1. Implementing Electronic Health Records
Chapter 4
Implementing Electronic Health Records

2. Implementing Electronic Health Records
Lesson 4.1
Implementing Electronic Health Records
Explain the considerations that must be addressed in planning a successful transition from paper charts to electronic health record (EHR) systems.
Develop a conversion plan for the EHR.
Explain the requirements of the Centers for Medicare & Medicaid Services (CMS) meaningful use program for eligible professionals.
Describe the information a practice should supply to each software vendor in its request for proposal document, and outline the information the practice should expect to receive from the vendors in return.

3. Implementing Electronic Health Records
Lesson 4.1
Implementing Electronic Health Records
Give examples of the workflow processes that must be redesigned when an EHR system is implemented.
Outline the process of collecting and entering data from paper sources into the EHR.
Discuss common problems that may be encountered when information is transferred from paper charts to EHR systems.
Identify specific challenges that may arise in training to use a new EHR system.

4. Implementing Electronic Health Records
Lesson 4.1
Implementing Electronic Health Records
Indicate how patients can be introduced to the new EHR system.
Specify the contingency plans that must be in place before an EHR is launched.
Discuss the EHR implementation process.
Explain how the success of an EHR can be measured after the transition period ends.

5. Planning a Successful Transition
What is the practice’s motivation for making the change? What does it hope to achieve in making this change?
Will the organizational culture support a technologic conversion, and can it endure the frustrations and sacrifices associated with it?
Are patients likely to support a migration from paper to digital charting?
A methodic approach seems to be the key to making a successful EHR transition. The first step in a well-planned transition is to assess the practice’s readiness for the change.

6. Planning a Successful Transition (Cont.)
Does the practice have, or can it obtain at a reasonable cost, the necessary technological and operational resources to make the switch?
Does the practice have enough capital in reserve to stay afloat during a period of reduced productivity?
Does it have enough cash on hand to purchase hardware, software or a software license, and training and information technology (IT) support?
The preimplementation process itself offers a chance for the practice to examine these questions in depth.
Even if it has already decided to go digital, assessing readiness would produce a useful inventory of strengths and weaknesses.

7. Developing a Conversion Plan
Create a team to help research, select vendors, train, implement, and evaluate the EHR system
Maybe the entire staff or a select group
Include providers, office managers, and support staff (medical assistants, receptionists, billers, medical records personnel, etc.)
Various points of view can be invaluable in this process.
It is important to be aware of possible pitfalls of EHR transitions in order to avoid them.

8. Pitfalls of EHR Transitions
This table shows some common mistakes that medical offices make when making the EHR transition.

9. Pitfalls of EHR Transitions (Cont.)
The table also offers tips for avoiding some of the mistakes.

10. Meaningful Use Certification
The main goals of the MU program are:
Improve quality, safety, and efficiency and reduce health disparities
Engage patients and family
Improve care coordination and population and public health
Maintain privacy and security of patient health information
EHR vendors are evaluated on a set of core and menu objective measures. The meaningful use (MU) incentive program is a payment incentive program made available for eligible professionals (EPs) or physicians who implement and use their EHR technology in a meaningful way.
EHR usage must meet specific requirements. These are organized into three stages of core and menu objectives.
Since the implementation of meaningful use incentive programs, have you noticed any changes in the way patients are seen in the medical office? (Answers will vary.)

11. Selecting a Type of Conversion
Complete switch
Incremental conversion
Hybrid office
Slow incremental conversion
What is a hybrid office? (Existing patients’ charts are kept on paper and only new patients are entered into the electronic database.)

12. Selecting an EHR Vendor & Network Platform
There are thousands of vendors; know what your practice wants
Assessing practice needs
Surveying available software applications
You control the demos, not the vendor marketing team
Selecting a network platform
It’s important to base the decision on criteria specific to the practice.

13. Assessing Practice Needs
Pick a company with long-term service, training, and software updates
Is the system compatible with other systems?
Is it CCHIT certified?
Customizable? Templates?
Cost?
Many of the practice’s needs should have been identified during the initial readiness assessment/preimplementation discussions.

14. Surveying Available Applications
Ask vendor to supply basic information for comparison of other vendors:
References
EHR features
Proposed hardware and network architecture
Customer service
HIPAA and coding compliance features
Interoperability functions
Cost
It’s good practice to submit a request for proposal (RFP) document after narrowing the list to a handful of vendors.

15. Selecting a Network Platform
Client-server model:
User purchases the software
Installs it to practice hardware
Application server provider (ASP):
Subscription agreement
Access software over a secure Internet connection
EHR software can be licensed (purchased outright) or accessed by paying a monthly subscription fee to use it.
Refer students to Table 4-2 (pp ) for a comparison of the two types of network platforms.

16. Redesigning Workflow
With EHR implementation, workflow redesign is inevitable
Ask vendor for redesign recommendations
Start redesign process during preimplementation planning
Refer to the policies and procedure manual to examine current routines
EHR adoption is not just the launch of new technology, but a shift in the way the office conducts its business.

