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Tips, Tricks & Best Practices to Get
Maximum Benefit from Your EMR

Dr. Alan Brookstone
1. Adoption ≠ Effective Use of EMR

• 16.1% of physicians report using Electronic Medical
  Records instead of paper charts. This compares to
  9.8% in 2007
• 34.1% of physicians used combination of paper
  charts and EMR in 2010 vs. 26.1% in 2007.
  2010 National Physician Survey - http://www.nationalphysiciansurvey.ca/nps/home-e.asp
US – Regional Extension Center Program
US – Regional Extension Center Program
National US Meaningful Use Data
Focus of Today’s Presentation

•   Adoption & Implementation
•   Data Quality
•   Change and Workflow
•   Training and ‘Meaningful Use’
•   Tips and Tricks
Observations

•   Goals
•   Expectations
•   Leadership
•   Foundational computer skills
•   Practice, Practice, Practice
•   Collaboration
•   There are some things you cannot change, right
    now…
EMR Adoption Journey – Level of Effort

                    Implementation




      Readiness                      Optimization + Ongoing Use
      Preparation




Pre-EMR
                                     TIME
EMR Implementation

• Schedule reduced patient load for at least a month
• Get Staff buy in
• Set up training schedule
• Paper chart conversion
• IT support staff (Consultants/Vendor)
• Workflow analysis
Implementation Types

• Big Bang: turn on everything at once
   – Theoretically a shorter implementation

• Staged: start using new features gradually, e.g. e-
  presribing, PMS, Medications
   – Theoretically longer implementation

• Recommendation to set implement make it or break
  it systems first (PM/Billing systems) to ensure
  sustainability of practice.
Principles of Data Discipline
• Data Standardization
   – Coding
   – Diagnoses, Medications, Labs, History
• Data Cleaning
   –   Coverage –all patients are in the system
   –   Completeness –all data is in the system
   –   Consistency –all data tells the same story
   –   Correctness –right patients in, wrong patients out
   –   Coded –all relevant data is coded or in a single format
• Data Discipline
   – Systems thinking
         • Templates, reminders and searches work together
   – System supports humans
         • Provides clues that data is incomplete or inconsistent or not coded

       Dr. Karim Keshavjee, McMaster University
Change

• Change is disruptive
• No disruption = Not sustainable
• How to manage the change
   –   Set clear direction, goals and objectives
   –   Communicate regularly
   –   Invite and acknowledge contributions and concerns
   –   Address resistance by asking for input
   –   Reward initiative
   –   Build commitment
Workflow
• Workflow describes how a process takes place. The
  process is evaluated and improved to ‘flow’ more
  smoothly
• Optimizing workflow
   – Improve efficiency
   – Reduce redundancy (waste/duplication)
   – Identify gaps or areas of instability
• Plan on paper first
   – Office Visits
   – Chart Conversions
   – Allergy/Therapeutic injections
Workflow – Vitals Collection
   Chart is placed                  Paper
   at vitals station
                                    trigger                      How many vitals
                                                                 stations?
   Patient is called
                                                                 How often do we
   to vitals station
                                                                 see patient in
                                                                 room without
     Ht, Wt, BP                                                  vitals?
  Taken & recorded              Templat
                                                                 Are cuffs and
                                e needed                         scales available in
   Patient is taken                                              all rooms?
    to exam room
                                                                 How many BP’s do
                                      Paper                      we miss?
   Chart is placed in
 sleeve on exam door
                                     trigger

                        Ann Lefebvre MSW, CPHQ, Executive Director, NC Regional Extension Center
Pearls

• Expect and manage disruption
• EMR implementation is just the beginning, not the
  destination
• Change is never complete – processes can always be
  improved
Training

• Training not just for implementation and upgrades
• Two stages 1) go live 2) follow up after baseline
  implementation
• Should be ongoing and comprehensive - includes
  new learning and advanced functions
• As users get comfortable with a system, they learn
  new and faster ways to work using the EMR
• More complex features require more training
• Super User Training
Study – October 2011

• Correlation of
  Training Duration
  with EHR Usability
  and Satisfaction:
  Implications for
  Meaningful Use
Methodology

