'Go Live' Without Going Nuts

January 1, 2006

So you've finally decided to get that EMR. It's a big investment, and you're convinced it will help you be a better doctor - that in the end it will pay for itself. Great. But how do you get past all the implementation hurdles after you've made your choice? Expert advice on making it happen.

So after months of searching, you've purchased and installed your new EMR. Congratulations: if all goes as it should, your practice will soon be saving time and money while improving the level of care you provide patients. Your staff, physicians, and patients will be happier once you're up to speed, and you're now in a much better position to demonstrate your clinical excellence and patient satisfaction in negotiating payer contracts and navigating the world of "pay for performance."

But selecting and installing an EMR is just the first step in a major process that will transform the workflow within your office. You can't just flip a switch and expect the transition to take care of itself. Taking the time to visualize all the essential implementation steps will lead to a smooth, successful conversion.

The first essential step is gaining physician support. If some, or even one, of your physicians remains firmly resistant to change, it could seriously damage your ability to move the rest of the practice onto the system efficiently.

"Present this to your doctors as a quality project," says Joel Diamond, a family practice physician in Pittsburgh. "Don't focus on the technology; focus on the ways [an] EMR helps us practice better medicine. For example, it helps us identify people who need smoking cessation counseling or pneumonia vaccinations, and this information will become increasingly significant in a pay-for-performance world."

Next, consider the varying personality traits and technical abilities of the physicians in your group. Some physicians can't type; for them, alternative ways to enter information into the computer, such as voice recognition software, will be extremely important.

Some physicians prefer standardized templates for common health conditions, so they can enter data for a typical patient with just a few clicks. Others prefer to work with a trained assistant who sits at the computer and enters data during the patient encounter. "The larger your group, the more diversity there is among your physicians, and that increases your need for flexible, customizable software," says Rodney P. Lusk, MD, director of the Ear, Nose & Throat Institute at Boys Town National Research Hospital, in Omaha, Neb.

Be reasonable

Have realistic expectations for the implementation process. It's not as straightforward as buying Microsoft Word and installing it on your computer, says Ronald B. Kuppersmith, an otolaryngologist in private practice at Texas ENT and Allergy, in College Station. A couple of years ago Kuppersmith's practice was working with separate vendors for a practice management system and an EMR. "They gave us conflicting advice about the hardware we needed. In the end, it came down to a judgment call," he says. "Someone from the practice has to be thoroughly involved in the process. All our vendors were really helpful, but you can't let them take over."
Once you've chosen your vendor, software, and hardware, budget time and energy for an intensive period of preparation. eClinical Works, of Westborough, Mass., a well-known supplier of EMR and practice management software, sends its clients a 12-week timeline listing all the essential steps between signing the formal contract and the "go-live" date.

During this preparatory phase, all physicians and employees should have a chance to become familiar with the software. Many vendors supply audiovisual training materials, so employees and physicians can start learning various features of the software even before it's been installed.

In addition, expect to work with the software vendor to customize the system and develop templates that match the forms you currently use. Build upon your current style of practice, instead of forcing doctors and other clinicians to adapt to the new software.

Some practices have sought to mollify technology holdouts by maintaining a separate paper-records system, just for them, even after installing an EMR for everyone else's use. That, says Lusk, is a recipe for disaster. "You double your costs, and you're never sure which system has the most accurate information."

Get your team in place

To successfully implement an EMR, you need several key people in place.

For starters, you should have a physician champion who can sell the other physicians on the value of having an EMR in the first place. Your champion should be a physician, because no one else in the practice has as much credibility with the other doctors, or is able to speak to them on their level.

"That means someone who does this as a labor of love, who lives it and breathes it, who can demonstrate the benefits to his peers," Diamond says. The ideal person may not be the most computer-savvy person in the office. Instead, seek out a physician with a strong commitment to quality of care.

You also need a project manager, who probably shouldn't be a physician, says Rosemarie Nelson, a principal with the Medical Group Management Association Health Care Consulting Group. "They could be a nurse or any midlevel provider. The reason I recommend against a physician in this role is that doctors need to continue seeing patients, so they usually don't have enough time to monitor all the details of the project."

