Effectively integrating your EMR initiative.

Everyone is talking about it. Everyone is thinking about it. Everyone has an opinion.

This is uncharted territory. What has begun to unfold in the physician marketplace is a process that is going to revolutionize the health care industry, and it is long overdue. There is no real model for it, but there is no doubt that the change is coming.

For years, physicians have had to operate in a paper environment. While the science of medicine significantly advanced, the "business side" of the equation remained stagnant. In the digital age of cell phones, wireless technology, PDAs, e-mail, the Internet, most industries have capitalized on these advances--but health care has been slow to adopt.

Most physicians have come to realize that they must adopt an electronic medical record to position themselves for the future. The federal government has made it a priority. Payers are striving to link baseline reimbursement scenarios, pay-for-performance initiatives and payment for services to quantifiable performance and quality of care.

Unfortunately, with the multitude of vendors and setup scenarios, the variable return on investment may not be realized for years. With the lack of personal expertise, and a scarcity of experienced resources, this has become something of a leap of faith.

While no solution is perfect, there are lessons that have been learned along the way while working with large groups and independent physician associations to develop a clinically integrated model, specifically by implementing an electronic medical record (EMR).

Expanding your vision

Naturally, the first place you look is how a clinical integration initiative for you will impact your own practice. This obviously is the right place to start, but not necessarily the right place to end.

Often, when physicians take this approach to selecting an EMR strategy for their practices, they will be setting themselves up for a scenario that will present much more limited capabilities in the future.

With "interoperability" looming somewhere out there in the next few years--whatever the definition and outcome may be--physician practices need to approach this initiative in a manner that is "out of the box" from the way they would typically approach a vendor selection.

It's about more than price. It's about more than a slick demo. It's a marriage. When selecting a vendor, approach it like it is a marriage.

Although what you purchased is not going to be what you will have in five years (you may have the same vendor, but the product will have evolved), physician practices need to consider what their optimal workflow would be and work toward that solution.

The practice needs to include items that are not necessarily in the realm of control or feasibility at this point. These can include bi-directional lab interfaces, referrals and communication with other practices in the continuum of care for a patient, your affiliated hospital's strategy for sharing and receiving information, and other community initiatives. In addition, items such as pay-for-performance and risk-adjusted coding are also strong considerations.

Keep in mind that it is still early on in the process. While you will want to use references, the likelihood is low that you will get a reference that exactly mirrors what you are looking for in your initiative. Everyone has an opinion, but if you go back to the goals for your practice or entity, you will be able to keep your eye on the ball.

Once you have assimilated all of the information that you can gather, that is where the leap of faith comes in and your entity needs to go for it with confidence, momentum, a positive approach, knowledge that workflows will need to change and a sense of urgency. It will not be easy.

10 Common mistakes

With all of the momentum toward integration and interoperability between physician groups, hospitals, payers and other entities, understanding how to develop an appropriate and robust support infrastructure and implementation methodology is critical to efficient and effective delivery of care in an electronic environment.

Having facilitated this process for organizations representing thousands of physicians across the country, we learned numerous lessons that can help position you for an effective initiative.

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1. The software is the solution

Many enter into this process thinking that the software is the solution without the knowledge that the practice has to change. Many enter into an EMR initiative thinking that the software needs to be able to do everything that we think at the time it needs to do. This assumption is false.

If you approach your EMR initiative with this mentality, you will be setting your initiative up for failure. While the software vendors--particularly the best-in-class vendors--have made a lot of progress in the last two or three years, the software is far from perfect. In fact, the software will probably never be perfect.

Physicians need to place a heavier weight on support, implementation and service--the items that are going to get them through in the long run.

2. Designing and implementing

This is one of the biggest mistakes in approaching your initiative. We've found that when an entity chooses to take this approach (assuming that most of the functionality is already there with the software vendor), at least 75 percent of recommended changes prior to implementation would not be necessary or recommended post-implementation.

These are simply suggestions that would take an old "paper environment" workflow or function and place them into the electronic environment. In essence, the physician is stating that "this is the way I do it now" so "show me how I can do it in the EMR." This will not work.

The key to successful implementation is attempting to work with what is already available in the software--knowing that it is not perfect, but workable. Give yourself at least six months to get used to the new environment and really try to understand it. That way, when you get to the point that you want to make modifications to your templates, you will be making a much more educated recommendation that will result in a more efficient and effective outcome.

3. My practice can effectively support my own network infrastructure

Keep perspective on your core business. I have run practices in which we have attempted to support our own network, and, while I like to think that we have been relatively successful at doing it, the cost and required resources over time do not make sense.

