Teach, Listen, and Learn: Successful EHR Implementation

During a Tuesday morning educational session at HIMSS, Kathryn Kern-Stout, MD, MBA, from the Virginia Women’s Center in Richmond, VA, discussed some of the challenges her institution had to overcome during the EHR selection and implementation process. She spoke about the benefits of adoption and outlined key objectives that had to be met to ensure a successful implementation.

First, to provide a little context, she gave some demographic information about the Virginia Women’s Center: there are 26 physicians, a host of mid-level providers and other providers (including psychologists, maternal-fetal medicine specialists, nurse practitioners, midwifes, and nurses), and more than 25 office and research staff. The institution serves five hospitals across three health systems, and offers eight areas of practice in addition to OB/GYN services. The providers average over 5,600 patient encounters per year.

From the beginning of implementation, the staff at Virginia Women’s Center held the standard that the EHR should be a juncture between patient and physicians, not an obstruction; should facilitate patient encounter from call center to checkout. The goal was also to implement a system that did not create an environment where the physician would be tempted to turn his or her back to the patient during an exam to interact with the EHR. This was accomplished in part by electing to use tablet PCs, which allow the physician to maintain eye contact with the patient even while he or she is entering data into the record.

The question confronting the implementation team, as is the case for so many other organizations seeking to implement EHRs and other IT solutions, was how to gain acceptance for implementing new IT tools in practice. Gaining acceptance from all stakeholders was paramount. Focusing on improved safety goals and minimizing the effect of the logistics of implementation and use on the overall operation of the practice were also key.

So, how to gain acceptance for an EHR? The physicians in the practice were concerned about the effects on patient care and safety, data availability with the new system, the time commitment required to train for and use the new system, and the cost of lost productivity, among other worries. Staff concerns included the potential impact on their relationships with the patients, as well as the impact on the provider-patient relationship. They were also concerned about how much time was going to be allowed for learning to use the new system and whether a successful implementation would result in the need for fewer staff.

To allay those concerns in part, it was beneficial to take note of the challenges the practiced faced because it used paper records: these included onerous chart documentation requirements; discrepancies in coding, charge entry, and billing; and limited and difficult access to patient safety data and third-party payer data for negotiations, among many other barriers to care.

The EHR the practice selected is an in-house hosted solution that features a variety of patient-facing features, including online appointment scheduling, Rx refills, and bill payment. It will soon offer secure messaging and the ability for patients to view their medical records online and add/edit data. Implementation began with advance meetings with all stakeholders to determine the system requirements needed by each group and to listen to and address the concerns mentioned above. Stout said that the process took eight years from the initial phases of research and review of EHR options, to gaining the trust and buy-in of physician leadership, to making the final purchase decision. The practice decided to pursue a sequential phase-in of the new system to facilitate uptake, with the smallest office first in line, with additional installations at the remaining offices following at two-week intervals. During the go-live process, the practice had 24/7 help desk support. Workflow redesign was “absolutely critical,” said Stout. In order to provide the necessary resources to ensure successful implementation, the practice added a network administrator, a director of operations, a director of clinical applications, and a physician EHR director (a position that was filled in-house). The process was designed to be as flexible as possible, with the mantra throughout being “Teach. Listen. Share.” However, Stout said that the key to rolling out the system was “intolerance of non-success.”

What has the practice learned four years post go-live? How has it benefited? Stout said there is no way the practice would go back to using paper-based records and has actually found that, among its other benefits, having an EHR system nowadays is mandatory for effective physician recruitment. Other lessons learned include:

The EHR allows practices to meet the new standard for 21st century patient care: optimal standards optimal safety = optimal patient outcome.

A practice with an integrated EHR system needs to have defined clinical workflows that replace the old-fashioned view where the physician is at the center of care; now it’s a team environment, with the patient at the center of care and the EHR as the means of accessing information.

Practices need to develop and use standardized forms. People within defined roles need a standardized data entry mechanism that allows them to enter and retrieve data from the system. Standardized problem lists are one example: at Virginia Women’s Center, physicians are only allowed to select a diagnosis from the standardized list because it’s linked to the proper billing codes.

A common complaint is that EHRs document too much information that is not usable at the point of care, but also spread useful information across multiple screens and views. Providers need to be able to identify if necessary data is there in the record — one screen view should tell the whole story of the patient’s complaint.

To illustrate the ways in which the EHR implementation enabled the practice to deliver a higher quality of care, Stout offered two “examples of catastrophes avoided thanks to the practice’s EHR”: she noted that pregnant women have to be tested for group B strep. Shortly after implementation, the practice received a call from the lab saying that a reagent had been recalled because it had been found to be producing false negative tests; by the end of the same day the practice received notification, they had used the EHR to identify all potentially affected patients for antibiotics and retesting. The second example concerned the potential for adverse interactions between low molecular weight heparin and dietary supplements containing omega 3s. The practice extracted data from the EHR to find all of the patients who were taking heparin and advised them about the potential interaction with omega-3-containing supplements.

At the end of the day, it’s all about ROI. Post-implementation, the practice realized a $300 thousand decrease in transcription costs; staff-to-provider ratio stayed relatively stable after implementation; volume of throughput increased 11%; RVU per provider increased 13%; operating costs as a percentage of revenue and staff costs decreased; and average profits per physician and shareholders increased.