While some practices are clinging nostalgically to their paper chart-filled cabinets, growing numbers of clinics have flung themselves wholeheartedly into the digital revolution. As a result, the must-have tool in the smart physician's armamentarium is an electronic medical record (EMR) system. Despite being only the first step on the road to fully paperless care, the question of whether or not a practice is EMR compliant is fast becoming the dividing line between 20th and 21st century patient care. So what is behind the allure of EMR?
Quite simply, says Dr C. Martin Harris, chief information officer for the Cleveland Clinic, Ohio and Cleveland Clinic Abu Dhabi, the promise of faster workflow, reduced costs and a better deal for your patients.
"Electronic medical record systems will play a vital role in improving the quality of medical care we can provide to patients, " he explains. "They provide the continuous connection to the healthcare system that is going to be required to effectively treat conditions like cancer, hypertension and asthma over a long period of time."
Edward Cowdery, director of Sensitron MENA, a wireless healthcare solutions company, describes the perks of EMR as "Supporting staff, workflow and costs and saving time and money.” "EMR systems remove barriers to the delivery of care," he says. "They reduce medical errors, and enable a comprehensive treatment plan with timely interventions." But the task of prepping your practice for the prime time can be smoother sailing for some clinicians than others. While some implementations proceed on schedule with minimal disruption to workflow, others flounder at the first hurdle, and crash and burn within the first year. As Ferhad Patel, GCC regional business manager at Intel, admits, "Selecting the system is the easy part." So for practices contemplating the jump to online care, how can you best avoid digital dilemmas for a successful conversion?
The IT in team
First and foremost, says James Hildebrand, a senior consultant with consulting firm InterHealth Canada, is getting your team on side. Everyone will play some role in the implementation process, and if your staff or physicians think change is a dirty word, it will seriously impact your project.
"Involve key management and end users who will be impacted by the change to EMR," Hildebrand suggests. "Ask them to define current issues, and their views of EMR. This will help identify some of the cultural views, biases, and perceptions (true or false) of what EMR is and what it can do for their day-to-day work."
Persuading IT-phobic physicians can be a particular challenge, Patel explains, so it is worth presenting EMR in terms of its clinical benefits rather than its technology. "If everything is automated, for example, including the patient's history, you can see and predict clinical trends," he says. For practices that offer diabetes or obesity counselling, or smoking cessation programmes, EMR systems can be a fast route to providing better preventive care.
Cowdery also advises holding a team meeting to evaluate whether the time is right to jump to online care. "You must make sure you are at a stage as a corporation to commit to putting the necessary resources into the IT," he stresses. "Each corporation should receive a clean bill of health as being ready to accept technology." The message is that EMR will not fix your practice - if your company is failing, your implementation will too.
EMR experts also recommend establishing a crack team of decision makers to oversee the entire implementation process. The team should include a physician champion, to marshal discussions and problems among other physicians, a project manager to oversee the process on an ongoing basis, and at least one person to train as a ‘super user' on the new software. This person will support other, and new, staff members in a real-life environment once the official training period ends. Describing this team arrangement as "the model for implementation," Harris urges, "You wouldn't do it any other way."
"Staff, especially those from the old school who have been used to doing everything manually, they are often hesitant about using IT," adds Patel. "If they run into any errors, they immediately want to drop the whole IT solution and go back to the manual way of doing things. It is really important to have a team on side to support the implementation through these problems."
Picking your partner
It may sound obvious, but your choice of software vendor will be one of the primary factors behind your practice's success. Installing EMR is not like updating your Microsoft programmes; it is much more complex. And when a brief search on the internet can reveal more than 200 companies that claim to offer EMR systems; it's enough to make any physician feel overwhelmed.
Time and planning is key to making the right choice, says Hildebrand. "Give yourself time to select the right vendor," he explains. "Don't rush or you will find yourself having to replace and retrain the new vendor to your environment all over again, who will likely also rethink your IT strategy."
When choosing your company, remember that experience counts. "Find a vendor who has their critical mass within Healthcare IT/EMR implementation, and within the area of expertise you seek," Hildebrand adds. "If the vendor has a consultant expert in EMR, make sure he/she is not the only one and, if so, that he/she is actually the one who will be working on the project. Vendors will often promote their top people only to have them working somewhere else. You need to get it in the contract."
Although all vendors should have case studies or references from past clients to demonstrate their expertise, it's also essential to do your own digging. Hildebrand recommends sourcing clients who are not on the reference list. "These people will likely give you a more balanced response as to the strengths and weaknesses of the company," he explains.
Lastly, don't be swayed by price. What appears cheap at the outset could prove a costly mistake if you need to change vendors halfway through the implementation process. A higher budget at the start can save you time and money down the road, says Cowdery. "Spend the money with the person who knows the market," he recommends.
"When your practice has a bottom line to consider, you need a product that will deliver it. Select a firm who is committed to your company."
A common error among first-time EMR buyers is the failure to plan exactly what they want the system to do. Without a shared game plan, it's difficult to tell whether a system is hitting the right notes or falling at the first fence. Getting your EMR goals in place early is key for gauging your digital progress. But as a virtual virgin, how do you identify your objectives? One way, says Cleveland's Harris, is to map out your workflow patterns to see how an EMR system could save you time and money.
"Workflow from everyone's perspective is important in designing a successful electronic medical record system," he explains. "For example, renewing a prescription must include the role the patient will play in recognising the need to renew, the physician approving the new prescription and the role the retail pharmacy will play in fulfilling that request. By thinking about these three workflows at one time, the process of prescription renewal can be optimised for everyone."
