EHR implementation is not an event as much as a process. The key to implementation is managing a variety of transitions from the paper chart to the electronic chart. Your transition strategies and decisions could have repercussions on patient care and malpractice risk.
EHR transition must be based on sound clinical decision making and coordination of dramatic changes to clinical operations. In too many cases, practices let the technological issues dominate EHR deployment and relegate clinical issues to an afterthought.
A technology focus could leave a number of vulnerabilities in the patient medical record and call into question your practice’s due diligence in managing patient care or preserving the patient record. For example, some practices have been unable to scan all of the necessary information into their EHR since the vendor did not recommend scanning paper chart contents and designed their hardware accordingly. Indeed, many practices move to an EHR without defining clinical information needed to properly treat the patient in the EHR. For example, failure to note a continuing patient problem or a previous procedure will prevent the EHR from informing users about established standards of care.
In other cases, the rush to implementation bypasses adequate analysis and design resulting in problems after the EHR is in use. Note that any failure to adequately consider the clinical issues and make patient care based decisions about EHR deployment could come back to haunt you in the event of a malpractice claim. More importantly, problems due to a failure in analysis and design could be replicated across all of the patients in your practice and have long term implications. For example, if a practice fails to adequately and consistently document patient care, how will the practice be able to reliably produce lists of patients under the Meaningful Use standards?
As you traverse EHR transition, you should maintain complete documentation on your decisions and analysis to demonstrate and document you diligence. You should document the factors that went into your analysis as well as significant events that may have affected your decisions. For example, you may not be able to document preexisting patient conditions since the clinical records do not have the appropriate ICD9 codes, while the new EHR requires ICD9 coding. These documents should be presented to and accepted by the practice’s medical management team.
EHR transition areas to consider include:
Introducing the Patient to the EHR – The disposition of the paper chart is a major decision for any practice. The paper chart may contain documents that will be needed in the EHR as well as discrete information that must be separately entered into the paper chart. For example, many surgical practices want to enter in the patient surgical history directly into the EHR. Similarly, many practices want to scan selected documents such as abnormal results, treatment reports or even all documents from the last 2 years into the EHR. The key problem is making sure that adequate patient paper chart information is available from the EHR. Otherwise, the practice could be open to claims that relevant clinical information that did not make it from the paper chart to the EHR. Such a decision should be based on the realization that the paper chart at some point will not be available on an as needed basis for patient care. For example, some practices may deliver the patient chart for the first few visits after EHR Go Live, but stop paper chart delivery after a certain point in time. Regardless of your strategy and approach, you have to insure that you maintain the patient’s complete medical record. (Note that if you scan the entire chart, the EHR based patient record may become your designated patient chart.)
Transition Planning – In many cases, practices need to establish a multistage transition plan that minimizes disruptions to the practice. Each stage in the transition should include a design phase, and a proof of concept phase before committing to the complete rollout of the feature or function. The design of how you use the EHR as well as adoption issues should be included in your user training program. For example, users should be trained on the clinical requirements for initially entering a patient into the EHR. Potential stages include:
Paperless Chart — The paperless chart phase involves replacing the paper chart with the EHR based patient record. Such a process may include scanning portions or all of the patient paper chart as well as serving patients without a patient chart. For example, paper notes from new visits may have to be scanned into the EHR before doctors start directly charting visits into the EHR.
Charge and Limited Clinical Information Entry—The physicians and staff use the EHR to enter charge and limited EHR information, such as prescriptions, allergies and other basic patient data.
Transcription into the EHR — Dictated notes are entered into the EHR by a transcriptionist. The notes are saved in the EHR and the EHR may be used to coordinate review and distribution. Using the EHR to manage transcription offers an easy way to build up patient information in anticipation of the next adoption stages.
Order Entry and Management—Doctors and clinical staff record and manage testing and treatment orders through the EHR. Orders are entered and managed by the practice staff. Staff tracks the order status in the EHR. Note that order entry and management is an important meaningful use standard.
Prescription entry—Prescriptions are entered into the EHR and printed, faxed and/or electronically submitted to a designated pharmacy. Electronic prescriptions and drug utilization review are Meaningful Use Standards.
Messaging and Patient Visits—Practice staff and doctors use the EHR to collaborate on patient flow and issues. Patient messages, office issues, prescription refills and other items are entered and tracked in the EHR.
Doctor Charting— Doctors chart patient care at time of service into the EHR. Doctors may start EHR charting with selected patients (Ex. Only new patients initially.) Doctors may even have transitions within the doctor charting process. For example, subjective and objective findings as well as the plan may be entered into the charting portion of the EHR, but the doctor may dictate the assessment.
The design phase involves reviewing the software features and designing how those features will be used in your clinical operations. These use decisions and strategies should be integrated into the training plan. Indeed, the training plan itself should account for the various transition phases. For example, the training plan should include strategies for dealing with calls from patients who have yet to see the doctor since the EHR was deployed and therefore their paper records have not been transferred into the EHR.
The design phase should be followed by a focused proof of concept with an initial doctor before expanding the use of that particular stage. Continuing deployment of the EHR should be based on monitoring performance and results. For example, you should attain a certain level of productivity or proven improvement before moving onto the next stage of your implementation. Otherwise, the next step in your effort may be negatively affected by problems and issues from the last transition. Similarly, the first office should be fully functioning for the current phase before initiating EHR use in another location.
Many EHR failures can be traced to a focus on the shortest time to starting EHR installation and not on the time to complete deployment. The difference can be dramatic. In many cases, transition and deployment was not based on appropriate planning, analysis and design. Such organizations rush to complete a dysfunctional process that didn’t work at first and got worse. In the worst cases, whole practices rush to start using the EHR without understanding the implications of the product or the challenges.
However, understanding the transition stages and backing your implementation effort with clinically based decisions as well as results focused deployment will help you achieve your patient service and practice objectives.
(c) Sterling Solutions, Ltd., 2011