Note: This post was written in 2013. We’ve written more content with new research since then, including Patient Expectations for Modern Medical Practices (Pt. 2): Patient-Centered Technology.
It’s no secret that implementing an electronic health record (EHR) solution can be a challenge, whether you’re a solo primary care practice or a large multi-specialty clinic. And there is perhaps no better organization than Cleveland Clinic – a recognized leader in research, education and health information – to help demystify the implementation process.
Cleveland Clinic has been using the Epic electronic records system for over a decade. Their MyPractice Community team assists their physicians and affiliated practices with EHR implementation, while their MyPractice Healthcare Solutions team provides consulting services to external practices in need of EHR implementation or optimization assistance.
I recently had the opportunity to speak with Kelli Mangino, Director of Implementation for both of those teams. Since Kelli initiated the MyPractice Community group in 2005, her team (now 30 employees) has overseen EHR implementations for 367 physicians at 142 facilities (not including the Cleveland Clinic main campus and Family Health Centers implemented prior to 2005).
Kelli and her team have a wealth of experience with implementing and optimizing EHRs in practices of all sizes. In my discussion with Kelli, she shed some light on what makes – or breaks – an EHR implementation.
Q: What is the single most important component of a successful EHR implementation?
A: Up-front engagement from physicians. Office staff tends to be more engaged than physicians; in some cases, staff have been using scheduling or billing software already and are more comfortable in the digital environment.
Some physicians prefer to leave initial decisions in the hands of implementation specialists or administrative staff, but physician buy-in from day one is key. If a physician has a say in which vendor is used, she should be involved in evaluating and selecting the vendor. If that choice is dictated by his employer, he should still get involved in designing workflows: creating templates within the EHR to use in patient encounters, and selecting preference lists based on his common orders and commonly-prescribed medications.
Q: What is step one for training a new EHR user at Cleveland Clinic?
A: MyPractice Community users participate in classroom training with EHR trainers. They spend four hours in class, learning about the features of the EHR – what it looks like and how it works – before they actually use it in their practice. After the classroom training, physicians and support staff receive “elbow support:” a dedicated trainer who works side-by-side with them in their practice for 10 days. But the initial introduction to the EHR is in that classroom setting.
There is also a separate training class early on for practice managers. This class assists them in making good decisions for successful workflows and introduces them to what is coming.
Q: What are some of the more surprising benefits to practices from using an EHR?
A: The biggest “wow” factor is continuity. For a health system like Cleveland Clinic, doctors can access the EHR from any affiliated facility. If they go from an inpatient to an outpatient setting, they can access the EHR in either location. It “follows” them; they don’t have to lug around paper charts. They can even log in from home after having dinner with their family instead of staying at the office to finish paperwork.
The availability of a patient portal is another unexpected benefit. Patient portals allow patients to do things like view lab results, schedule appointments or request prescription refills. When patients schedule appointments or request refills via the portal, that cuts down on call volume for office staff. If physicians provide access to lab results or other documentation on the portal, that can cut down on mailing costs.
Q: How quickly do practices start to notice benefits?
A: When the MyPractice Healthcare Solutions team assists a practice unaffiliated with Cleveland Clinic with their implementation, they embed with the practice for 10 days. By the end of that time, practices are already seeing some benefits of increased efficiency. E-prescribing is immediately noticed, as are the reduction of paperwork and time spent on the phone.
“Parking the chart” takes a little longer. With any given patient, the physician will often bring their paper chart for reference during that patient’s next visit or two, even though the new visit is charted electronically. Getting comfortable enough to put the paper away for good is “parking the chart,” and usually takes around six months (though it depends on the nature of the practice and how often they see each patient).
Q: What does Cleveland Clinic look for in EHR trainers?
A: Great trainers are extremely important. Medical assistants and nurses tend to be overlooked because they don’t have the educational credentials of a physician, but they are the secret weapon for training success. They have often worked in practices similar to those they’re training; they’ve been in the users’ shoes, learning an EHR from beginning. That, combined with their clinical experience, makes them uniquely able to connect with everyone in a practice.
Q: What are the biggest mistakes you see practices make?
A: Trying to do everything at once. Moving from paper to electronic charts is overwhelming. For those who are a bit tentative about the move, they shouldn’t try to chart every patient electronically from day one. Start with a sub-segment of patients – maybe every third patient visit, or only new patients.
Some physicians expect that once they have an EHR in place, they’ll be able to move through visits more quickly and see more patients in a day. EHRs do increase efficiency for a practice, but that doesn’t always mean physicians will be able to chart more quickly. In reality, the amount of time spent with each patient may not change much, and during the learning period charting will probably take longer, so physicians shouldn’t try to schedule many more patients in a day.
Q: For an organization at the early stages of planning to implement an EHR, what’s the best way to get started?
A: Smaller practices with the freedom to pick from several vendors should look at the health system they’re most engaged with. If a practice uses the same EHR as the hospital or clinic it works with most, then doctors and staff won’t have to wait for documentation from other physicians or labs or radiology; that documentation will be available digitally on the EHR. Another advantage is the ability to see ER visits, inpatient notes and medications, which helps with continuity of care.
Once a vendor has been selected, the focus should be on up-front engagement. Have a kick-off meeting with everyone in your practice who will touch the system to explain what’s happening. Involve the entire practice in training. Communication helps counter anxiety.