• Based upon surveys conducted with five different
  professional societies between April 2010 and July
  2011.
• 4,280 responses. The average response rate was
  8.5%, though rates differed across professional
  societies.
• Of those who responded to the survey, 2,384 (54%)
  had an EHR system and completed the entire survey.
• 69% of the surveys were received from physicians in
  practices of <10 clinicians.
Key Finding # 1 - Overall satisfaction with an EHR was highly
correlated with whether the respondent was involved in the EHR
selection process.
Key Finding #2 - At least 3–5 days of EHR training was necessary
to achieve the highest level of overall satisfaction.
Key Finding #3 - Nearly half (49.3%) of respondents indicated
that they received 3 or fewer days of training
Patient Portal

• Review availability
  with your EMR
  vendor
• Leverage patient to
  take more
  responsibility for
  their care
• Good example –
  Waiting Room
  Solutions
Integrated Medical Devices

• Can you integrate data directly from diagnostic
  devices?
• Benefits
   – Accurate information – no transcription
   – Fast (wired or wireless connectivity)
   – Linkage directly into the patient’s record
• Examples include: Welch Allyn
Establish a User Group

• Identify individuals within your community who are
  using the same EMR
• May be practice level if in larger group
• Combine clinical with technology sessions e.g.
  journal clubs
• Present use of a clinical feature (10mins) plus Q&A,
  e.g. search methodology, reporting function
• Ideal – monthly
• Building into standard operations
Tips & Tricks

•   Set goals, personally, at the practice level
•   Get complete buy-in from physicians and staff
•   First, optimize your internal practice environment
•   Hold regular practice meetings
•   Make your data comparable and reproducible.
    Standardize on lists, codes, medications, order sets
    and templates
Tips & Tricks cont.

• Avoid short cuts in documentation. It may be tempting
  to enter certain data in narrative format – time
  pressured. To make data reproducible, it needs to be in a
  standard format
• Trust your gut. The EMR is a tool. Use clinical judgment
  when making decisions. Your EMR vendor is not infallible
  and needs your support and feedback
• Keep an open mind. What can your EMR do for you that
  you were never able to do before?
• Optimize for Chronic Disease Management
• Are you taking advantage of all of the incentive
  payments available?
How to Become a Super User
• A ‘Super User’ is someone who knows more than
  the average User about the functional and technical
  aspects of an EMR
• Can be anyone in your practice – MOA, Nurse, Nurse
  Practitioner, Physician
• Aptitude and desire to learn
• On-site expert for trouble shooting & customizations
  e.g. template creation
• Need time and support to receive education sessions
  and training well in advance of go-live date
Measure Your Results

• “If you cannot measure it,
  you cannot improve it.”
   Lord Kelvin


• “X-rays will prove to be a
  hoax”
• “Radio has no future”

• More simply put, you
  cannot manage what you
  don’t measure

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Tips, Tricks and Best Practices to Get Maximum Benefit from your EMR