Most vendors will have a Q&A template to help practices reevaluate their workflows. Hildebrand, however, recommends also putting a price tag on the time and money it takes to complete daily tasks under your current manual system."Establish a baseline of your costs and time required to do business with the existing paper based medical record system, and then define problems and benefits under the EMR implementation," he says.
For example, to cost the task of finding paper charts, calculate the number of times the procedure is performed daily, then multiply by the time taken each time, and again by the average hourly rate of your administrative staff. So if your secretary locates 80 charts a day, at five minutes each time, then the total time daily spent finding charts is 6.6 hours. Multiply that by your secretary's hourly rate, say AED 50 per hour, and you can determine that the ‘cost' of locating charts is AED 330 per day, per physician. This allows you to establish how EMR would reduce that overhead, giving you a cost guideline to work towards.
"You don't have to reinvent the wheel with each workflow," Patel stresses. "But system integrators need to understand the practice and what the physicians are trying to accomplish."
Your goal plan should also factor in potential problems and hidden costs. Almost all practices will experience a period of reduced productivity as staff grapple with the new system. "EMR conversion can be an evolutionary process," warns Hildebrand. "While staff are used to one-stop-shopping with paper charts, the EMR will take some time to evolve towards this same status."
Hardware may also need to be updated, and technology decisions should be weighed against future objectives. Some of the common shortfalls vendors see include lack of storage capacity; lack of bandwidth and wireless technology and poor integration between varying systems.
Aim to be realistic with your objectives and timescales, says Harris. "Focus on the goals that you truly need to accomplish in any given time period." In the first six months of an implementation, if the caregivers have never used an EMR system before, it is important to get them used to retrieving information from the information system.
Practices should also be prepared to fork out extra for temporary staff to help with converting paper charts to digital records. The process is, admits Patel, costly and time consuming, but it's essential for acceptance of the EMR system. Scanning strategies vary, and no one answer is right for all practices. Some prefer to intensively scan all charts before launching their EMR system, while others prefer a phased approach.
"We recommend starting with the latest inactive patient files (2-12 months)," explains Hildebrand. "They're not very old but not critical as part of day-to-day operations. This will allow for scanning to occur with fairly early information and test the system of scanning without impacting clinical activity."
"You have to allow for the fact that there will be problems along the way," adds Patel, frankly. "I would say, realistically, plan for at least one year before expecting EMR to makes a real impact on workload. The first six months are early days."
Education, education, education
Training, experts agree, can make or break your switch to digital care. Even the most high-end system is useless if you don't know how to use it effectively in your practice. For busy physicians, however, the thought of fitting in pre-launch sessions, job-specific sessions, and follow-up training is enough to bring on palpitations.
One way of ensuring training is as quick and effective as possible, is by tackling computer illiterates before sessions start.
"Everyone should have at least proficiency in Microsoft Office," stresses Patel. "It is nearly impossible to train a class where one user is totally proficient and another hasn't touched a PC in their life."
Healthcare groups, such as the Hamad Medical Corporation, have responded by sending all staff on a general IT course before implementation begins. One such course is the International Computer Driving Licence (ICDL) digital literacy programme for the Gulf States. According to director general, Jamil Ezzo, the healthcare sector in the Middle East is lagging on technology, particularly on the administrative side. "Digital care is dictated by the level of skill the administrators display," he says. "If a practice has historically done things manually, it is impossible to upgrade without common computer literacy."
The ICDL course takes approximately 20 hours, per user. Staff can attend classes, or larger healthcare facilities, such as the UAE Ministry of Health, may choose to become ICDL accredited and adopt in-house training procedures. "If computer literacy is adopted, practices will find they get far more out of their employees," Ezzo reports.
Most vendors will provide in-house training before an EMR system goes live. The key, states Hildebrand, is to free up staff as soon as possible to try out their new skills so they don't forget what they have learned. "Timing is important," he says. "For cost and implementation reasons, the goal for training is to get staff up to speed as quickly as possible."
The daily routines of practice, however, can wreak havoc with training sessions. Between patients, phones and physicians, administrative staff can find it tough getting to grips with new skills. Where possible, squeeze in sessions outside surgery hours, or consider reducing your patient load on training days. For uninterrupted learning, Hildebrand suggests, vendors should create demonstration models the work environment, and train staff within this environment before the system goes live.
"Then migrate the demo system to the go-live phase where the staff can use the system for real, with on-site support to deal with any unforeseen issues," he says. Your designated ‘super user' also comes into play here, to help less experienced staff with the transition. "Super users are important to develop within the organisation," Hildebrand agrees, "But vendors can rely too heavily on them to bear the load of training. Don't underestimate the need for on-site support and advanced training over the long run."
For ongoing training needs, Patel is an advocate of web-based learning, to help keep skills fresh. "Training shouldn't just be in a classroom environment, especially when staff are already busy," he explains. "With web-based training, staff can learn at their own pace and it allows you to monitor their progress."
Regardless of the training schedule you choose, says Hildebrand, encouragement goes a long way towards keeping staff on side and happy. "Training staff on the system is about changing behaviours and attitudes about their own work process," he explains. "Much work needs to go into communicating to staff about the changes to workflow, dealing with resistance to change, and fostering communication between IT and clinical team members."
EMR implementation is daunting. A lot can go wrong. But with the right preparation, it can lead to more cost-effective, efficient workflows that will have a real impact on a clinic’s bottom line. And if considering a move to digital care, Patel states that there is only one point to remember: "Planning. Plan everything; your implementation, your training, your future needs. There will be hiccups and teething problems, but if you plan ahead from day one, EMR will save you time, effort and money in the future."
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