The Perfect EMR Implementation? Let Me Know When You Find It.
The ambulatory EMR adoption train has clearly left the station. Improved quality of care and communication have provided the initial fuel; however, meaningful use, pay for performance and data reporting requirements are what's on the "third rail" and truly powering adoption. For many providers, the urgency of these forces has encouraged them to lay the train track without a clear map of where they are headed, or what terrain to expect. So, I have "this friend," a CMIO at a similar-sized institution, who has been implementing an ambulatory EMR for several years. I asked him to share his lessons learned and failures along the way. Here are a few:
Balance customization and standardization. It is tempting to allow significant customization to facilitate acceptance by the clinicians and to "fit" the existing paper workflow to the EMR. Early in the process, the organization allowed significant customization for various workflows in different offices, requiring multiple screens and templates to complete an office visit. This led to unwieldy screen flow and an inability to extract meaningful data. The clinicians were very inefficient and, not surprisingly, very unhappy.
As experience with EMRs grows, it is becoming clear that standard workflows and screen designs are more efficient. Customization is often most effective across broader levels (i.e., for a particular specialty), not at the group or individual level. Workflows should be optimized to leverage the technology, and not recreate the paper world.
Include local physician leadership at the practice level. Have clinicians involved in the design of the screens and templates. But, it is essential to have a clinician "driving the train" and acting as the interface between the passengers (clinicians and other end users) and the engineers. Someone who speaks the language of the end users and the analysts, while simultaneously acting as the change champion for the process is ideal. At my friend's organization, they clearly had the former, but often lacked the latter, especially during early practice implementations. This led to breakdowns in communication, unclear expectations and, ultimately, disappointment with the end result. The effort required to rebuild communication and trust was enormous.
Understand the productivity hit and how it will be covered. Everyone pays a significant toll to board the EMR train. For providers, there is usually a decrease in productivity during the acclimation period which can last from two weeks to several months. At my friend's hospital, providers are paid based on productivity (RVUs) and it was not completely clear during the initial implementations how the decrease in productivity was to be covered and for how long. This created some resentment among the providers, and added to the stress of the implementation. It is important to manage provider expectations during the implementation; and these discussions must happen before the project goes live.
No EMR implementation will be perfect. But as Garry Marshall said, "It's always helpful to learn from your mistakes because then your mistakes seem worthwhile."
Balance customization and standardization. It is tempting to allow significant customization to facilitate acceptance by the clinicians and to "fit" the existing paper workflow to the EMR. Early in the process, the organization allowed significant customization for various workflows in different offices, requiring multiple screens and templates to complete an office visit. This led to unwieldy screen flow and an inability to extract meaningful data. The clinicians were very inefficient and, not surprisingly, very unhappy.
As experience with EMRs grows, it is becoming clear that standard workflows and screen designs are more efficient. Customization is often most effective across broader levels (i.e., for a particular specialty), not at the group or individual level. Workflows should be optimized to leverage the technology, and not recreate the paper world.
Include local physician leadership at the practice level. Have clinicians involved in the design of the screens and templates. But, it is essential to have a clinician "driving the train" and acting as the interface between the passengers (clinicians and other end users) and the engineers. Someone who speaks the language of the end users and the analysts, while simultaneously acting as the change champion for the process is ideal. At my friend's organization, they clearly had the former, but often lacked the latter, especially during early practice implementations. This led to breakdowns in communication, unclear expectations and, ultimately, disappointment with the end result. The effort required to rebuild communication and trust was enormous.
Understand the productivity hit and how it will be covered. Everyone pays a significant toll to board the EMR train. For providers, there is usually a decrease in productivity during the acclimation period which can last from two weeks to several months. At my friend's hospital, providers are paid based on productivity (RVUs) and it was not completely clear during the initial implementations how the decrease in productivity was to be covered and for how long. This created some resentment among the providers, and added to the stress of the implementation. It is important to manage provider expectations during the implementation; and these discussions must happen before the project goes live.
No EMR implementation will be perfect. But as Garry Marshall said, "It's always helpful to learn from your mistakes because then your mistakes seem worthwhile."