GET YOUR STAFF READY FOR EMR

Approach the process as a marathon rather than a sprint.

By René Luthe Senior Associate Editor

Physician frustration with the ongoing conversion to EMRs is well known, but the process isn't a walk in the park for the rest of an eye-care practice's staff, either. While younger techs may typically be more computer savvy than the doctors, EMR offers challenges for all concerned. As consumed as you might be by your own struggles in the process, it's also important to make sure your staff adopt quickly. Practices that have made the conversion tell how to smooth their path.

It Starts with the Selection Process

One way to almost guarantee a difficult staff conversion to EMR is for the physicians to select a system without any input from staff. One practice administrator tells of hearing horror stories of physicians making an impulse buy at a medical meeting and then surprising their staffs with it. “They brought it home and said, here you go! That's a huge problem,” says Laurie Brown, administrator at Drs. Fine, Hoffman & Packer in Eugene, Ore.

Instead, the physicians should have representatives from each part of the practice involved from the earliest stages of EMR selection. When going to view a demo, Janna Mullaney, chief operations officer of Katzen Eye Group of Baltimore, advises bringing along a work-up tech and a scribe.

It is crucial not to leave any component of the staff out of the selection process, Ms. Brown says. “You have to talk with the doctors and the staff about what their goals and needs are for EMR, so that you will have a wider perspective.”

Fishkind, Bakewell & Maltzman in Tucson, Ariz., also took the staff-inclusive approach to their EMR hunt, according to practice administrator Beverly King. Their EMR committee consisted of four employees who served different functions within the practice: an IT person, a technicians' manager, a staffer who “floated” between the front office, the clinic and the ASC, and herself.

The Value of Varied Viewpoints

Those in on the hunt for a system get a feel for what changes will be required to the daily routine for positions throughout the practice. Techs and scribes, Ms. Mullaney says, “actually have completely different feedback than the doctors. The doctors tend to look at the end of a patient visit; how do they code the visit? How do they document their discussion?”

Work-up techs, on the other hand, focus on the data gathering in the early stages of the exam. “They want to know things like how to record that the patient has changed medication, or is not complying with their dosing schedule, or how to record that the patient is not sufficiently coherent to give the history, so the patient's grandchild is giving it,” Ms. Mullaney explains.

Another significant benefit of including staff in the search — to paraphrase Tip O'Neill, people appreciate being asked. “It really does help the morale, moving forward, if they feel that their opinion was valued enough to get them involved before the buy,” Ms. Mullaney says.

Thorough Prep = Smooth(er) Process

There's no way around it: For staff to master their new EMR duties quickly and smoothly, the practice must put in the time laying the groundwork. How much time? Ms. King reports that her practice spent eight months preparing before go-live day. “We wanted to avoid as much pressure and chaos as we could,” she says. The entire staff was trained to abstract charts, so all could help with scanning during their down time.

Ms. Brown, too, familiarized the staff with computers through small steps. Everyone was moved to e-mail communications, even those whose jobs hadn't directly entailed access to it previously. Keyboard and Windows skills were evaluated to determine who would need more training. “We gave assignments and helped people keep touching the EMR and learning about it until we went live,” Ms. Brown says. And before they began seeing patients, the practice began doing prescription refills and documentation of patient phone conversations in EMR. “So staff had a baby-step use of it. That helped a lot.”

An additional critical component in laying the groundwork for successful transition, Ms. King says, was evaluating working relationships between physicians and their technicians or scribes. Previously, techs had “floated” in their pairings with the various physicians, but given that EMR adoption was a rather stressful undertaking for the physicians, changing sometimes even their choreography in the exam room, the practice decided to designate teams. “We tend to have the chair sides that work best with that doctor assigned to that doctor more often,” Ms. King explains. “We look at who communicates well with that doctor.”

The Training Itself

The “train the trainer” approach — in which the selected EMR manufacturer provides instruction to a few employees within the practice, who then train their fellow employees — was the preferred choice among the practice administrators who spoke with Ophthalmology Management, They say it reduces the need for the practice to pay for additional training time for the entire staff. Just a few key personnel are necessary.

At Ms. Mullaney's practice, the EMR company trained the practice administrator, a lead scribe and a lead tech. Each of them, in turn, worked with another staffer. “As the next person becomes developed as a super user, we would bring in two more,” Ms. Mullaney explains. “Every time we had someone up to speed to mentor someone else, we would add to the super-user group.” It helped, she believes, that the trainers and trainees already knew each other — and the practice. “They understood each other very well and they already knew the way that we do things.”

At Ms. Brown's practice, the designated super users received training firsthand from the EMR vendor. They then returned to their offices and trained others. This continued for nearly a year. Ms. Brown says a super user should be trained for each area of the practice, including for front office personnel. The next step is to ensure the super users are sufficiently accessible to the people who rely on them for training. “The end user is new to this; they have to have someone to answer their questions and support them,” Ms. Brown explains. “A lot of companies, I think, struggled when their project people for EMR didn't have enough dedicated time. Without that, they couldn't be a good support to the end users.” Be sure to leave time in the super user's schedule specifically for dealing with questions and comments from staff.

