The State of Things... or "Er, Where's My EHR?"

What is up with the EHR project, you may be wondering.

In recent weeks the network plan is being finalized - in short we will use Frontier high bandwidth connections to the offices and have our data servers at Noyes Hospital.

The contract with eClinicalWorks is moving (slowly) toward finalization and signing. TCFM has been seeking -- and getting -- advice from Innovative Solutions and CHCANYS regarding details of the contract. A law firm is overseeing the contract revisions.

CHCANYS (Community Health Care Association of New York State - www.chcanys.org) is providing experience and skills regarding EHR rollout, from a clinical process perspective. Innovative Solutions is providing the networking, hardware and software expertise. CHCANYS and Innovative Solutions have worked together before on rolling out eClinicalWorks in clinical setting similar to TCFM, so we have an experienced team of project managers.

Richard Johnson was at our TCFM staff meeting in October and led an informative discussion about several aspects of the EHR project, including desktop versus laptop versus tabletPC, scanning old records, data entry, and voice recognition. According to Rich the Dragon NaturallySpeaking voice recognition software is workable with eClinicalWorks, and Dr. Markowski has been using the two together successfully.

Although voice recognition software can be a time saver, it takes practice to use it effectively, so Rich recommended that we not try to learn to use voice recognition software at the same time we are learning to use the EHR.

Once the eClinicalWorks contract is signed, things may start to happen fairly rapidly.

Best Laid Plans

As we get nearer to implementation of EHR, we will become more aware of how difficult change can be. And change intended for the better sometimes makes things more difficult, at least at first.

Most likely our EHR will make some things safer and easier, such as health maintenance tracking or keeping medication lists updated, and other things harder such as documenting a complex visit. With planning and foresight we may prevent major disasters and anticipate the struggles. There is already an expectation, for example, that our efficiency will take a hit for months (6 to 12) after implementation, and that additional support staff hours will be budgeted for data entry and scanning as we move from paper to electronic records.

But sometimes despite planning, things don't go as intended. Just last week, TriCounty pulled the plug on the staff time-clock system, a web-based system that was intended to add efficiencies, but unfortunately had the opposite outcome. I do not know the details of that system or the decisions around it, but it is a cautionary tale for us as we move toward the far more daunting EHR launch.

Some likely lessons? Anticipate what could go wrong; listen to all the stakeholders; learn from other clinics who have done it before; keep the lines of communications open; keep the goals in sight; where necessary pull the plug!

Innovative Solutions

Last Friday we met with the team from Innovative Solutions (InSo) to review the analysis of our current network and proposals to upgrade our network for electronic health records.

The upshot, according to InSo, is our network is hopelessly inadequate, and rather than getting beefed up, it needs to be tossed out and an entirely new network constructed. In the proposed scheme, each office would be directly connected to the Internet.

Furthermore, because our practice is located in so many locations, all that connectivity will be costly.

We also discussed options for where to keep the data servers for the EHR: at Tri-County, at Noyes (which we do now), at a data center (probably in Rochester), or at eClinicalWorks in Massachusetts. InSo argued that a professional data center would be the best option, which InSo claimed would give us the best combination of security, reliability, control, and access.

The technical terms and concepts discussed are daunting. Evaluating the recommendations and costs will be challenging. The plan is to at least get input from Noyes' IS people regarding the proposed network scheme.

One thing that became clear to me is that because Tri-County is located in so many places, our EHR implementation will be much harder than those local offices with one or two locations. Launching at seven locations is not seven times harder. It may be seven-squared, or 49 times harder!

Workflow Change

Last week we had an office meeting.  Our office manager had prepared a list of issues to discuss, and the session was productive.  Afterwards I considered how many of the issues we discussed will be completely different when we have an EHR.  Some processes will be better, like chart hunting will become a thing of the past, and some just different, like taking a phone message may involve creating an email-like message to the nurse or doctor that is automatically attached to the electronic chart.

So many actions we do every day in the office will be utterly transformed.  Piles of charts will be replaced with e-message in-boxes.  Piles of lab reports will be replaced by lists of labs to review.  Multiple copies of abnormal lab reports will be banished.  Transcriptions will no longer be on adhesive-backed paper, just on a computer screen to be electronically signed.

