A couple of months ago in our January Views column, I touched on the learning curve that's inherent in the adoption of electronic medical records (EMRs) and other information technology. It's a curve that can turn into the classic “hockey stick” shape as an organization's members struggle to understand the possibilities of technology and link it to their needs through a commitment to system selection, implementation, and training.
After that steep learning curve, there's often a welcome surprise as users begin, one by one, to “see the light” of how, after all their hard work, information technology can not only help accomplish organizational goals, but can be harnessed to make their work a little easier, a little more organized, and considerably more successful.
Will Walser, CIO of Colorado's Jefferson Center for Mental Health (JCMH), near Denver, reflects on a year-long implementation process in his organization, which involves 250 clinical and 80 administrative staff providing $30 million in services to 10,000 consumers annually.
In 2004, Walser confronted an aging, first-generation EMR and a decision to upgrade or replace it. Rather than risk upgrading the old client/server system, a process he likened to “changing the engine on an airplane in flight,” Walser and his colleagues opted for a new system built around the TIER EMR platform developed by Sequest Technologies (Lisle, Ill.).
JCMH's implementation continues to use its established client/server model, with the TIER application hosted at servers at the organization's administrative office and distributed via a high-speed, virtual, private network. However, the organization's remote users experience a web-like application, with the EMR program delivered through a relatively simple “thin client” program called Citrix that operates within a web browser on the user's desk. Users access EMR and billing information through a series of TIER electronic forms delivered by Citrix. Data fields within the forms feed into client records in the TIER database.
Walser says that delivering the forms through a web-style program like Citrix “gave us a lot of flexibility. We can log on from almost anywhere via the Internet. Basically, we deliver a screen on the user's desktop and data transfers over our intranet.” Flexibility was vital since JCMH's operations reach far beyond its eight hardwired offices. The system also reaches to 20 counselors working in regional elementary, junior high, and high schools, as well as professionals at nursing homes, group homes, and other sites in the community.
But continuing the client/server approach wasn't an instant hit with remote users, Walser recalls. “Early on, one of our remote users noted that, with a central database, ‘If you go down, then I go down, and that's not acceptable, is it?’ The user was right.” JCMH decided to back up its database and servers with a generator to ensure remote users would stay on line. “Later on, after we went live, we had the same problems with phone lines going down. So, instead of backing up our T1 line, we put a broadband cable modem in their offices. It didn't replace the lost capacity, but it kept them going on the system.
“We consider Sequest's billing module part of our EMR. Part of the EMR generates bills to payers and clients. We have our own general ledger system and human resources system. You can't run an EMR without having some components of those systems interfacing them. For example, you've got to have your licensure and credential information interfaced so that you can demonstrate that you meet payer requirements.”
Implementing EMRs can bring much efficiency to mental health and substance use treatment providers. But implementation can also bring about important and sometimes uncomfortable process changes-changes that clinicians may dislike or resist at first, says Walser. “Clinicians' biggest concern is about the requirements-from external and sometimes internal entities-that they must meet to generate complete documentation.” He explains that many providers adapted readily to typing in patient information during the course of the patient visit. However, some of those who have the habit of entering notes after service have not fully adapted yet.
While the EMR makes it easier to recognize and complete the requirements for service, he says that the system's ability to present so many variables means that “clinicians are confronted with the total load of documentation requirements needed for the patient. While this ultimately makes for a far faster billing and claims process-since it can eliminate a lot of administrative work downstream-confronting that load can be daunting.”
Translating the many needs and requirements associated with a client record into an electronic format is something of an art. In this area, issues typically arise as many professionals see that blending various needs, preferences, and variances into a single client record exposes small, but important differences. According to Walser, three concerns stand out in the development of data entry forms for an EMR:
Order of data fields. “Sometimes if you're using paper forms, you have fields arranged in a particular way. But translating those form fields into an electronic form is tricky, since you often find the forms used don't always follow with the processes.”
Mandatory data fields. The differing needs of internal groups, as well as the differing and changing needs of payers, may result in differences about what is considered “required” data in the EMR. These may result in some data fields being changed to “required,” or in the addition of new fields of “required” data.
Ownership of the information. By recognizing that “the clinician is the content expert,” IT teams may decide to collect feedback, but “go light on edits” whenever possible. “Our approach was to go real light on edits to the form data fields.” Preliminary meetings with various teams hashed out a general order, which was built into the system used for training.
