We are now three years into ARRA/HITECH, and yet implementation tales of woe with unexpected costs and decreased productivity are ever present.    Why? We have RECs, workforce enhancement programs, and more EHR consultants.  Even so, the fact that successful EHR implementation requires significant planning and attention to detail seems not to have sunk in.   It’s almost as if no one wants to discuss it.  In fact, a consultant from a large firm once told me that she didn’t mention how much planning was required for implementation during early discussions with clients because it would frighten away clinicians who were already “spooked” at the idea of getting an EHR.   While this may help secure consulting engagements, it does a disservice to unsuspecting practices.

I believe that honesty and transparency are essential, whether in consulting or patient care.  With this in mind, I offer the following admonitions to my colleagues who are contemplating moving to an EHR.

1.            An EHR will change every aspect of your practice: work habits, workflows, patient interactions, hiring practices, employee training, privacy and security practices–everything. Changes that occur may make any aspect of your practice better or worse.  Detailed planning is the only way to ensure that things change for the better.    As the saying goes, “If you fail to plan, you plan to fail.”

2.            Change will be a constant.  Once the initial implementation has been completed, there will be software updates, bug fixes, new regulations, new reports, new technologies, and new security threats.  Implementation never actually ends–it simply changes focus.   Any item mentioned above may trigger the need for more training, additional job skills, altered workflows,  and new hardware or software.   This means that some aspects of the mechanisms, processes, policies and procedures that were used for the initial implementation will be needed as long as the EHR is present.

3.            The most important step in EHR implementation is selecting the right product.   The right product cannot be chosen simply by looking at a feature list, watching a demo, and talking to colleagues.   Selecting the right product requires knowing what you are trying to achieve in your practice.  In other words, what problems are you trying to solve and what goals do you hope to achieve?    Everyone in the practice should be involved.  This is not a one-day exercise because not all issues are obvious.  Take the time to give problems and goals sufficient attention.   Try scheduling 4-6 meetings for this over the course of a month or so. Write down everything.

4.            EHRs have built-in workflows, and using an EHR requires adapting practice workflows to those of the EHR.   Workflows are the actions that get things done in a practice.  When EHR workflows clash with practice and individual workflows, misery ensues.   Lost productivity is the cardinal sign of this problem.   The only way to address this issue is by workflow analysis.    Workflow analysis is a form of reality check.  Practices rarely work in the manner that those involved in the practice believe they do, and most people are not aware of their personal work habits.

Conducting a workflow analysis requires looking at every process in a practice, writing down every step,  determining why it is done, and if it should be done.   Occasionally, time must be taken into account (e.g., how long it takes to write a paper prescription).

A proper workflow analysis can take weeks or longer to complete, depending on practice size.  However, it is absolutely critical because the workflow analysis is essential for both product selection  and implementation planning.   Since the EHR will change all practice workflows, everyone, and I mean everyone, must be fully engaged in conducting the analysis.   Yes, everyone is busy, but skimping on the workflow analysis is a ticket to failure.   A proper workflow analysis allows for graceful adaptation to the EHR’s built-in workflow.   Without one, the first six months after go-live will be spent putting out fires, arguing, and watching productivity and revenues drop.

5.            Get help.    Few clinicians have the skills required to select and implement an EHR.  There are a number of resources available–RECs, books, consultants, and professional associations.

6.            Take your time.   Too often, once the decision has been made to implement an EHR, there is a rush to get one.   Considering the amount of change that a practice will undergo, six to nine months should be set aside for planning.  This time is used for identifying problems/goals, workflow analysis, reviewing staff computer literacy, reviewing job positions/skill requirements, reviewing products and making a selection.   Once a product has been selected, additional planning, focused on that specific product’s functions and features, is usually required prior to starting the actual implementation.

An EHR will change every aspect of your practice. Whether things change for the better or for the worse, is up to you.   Planning is time-consuming and tedious; it is also essential.  Take the time to do it right.



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