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EHR best practices for multi-physician ambulatory care facilities

The head of an award-winning electronic health record installation offers advice to her peers on managing the transition from paper medical records to ambulatory EHR.

Successfully rolling out an ambulatory EHR (electronic health record) system for a medium-sized facility takes a team of training specialists deploying it department by department, Dr. Kathryn Stout said in a presentation at the 2010 HIMSS annual conference. That, plus hanging on to paper backups for a few years -- just for the doctors' peace of mind -- whether you need them or not.

Stout led the transition from paper to an integrated ambulatory EHR system at the Richmond-based Virginia Women's Center (VWC), a rural ob-gyn provider that includes 26 physicians and 12 nurse practitioners serving 65,000 women at five hospitals. Her team won a 2009 HIMSS Davies Award for the process, which took seven years of evaluation, starting in 1996, and an additional 14 months of implementation during 2003 and 2004.

The decision took so long, Stout said, partly because VWC waited to green-light implementation until all the physicians unanimously approved the vendor, and partly because it took software developers that long to create obstetrics-specific systems.

Like everybody else, if you asked the question, 'Would you go back to paper?' there's a resounding 'No!'
Dr. Kathryn StoutVirginia Women's Center

Stout shared nine tips from the experience with HIMSS10 attendees planning their own transition from paper to ambulatory EHR systems:

• Get your own IT staff. It might seem cost-effective to engage an application service provider or consultant, but dedicating an in-house staff to tending to IT needs -- EHR implementation included -- leads to a more effective implementation and better physician buy-in, because they're more invested in positive outcomes.

• Find the right person to be the project's medical champion. Do not assign the job to the doctor who happens to be a technophile. Get a doctor involved who knows about EHR systems and has experience with them -- it's a job, not a hobby. And compensate your champion well for his or her efforts.

• Set up implementation teams. Devote IT resources and other trainers to "go-live teams" that will spend an allotted amount of time during the ambulatory EHR rollout. In VWC's case, teams spent two weeks with every department to get it up and running, and adjusted their training as they went along so that the departments that were trained last benefited from lessons the teams learned along the way.

• Throttle back appointments. Give physicians time to get used to using the system. At VWC, physicians' appointment schedules were reduced by 50% at first. Most made up for the shortfall later, in increased productivity.

• Carefully consider hardware. Stout's facility settled on smartphones and tablet PCs, she said: smartphones to enable doctors to check in from their kids' soccer games and adjust a patient's treatment on the go as needed, and tablet PCs because VWC did not want physicians to ever have to turn their back on a patient during a visit. (Individual needs may be different, but think out hardware early on in the process.)

Give physicians alternatives to data entry. Some VWC physicians tried using scribes, who followed them around to enter data into the ambulatory EHR system; others tried speech recognition software, which has a steeper learning curve than most wanted to take on. In the end, they ended up learning the EHR system and entering the data themselves.

Maximize efficiencies through online services. Offer patients the ability to request prescription refills online, make payments and schedule appointments -- not just the ability to request a callback online, which many providers offer, but actual automated booking.

Build employee enthusiasm. Improving patient care, enriching safety and cutting costs are probably the top objectives for your organization, but building employee enthusiasm for a transition to ambulatory EHR involves proving two things to them. The first is that they won't be spending more time at the office learning the system and keying in data; the second is that ambulatory EHR isn't going to cost them anything. (It might in the case of VWC, a physician-owned company, but the dividends to the doctors in cost savings and expanded patient throughput eventually will be greater than the amount of money coming out of their pockets.)

Finally, and above all, understand that the EHR implementation process never ends. Once a health care provider is up and running with ambulatory EHR, it's time to review, revise and improve workflows -- and, of course, run down the glitches that invariably pop up.

"Meetings are still ongoing at all levels -- provider, staff and physicians -- so the cycle of teach, listen and share continues," Stout said. "Now it's definitely more Web-based communication. Like everybody else, if you asked the question, 'Would you go back to paper?' there's a resounding 'No!'"

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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