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July 30, 2008 Readers Write 18 Comments

Mike Gleason on Reasons Small Practices are not implementing EHRs a fast as we would like

A little history on me so you don’t think I’m some new hire right out of training class.

I first started in this field known as HIT in 1984. After completing a run in Washington DC as a Manager of a third party maintenance company I decided the switch to hardware support for a small company, (who doubled my salary) would be a great move. The second week at my new company as the new hardware support guy, every software support tech quit. Yep, both of them. Not due to me, mind you, but due to “budgetary constraints” or some people would say bounced paychecks. I had already bought my groceries for the week and I was able to stick it out till new checks were cut next Wednesday. (One time where it paid to get a keg vs. 2 or three 12 packs). I figured, “How hard could it be to support Medical software” and cracked open the user manuals and then quickly developed a relationship with my vendors phone support. And like all pain in the rear VAR’s I eventually worked directly with the president of the company. (Articulate Publications, Medicalis and Dentalis) He was also one of the chief software designers. Back then CEO’s still knew how to code too. I think Bill Gates retiring has completed that run as CEO’s who also code.

My journey of 24 yrs has lead me through titles of account manager, territory manager, inside sales, regional sales manager, Project Manager, Implementation specialist and a host of other titles with 3 prominent HIT companies.

Being an EHR implementer for the past 7 years has given me (I think) a unique perspective on why Dr’s make decisions and defer decisions. It differs for most Physicians’ but I think I can provide a few reasons. I’m sure it applies to all of us as well.

  1. Fear
  2. Ego
  3. Money
  4. War Stories
  5. No one wants to go first
  6. Product not perfected yet
  7. Waiting on Govt mandates
  8. Waiting on hospital install or Stark gift
  9. I have people for that
  10. Change

Fear

We all have it but MD’s and Nurses often fear the EHR implementation more than taking a rectal temp. Doctors don’t want to appear inept in front of their patients, nurses don’t want to feel inadequate when they are used to getting what they need in a few lines in a chart. Both have invested years in education and residency training and this little laptop can erase all that prestige in one office visit. Many clinicians start off training with these fears.

A proper implementation can alleviate most of these fears. Small steps like outlining the install process. Training the practice to customize their EHR so they feel comfortable making changes. Implementing in phases to minimize the changes. Outlining workflow ahead of time and training to your workflow documents are a few ways to calm fears.

I also like involving all levels of the practice in the implementation; this allows the whole practice to own the process.

So not only MD’s, NP’s, PA’s, LPN’s, RN’s and MA’s but also the Ultrasound tech, The lab phlebotomist, front desk, surgery scheduling, office admin, billing, etc. Many times in small practices these are the same people.

Involving the billing office is key. This assists in customizing with proper ICD-9’s, CPT’s, admin codes, modifiers etc., a benefit not often felt till we start passing charges from the EMR to the PM charge entry. We need to build the EHR customization so we are billing properly to maximize reimbursement.

I also recommend to all my installs prior to go live to take live patient charts randomly from the day’s schedule and complete a few notes per day with the current customization on test patients. This helps in guiding where you might need to add or adjust your customization. I also recommend Faxing sample scripts and progress notes to your own fax machine if possible from these same test patients. Set up a test pharmacy with your fax as the pharmacy fax. Print the DME scripts and the referrals and make sure you are happy with how they look. Seeing the fax coming out on your manual fax goes a long way to calming fears.

In typing this paragraph I’m reminded of an event at an install 5 years ago. I was teaching a nurse class and we often pair class members according to computer confidence levels. Experts with experts, newbie’s with newbie’s etc. I was teaching what I refer to as a catch all class. All nurses thrown into one class. One nurse was really struggling and I was not sure if she was just a smart alec or really dense… After struggling through the class we had a lunch break. I asked the nurse that was slowing down the class if we could speak in private. We went to a conf room and when I asked if there was anything I could do to help her get up to speed…. she proceeded to tell me with tears in her eyes that she had feared this EHR for this exact reason. She’s had a learning disability since elementary school and it was causing her to drop behind the other nurses. She was the Lab supervisor and felt she was looking bad in front of younger nurses that were better at computer skills than her and were thinking she was slow. I told her I was sorry for not noticing and offered to teach her over lunch breaks the next 3 days. She came every day and we spent our lunch hour teaching her the EHR instead of hitting Chick-Fil-a. This gave her confidence and she was very adept at the lab functions and able to run lab audits etc. by the end of my week of training and go-live support. On my last day onsite I came early about 7:30am and she called me into the lab. She introduced me to her husband who had come to work with her that morning. He wanted to meet me, shake my hand and thank me for helping his wife out and for helping her confidence in her job. He let me know she had not been the same for the previous 2 weeks and was complaining and thinking of quitting and he knew something at work was not right. Once we started our lunch training sessions he said she would come home and talk about what they learned that day and they made dinner together while she talked to him and she was so proud of sharing what she learned. He then gave me a bottle of wine from their favorite local winery, told me how proud he was of his wife and shook my hand and told me thanks for taking the time to work with his wife. She was just all giggly and had to show him all the lab screens and how she could replace manual processes with the EHR. I was blown away. I never realized how such a small thing on my part could help someone so much.

