helpful for optimization. Since they are so short, people remember what they learn. They also fit easily into the workday. E-learning sessions can be interactive, which helps the learning process. They can also be posted on your organization’s intranet as a resource if someone needs to “brush up” on EMR efficiency techniques (i.e., smartphrases, favorites pref list, smartlink, etc.)

Develop an optimization request process: Users are the first to recognize the need for a new EMR tool or process that can improve efficiency. Develop an electronic request process/form that can be easily completed and sent to the analyst team. These requests should then be part of a standing meeting of decision makers to review, approve and prioritize the requests. Don’t forget to communicate the execution of these requests so that users know they are being acted upon.

Optimization is just as important as implementations and can be done cost effectively. Good optimization techniques make users more efficient, save time and money, increase compliance, correct coding issues, and give users a feeling of trust and ownership in the use of their EMR.

When it comes to implementing your EMR system, there are no shortcuts and focusing solely on cost reduction can introduce a host of problems that in the end can derail your project and lead to eventual cost overruns. Proper, prior planning and the support of a dedicated Healthcare IT support vendor experienced with EMR implementations can mean the difference between the successful implementation and meaningful use of your EMR and a nightmare of a deployment that can cost you thousands of extra dollars while wreaking havoc on your practice and patients.


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