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Lessons Learned: How to overcome the cultural barriers to EMR implementation

by Michael J. Koriwchak, MD •

Lessons Learned

Health care reform and government incentives have intensified the dialogue on electronic medical records (EMR). Despite the financial incentives for EMR adoption included in the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, physician response remains lukewarm. The HITECH incentives program fails to recognize that the greatest barrier to EMR adoption is not financial, but cultural.

Contrary to popular belief (even among ourselves), we physicians are not tech savvy. The practice of medicine is far more interpersonal than technical. Our decisions may depend as much upon a patient’s facial expression as on any objective data. That is how it should be. We got into medicine to work with people, not machines. Physician practices have never been centered around information technology (IT), so bringing a medical practice into that environment takes time.

A Transitional Approach

Ear, Nose and Throat of Georgia serves the metro Atlanta area with 20 physicians in 15 offices. We have offices staffed with anywhere from eight physicians to a single doctor. In 2003, we were ready to replace our outdated practice management (PM) computer system. In our strategic planning, we saw in EMRs an opportunity to strengthen our leadership position in the market and better serve our patients. We purchased EMR and PM products together to create a larger project.

Michael J. Koriwchak, MDPhysician practices have never been centered around IT, so bringing a medical practice into that environment takes time.

The EMR adoption process was broken down into many incremental steps. After a short teaching session, physicians had a training version of the EMR, complete with fictitious doctors and patients, installed on their laptops. The physicians spent a few evenings working with the program to get used to its basic operations and functions. Once they were comfortable with these, we put the server communication software on their computers and showed them how to log in and use the same training EMR program on the server, which was configured with our custom templates. The physicians were then taught how to create chart notes using our templates so they could spend more time practicing, logging onto the server from home.

After a few evenings of practice, most physicians were comfortable with both the EMR itself and our custom templates. At that point, it was time to use the “real” EMR program on patients, but not all at once. Most physicians started with only one patient, usually one of the last patients of the day. Those first few notes took forever to complete, but with our approach, that was no problem. For a while, many of the physicians printed out the completed EMR note and put it in the paper chart. Why bother doing that? It was a cultural trust issue. With time, trust in the EMR increased, and the practice disappeared naturally.

We advanced each physician at his or her own pace. For example, we started by having a physician complete an EMR for the last two patients of the day, then the last three, and so on. When ready, the physician would take on a half day of patients, then an entire day. There were no deadlines and no pressure. After getting settled with documentation, we had the physicians move on to workflows such as prescriptions, ordering tests and imaging. The last part included learning CPT/ ICD-9 charge code entry.

Our incremental approach served two goals. First, it allowed the cultural change to progress at an acceptable, sustainable rate. It also allowed the practice to implement EMRs without decreasing patient volume. It took almost a year to set up 20 physicians in 15 offices with basic EMR functions. There was no panic, no chaos and no loss of patient volume. We had our frustrating moments, but I am convinced that they would have been far worse with a conventional implementation plan that used “go-live” dates and other hard deadlines.

Strategies

We overcame the IT cultural barrier by creating an approach to EMR that differed from the prevailing wisdom at the time. Some of the strategies we used are as follows:

  • We recognized that implementing EMRs was not a project with a defined endpoint. It would instead be an ongoing “work in progress.”
  • We refused to be “led” through this project by our vendor. If we had a problem and didn’t like the vendor’s solution, we found another answer or created a solution ourselves.
  • We avoided “go-live” dates and hard deadlines for abandoning paper charts. Paper charts were eliminated gradually, via attrition, over two to three years.
  • We rejected the notion that we would have to decrease patient volume and lose revenue, even temporarily, to implement an EMR system.
  • Physicians were allowed to progress along their own timelines. We also offered—and continue to offer—each office and physician a fair amount of latitude on exactly how the EMR is used. For example, some physicians use speech recognition, some don’t.
  • Like any practice, we had some physicians who were enthusiastic about getting on an EMR system and some who were reluctant. We let the enthusiastic ones go first. This gave the reluctant ones time to watch the others.

Benefits

We began our EMR project with the faith that we could solve any problem we encountered—and there were problems. Some were predictable, while others completely blindsided us. Nearly six years later, however, it remains a successful work in progress.

We invested in an EMR system because it is good for our patients and our practice. We save about $1,000 per physician per month in transcription costs alone. Over five years, we will save $60,000 per physician, much more than the $44,000 promised by the federal government’s “meaningful use” incentives introduced last July. With our savings in office space and staffing, the total is over $20,000 per doctor per year. Patient complaints over missed phone calls have been sharply reduced. And we have barely scratched the surface.

The timely acquisition of EMR is a vital step toward controlling our destiny as otolaryngologists. Eventually all practices will become electronic; only by embracing EMR soon can we do it on our terms and on our timetable. From a leadership role, we can engage the IT community to improve EMR products for otolaryngologists, while also gaining enough credibility to work with the government and private insurers in a more equal partnership than currently exists. Surely it is worth leaving our comfort zone to reach these goals.

Dr. Koriwchak, MD, is attending physician at Ear, Nose and Throat of Georgia in Atlanta, Ga. Read his blog, “The Wired EMR Practice,” at wiredemrdoctor.com.

Take It Step by Step

Learning how to use EMRs is like learning how to play a musical instrument. Through practice, proficiency is built slowly over time. Our physicians first practiced at home using a training version of the EMR program. When they felt comfortable at that level we transitioned them to step two, making the task a little more complex by adding the server login and our custom templates to the training EMR experience. Then they started using the real EMR on patients in the office. We started with easy tasks: follow-up visits, patients that are doing well, and so on.

Next, we brought in the medical assistant (MA) and began designing a two-person documentation workflow. The MA would interview patients first and enter their data into the EMR chart note. The physician would then open the chart note on a separate computer, review the data, see the patient and complete the note. We looked at the appointment schedule ahead of time to identify appropriate patients for our first EMR notes. It was slow and awkward at first but improved with time.

When physicians and staff were ready to progress to another level, we added EMR-based prescriptions (paper at first, e-prescribing later), test ordering and, finally, charge code/diagnosis code entry.

Just as musicians never regard themselves as having completely mastered their instruments, EMR implementation will never be totally finished. New technologies and features will come along periodically, each one raising the bar a notch higher.