Once implemented, an EHR can bring many benefits to a practice. But minor mistakes can cause major problems. Here's what to watch out for.
Family physician Saroj Misra is an educator, and thinks that physicians are at the low end of the learning curve when it comes to EHRs.
"Despite the fact that we've had EHRs in some form or another for the last 15 to 20 years … we are surprisingly behind the times in terms of how they work; what they do, and, most importantly from a physician's perspective, how they help in the delivery of healthcare," says Misra.
That is probably a perspective that many physicians would share. In the 2015 Physicians Practice Technology Survey, Sponsored by Kareo, only 53 percent of 1,181 respondents said they had a fully implemented EHR system. And, despite seeing an improvement in documentation (66 percent), 68 percent said they did not see a return on their investment in EHR. Respondents said one of their top information technology problems was "a drop in productivity due to our EHR," indicating a significant disconnect between the intent of EHR and its reality.
If you are wondering what EHR trip-ups other physicians are struggling with, our experts tell us these areas are the worst offenders.
Inadequate training on EHR systems for both physicians and clinical staff can be a significant source of frustration. Yet there are many other demands for a physician's time and money. It is a paradox that devils many practices: If a practice doesn't go "off line" and dedicate enough time to initial training on the EHR, implementation and subsequent productivity will suffer. But few practices can afford to take a full week or more away from patient care.
Tom Giannulli, chief medical information officer for EHR vendor Kareo, counsels physicians to avoid learning a new system while they are seeing patients. "EHRs have learning curves, for some they may be steep, and if you do not ascend the curve in a productive learning environment, you will be paying for it with wasted time and frustration," he says.
Misra, who directs the development and implementation of curriculum at Michigan State University's College of Osteopathic Medicine, incorporates technology use in his teaching. He says in order to have true success with understanding and efficiently using the EHR, physicians need to "commit time each week to relearning [the system]." He gives the example of a "power-user" who goes beyond learning basic system functionality and commits time each week to really learn what the system can do. Understandably, that might sound like a pipe dream, given the lack of excess time in a busy practice. But there are ways around that limitation. Misra recommends carving out one to three hours each week for a single physician or staff member to learn the functionality of the practice's EHR. "Then, that person becomes a liaison or a de facto liaison to the EHR vendor," he says, "but also a person who can educate and provide ongoing education for the physicians and the office staff."
• Training should be timely, and repeated for both new staff and current users.
• Training should focus on specific tasks that staff/providers will use daily.
• Identify a practice "super-user" who will be a clinic resource/trainer/ IT support person.
Marissa Rogers is program director for a large family medicine residency at Genesys Regional Medical Center in Burton, Mich., and a practicing member of a 46-provider faculty practice. She says her providers often struggle with spending too much time on documenting the patient encounter in the EHR. She encourages her residents to chart on the computer when the patient is in the exam room, to "get the meat of what the patient is telling them," but admits it is not always an easy task. "It's very difficult for physicians to do because we are used to wanting to talk and listen [to our patients]," she says, "… But in the new world that we are living in, we now have to get used to having a computer in front of us."
Rogers says completing the patient note while the patient is present in the exam room is a necessary component of providing a summary of care for the patient to bring home - a meaningful use requirement. So for physicians who are not ace typists, being required to enter the patient note during the encounter can slow down their day and reduce overall productivity.
Another productivity drag? Misra says physicians commonly fail to make use of time-saving EHR features like shortcuts, templates, built-in coding, and voice recognition software to dictate the patient note. And, when he visits other clinics, he often sees them using out-of-the-box templates provided by the vendor, which he believes slows down physician work flows. Knowing your practice's work flows and how they are affected by the EHR can allow your practice to create customized templates that will speed up documenting the patient encounter.
"Many EHRs have the ability, with time and effort, and that's the problem, to make some modification to these [templates]. But most physicians find those barriers too high, in terms of time and effort. But if they did [modify the templates]… that would speed things up immensely for them," says Misra.
Elizabeth Woodcock, principal of Woodcock & Associates, a practice management consulting firm, says that in some cases, it is not possible to customize EHR documentation to fit practice needs, especially in the case of a unique specialty practice like a fertility clinic. But even when customization is not possible, Woodcock says that correctly configuring the EHR during implementation is crucial. Small things like incorrectly setting up the dictionary can cause a physician to hate his EHR and negatively affect "the whole course for the EHR for years and years to come," she says.
• Integrate the EHR into clinical work flows, and revisit work flows after implementation.
• Develop templates/customization that work for the specific practice.
• Ask the vendor for system enhancements to facilitate improved work flows, where possible.
INADEQUATE TECH SUPPORT
Many practices have vendor-provided tech support onsite for the first week of EHR implementation, and after that they are essentially on their own. Obviously that can be a huge detriment to a practice. Woodcock advises administrators to have tech support return within 90 days after the initial implementation, for one or two days, to answer questions that have cropped up at the practice.
Misra advises practices to communicate with the vendor on a regular basis. He suggests that the appointed EHR "super-user" should also be the practice's vendor liaison. "That person should not only be communicating back to the vendor what they need and what's working, but they should be communicating back to the office what updates are coming out for the software."
Large health systems typically have their own onsite tech support, which is a definite plus for busy practices. But that doesn't always mean your practice can get the personal attention it deserves. Woodcock says a new trend that she sees beginning to take hold in health systems is the use of an EHR optimization team. "Their goal is to make that system work better for you." She says these professionals tend to have EHR vendor experience and approach their work from a "lean-thinking" perspective.
• Build in adequate tech support in the initial vendor contract, with a return visit within 90 days.
• Develop a practice work group (physicians and staff) that will initiate and support EHR implementation/use.
• Task the EHR super-user to act as a vendor liaison.
SOAP NOTE SLOWDOWN
According to a member survey of the American College of Physicians, most of whom were experienced EHR users, 89 percent of respondents said they experienced slower data management; 63.9 percent said the SOAP (subjective, objective, assessment, and plan) note documentation took longer; 33.9 percent said it took longer to review medical data; and 32.2 percent said it took longer to read another clinician's note using EHRs.
"Use of Internist's Free Time by Ambulatory Care Electronic Medical Record Systems,"
McDonald, et al, JAMA Internal Medicine (2014)
Erica Sprey is associate editor at Physicians Practice. She can be reached at firstname.lastname@example.org.
This article originally appeared in the July/August 2015 issue of Physicians Practice.