  • 1. Tips, Tricks & Best Practices to Get Maximum Benefit from Your EMR Dr. Alan Brookstone
  • 2. 1. Adoption ≠ Effective Use of EMR • 16.1% of physicians report using Electronic Medical Records instead of paper charts. This compares to 9.8% in 2007 • 34.1% of physicians used combination of paper charts and EMR in 2010 vs. 26.1% in 2007. 2010 National Physician Survey - http://www.nationalphysiciansurvey.ca/nps/home-e.asp
  • 3. US – Regional Extension Center Program
  • 4. US – Regional Extension Center Program
  • 6. Focus of Today’s Presentation • Adoption & Implementation • Data Quality • Change and Workflow • Training and ‘Meaningful Use’ • Tips and Tricks
  • 7. Observations • Goals • Expectations • Leadership • Foundational computer skills • Practice, Practice, Practice • Collaboration • There are some things you cannot change, right now…
  • 8. EMR Adoption Journey – Level of Effort Implementation Readiness Optimization + Ongoing Use Preparation Pre-EMR TIME
  • 9. EMR Implementation • Schedule reduced patient load for at least a month • Get Staff buy in • Set up training schedule • Paper chart conversion • IT support staff (Consultants/Vendor) • Workflow analysis
  • 10. Implementation Types • Big Bang: turn on everything at once – Theoretically a shorter implementation • Staged: start using new features gradually, e.g. e- presribing, PMS, Medications – Theoretically longer implementation • Recommendation to set implement make it or break it systems first (PM/Billing systems) to ensure sustainability of practice.
  • 11. Principles of Data Discipline • Data Standardization – Coding – Diagnoses, Medications, Labs, History • Data Cleaning – Coverage –all patients are in the system – Completeness –all data is in the system – Consistency –all data tells the same story – Correctness –right patients in, wrong patients out – Coded –all relevant data is coded or in a single format • Data Discipline – Systems thinking • Templates, reminders and searches work together – System supports humans • Provides clues that data is incomplete or inconsistent or not coded Dr. Karim Keshavjee, McMaster University
  • 12. Change • Change is disruptive • No disruption = Not sustainable • How to manage the change – Set clear direction, goals and objectives – Communicate regularly – Invite and acknowledge contributions and concerns – Address resistance by asking for input – Reward initiative – Build commitment
  • 13. Workflow • Workflow describes how a process takes place. The process is evaluated and improved to ‘flow’ more smoothly • Optimizing workflow – Improve efficiency – Reduce redundancy (waste/duplication) – Identify gaps or areas of instability • Plan on paper first – Office Visits – Chart Conversions – Allergy/Therapeutic injections
  • 14. Workflow – Vitals Collection Chart is placed Paper at vitals station trigger How many vitals stations? Patient is called How often do we to vitals station see patient in room without Ht, Wt, BP vitals? Taken & recorded Templat Are cuffs and e needed scales available in Patient is taken all rooms? to exam room How many BP’s do Paper we miss? Chart is placed in sleeve on exam door trigger Ann Lefebvre MSW, CPHQ, Executive Director, NC Regional Extension Center
  • 15. Pearls • Expect and manage disruption • EMR implementation is just the beginning, not the destination • Change is never complete – processes can always be improved
  • 16. Training • Training not just for implementation and upgrades • Two stages 1) go live 2) follow up after baseline implementation • Should be ongoing and comprehensive - includes new learning and advanced functions • As users get comfortable with a system, they learn new and faster ways to work using the EMR • More complex features require more training • Super User Training
  • 17. Study – October 2011 • Correlation of Training Duration with EHR Usability and Satisfaction: Implications for Meaningful Use
  • 18. Methodology • Based upon surveys conducted with five different professional societies between April 2010 and July 2011. • 4,280 responses. The average response rate was 8.5%, though rates differed across professional societies. • Of those who responded to the survey, 2,384 (54%) had an EHR system and completed the entire survey. • 69% of the surveys were received from physicians in practices of <10 clinicians.
  • 19. Key Finding # 1 - Overall satisfaction with an EHR was highly correlated with whether the respondent was involved in the EHR selection process.
  • 20. Key Finding #2 - At least 3–5 days of EHR training was necessary to achieve the highest level of overall satisfaction.
  • 21. Key Finding #3 - Nearly half (49.3%) of respondents indicated that they received 3 or fewer days of training
  • 22. Patient Portal • Review availability with your EMR vendor • Leverage patient to take more responsibility for their care • Good example – Waiting Room Solutions
  • 23. Integrated Medical Devices • Can you integrate data directly from diagnostic devices? • Benefits – Accurate information – no transcription – Fast (wired or wireless connectivity) – Linkage directly into the patient’s record • Examples include: Welch Allyn
  • 24. Establish a User Group • Identify individuals within your community who are using the same EMR • May be practice level if in larger group • Combine clinical with technology sessions e.g. journal clubs • Present use of a clinical feature (10mins) plus Q&A, e.g. search methodology, reporting function • Ideal – monthly • Building into standard operations
  • 25. Tips & Tricks • Set goals, personally, at the practice level • Get complete buy-in from physicians and staff • First, optimize your internal practice environment • Hold regular practice meetings • Make your data comparable and reproducible. Standardize on lists, codes, medications, order sets and templates
  • 26. Tips & Tricks cont. • Avoid short cuts in documentation. It may be tempting to enter certain data in narrative format – time pressured. To make data reproducible, it needs to be in a standard format • Trust your gut. The EMR is a tool. Use clinical judgment when making decisions. Your EMR vendor is not infallible and needs your support and feedback • Keep an open mind. What can your EMR do for you that you were never able to do before? • Optimize for Chronic Disease Management • Are you taking advantage of all of the incentive payments available?
  • 27. How to Become a Super User • A ‘Super User’ is someone who knows more than the average User about the functional and technical aspects of an EMR • Can be anyone in your practice – MOA, Nurse, Nurse Practitioner, Physician • Aptitude and desire to learn • On-site expert for trouble shooting & customizations e.g. template creation • Need time and support to receive education sessions and training well in advance of go-live date
  • 28. Measure Your Results • “If you cannot measure it, you cannot improve it.” Lord Kelvin • “X-rays will prove to be a hoax” • “Radio has no future” • More simply put, you cannot manage what you don’t measure