This approach proved valuable, since form data developed by clinicians is used by others as well. “Anytime you implement a system, you get comments that ‘we don't always do this, we don't collect this.’ So, business information and process issues would arise. Is this [data] essential or is it optional?” One such question arose over the need to have a clinical diagnosis at the time of admission.
“Do you need a diagnosis at admission or not?” Walser asks, adding that “we didn't start out that way.” He explains that, early in the planning process, diagnosis was assumed to be part of the documentation required for an “admission episode,” the various forms, authorizations, treatment planning, and state or payer information required to admit a patient for care at the center. “When we looked at that process, we were told that the patient always gets a diagnosis. But we found, in practice, that clinicians were not always putting a diagnosis into the system right away. Or, they just forgot to enter it. Either way, we found this created problems in billing. We had to go back and re-match the diagnoses with the documentation later on.” The need for a “required” diagnosis data field thus became clear to all.
In other cases, it is payers who need additional “required” data, he explains. “I believe that documentation requirements have become more stringent over time. For example, auditors today might ask for specific information about how we're using strength-based treatments with our clients. If they require that, we'll add it as a requirement to the system.”
By “going light” on data field edits and requirements, Walser and team tried to minimize the documentation load for clinicians while they worked directly with patients, giving them flexibility to “fill in what they wanted and allow them to go back later and finish.” With time, as the system matured and users could better judge their needs, “we put in those additional requirements.”Like many IT experts, Walser recognizes that users differ in their affinity for adopting technology. Thus, he offered several types of “training wheels” and made it clear that when it came to system adoption, many approaches could work. For those lacking typing skills, he made copies of Mavis Beacon's typewriter training program available. Clinicians unfamiliar with working with patient EMRs on computer screens were given easy access to an old friend-paper charts-until they learned to trust their screen displays. Recognizing that new users were prone to making mistakes in the system, Walser's team offered “free, no-risk” fixes to ensure that no user would be haunted by a beginner's mistake. And, during the final rollout phase, users got on-site support so that they could, without fear, work through “freeze points”-points where uncertainty or inexperience with the system could cause a frustrating halt in their work.
What do clinicians want most from an EMR system?
To write client information in the system once. The biggest complaint heard from clinicians before the EMR system was put in, says Walser, was, “I have to write in the client's name and number ten times before I can do anything with the patient.”
Easy access to patient records. Compared to paper records, which require manual retrieval, the EMR system makes it easy to query the database in a variety of ways to generate a list of all records relevant to the consumers. Essential information is never lost, misfiled, or misplaced.
Complete client documentation. The EMR system makes all relevant clinical information easily available to the clinician, supporting them in making the best clinical decision. “This has been the greatest benefit that we have achieved from our EMR.” Unlike paper records, which may be generated throughout the course of treatment but must be collected later, electronic records allow real-time access by multiple provider personnel. For example, says Walser, “We can support residential units and caregivers, doctors, clinicians, or our emergency access team working at different sites. All four of those entities can record into the same record, all at the same time if needed. So, the doctor can see what the clinician has recorded; see what's going on in the residential unit. If the person is admitted to the hospital or goes into the ER, we can see what the hospital or emergency therapist has written about the encounter in the ER. The system, and the EMR record, has really opened up the communication between all entities providing care to the patient.”
Information quality and clarity. Unlike handwritten paper records, the quality and legibility of information in the EMR is consistently high. The information not only assists in the treatment process, but is a favorite of external auditors as well. “It really helps the auditors. They can read what is going on. The clarity of the typed word versus the written word is amazing.”
E-prescriptions. This feature will soon be utilized by JCMH to allow prescribers to submit prescriptions direct from the TIER system to pharmacies.
Hints for EMR adoption
EMRs aren't IT projects—they're organization projects.
Involve every team in planning the system, but rely on a core team, representing all groups, to drive the implementation process.
Use training as an opportunity to test and adapt the system, so users can see how the assumptions and processes from the planning phase translate into a working system.
Offer “training wheels” because users learn with different methods and at different rates.
Encourage system testing and adoption by making mistakes “risk-free.”
Trust users to be process and content experts: “If you're not sure of a [data] requirement, wait a little while-you'll get the feedback you need.”