Speaker 1: Alright guys, this is the fourth lecture to the electronic health records portion of the course. Today we're going to be talking about implementing electronic health records into practice. So some of the things we're going to talk about is explaining the considerations that must be addressed in planning a successful transition from paper charts to the electronic charts. You need to develop a conversion plan for the EHR, we'll talk about the requirements for the CMS meaningful use program for eligible professionals, and we'll describe the information that practice should apply to each software vendor in its request for proposal document and outline the information that practice should expect to receive from the vendors in return. We'll give examples of the workflow processes that must be redesigned when an EHR system is implemented, we'll outline the process of collecting and entering data from paper sources into the EHR, and we'll discuss problems that may be encountered when information is transferred from paper charts to the EHR system, and then identify specific challenges that may arise in training to use a new EHR system, and there's lots of them here today guys. We need to indicate how patients can be introduced to the EHR system, specify the contingency plans that must be in place before EHR is launched, discuss the EHR implementation process, and then explain how the success of EHR can be measured after the transition period ends. So there's lots of stuff to go over here guys, and this is an important chapter. So planning a successful transition, that's key number one. 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. So these are some questions that you need to ask yourself as a medical office and a medical practice. So what is the practice's motivation for making this change? What does it hope to achieve in making the change? Will the organizational culture support a technological conversion, and can it endure the frustrations and sacrifices associated with it? Are the patients likely to support a migration from paper to digital charting? 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 the period of reduced productivity? And does it have enough cost on hand to purchase hardware, software, or a software license and training and information technology support? So there's a lot there guys. So the pre-implementation 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. So it's really important that in order to implement this into your medical office, into your practice, that you really sit back and look at all these questions and be ready for anything that may arise. So developing a conversion plan. And basically this is when you need to create a team to help research, select vendors, train, implement, and educate about the EHR system. It could be the entire staff or even just a select group depending on the size of the practice. And this could include and should include providers, office managers, support staff such as medical assistants, receptionists, billers, medical record personnel, because all these various points of views can be invaluable in the process. It is important to be aware of all the possible pitfalls of EHR transitions in order to avoid them. So having everybody's point of view address this will really help you guys. And if you look at table 4-1 on page 91, I know it's really hard to see on here guys, but basically this table shows some common mistakes that medical offices make when transitioning to an EHR system. And this table also offers tips to avoiding some of these mistakes. So here's the problem. There might be poorly designed software or a lack of network server capacity. So the effect this could have on the practice. Security vulnerabilities. You could have poor performance, implementation delays, crash and downtime, undermining of confidence in the system, lower productivity, the need for inexpensive upgrades. So some of the things that you can do to prevent this and troubleshoot this would be to conduct accurate needs assessment, which we just talked about, accounting for future growth of the practice, purchase more bandwidth and switch servers if necessary. So it kind of just helps lay it out of things that we might need to change about our medical practice before making this implementation. This is just the second half of that chart right there. So meaningful use certification. So EHR vendors are evaluated on a set of core and menu objective measures. The meaningful use or the MU incentive program is a payment incentive plan made available for eligible professionals or physicians who implement and use their EHR technology in a meaningful way. So the main goals of the meaningful use program are to improve the quality, safety and efficiency and to reduce health disparities, engage patients and family, improve care coordination and population and public health, and then maintain privacy and security of all the patient health information. So in order to convert from paper medical records to electronic medical records, you need to select what type of conversion you guys are going to look to implement in your office. Is it going to be a complete switch? Are you going to take all the old paper medical records and then scan them and then turn them into electronic health records? Or are you going to do an incremental switch or conversion such as a hybrid office? And a hybrid office is basically the existing patient charts are kept on paper and only new patients are entered into the electronic database. This will have a slow incremental conversion because you'll only be a fully functional EHR system when all your existing patients have died, moved away or changed providers. There's also a modified hybrid and basically new patients are used in the EHR system while old patients are gradually turned into EHR records until there are no more established patient paper medical records. So selecting an EHR vendor and the network platform. So there are thousands of vendors and you need to know what your practice wants. So that starts by, again, assessing your practice needs. Then you need to survey available software applications and you can control the demos, not the vendor marketing the team. So it's selecting a network platform. It is important to base the decision on the criteria specific on the practice. Make sure that everything in the EHR system that that offers is addressing everything that you do in your medical practice. So how to