I still have that bottle of wine unopened on my desk…along with a Viagra clock a Urologist gave me for helping him learn to e-prescribe 4 years ago. My desk is littered with little drug rep tokens that all represent specific people at clients who have said thanks for taking time to give them some extra support to alleviate their fears. Even transcriptionists have thanked me. I collect these drug rep freebies as a hobby and my clients often show their thanks by presenting me with their favorite drug rep pens, clocks, note pads etc. I’m very proud of my collection all proud EHR students. Knowledge is power and power goes a long way in alleviating fear.

Ego

Not all installs go well. Many physicians think implementing an EHR turns them into a transcriptionist and they went to school to practice medicine and not type progress notes.

Also not wanting to look inept in front of patients applies here.

Money

We all know the reason here. New EHR or college tuition. Many Doctors are faced with tough monetary decisions every day.

War stories

Every practice has colleagues, or neighbors who have had a failed EHR implementation. These failed implementations are the bad news that circulates 10 times more than the one good install. I’m currently working with a solo MD that is now on his fourth EHR since 2000. Wish me luck.

No one wants to be first

Being the first is often a drawback for many physicians. They want to see what other practices implement and then ask them how it went.

Product not perfect yet

You see it all the time. Wait and buy the third generation of the computer not the first version. Vista is a good example of this. Many physicians’ think the current levels of EHR’s are just not advanced enough for them yet.

Govt Mandates

Why spend the money until the Govt says I need to? We all know this has occurred now with the recent house resolution. First they provide incentives then they provide penalties. Smart way to do it.

Waiting on local Hospital or Stark donation

Many practices don’t understand that hospitals move in 2 or 5 year increments not quarterly. If you’re waiting for a hospital to make a decision will they cover your loss of incentives and pay your penalties between now and 2010?

I have people for that

And many are the MD’s relatives… My mentor back in 1984 explained the HIT market to me this way. A doctor is the only business person I know that will place their business success in the hands of a high school graduate rather than a CPA or MBA. Meaning many office managers or front desk managers in small offices, are high school graduates with little to no business experience. Not as true today as it was back in the 80’s.

Man, many of these Doctors are loyal to a fault. I know many clients who have called me asking for advice on how to catch an embezzling biller, office manager, front desk employee. Or worse, how can we find out how much they stole? I have seen all types: Changing check names, billing false claims, taking cash payments, writing off to collectors that are their family members and getting kick backs. Many doctors have little fiefdoms and they love being the overlord. This can often cause them to become detached from their day to day operations. They often think, Doctors see patients and dictates, transcriptionists transcribe, nurse gives injections and prep patients to maximize my time, and medical records handles the charts. Sometimes the wife as the office manager really helps in this instance. If they are spending too much money at the office they have less to spend at home.

Many Physicians’ are very proud of how they can provide a living for their employees. They often develop deep bonds similar to family ties with employees. If you are selling them on reducing FTE’s know that they may not want to get rid of their “Family members”. If you approach it with freeing up the Medical records clerk so they can attend MA school or Ultrasound school to become a revenue generator they are much more receptive. One of my first large installs (22 MD’s) back in 2002 had over 8 medical records clerks in one office. Five of the eight were related to each other and they were all related to the office manager. Today the medical records room is gone and one person handles all incoming faxes electronically and scans all incoming paper and handles all outgoing faxes of medical record requests. They now have over 75 MD’s on the EMR with 3 specialties. What happened to the family members? One manages the records requests, two are MA’s, one is an office manager of a new remote office and one is now a PA. Key is: THEY ALL STILL WORK FOR THIS PRACTICE.

Change

Many people fear it some embrace it. Why is there such disparity? If you fear change it may be due to lack of knowledge or lack of a comfort factor. Training and exposure to the new workflow as well as input into the new workflow goes a long way in alleviating fear of change. I’ll be the first to agree many nurses and Dr’s can write in a chart faster than they can use an EHR. Keep in mind they have used paper for hundreds of years in medical charts. Tough argument to win with a new client only interested in time factors of documenting the current visit. Just ask them to run a report of all patients they gave X injection to with Y lot number and you will win that argument. Graphing lab trends from the last 3 labs also helps win this argument. I often take before and after pictures of the practice and bring them out at my 2 month follow up to show them how many paper charts were just laying around in stacks. You would be amazed at the change in just 2 months much less 2-3 years on an EHR.