What does make sense is letting someone who has expertise in operating the selected software run the network, server hosting and infrastructure. It is their expertise, and most practices do not want to be in the information technology business.

In addition, these companies have economies of scale where they can offer the service--and a higher quality one--at a more competitive price. Most agreements also factor in replacement of hardware (such as servers, routers, etc.) after three years, which is about the normal life cycle that you will want to maintain on this equipment.

4. Underestimating the required support staff

A common mistake that we have made ourselves is underestimating the amount of support staff required to operate and effectively support your EMR initiative. The amount of staff greatly depends on the model you are implementing.

If you are participating or leading a larger clinical integration initiative, the amount of staff and built-in expertise will be greater. Staff will range from general help-desk and desktop support to applications specialists and implementation specialists who understand how the system operates and what practices will be looking for with regard to implementation.

If you do choose to be trained and implement it yourself, make sure that your "superusers" are well trained prior to taking the implementation to the next step.

5. Taking too long to implement

This is pure and simple resistance to change. An effective implementation must balance revenue and cost considerations--such as a reduction in the physician's patient load for two weeks while they are learning the system.

However, you should set a window of time that is somewhat condensed to make sure that all physicians in your practice are "live" within that window of time. Too often, it is stretched out over a period of months to the point that the implementation stagnates.

The key is effective preparation--both with training and with adopting the right mindset--that will get you through. Once you convert, most do not want to go back.

Another false assumption is that the EMR implementation should be easy and flawless. While we would like for this to be the case, it is not. When such a radical change is occurring to the way physicians are used to practicing and have been for decades, it is going to be rough.

Some will have differing opinions. Some will want to throw it away. Some will want to go back. Some will adopt quickly. Let the change effectively run its course.

6. No physician champion

Each group or entity must have a physician champion in order to be successful. This is a person who is going to "champion" the cause of the conversion to the EMR and work to understand the software and possible implementation variables.

This will dramatically help to quickly build credibility and momentum toward effective adoption and implementation. Initiatives that do not have a physician champion seem to fizzle ... rather quickly.

7. Site visits

It is the nature of physicians--as it should be--to want to see live proof of something that works. They want to see their physician peers utilizing an EMR in the exact manner in which they do--on the same version that is being sold to them with the same sets of considerations.

Over time, this will become possible. Right now, it is less than likely. We have been part of a number of site visits where it turned out to be a waste of time. You can get more out of these potential visits by using them as a "reference" for the product--and probably do that over the phone.

Some site visits have tended to be disastrous for the vendor--and the practice--as it could tend to steer the initiative in the wrong direction. If you do go on a site visit, do not place as much weight on it as you would typically do for other products.

8. Not selecting software for the long-term

Make it as easy as possible on you and your practice--look at the long-term vision of your practice and try to match up as many of the variables with your vendor as you can--and then go for it.

9. Not taking advantage of regionally sponsored initiatives

Many "regions" have organizations such as IPAs, hospitals, large group practices, and RHIOs that are hosting the infrastructure for an EMR and allow physician practices to subscribe for the system and services for a period of typically three to five years.

Take advantage of them. The economies of scale are much greater. Plus, you don't have to go it alone--which is the way that the care model is evolving in the electronic environment.

Most are looking at it from a return-on-investment standpoint. While a compelling case can be made that there is and will continue to be a compelling ROI story, the way it is viewed is that it is a cost that I am not paying now, so why should I do it.

EMR will effectively position you for the future, so it needs to be factored in as a cost that will be there for the long term. In other words, reset your baseline. This will be a way to make your practice eligible to turn the revenue curve in the direction opposite it has been heading over the past 10-15 years.

10. I will only have to make this transition once

This is a painful thought. This is a model that is going to dramatically evolve over many years to come. Your practice will have to be sound in its implementation but flexible enough to adapt as the environment, standards, and capabilities continue to evolve. You will not have to just go through the transition and then it is done. However, the worst may be over.

Fortunately or unfortunately, this is just the tip of the iceberg. The model of interoperability--not only with individual practices--but with all health care constituents will continue to dramatically evolve over the next two decades.

You have the capabilities to help shape that change, and with the appropriate set of considerations, you can set your clinical integration intitiative up for success.

John C. Whitham is a partner in the JHD Group headquartered in Dallas, Texas, and chairs the clinical integration practice within JHD. He can be reached at 972-220-0474 or [e-mail]

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Steve Davis, DO, is medical director for PACIS, Physician Associates Clinical Integration Services, providing full EMR and practice management systems to member physicians in Pasadena, Calif. He can be reached at 626-817-8300 or [e-mail]

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By John C. Whitham and Steve Davis, DO