Implementing an EMR: Why Do A Readiness Assessment?

Jill Arena, for HealthLeaders News, September 18, 2007

Electronic medical records (EMRs) have become the topic du jour among healthcare and medical group leaders today. You've decided to install one. You're going to spend the money. You're going to take the time. Do you really know how ready you are?

Consider leadership, clinic culture, management and technical expertise. All are important to a successful implementation. If any of the four legs of the chair are lacking, the whole project can topple.

Readiness assessments come in many shapes and sizes. The best ones will enable you to measure your own progress over time, as opposed to trying to compare to some ideal that doesn't exist. The right tool will have you asking yourself the hard questions, and documenting the answers. The outcome of using the tool should be a clear road map of the things you need to do in order to have a successful implementation.

Despite the risk of dwelling on the negative, your leadership team should have a very clear understanding of the implications of a failed implementation - including the costs: measured in fiscal, political and human capital. Bear in mind, you don't get a second chance to do this right any time soon.

GreenField Health, a clinical practice and consulting group based in Portland, OR, completed its EMR implementation at the inception of the group in 2001. The innovative medical practice is a national model for primary care, incorporating such things as open access scheduling. We have no waiting room, but we do have a great deal of technology. E-visits are the norm at this practice of nine physicians, and more than 80 percent of follow up care is delivered via phone or e-mail. The practice makes very robust use of its homegrown EMR and related software products. Principals from GreenField consult to medical groups across the country about effective EMR implementations. GreenField leaders are frequently called to speak to HIMSS, MGMA and other industry groups about cutting edge use of technology in the outpatient setting.

GreenField's implementation was completed with the assistance of several experienced project managers, and a group of highly committed physicians. Several of GreenField's leaders had experience with the EMR product in previous practices, so there was a collective goal to make the implementation one that could be used as an example throughout the industry.

Your readiness assessment should answer questions on multiple different levels in all four areas. How involved are you? How well do you know your staff? Do you walk the talk? Is your group open to change, and are you solution oriented? Are your paper charts well organized and ready to be converted? Lastly, and probably least important overall - do you have appropriate technical support?

Leadership
Successful implementations start and end with strong leadership. Do you have a leadership team, and does that group meet regularly? If not, create one. The group should have representation from all roles -- especially senior leaders with decision-making authority. Weekly meetings are recommended for this group for up to six months prior to go-live. The leadership team should begin by gaining clear consensus around the goals for the project. These goals should be specific, measurable and time limited. They should be written down and shared with the group. Everyone on the leadership team should know exactly what constitutes a successful implementation. This way, you can celebrate once you've gotten there. Your leadership team must also fully understand the implications of a failed implementation. This is not to be taken lightly, and is worthy of a fair amount of conversation.

One of GreenField's consulting clients did not have full leadership commitment prior to beginning its implementation. It had good external support and a hard working mid-level project manager, who unfortunately did not have the organizational horsepower to work through the various challenges she encountered. Without full leadership support, she continued on valiantly for a while, and finally burned out, leaving the project floundering and the end users frustrated.

Clinic Culture
Culture, while a bit amorphous, is a critical component of successful change management. You should assess your group's ability and willingness to change old habits. Is the group well-versed in change management strategies? If not, it's time for a bit of a crash course. It's also time for plain talk about what will change, and what will remain the same. Your group should also have a good understanding of the pros and cons of standardization versus customization given the product you've selected. Some products allow for more customization without compromising the ability to retrieve structured data. Most groups' tendency is to placate skittish physicians with promises of customization, without a good understanding of the overall cost of that deviation from standard. Lastly, your clinic culture should seek input from all levels of the organization. If you do not presently do that, this is a good opportunity to revisit that cultural norm. The pervasive change that is an EMR implementation will work far better if the stakeholders all feel a part of the journey.

Six years after its implementation, GreenField still convenes weekly meetings of the entire team to solicit feedback about all of its operations. We revisit technology use, and even have an IT committee that meets weekly as well. The group meets to review high-level IT strategic priorities, and day-to-day level detail that makes the work of providing patient care more efficient. GreenField's IT system and its components are in a constant state of review and improvement.

Management
The project manager role is critical for a successful EMR implementation, and the individual who fulfills that role--whether it is a full time role for them or if it is an added duty--must have dedicated time set aside to work on the project. The project manager must also be vested with an appropriate level of latitude and authority to make the project happen. Anything less will leave the whole project in a vulnerable state. As a second component of the managerial considerations, the clinic should project a reasonable slow down in production post go-live and there should also be a reasonable return on investment projected for the entire project. This can be quantified in many ways--most groups look for hard cost savings and revenue enhancements to make the financial case for change. Again, it is important to understand where you are going, so you'll know when you get there. Lastly, from a management perspective, the leaders should assure that the EMR implementation can be the top priority--or one of the top priorities--of the organization at this time. If not, wait and reschedule the implementation for a time when it can be.

When GreenField's clients look for a financial justification, we suggest visiting hard expenses that can be eliminated, such as transcription ($500-$1500 per physician per month), medical records supply expense ($5-15 per chart), and medical records storage space ($15-35 per square foot per year). This is offset by some new expenses, but most groups have been able to make a positive financial case for implementation.

Technical
Although it seems strange to list the technical components last in a list of readiness factors for a technology implementation, the boxes and wires are truly a minimal part of the whole undertaking. Prior to bringing in all of the hardware, a basic computer skills assessment should be completed on each user. At this time, the sensitive subject of physician keyboarding skills should not to be overlooked or under emphasized. As respectfully as possible, get keyboarding training for physicians and others who cannot type a minimum of 30 words per minute. There are many reliable testing programs available via the Internet, and keyboarding tutorial software is inexpensive compared with the returns in time savings and efficiency. It is critical to identify your IT expertise for both hardware and software. These may be available in-house or you may decide to out-source. Regardless, there should be system redundancy, as well as personnel redundancy, so that system performance does not rely on one individual. Lastly, written downtime and disaster recovery plans should be in place and should be tested. The first time the system is unavailable to your users is not the time to discover that you don't have a system recovery plan in place.

Readiness will vary from group to group, and the use of a good readiness assessment can help to drive your group towards a successful implementation.

One of GreenField's consulting clients, Alameda (CA) Family Physicians, completed an in-depth readiness assessment in preparation for its EMR implementation. The discussion amongst its five physicians took about four hours, and left the group with a clear idea of where to focus their energy in preparation for their go-live. Parts of the discussion were challenging and rigorous, but the group was honest in its responses, which produced a great road map. It also allowed the group to focus on areas of strength and to give some of the physicians in the group credit for previous work that had been accomplished to help the group prepare for the upcoming transition.

Michael Zimmerman, MD, one of Alameda's physicians, and director of performance improvement of Affinity IPA, says "The EMR readiness assessment has proven to be a critical piece of our practice management and EMR implementation. The conversation around the assessment helped identify areas of particular strength and agreement but more importantly, it helped surface areas of concern and uncertainty. This has allowed our practice to view the practice management system and EMR work as something being chosen and done by us rather than something being done to us. Our implementation thus far has been methodical and deliberate rather than reactive. We have taken the opportunity of EMR implementation to reconsider and modify our most labor consumptive work and create the space and time for real improvement efforts. There are certainly 'bumps' in the road but the direction is clear."

While the use of a readiness assessment won't guarantee a successful implementation, it will definitely help to drive the conversation, and to focus the leadership team…now that you have one.

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Jill Arena is chief operations officer at GreenField Health. She can be reached at jill.arena@greenfieldhealth.com.