One Dr had a funny take on it. He had a nurse that decided to retire after 25 years of nursing at the practice rather than under go EHR training. I was talking to him about it and apologized for not doing a better job of getting her trained enough to stay.

His reply? “If I knew all it took to get her to quit was implement an EHR I would have done it 2 years ago when I bought the practice!” That made me feel better.

Workflow documents are key here. Making sure the Dr and Nurse can get their pre EHR duties done quickly and easily helps many clinical staff to buy into the process at go live.

There is a process all clients go through. Some take 3 months others take 6 some take a year or two.

Phase one is the Go-Live. You are basically shooting for 100% EMR documenting as the goal and if you hit it you’ve done your job as an implementer. You may leave the practice somewhat worried if they can keep it up.

Phase two is when they can see the same amount of patients per day pre EHR vs post EHR. This can take 3 months sometimes. You do still get those freaks that do it from day one.

Phase three is when the practice starts looking for new ways to maximize efficiency and use modules like reporting, PQRI, advanced customization, interfacing more office devices, implementing lab or radiology interfaces etc. Show me more that I can do with your EHR. They become an EHR user who does not know how they ever worked on paper. These are the golden reference site,

So I think the rate of adoption in a small practice is a combo of all of these and maybe a few we have not thought of. Just my take on it from someone who is immersed weekly with new installs at new clients.

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Currently there are "18 comments" on this Article:

  1. Wow! This was one of the best you’ve ever published. This fella really has seen the reality of implementations and is spot on!

  2. Agreed. Interesting insights presented with some spot-on stories that were actually funny and even uplifting. Nice for a change of pace.

  3. This is an excellent piece – ONCHIT should be reading and incoporate some of this insight into their strategic plan!

  4. 50+% of US healthcare today is delivered in the manufacturing equivalent of “ye olde blacksmith’s shop” – small, autonomous, skilled craftsmen

    Imagine trying to implement ERP in a blacksmith’s shop: why do I need this? It’s going to slow me down, etc., etc. It just doesn’t make sense.

    Somehow the forces that re-structured every other industry into working units large enough to realize the efficiencies and benefits of process automation/IT have passed the US healthcare system.

    Until then, EMR implementation in the small physician practice will require small practices to largely work against their best interests. And the kind of highly effective hand holding that Mike provides.

  5. Nice to see the daily challenges put together in a way that makes me laugh. It is hard to do that when you are right in the middle of it. Thanks for giving those of us in the daily trenches a voice!

  6. This is really insightful EHR information. I know some people are concerned about privacy and security HIT issues. The feds are helping by piloting education projects about HIPAA and other protections for medical records.

    If you are interested, EHR Today at http://www.ehrtoday.org is one of those projects developed in my state by a group of people working on a fed grant. It includes various EHR resources and has a FAQ section that is good, (we worked on it!). But there are other sites too at HIMSS, etc.

  7. I think Mike has hit on many good reasons why…but dogofwar brings up an interesting analysis that I think nobody has considered. Hopefully there is an HISTalk reader that has this info.

    The pitch about docs not using EMRs is squarely aimed at small practices, usually 5 docs or less. Almost all big practices either have or are in the process of implementing EMRs.
    So out comes a report that only 4% of docs use EMR tools…and the knee jerk reaction is that if you are a doc and you don’t, or don’t want to, you are a Luddite standing in the way of progress and all that’s good.

    Now consider this, let’s take dogawar’s blacksmith analogy a little further. Docs in small practices are basically small business people doing less than a few million a year in gross revenue. This is equivalent to the many hundreds of thousands small retail and service business in the country. How many of these businesses have computerized their core operations? I am not talking about payroll and inventory – I am talking about what work they do and how they do it. For example the last time the air condition guy (HVAC) came to my house to fix my AC he did not have a tablet PC to document the problem and the solution. Outside his diagnostic electronic tools, his high tech documentation tools were a cell phone and paper forms in a tear box. And this was a rather large HVAC operation – 20 trucks, 40 employees, etc.

    So before we keep beating up that little old independent doc for not being more like commercial industry, and for not jumping on the chance to install an EMR, let’s find out what percentage of small business (less than $5mill gross) have invested in, and installed computerized documentation systems? I bet it isn’t greater than 4% and it’s probably for all the same reasons Mike noted.

    If we find that to be the case, then maybe there are other issues we need to address

  8. Excellent post that accurately captures what is really happening in the market today.

    No if we could only take these experiences and codify them into a set of policies that the govt could use to help foster adoption, hey, we may get somewhere.