17. Office Procedures Requiring Workflow Redesign
Until the staff has some real-life experience using the software, it’s difficult to understand how to integrate it effectively into office processes.
The keys to success are flexibility, communication about what’s working and what’s not, and a willingness to make continual readjustments on the fly.

18. Adjusting to Point-of-Care Documentation
Documentation is done during or immediately after the patient encounter
Adjustment for providers at first but:
Increases the accuracy of patient visit documentation
Will decrease the amount of “after hours” paperwork
The most difficult new workflow for some clinicians to adapt to is point-of-care (POC) documentation.

19. Setting Up Billing Cycle Documentation
The American Health Information Management Association (AHIMA) makes the following recommendations for practices that are going digital:
Create a common list of diagnosis and procedure codes
Take advantage of auditing features of documentation
Pay attention to accuracy of code reporting
Design the EHR to avoid shortcuts that could lead to fraudulent behavior
When a practice converts to an EHR, it must identify potential glitches in claims processing and reimbursement or be prepared to sort out such problems once they’re discovered.
The practice management capabilities of an EHR system are extremely useful in performing ongoing financial analysis and billing management functions.

20. Setting Up Billing Cycle Documentation (Cont.)
Establish regular and random internal auditing to verify:
Accurate data capture and documentation
Procedures performed are medically necessary
Progress notes are not cloned
Electronic signatures are used appropriately
Prescribing activities are well documented
AHIMA has released a position statement on billing cycle documentation in the EHR, available online to AHIMA members.

21. Collecting and Entering Data
Methods for data entry:
Data input from compatible, interfaced systems
Transcription using voice recognition technology or dictation
Scanning of typed or handwritten documents
Direct keying or rekeying (typing)
Most of the data initially entered into the EHR come from the paper chart. However, to offer the best possible healthcare and to protect the practice legally, it’s important to gather patient data from all available sources.
The need to key data from paper charts into the new EHR is one of the biggest deterrents to adopting an EHR system.

22. Under-documentation and Over-documentation
Transfer of documentation from paper records to electronic has its risks:
Requires judgment of clinician (provider)
Under-documentation
Over-documentation
Prioritize information to transfer
Example: Medication lists, allergies are given a high priority
When too little information is entered, the skimpy EHR tends to generate drug interaction alerts and health promotion reminders more often.
Excessive detail may indicate a higher level of care than was actually delivered, leaving the provider vulnerable to charges of fraud and abuse.

23. Structured and Unstructured Data Entry
Controlled vocabulary
Structured data entry
Straightforward clinical findings
Example: Strep negative, PERRLA
Unstructured data entry
Allows free documentation
EHR templates
Carry both structured and unstructured data entry abilities
SimChart for the Medical Office (SCMO) offers a full range of experience using both structured and unstructured data entry options throughout the system.

24. Electronic Misfiling and Interfacing
Information recorded in the wrong part of chart
Establish guidelines for data during preimplementation phase
Controlled vocabulary is able to communicate more easily with other systems
Hospitals, labs, specialist offices
What is the importance of software interface? (Using a controlled vocabulary, most EHR software systems can interface with at least some other systems, such as a hospital or laboratory system. When this interface is seamless, reports from one system automatically populate templates in another.)

25. Scheduling Training
Staff to agree on customization options before the training begins
Adhere to level of computer experience
Train to level of access
Provide training manuals for troubleshooting or refreshers at work stations
The better the training before the transition is implemented, the less hand-holding everyone will need afterward. Costs will be lower and productivity will be higher.

26. Notifying Patients Introduce using three C’s: Connect Collaborate
Close
What different means may be used to notify patients of the change to EHR? (By connecting with the patient through interpersonal communication, by collaborating with patients to be sure they understand the new system, and by closing through showing patients that you are logging out to secure their information as well as thanking them for their support.)

27. Incorporating POC Documentation into the Patient Encounter: The Three C's
Some patients will be delighted with the change, while others will be apprehensive.
Modified from Doctor’s Office Quality Information Technology University, Centers for Medicare and Medicaid (Masspro), U.S. Department of Health and Human Services.

28. Incorporating POC Documentation into the Patient Encounter: The Three C's (Cont.)
Medical assistants are among the first to make contact with the patient on each visit. They can begin the process of making the patient feel comfortable as the provider documents the visit.
Modified from Doctor’s Office Quality Information Technology University, Centers for Medicare and Medicaid (Masspro), U.S. Department of Health and Human Services.

29. Making Contingency Plans
Required by HIPAA Security Rule
Backup plan
Plan in event of an emergency
Gradual rollout
The rule requires that patients’ health information be protected from disasters of all sorts, including system crashes that may occur when a new system is launched.

30. Implementing the Transition
Test phase
Staff must be flexible
IT support for troubleshooting
Readiness to launch the implementation phase depends on the installation of technologic resources, the completion of staff training, the existence of funding to carry the practice through the transition period, and the availability of staff and clinicians.
As the EHR is put into use, the plan for its implementation is tested. Its limitations quickly become apparent.

31. Measuring Results & Conducting Evaluations
EHRs have been associated with improved safety and patient care, better financial performance, higher provider satisfaction, and more efficient communication
Generate baseline data
The attributes that can be measured with an EHR are nearly unlimited.

32. Questions?