The project manager will be responsible for ensuring that hardware has been ordered and is being installed on schedule. She coordinates the training process. When there are separate vendors for practice management software and the EMR, the project manager monitors both vendors to ensure that the two systems will interact properly. As the rollout date approaches, the project manager helps develop templates to meet the practice's specific needs.

During the start and end of the implementation process, the project manager may spend only a quarter to a third of her time on the EMR. But just before and after rollout, expect it to be a full-time job. Nelson estimates that six months after the go-live date the project manager will be down to half time. However, she'll always need to spend some time maintaining the system as a whole, installing new software releases, and monitoring new functions that can improve the way the practice operates.

Finally, you need at least one person, and often more than one, to train as a "super user." These people will become thoroughly familiar with the software; they can help train and support staffers in a real-life environment after the formal training period ends. In a small practice, the project manager may fill this role, but in a larger practice, with two or more work sites, you need at least two people who can help other staffers learn and remember key software details.

When you go live

By the go-live date, all systems should be installed and operating correctly. This is the moment when practice sessions end and real use begins. Your software vendor will supply onsite training for all your staff during this period, usually for one to two weeks, depending on the size of the practice.

When you go live, it's a good idea to schedule fewer patients than usual. Ideally, allow double the usual appointment time.

Many practices follow a gradual implementation strategy. For example, a practice with several locations may implement an EMR at one site, then another. Or a practice may implement one module of the system at a time.

Diamond, whose practice followed this latter strategy, estimates it took about two months until everything was up and working correctly. At that point, some aspects still felt a bit strange and unfamiliar, like a pair of new shoes, he says. But by the end of six months, everyone was comfortable with the new system.

How much should you budget for the implementation process? Nelson advises practices to plan on $20,000 to $35,000 for EMR acquisition costs for each full-time physician (or full-time equivalent). That includes hardware, software, initial training for the physician champion and super-users, and onsite support for the whole practice during the "go-live" period. Vendors generally charge $100 to $180 per hour for on-site consulting, she says, and you may be able to negotiate a daily or weekly rate. Her estimate for acquisition costs includes about $7,500 per physician for the software license fee; after the first year, you can expect to pay 18 percent to 22 percent of that fee annually for software updates and continuing phone support.

Nelson advises practices to budget for an additional period of onsite vendor support, three months after the go-live date, and again six months afterwards. "What usually happens with technology is that we learn just enough to get today's job done," she points out. "Often we don't learn about all the functions we could use to make our jobs easier." She recommends an onsite visit so the trainer can observe people at their workstations, and note bad habits they may have developed, or shortcuts they aren't using.

eClinicalWorks president and CEO Girish Kumar Navani agrees that practices need to develop their software skills on a continuing basis, since some features of the software become more relevant over time. For example, if you see a patient for a recurring ear infection, the software remembers which antibiotic you used last time. These special features are difficult to demonstrate when the system has just been installed.

However, Navani doesn't think additional onsite visits are the most appropriate way to teach these additional skills, since most new functions are best learned in short training sessions. Instead, eClinical Works invites practices to sign up for its training Webcasts, of which it hosts eight weekly.

Stay positive

Installing EMR and practice management software means a major change in work processes for everyone who works at the practice. It's not surprising that this degree of change can be intimidating.

But the change is inevitable. Navani, who has observed 1,800 practices implement an EMR, says, "don't allow small issues to become show stoppers. Take a positive approach. Even if there is a feature you wish had been designed differently, don't let that slow you down."

MedPeds, LLC, in Laurel, Md., a five-physician practice, installed eClinicalWorks in May 2004. Since then, total practice overhead has declined by more than 15 percent, overdue accounts have been cut in half, and income per visit has increased due to improved documentation, according to practice manager Heather Lynch.

Once MedPeds decided to move to an EMR, the practice acted decisively. It sent all active charts out to be scanned and, "after that day, we never used paper again." Lynch's advice to other practices is, "make your decision, and then implement it 100 percent."

Elaine Zablocki can be reached via editor@physicianspractice.com.

This article originally appeared in the January 2006 issue of Physicians Practice.