EHR Best Practices: Surviving the 'go-live' stage

After weeks, or even months, of preparation, the real test of your electronic health records (EHR) system is when you start using it in office with real patients on real time. Though you may have anticipated a few glitches, it is inevitable that productivity will suffer, your staff will be frustrated and you will have to explain the new digital system to your patients.

“The first couple of months were brutal, and much of that was just extra hours spent getting up to speed on the nuances of the system,” said Daniel S. Goodman, MD, an Atlanta, Georgia, internist, and one of the 29 participants in the 2-year Medical EconomicsEHR Best Practices Study. “But we’re used to it now, and things are running smoothly. The entire staff is onboard with the EHR, and productivity is high.”

So why is go-live so frustrating?

“Consider that physicians are faced with integrating records and trying to achieve a level of functionality with the system,” says the Medical Economics EHR Best Practices Study leader George G. Ellis, Jr. MD, FACP, in Boardman, Ohio. “At the same time, they are learning how to use it while examining patients, diagnosing conditions, and treating them. Workflow adjustments add new complications to an already complicated process.”

The reality is that doctors are populating medical records from scratch. And there are many steps in the process from verifying insurance eligibility, processing payments, to gathering family, social, medical, and surgical histories, to diagnosing and/or treating health conditions or diseases. The point? It takes time; a lot of it especially during the first days of go-live. Prepare to see fewer patients, because most physicians are spending the time “trying to smooth over the patient experience,” Ellis says.

Some of the key findings from the Medical Economics’ Best Practices Study were that 96% of the physicians participating cited excessive time to implement, and 89% noted a disruption to the practice. And when it came to that dreaded go-live date, only 37% of the physicians in the study said they were truly ready.

According to the Center for Health IT of the American Academy of Family Physicians, practices should concentrate on implementing the system for the staff and office first, and physicians second.

Part two of this three-part series is designed to look at training, workflow design, patient engagement, go-live tips, obstacles, testing, and productivity, supplied by the 29 participating physicians, vendors, and other sources.

Below are real-world suggestions about how you can minimize the stress of implementing an EHR system in the first months.

Workflow

Review the workflow process map you created prior to implementation.
It’s critically important to evaluate your current workflow, says Frank Cohen, a practice management consultant. He recommends reviewing your process map and working with your EHR vendor to create a new one that shows how you would like your practice to operate.

Scanning in documents or starting fresh?
Most practices have thousands of patient records, and if implementing a new EHR system, you will have to decide between scanning all the documents into the system, and entering information manually as patients make appointments. Experts say that you should set a goal of retiring the paper version of charts by the patient’s second visit. And it takes a lot of time.

There are pros and cons to scanning paper documents into your EHR system. On one hand, all of your data will be electronic and you can move paper charts off site to a secure place. However, the charts will be attached to the record, which makes them harder to search, and you will have to sort them into categories (X-rays, labs, administrative, etc.).

You will probably have to pay staff overtime, hire additional staff members, or contract scribes to manually enter, or preload, your charts. Nurses or physicians can update EHRs with the patient when they come in for a visit, or your staff can enter charts a little at a time. It will be important that immunization records, allergies, medications, recent imaging and other important consultations be entered or scanned into the EHR system as soon as possible.

Conduct a practice run with team members before you go live.
Before your go-live date, Dean Sorensen, MBA, CPHMS, principal consultant and chief executive officer of Sorensen Informatics, recommends establishing a test environment to make sure production is not impacted while training or testing new suggestions.

According to Health and Human Services (HealthIT.gov), “Make sure to cover all aspects of the EHR Implementation cycle and allocate enough time to become familiar with new tasks. Your organization should complete the following tasks before your EHR implementation go-live.”

HHS offers these suggestions:

• Test your EHR.

• Begin training your staff in the EHR application and on new policies and procedures.

• Ask your staff to create usernames and passwords.

• Complete a “patient walkthrough” to simulate an entire patient visit.

• Place signs in offices and hallways to notify patients the go-live is taking place and to request their patience through the process.

Consider a scribe or temporary staff.
Many practices find it beneficial to hire a scribe to enter information into the EHR system at the direction of the physician. EHR study participant Andrew Garner, MD, said he received complaints from patients about specialists who focused too much on their EHR, and he wanted to make sure that didn’t happen at his practice. “That’s why I’m choosing to do the scribe model,” he said. “When you use a scribe, you’re implementing two new things at once. That has its challenges, too. But when that patient said, ‘I feel like I lost you, Doc.’ It was a wake-up call. I thought I was doing a good job of not getting lost in the computer.”