Other things discussed at our office meeting will always be important: communication among staff is vital; positive attitudes help everyone.

And the ultimate goal, the reason we show up to work - compassionate and appropriate care for our patients - will remain the same.

Hurry Up and Wait

Nearly two weeks ago I posted that Heal NY sent confirmation of grant funding and that our project will soon contract with vendors.  That is still true, depending on what "soon" means.  What we got from Heal NY were contract documents for grant funding.  TriCounty has completed and signed these and sent them back to Heal NY.  Now we wait for Heal NY to sign these documents and send copies back to us.  THEN we can start committing funds to our EHR project....

Joyce, Anne, Karen S and I met earlier this week and went over our timeline and next steps.  I expect things to become much more focused once we sign agreements with vendors.  eClinicalWorks already sent an updated contract this week, and we expect similar from Consilium, our network support vendor.

Karen S is arranging visits for providers and office staff with local offices which already use eClinicalWorks so we can see EHR in action.  

Stay tuned!

Characteristics for Success

AAFP has many articles regarding EHR implementation in their Center for Health Information Technology (http://www.centerforhit.org).  The excerpt below offers a list of traits that successful offices and providers embody as they undertake EHR implementation:

Medical offices that have had successful electronic health record implementations have the following characteristics:

1. Excellent teamwork
2. Excellent communication skills
3. A spirit of adventure and continual improvement
4. The ability to handle adversity and bumps in the road well. 
5. Excellent problem solving skills
6. A willingness and flexibility for individuals to go outside their job descriptions in order to make things work. 

Family physicians who have had successful electronic health record implementations have the following characteristics:

1. An interest in how their entire practice works as well as parts of the practice that are inefficient and may be subject for improvement with an electronic record. 
2. A teamwork mentality and the ability to trust employees as well as delegate appropriately. 
3. An appreciation of the work involved in transitioning from paper charts to electronic charts and a willingness to perform this work. 
4. A willingness to change their work process from a paper-based system to a new work process that takes advantage of information technology.

These traits would apply, of course, to any successful organization in any endevour, but we at TriCounty may want to ramp up our strengths and attend to our weaknesses as we move into the hard work of the EHR implementation.

Templating Mediocrity

A thoughtful article in the April 17 2008 NEJM co-authored by Jerome Groopman, MD ("How Doctors Think" and other insightful works), warns of the danger that EHR's with their templates, canned language and copy-paste abilities risk making the medical record much less readable. More importantly, the process of recording a history in an EHR could so restrict our listening, querying and thinking during the encounter with the patient that we may be more likely to miss the appropriate diagnosis or plan for the patient.

While the authors insist that they agree that EHR's have many benefits, they warn us to be wary of letting technology and "efficiency" become barriers to good care.

From the concluding paragraph: "as medicine incorporates new technology, its focus should remain on interaction between the sick and the healer."

As TriCounty moves ahead with EHR, these are warnings we should keep in mind.

eClinicalWorks Users Group

As you are probably aware, TriCounty plans to purchase eClinicalWorks, the same EHR system used by our local pediatricians and two independent family docs.

eClinicalWorks has an online user forum, created and maintained by doctors who use the system, not by the company.  There is a huge amount of experience and wisdom chronicled there.  I recommend checking it out and signing up to be a member (free).

Here is the address:

http://www.ecwusers.com/

Our EHR Project Begins

We have confirmation from Heal NY regarding the payments for our grant!  This means Tri-County can move ahead with the long-awaited EHR project.  The first order of business will likely be signing a contract with Consilium, a computer services consulting service that TCFM and Noyes have worked with regularly.  Consilium will help build and fine-tune our network for the increased traffic that the EHR will entail, and will also help manage the project.

However, we (the docs, PA's, nurses and secretaries) who are on the front lines need to keep our hands on this project from the beginning and not assume the computer experts will know how a medical office runs or a provider cares for patients.  We need to keep the goals in view of good care, provided efficiently and compassionately.

I intend to communicate the progress of the EHR project regularly, and to keep the clinician's perspective close to the details of the project.  Your input will be necessary and welcome.

This project will be hard work, like moving your household or starting a new job.  But like those challenges, this will be a real opportunity for us to improve things.  Improve our processes, strengthen our team work, and rebuild our organization.