Do It in Phases

Even if you are sure your staff has undergone sufficient training and you think they know the EMR backwards and forwards, conversion in small bites is the best route. Eye Centers of Tennessee practice administrator Ray Mays warns that no matter how many hours staff has put in learning the system, “Each patient encounter is different.” Just as no battle plan survives first contact with the enemy, no amount of training will prepare staff for every challenge presented by a real patient in real time.

“If we could have said, okay, we want the ocular pressure for the last three visits entered into the system for everybody, that would be easy,” Mr. Mays explains. “But for some people you need the last six visits, some you need 20 years' worth, so it's just a lot of stuff that you don't know what's going to happen until the patient is there. Where's that OCT? Where's that last GDX? Are we going to scan that in, or are we going to do a new one and store it in the system?”

To reduce the potential stress from these sorts of situations, Ms. Mullaney's practice took one doctor live at a time. Once a particular physician was chosen to be next, that doctor and her or his team would receive concentrated instruction from the super users. And since only a few members of the practice would be grappling with EMR transition at one time, the super users could easily offer them support during the process.

At Ms. Brown's practice, on the other hand, they began with new patients only. “From the day we went live, we didn't want to create any more paper charts that we would have to ultimately convert,” she says. “So we started with new patients and we made sure that each technician got at least a couple a day.”

Soon, however, the techs felt they were ready for more. “They felt like they weren't touching the EMR enough, and you want to use it as much as you can to get better at it,” Ms. Brown says. “So we ramped up and started adding established patients, or earmarking them throughout the day so that everyone got a few more new and established patients.” While the techs at the practice conquered EMR faster than anticipated, it's crucial to note their supervisors didn't attempt to move them to the next level before they felt they could handle it.

Avoid Regrets

Toward that end, don't rush EMR conversion, period. “I would go slow,” Mr. Mays says. “The money that you receive from Medicare for EMR adoption isn't worth rushing.” Ms. Mullaney notes that practices often try to move too quickly, first implementing a practice management system and only a few months later embarking on EMR.

Another reason to not try for a forced march toward conversion is that some staff or the physicians to whom they are assigned, or both, won't get the hang of EMR as quickly as others. Some not only might be very tech-savvy, but they also might be dealing with a more complicated patient base. Having some flexibility built into the schedule is a must, says Ms. Mullaney.

If they had it to do over again, two practices mention that they would have brought in more varied test patients during the training period in order to avoid time-consuming surprises once they went live. “We would have shut down completely for a week and had the trainers on site and just gathered up 100 patients that we know and trust and asked them to volunteer for an exam,” Mr. Mays says. “That way we would get a little better understanding of how the EMR works with a patient actually in the room and you trying to stay on schedule and not have a waiting room of unhappy people because you're stuck.”

Ms. King agrees that more detailed test patients greatly improve staff readiness. “It helps to go deeper in situations that may occur in the lane — really get into each diagnosis and connect it to the visual field functionality and all that process so there aren't surprises on the fly,” she says.

One situation to avoid at all costs is for a multi-site practice to covert all offices in one fell swoop, according to Ms. Mullaney. “If you do all your locations at once, you really split up your support staff on that day one, because they have to be in different places. You want that day one to be as positive as it possibly can be.”

After ‘Go Live’

Be warned that training doesn't end with your first day live on your new EMR. While the tutorials and homework assignments may have gone smoothly, the stress of dealing with live patients and trying to stick to a schedule will cause even quick studies to blank out. To help guard against brain cramps, Ms. Brown's practice hung instructions on what to do with an EMR chart in the staff kitchen, where everyone would be sure to see them and could review at their leisure.

As for those EMR committees established during the selection and training stages, don't think you can disband them once your system is up. EMR adoption is very much a work in progress. Ms. Brown points out that staffs need to know whom to consult when (not if!) they run into a problem. “We had lists going where people could express their concerns and ask questions about how ‘x’ would be done. If we didn't have the answer, we found out as we went through it,” Ms. Brown says. “We were going to keep making the process better all the way along, with everyone's help.” The committee also evaluates requested changes to the templates, examining how they would affect everyone who uses the system.

Ms. King agrees that it is essential to keep the lines of communication open. Her practice recently held a “tech appreciation” lunch and instructed staff to bring their EMR comments and suggestions. One thing your EMR commit tee must be ready to communicate is the “why” rather than merely the “how” of the new EMR system, Ms. King has found.

“The technicians in particular are pretty thirsty for knowledge and they want to know why, oftentimes. Especially with meaningful use, for example, we've been telling them they've got to do ‘x’ for MU. So last Tech U, we went into detail and told them about the measures, and why they had to enter this. Now that they understand the why, so it's easier for them to do it. They wanted to understand why they have to ask every person their ethnicity! We know why, but we didn't realize that they would want to.”

Prepare for Frustrations

Even with a thorough training program and attentive supervision, however, there will be frustrations. Many techs may echo a common complaint of physicians regarding EMR: less face-time with the patient. Staff must spend so much time looking at the computer and keyboard instead of at the patient that the patient may end up feeling ignored.

“You're not familiar with where all the information goes, so you have to hunt for that, put it in, get the next piece of information, hunt for where that goes, put that in. We've posted signs all over the office for patients explaining what we are doing, we apologize,” Mr. Mays says. As trying as that may be to everyone, though, he suspects there is no way to entirely avoid it on the way to EMR conversion. “Start making mistakes and get on with it,” he advises. OM