But hiring a scribe means additional costs. Objective metric reports will help practice’s determine if a scribe is financially beneficial, says Maxine Lewis, CMM, CPP, CPC-I, CCS-P, president of Medical Coding and Reimbursement in Cincinnati, Ohio. She says to evaluate the “relative value units per hour or shift, number of patients seen per hour or shift, clinical versus administrative time, average charge per billable visit, number of incomplete and deficient charts, door-to-discharge time, and patient satisfaction survey results.”
Garner calculated that alone it takes him 8 minutes to finish a chart. However, with a scribe, it only takes 4 minutes.

Go live on a Friday
Some physicians suggest going live with your EHR system on a Friday. Your practice will have a full week to prepare for any last minute issues, and you will have the weekend to assess the first day and make adjustments. You can also frontload patient visits to make Friday a light day in anticipation of a drop in productivity.

Patient engagement

Start training your patients
One strategy Ellis offers was to have a staffer float in the practice’s waiting room to help patients during check-in. If your practice has a patient check-in kiosk, it can save front-office staff  a lot of time and reduce paperwork. Either way, patients will likely be unfamiliar with the new process, Ellis says. So, you will need to factor in time to train your patients. To help facilitate this process, designate a staff member to help patients and be available to answer questions.

Educate patients about online portals
Your patients who aren’t as computer savvy might need help accessing online patient portals. They are actually very powerful tools to help engage patients in entirely new ways. Patient portals help patients access lab and test results, send refill requests and communicate with the physicians and practice. Provide postcards or brochures with step-by-step instructions on how to sign up for the portals online.

If you have an additional workstation, you can set it up in your waiting area and help patients log into the portals and access their information for the first time. (Remember to have safeguards in place to stay compliant with HIPAA standards.)

Should EHRs be in the exam room?
Some practices do not allow them in the examination rooms, while others find it useful to verify patient information and engage patients in their care.

Whatever strategy works best for your practice, test it and adapt it to see what is the least intrusive and most efficient way to use your system.

Here are some strategies to help:

• Some physicians have set up examination rooms with a work space so that the physician and patient can sit together to work within the EHR and verify its accuracy.

• If that is not possible, position computer screens so that you can see the patient. Try not to turn away from the patient when you have to input information.

• Make sure you listen to the patient’s concerns before using the EHR. One of the biggest complaints from physicians is that this computer system interferes with the physician and patient interaction.

The trick, physicians say, is to stay focused on the patient during the encounter and settle in on a workflow that serves the patient and accurately records patient health information.

Technology and system maintenance

Have on-site tech support the first few days of the launch
Many EHR vendors offer on-site tech support (sometimes fees apply). Practices could also choose to contract with an outside professional. In 2012, at the beginning of Medical Economics’ EHR study, 44% of the study participants contracted with an information technology (IT) professional or an IT firm, 12% hired other outside assistance, and 8% paid for assistance from a regional extension center, which offers local support for practices. Melissa Lucarelli, MD, one of the study’s participants, said her practice signed up with a regional extension center. They brought in vendors, and they also conducted HIPAA risk analysis assessments.

Customize templates for your practice
Practices often have their own way of documenting office encounters, and EHRs don’t have to be one-size-fits-all systems. Ask your vendor to help you create custom templates for clinical documentation.

You will need to use the system in ways to make the process faster. Templates can help.

Consider running your old and new billing system at the same time
Practices may have difficulties testing certain claims and payers with the EHR. But Lucarelli says running both the old and new billing systems could prevent a drop off in collections if those problems occur.

“It really worked well, because you have to transition your old medical management system over at least 90 days because there are collections in various states of payment,” she says. “So you can’t just shut off your old system and switch to the new anyway. We actually continued generating claims on the old system at the same time as we were generating 6, 8, or 10 new claims a day on the new system. I had my clinic manager pick which patients were be going to be arrived in the EHR, so that we had a mix of payers as well. We would actually track the time to collections and see where the system was hanging up.”

The reality is most practices can’t afford claims hung up in the system. The idea is to test and devise ways so it lessens the impact on cash flow.

Take advantage of scheduling features
Use the appointment reminder feature in you EHR system to save your practice time and help decrease no-shows. Your system may be able to send me reminders via automated phone message, email, or text. This feature will also free up time for your staff who would normally have to call patients individually.

Other useful scheduling features can remind your staff and patients of billing issues, and automatically require follow up visits. This helps everyone in the office know when changes in the schedule are made.

Create a spreadsheet to log any issues with the system
When problems occur with your EHR system, stay organized. Use a spreadsheet to track what the problem is, the date it occurred, who is responsible for fixing it and the status of the project. Lucarelli says at one point during implementation, she had more than 100 open issues. But her spreadsheet allowed her to easily communicate them with her vendor.

Communicate issues with your vendor
Expect errors to occur within the system when it’s first up and running, and communicate the problems with your vendor. “Heaven help the practice that gets an EHR and thinks it’s all going to work just because the vendor says so,” says Frank Cohen, practice management consultants. “They’re going to be in real trouble.”