Hard Lessons From EHR Case Files

Those who have been through it tell what they would have done differently

BY BILL KEKEVIAN, ASSOCIATE EDITOR

With Karen Gibbs leading the charge, seven employees of The Center for Sight in Lufkin, Texas, marched into the 2011 AAO meeting on a mission. Each person, representing a different department, would scour the EHR vendor booths in search of a system that could get high marks from everyone. It was an integrated approach, one the practice’s staff wished it had taken three years earlier.

“When we hit the floor, we all spread out and looked at vendors,” says Mike Green, COA, the technician the practice designated to be responsible for coordinating EHR transition. Each team member “hit their favorites pretty hard.” They were trying to build a case to share with the rest of the team. By then, they all had been through the nightmare of an EHR vendor that didn’t live up to expectations, so they knew what to be wary of and what was on their wish lists.

They wanted something customizable that would still qualify for meaningful use; something that would translate across departments; something affordable, yet sturdy enough to carry the weight of six doctors working at two locations. The requirements were numerous. “Best money I ever spent,” says practice founder Richard J. Ruckman, MD, FACS, of the undertaking.

Installing EHR can be costly, time-consuming and, thanks to Medicare imposing penalties (a 1% meaningful use penalty and a 1.5% PQRS penalty) on reimbursements to noncompliant physicians in 2015, all but necessary. Darrell White, MD, of Skyvision in Westlake, Ohio, calls it “taking your medicine. You’re just going have to swallow hard,” he says.

Karen Gibbs, CPA, practice controller at The Center for Sight in Lufkin, Texas, at a now tech-heavy work station. The Center for Sight is one of many practices learning that EHR implementation is a team effort.

Some sound shopping advice from practice managers who have been through the process may help the transition go down easier. Here, practice managers and principals share the lessons they’ve learned while implementing their own EHR systems.

The Second Time Around

Dr. Ruckman’s practice got it right the second time around with every department represented through the process. “When we went to EHR at first, we didn’t have everyone involved. When it comes down to really selecting a system, you have to consider who’s doing a lot of the work,” Dr. Ruckman says. “The second time we had doctors, nurses, technicians, the billing department all bringing a different perspective.”

Ms. Gibbs, a CPA and the controller of the practice, pushed for an integrated system, according to Dr. Ruckman. “Make sure it’s a package deal that takes care of all your needs, including the financial aspect,” he says.

The original EHR system wasn’t compatible with the billing software, Ms. Gibbs says. It created transfers between subaccounts within the same patient account, effectively quadrupling the billing department’s work. It also caused a lag in relaying information from the clinic to the front desk for checkout. The monotone EHR layout caused problems with coding. The new system uses multicolored fields that “make it intuitive and easy to follow,” Dr. Ruckman says. “You know pretty clearly when you’ve created a meaningful use element.”

Mike Green, COA, is the technician responsible for coordinating The Center For Sight’s EHR transition.

Hardware Issues

That’s not the only aspect that caused a lag. Because the practice had just purchased new laptops with the original software, the managers decided not to upgrade the hardware, Mr. Green says. If he had it to do again, he says, “Without a doubt I would have made sure that our computer systems would have been compatible from the very start.” The inadequate hardware led to a multitude of compatibility problems. Updating that hardware at that time “was not cost-effective, or so we thought,” Mr. Green says.

The result, Dr. Ruckman says, was waiting 10 minutes (or twice as long at the satellite office) just to launch preloaded data for a postoperative cataract follow-up exam. The whole visit, he says, should only take 15 minutes.

“We should have paid more attention to the fact that, while the first EHR was good for a small optometric practice with an optical shop, it was not a good fit for a two office ophthalmology practice with optical shops and a surgery center,” Ms. Gibbs says.

“With our initial system, we found it would work well with perhaps a single doctor or small practice, but did not function at all with an office having a surgery center, multiple doctors, and multiple locations,” Dr. Ruckman adds. “We were also virtually shut down for a day or two every time an update was performed.”

Customization a Key

The Center for Sight team realized they had to determine if the practice needed a customizable system or one off the shelf. One question Ms. Gibbs advises asking: “How easy is it to customize and still meet meaningful use criteria?”

Dr. Ruckman at first leaned toward the off-the-shelf system “because it would be easy to introduce.” But he came around to a customizable EHR. The off-the-shelf system lost its luster. “It ended up giving us a lot of useless information and we were clicking lots of multiple screens and drop-down menus,” he says. “It would take 15 minutes to do a simple slit lamp exam.” Now, with the customized system, “our drop down menus just show the most important aspects and then allows us to put in the information we need,” he says.

With many off-the-shelf systems, doctors have to scroll through multiple meaningless menus, including patient height, weight and blood pressure, Dr. White in Ohio notes.