assess practice needs. So many of the practice needs should have been identified during the initial readiness assessment, pre-implementation discussions like we talked about at the beginning, all those questions. But these are some other things that you should look at. You need to pick a company with a long-term service, training and software updates. Is the system compatible with other systems? Can we easily talk to the local hospital? Is it a CCHIT certified? Is it customizable? Can we do templates? How much does it cost? These are all things that we need to be thinking about when implementing electronic health records. So these are some of the things that you might want to ask the vendor to supply this basic information for the comparison of other vendors. Do they have references? Are there people talking good about their product? What are the EHR features that are available? What are the proposed hardware and network architecture? What is it going to take to make this EHR system compatible with our computers? How is the customer service? What are the HIPAA and coding compliance features? Is there interoperability functions? Can I take it and use it in my office and then send these records over to the local hospital? And of course, what is the cost? So when selecting a network platform, EHR software can either be licensed, which means it's purchased outright, you just buy the whole product, or it can be assessed by paying a monthly subscription fee to use it. So you need to be aware of that. But there's a client-server model. And basically this is where the user purchases the software, installs it, and then installs it to practice hardware. And then there's the application service provider, which is a subscription agreement. And that gives you access software over a secure internet connection. So there's the difference there. If you look at Table 4-2 on page 96 and 97, there's a comparison of these two types of network platforms. And that's important to know the difference, guys. So EHR adoption is not just for the launch of new technology, but a shift in the way the office conducts its business. You are going to have to redesign your workflow. By what I mean is you are going to have to design the way the office is run. So with the implementation of EHR, the workflow design is inevitable, it's going to happen. So it's important to ask your vendor for redesign recommendations. Do they have a way to help make this transition easier? And then you need to start a redesign process during the pre-implementation planning. And this is basically just refer to your policies and procedures manual to examine the current routines and then establish how you're going to handle these old routines moving forward. So if you look at Box 4-1 on page 98 of your textbook, you will see the office's procedures that will require a workflow redesign. So until the staff has some real life experience using the software, it's difficult to understand how to integrate it effectively into the office processes. The keys to success are flexibility, communication about what's working and what's not, and willingness to make a continual readjustment on the fly. So some of the things that you're going to need to rework and redesign the workflow of are ordering prescriptions, telephone messages, receipt documentation, a review of lab results, recording vital signs, maintenance to-do lists, and so on and so forth. So guys, there's a ton that you will have to think about redoing when you implement electronic health records into your practice. So you'll need to adjust the point-of-care documentation. So point-of-care documentation is documentation that is done during or immediately after the patient encounter. A lot of times you'll see doctors and providers and nurses now with iPads in the exam rooms, you know, entering in data as they go. That is point-of-care documentation. And this adjusts, it'll take adjustment at first, but eventually it will increase the accuracy of the patient visit and documentation. And then it will also decrease the amount of after-hours paperwork that you have to complete. The most difficult new workflow for some clinicians to adapt is the point-of-care documentation, just being able to adjust taking that iPad into the exam room and entering in the information as we go, instead of writing it down and giving it to the medical assistant to do after hours. You'll have to set up a billing cycle documentation. So when the practice converts to an EHR system, it must identify potential glitches in claim processing in reimbursement and to be prepared to sort out such problems once they are discovered. So AHIMA, the American Health Information Management Association, makes the following recommendation for all practices that are going digital. They suggest to create a common list of diagnosis and procedure codes that you use in your office to take advantages of auditing features of documentation. Pay attention to accuracy of code reporting and to design the EHR to avoid shortcuts that could lead to fraudulent behaviors. So the practice management capabilities of an EHR system are extremely useful in performing ongoing financial analysis and billing management functions. You should establish regular and random internal auditing to verify the following. Accurate data capture and documentation. Procedures performed are medically necessary. Practice notes are not cloned. Electronic signatures are used appropriately and prescribing activities are well documented. So going back and auditing yourself to just verify these will help make your billing cycle documentation go so much easier and smoother once you put this implementation into place. You'll have to edit collecting and entering data. So most of data initially entered into EHR come from paper charts. However, to offer the best possible healthcare and to protect the practice legally, it is important to gather patient data from all available resources. So methods for data entry. You can data input from compatible interface systems. You can use transcription using voice recognition technology or dictation. It could be scanned or typed or handwritten documents from old previous medical records. Or it could be the direct keying or re-keying or typing in of information. So the need to key data from paper charts into the new EHR is one of the biggest deterrents from adopting the new EHR systems. It's just going to take a lot of work, a lot of time, but it is