CONVERTING TO AN EHR IN A MEDICAID OFFICE

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Too Much Too Soon
The Implementation of Electronic Medical Records in an Urban Primary Practice
Written by Scott Sitner and Stacey Marie Chapman

October 2011
The decision to buy and implement an “Electronic Medical Records” system is, in and of itself, a major
undertaking and practice altering decision. Financial considerations, legal ramifications, practical
concerns and patient and practice management concerns all go into the decision to make the leap or to
accept the financial ramifications if you don’t. This article’s intent is to give physicians in a primarily
Medicaid/urban setting, a grasp of the issues they will encounter, the problems that are inherent in
starting with electronic medical records in general, and the concerns that this type of office will have to
address, which are vastly different than more modern, suburban settings. While EMR systems are at the
forefront and cutting edge of medical technology and may hold the promise for a safer, more secure
patient care, our experience is clear: buyer beware before jumping in.
I was asked by the Clinic, partially owned by family, to act as general legal counsel for the contracts and
implementation issues and any issues that would arise regarding privacy and patient care. Additionally, I
was also to act as a Project Manager, as the Clinic simply had no one who could step into that role,
without impacting their day to day operations. I have learned as much about practice management as I
ever thought I would need, but despite 20 years of business consulting and management experience,
nothing I had done could have prepared me for the role and actions I would be undertaking.
The Clinic
Junction Clinic PC, is by its own admission, a unique entity, having begun fifty years ago by two young
Osteopaths, both born and raised in Detroit Proper. Having gone to school there and graduated from Des
Moines College of Osteopathic Medicine and Science in the early 1960s, both doctors were committed to
having a private practice in Detroit Proper, which was at that time, thriving. The auto factories were the
center of the local economy and just a few miles away, employing tens of thousands of workers. The
neighborhoods were bastions of middle class, with small well-kept homes, good schools and nuclear
families. It was a perfect place to take over a small family practice and make it their own. The practice
has now survived for 49 years, celebrating its fiftieth year in 2012. It has seen the changing face of
Detroit and society. The neighborhoods went from middle class to impoverished, the factories closing
and its residents moving out to the northern and western suburbs. After the riots of 1967, the doctors,
who actually crossed into the city during the riots to stay open, had to make a decision whether to stay in
Detroit or follow their fellow doctors to the suburbs. For many reasons, they elected to stay where they
were, even upgrading in 1973 to a brand new building only two blocks from where they had started and
where the practice still exists to this day. (The old office which was vacant for years, is now a trendy
restaurant.)
Over the following decades, the Clinic has not only survived, but thrived, providing Primary Care services
to an urban population, now largely on some form of public assistance, a substantial majority of which,
are Medicaid and Medicaid HMOs.
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The clinic has thousands of office visits a year, employs three doctors, two physician assistants and over
a dozen office staff, some of whom have been with the clinic for decades. Also included is this writer, who
has helped out with legal and consulting advice over the years and was now charged with being the
project manager for the EMR roll out. Needless to say, the Clinic knows how to operate, changes only if
and when it needs to and is secure in its place in the medical hierarchy. It is not fancy, there is no
plasma TV in the waiting room, it takes no appointments, and up until recently only used computers for
billing, checking email and the news. It was, and is actually, a system that worked, so, as the doctors
asked many times before agreeing to implement an EMR system: why?
The answer to this came in two parts:
1) Because you will have to;
2) Because you will get paid something;
The first answer was the least satisfying, and as the clinic’s project manager and occasional legal
counsel, it was left to me to explain to them, with the help of its partner hospital, that in some sense, they
had no choice. It would just be a question of how and when it would happen and how bad it was going to
be.
The second answer provided a little bit of relief, but at the end of the day the amounts they would get
back, spread out over so many years, did not come close to offsetting the totality of its actual cost. Quietly
disregarded were the physical costs, employee downtime, training and the amount of aggravation to both
doctor and patient that would go into making the decision and going forward with what was and is, a
substantial change to how the practice had run, and run successfully, for close to fifty years. But at the
time, the decision, although slightly forced, seemed reasonable.
In September of 2009, in what was really not much more than a sales pitch in hindsight, the Clinic
decided to sign the contracts to implement a system for the office, personally obligating the doctors to
over $100,000 in financial liability and the practice to a fundamental change in its operation. The system
that was chosen (a word used with a touch of sarcasm), was not based on what was best for the doctors
or patients, but instead on what was presented to them by the hospital’s chosen vendor, and the hospital
itself, which was offering a subsidy (although to this day no one seems to know exactly what it actually
covered or how much) and a well-meaning sales representative from the vendor. No one actually took
the time to look at the clinic, evaluate the practice, what is the patient population, and most importantly,
how does the clinic work and what does the Clinic need? While the word “workflow” is a grossly overused
one and in some sense, one no one really seems to understand, in this case no one even asked about it,
the conversations taking place in the doctors’ private office and not out on the floor where it should have.
Lost in the shuffle was the simple question; should this clinic, even with the incentives, obligate itself not
only to this company but to an EMR system at all? What are the benefits, what are the costs, and is it, at
the end of the day, something that would ever work in this setting?
After all was said and done, the decision was made, the contracts signed and the process begun. The
clinic is, as are many clinics in a similar urban low income setting, technologically challenged. It’s
infrastructure consisted of a number of old PCs, some still having floppy drives, a broadband internet
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connection, aged dot matrix laser printers, no scanners, and a billing connection set up, which, while
familiar, was quickly becoming unusable. There were no laptops; nothing could be done on the
computers except for billing and some patient insurance verification. Even more importantly, was a fact
that our clinic, similarly to other urban clinics, typically have staff simply not trained or educated in the
changing face of modern practice management. The staff are all very skilled in what they do, mostly
medical assistants, and very capable, but not trained in modern medical office practices, nor even really
trained in basic computer skills except what was needed for billing. Adapting a sophisticated, challenging
and totally new EMR system in such an office would turn out to be one of the biggest challenges the clinic
had faced since it opened.