  9. To what dogofwar said, it’s highly unlikely that you’ll ever see MDs going into big groups in large numbers. There really aren’t the drivers that existed in other industries (like automation), and limited economies of scale to be gained by doing it. Seeing patients also doesn’t benefit much from centralization except for tertiary care needs, and in fact the opposite is probably true. Seeing patients is not really an “industry” in the same sense.

    Rather than lament that, though, what needs to happen is that the products need to be geared towards that small group practice. That probably means there are fewer bells & whistles, or they need to wait longer until those become commoditized (if such a thing happens in HIT) and cheaper, but the basics can be done pretty reasonably. If the incentives are there and the above are true, though, you will see them begin to move up the adoption curve much more rapidly than they are now.

  10. Nice of those feds to explain a mandate they themselves enacted. “I’m from the government, and I’m here to help.”
    So, if I have this right (and my intent is not to beat up anyone – I am curious):
    HISPC exists on taxpayer dollars to educate the taxpayers (providers included) as to the benefits of EHR technologies. I suppose we can assume that HISPC also supported most, if not all, the HIT bills that ultimately flopped in Congress?
    And when the feds finally succeed in mandating and regulating EHR adoption, will we see HISPC toe the line and shill for them?
    I apologize if that sounds rather jaded. My intent is not to attack; I am very interested to hear more about this use of tax dollars. The web site is very pretty, but lacking in substance.

  11. I love Mike’s observations and advice about EMR and totally agree with his point about fear. Physicians have achieved mastery in their profession and they can become extremely uncomfortable in EMR training because that sense of mastery disappears. That’s when fear and resistance can kick in, and the trainer needs to be flexible and use humor and compassion, as Mike described.
    Re: the blacksmith and HVAC analogies, I have two comments: first is that EMR may in fact be overkill for a small practice, whereas an EMR-lite type of solution might give them plenty of benefit with less of the cost (in time, resources, and money) – EMR is not the only answer! Also, the difference between the HVAC and the physician is the consumer — people with health conditions deserve to have medical information that is portable, secure, and accessible, in case they decide to go out-of-town on vacation or to a specialist in the city. Leaving the HVAC information at the HVAC business office isn’t going to save their lives if they get hit by a bus .

  12. To Wompa1 — thanks for the comments…I’d hate to think that ehrtoday.org is just another pretty website.

    It was really developed to educate providers and patients about Security and Privacy around EHR, ( If we are going to further EHR adoption in this country, I sure want my info to be secure and private.!)

    A couple of brochures are on the site under Education. The copy, from what I remember, was pretty direct, like “in case you didn’t know this, a lot of people get your medical info — so do what you can to protect it!” I guess we need to make those more substantive pieces show up more clearly on the front of the site.

    Thanks again … feedback is always good.

    Lisa

  13. and, just to set the record straight Wompa, a lot of corporate “in-kind” time as well as personal volunteer time goes into the project. — the Fed dollars didn’t come close to covering the costs. In fact, the website is currently being hosted by a volunteer non-profit for no costs to anyone except that non-profit.

    And, finally, to my knowledge, HISPC does not support any EHR legislation in Congress. (but, if you have info to the contrary, please do share).

    Lisa

  14. I’m glad that others thought that the “blacksmith” analogy was helpful.

    A couple of thoughts to extend it further:

    The only “automation” that might make ROI sense to the blacksmith would be a credit card machine and a cash register. Most small physician practices have adopted technologies to automate billing.

    While the blacksmith is a good craftsman, a close look at his work would probably reveal quite a bit of variability in one horse shoe to another…and quite a bit of time being spent on work and re-work. The kinds of technology that you see in manufacturing to reduce variability, speed processes, and measure key aspects of processes and products…are precisely the things that a blacksmith shop (or small physician office) would resist adopting…because they mean change and accountability.

    Market forces made the blacksmith shop an anachronism, while the small physician office is the prevailing care delivery organization in the US.

    Even an EMR-lite (if it contains much more than functionality for “better” documentation and automated billing) doesn’t pass ROI muster for the vast majority of physician practices. Which is why only about 4 in 100 (!) have implemented one.

  15. “No if we could only take these experiences and codify them into a set of policies that the govt could use to help foster adoption, hey, we may get somewhere.”

    Please provide an example of what you propose.

    I’m all for the government outlawing physician egos 🙂 And fear.

  16. EXCELLENT ARTICLE !
    Mike surely knows the details of a clinical IT implementation and has superbly written about it.
    The analysis of what can go wrong (and usually will) is one of the best I’ve recently seen.
    Kudos !







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