essential in moving forward with your medical practice. So under-documentation and over-documentation. So the transfer of documentation from paper records to electronic records has its risks. It needs to require judgment by the clinician or the provider, but it also could provide under-documentation. So when too little information is entered, the skimpy EHR tends to generate drug interaction alerts and health promotion reminders more often. And then if there's over-documentation, so excessive detail may indicate a higher level of care than actually was delivered, leaving the provider vulnerable of charges of fraud and abuse. So it's important to enter in the information correctly and accurately. So it's important to prioritize information to transfer. Examples could be medication lists. So allergies are given a high priority here. And then you have structured and unstructured data entry. So it could be controlled vocabulary, which is, it's just structured data entry. It usually gives you straightforward clinical findings, for example, like strep negative or perla. While unstructured data allows you to free documentation when you type in whatever you need to put in. So there are EHR templates, and they carry both structured and unstructured data entry abilities. And while we play around with SimChart for the medical office throughout this course, that uses both structured and unstructured data entry. So electronic misfiling and interfacing. So electronic misfiling is information recorded in wrong, so it's basically just information recorded in the wrong part of the chart. And there are established guidelines for data entering during the pre-implementation phases. So there is controlled vocabulary to communicate more easily with other systems. This is known as interoperability or interfacing. So using a controlled vocabulary, most EHR systems can interface with at least some of the other systems, such as hospitals or a laboratory system. When this interface is seamless, reports from one system automatically populate templates and others. So this will help with many different things. It'll just become much more easy to work with these medical charts. The next thing is scheduling and training, guys. So staff have to agree on customization options before the training begins. So it's important to adhere to a level of computer experience and to train to a level of access. And it's important that you provide training manuals for troubleshooting and refreshers at workstations. So the better the training before the transition is implemented, the less hand-holding everybody will need afterwards. Costs will be lower and productivity will be higher, you know, getting the most out of your medical office. So it's really important that your whole staff is well-trained, well-versed, and the system is up and running at a level for your office before you start with those training processes. The next step would be to notify the patients that this is happening. So the best way to do this is to introduce using the three Cs, connect, collaborate, and close. So by connecting with the patient through interpersonal communication, and then collaborating with the patient to be sure they understand the new system, and then by closing through showing patients that you are logging out to secure their information, as well as thanking them for their support, that is the best way to notify patients and to get them on board. So if you look at page 102 in your textbooks, you're going to see this box, which is incorporating POC documentation into the patient's encounter, the three Cs. And this really gets down and breaks down how you should educate those patients and notify them about this. So some patients will be delighted with the change, while some patients will be apprehensive. So knowing this information in this box, guys, is going to be essential in your transition into electronic health records. So 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. And then making contingency plans. So contingency plans are required by the HIPAA security rule, and the rule requires that patient health information be protected from disasters of all sorts, including system crashes that may occur when a new system is launched. So it's important to have a backup plan. Plan in the event of an emergency, and then it should have a gradual rollout when you are implementing the system. Don't just go all at once, boom, here it is, everything's up and running. Gradually roll those out to help with the implementation. And then finally, it's implementing the transition. Everything's all been done. Our patients have been notified. We are ready for it. The next thing is, so the readiness to launch the implementation phase depends on the installation of technological resources, the completion of staff training, the existence of funding to carry the practice through the transition period, and the availability of the staffs and the clinicians. As the EHR is put into use, the plan for its implementation is tested, its limitations quickly become apparent. So it's best to have a test phase. Try this out a little bit. See if it's going to work. Another important thing is the staff has to be flexible. There are going to be things that come up. There are going to be limitations. There are going to be issues. So the staff has to be flexible and handle these with grace, tact, and ease. And then your IT support for troubleshooting. Reach out to the IT departments and your customer service of your EHR vendors and really get the most out of your EHR system. And then the next thing is after it's been implemented, it's out there, you need to be able to measure the results and to conduct evaluations on how successful this is. So EHRs have been associated with improved safety of patient care, better financial performance, higher provider satisfaction, and then more efficient communication as well. So the attributes of all this can be measured with an EHR are nearly unlimited. You can really look at your costs, how many patients you're seeing, you can ask the patients how satisfied they are, and it's good to generate baseline data before you implement this system so you can see how much this has affected your practice afterwards. And that is it guys for this chapter. I know it was a pretty quick lecture. I know there was a lot there, but continue working hard. Do your chapter review exercises. If you have any questions, please feel free to come and ask me.