Pick A Super User

Ophthalmic Partners of Pennsylvania in Philadelphia had a unique opportunity to prepare its practice for EHR. The practice built and configured all its offices for EHR when it moved the main office and two satellites 18 months before EHR migration, says Julia Lee, JD, executive director. The practice installed wireless access points, purchased laptops and designed each exam room to accommodate EHR. Although some decisions required additional refinement, these extra steps made for a smooth transition to EHR.

Planning every step in advance resulted in no drop in patient volume or loss of revenue, according to Ms. Lee. However, she says, even with the best of planning contingencies arise. That’s one reason Ms. Lee says her secret weapon was assigning the practice’s clinical operations manager, Kellie Moore, as a “super user.” With more than 20 years experience as an ophthalmic technician and more recent management experience, Ms. Moore’s goal was to ensure that the technology would respond to the practice’s clinical needs.

“It was a leap of faith for Kellie to go to the training workshops and become certified by our vendor,” Ms. Lee says. “She took to it like a fish to water. Now, she’s even helping other practices.” Ms. Moore has assisted with EHR template customization for practices in New York and Utah as well asWills Eye Institute in Philadelphia.

What a ‘Super User’ Does

Although implementation is a team effort, assigning one member of that team as a super user is useful and common. Peter Polack, MD, FACS, explains the “super user” is a point person who acts as troubleshooter and motivator. This person must not only know the EHR system inside and out; she or he has to understand clinical flow and the users’ needs at the ground level.

“There are times Julia and I would be on the phone late at night talking about some EHR challenge I thought about on the way home. For small practices it’s difficult,” Ms. Moore says. “You’re asking managers and physicians to do things they’re not really trained or have the time to do.”

For the super user it’s a lot more work, but the rewards are high. “Any of us who actually work in the clinical field know the doctors are going to turn to [users well-versed in EHR] with questions,” says Johanna M. Keys, administrative clinical operations manager at Retinal Consultants of Arizona. “Doctors rely on them very heavily.”

A Team Effort

Even with a designated super user, the rest of the team should operate as a single unit throughout the implementation process. Here are steps practices can take to prepare:

► Scrap the deadline. “We thought implementation out so far in advance, but remained flexible,” Ms. Moore says. “It was a self-imposed deadline so we could move it. If you invest the time and energy into doing it right it can be much less (or not at all) traumatic.”

► Preplan. “If you’re up against an outside deadline, preplanning is even more important because there’s little or no room for error,” Ms. Moore says. “Think about what you want to look like at go-live and work backwards from there.” Adds Ms. Keys: “I would have four-hour training sessions once a week over three or four weeks. That way people don’t lose interest. It opens up other opportunities for staffers to notice new things. We did have a lower patient load when we first went live. I would do that again.”

► Make training fun. Be prepared to spend extra time in training for a while. “You need a staff willing to put in a lot of extra hours up front to be successful,” Ms. Moore says. “We had buttons and tee-shirts made that read ‘There is no crying in EHR.’ It had everybody laughing.” Adds Ms. Keys: “I’d have team pow-wow sessions, maybe bring lunch in and talk it out.”

► Keep everyone up to date. “Before we make any changes, I’ll call everyone in and explain them,” Mr. Green says. “There’s constantly new training, almost weekly.” Some EHR systems also offer Web access to pre-taped training sessions. The benefit of that, Ms. Keys says, is that users can go back and repeat steps at their own pace.

Rolling Out the EHR

Warren Laurita, practice administrator at Retina Associates of Cleveland, explained how his practice successfully rolled out its EHR. Four companies made pitches to their EHR team which consisted of doctors, clinical supervisors and Mr. Laurita. Then, they ended up doing three site visits.

Once the team chose a program, just two doctors started on the EHR system at first. They started with only two or three patients on EHR in the morning and the same in the afternoon; increasing the number daily. “After those two were fully up and running, we added two more doctors and then two more and then the last two,” Mr. Laurita says. “All the doctors worked full time maintaining their normal schedule.” He says it took about 60 days for the first two doctors to be fully up and about 10 months for everyone.

One Step at a Time

The principals at Ophthalmic Partners of Pennsylvania advise practices with satellites to roll out EHR one office at a time. Because the cataract and comprehensive division of this practice had the most straightforward documentation and it was the main office, it went first. Ms. Moore took the existing paper charts and adjusted the EHR templates accordingly.

Communicating freely with the physicians, Ms. Moore was able to match the particular terminology of each one to the software. This process took a few months, but once both she and the physicians were comfortable, the implementation team moved onto the pediatrics department, where they spent the next six weeks. Once pediatrics was up to speed, they tackled the cornea division.

“Our main location was the Guinea pig,” Ms. Lee says. “Some of our satellites translated seamlessly, but not all. We should have been more sensitive to the culture and dynamics specific to each location and customized the training or work flows’ a bit more.”

An “overnight transition,” Dr. White says, can mean countless hours of catch-up every week for unprepared staff and doctors, and that’s a lesson you do not want to learn.