The clinic is a “paper” office. With thousands of patient files behind the front check-in counter, mostly in
alphabetical order, doctors and assistants would simply write notes in the file, order tests and put the file
back when done. Billing information would be on the front of the manila folder, a chart of vaccines for the
kids, vital statistics and then, for the most part, just blank record forms where notes would be taken and
put back in the file. Nothing fancy, but at the end of the day, it worked and worked for them. Records
were easily located, information was accessible, and everyone simply knew where everything was. To
make a wholesale change to electronic records flew in the face of the established practices that did not
seem to need changing. It was, it seemed, change for the sake of change, without really examining
whether in this setting, such a change would offer any benefit to the clinic, its doctors, and most
importantly, and to this point largely lost, its patients. Or was this just something “they had to do”?
The first issue the clinic faced was the lack of any upgraded technology. As Junction Clinic is self-funded,
it has only a loose affiliation with a hospital and does not get the benefit of the hospital buying equipment.
The clinic was told, again without really an evaluation being done as to what right for them, to purchase
four tablet computers, six net books, and a scanner. Of course it had to upgrade its network and
infrastructure as well. At the same time, as part of the overall purchase, a new server had to be put in for
the software (which was part of what was purchased initially). All told, the cost was over $25,000 in
equipment purchases, again, out of pocket for the clinic, which was already seeing a reduction in
revenue. The office was then told that the physical setting for the new server was not good enough, there
was no place in such an older office that was safe for the server, and that the desktop computers were
too old and needed upgrading. $2500 later for an electrician and networking expert and two visits from
the EMR Company’s designated network person to get things set up, the system, six months after the
contracts were signed, was in theory, up and running.
Training and Implementation
The largest issue the clinic has faced and the one that had the biggest disconnect between the EMR
provider’s history with other clinics and Junction Clinic, was in the training and the actual use. First, the
sheer number of people who were “on our team” from the system side was amazing. What was more
amazing was that none of these people was very good at responding to issues and none of them, as a
general rule, would take a phone call, once going so far as telling the Clinic’s doctors, not to call, but to e
mail. This told to doctors who did not e-mail and just wanted someone to talk to and get answers from.
It was almost shocking that it was so difficult to get anyone to assume responsibility, with each person
saying, “no that is not me, but I will get you to the person who handles that ‘on your team.’”
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On one hand it was nice so many people were involved, on the other it was not so nice that none of them
seemed able to answer questions as simple as how many hours of training are left or when training could
occur or why were we being charged for something we did not use?
It was also clear from day one, that from the first “roll out” phone conference I had, that Junction Clinic
was nothing that this Company had encountered and that it clearly did not fit the mold for which the
system was developed. The questions that were asked by “our team” to get the system up and running
were designed for suburban clinics; ones who had the ability to shut down for three days to train, that
makes appointments and keeps them and has a staff that is technologically advanced and trained and
computer savvy from the start. More than one time, the clinic was asked how it makes and keeps
appointments and how it handles no shows. More than once they were told that no appointments were
kept, as the no shows would be so large in number, it was pointless to do so. The trainers were also not
at all ready to handle a staff that was very well versed in their jobs, and knew how to handle the patients,
but did not have a lot of technical training and did not use words like “reach out.” There was an inability
to deviate from the training script and to make changes for the clinic on the fly, changes that were needed
for the system to work in this setting. If something did not work, there should have been a way to make
quick changes, especially given that the providers, who are also customers, are spending a large amount
of money every month- over $2000 for the system and another $1000 for software upgrades and other
mandatory fees. But there was not. The trainers, who were all well-meaning, and clearly well versed in
the system, were not able to wrap their hands around this Clinic, as it was such a different animal.
Junction Clinic, as with most Medicaid/Urban Clinics, has to see people fast, make decisions and
evaluations based on what is front of them, and move on to the next patient-or they do not survive. With
reductions in reimbursements, increasing demands on staff for reporting requirements, increasing time to
bill and general office work, urban clinics must see patients fast to survive. EMR systems, just by their
nature are slow. Doctors must type, flip through different screens, load a patient into the system and then
check the patient out, all the while trying to be a doctor; communicating and diagnosing. It just can’t work
in this setting; especially with physicians who are older, not as familiar with technology and are resistant
to using it. The system was great for evaluating and treating a patient when there is unlimited time to do
so, and 45 minutes blocked out per patient, but for us, for dealing with a mom and her two kids coming in
for a preschool checkup or the sniffles and a fever, it was actually substandard. Flow charts that usually
ended up far away from the reality, turned a cold into cancer and were just not at all suited for a family
practice. Quick office visits were the expected norm but unrealistic. The templates, valued and
propounded by the vendor, simply had too much information in them, too many steps to go through, for
things like the flu or a virus and could not easily be adapted for a primarily Medicaid/almost exclusively
family practice clinic.
Most critically, those templates were not at all user friendly. Clinics are not cookie cutter offices, which is
how the system is set up; one size fits all. Practices such as this are different and need a system that can
see people, allow the doctor to take notes and record vitals and make conclusions, doing so quickly. The
system now in place is simply not adapted for this type of setting. The information may be there and the
ability in certain settings is acceptable, but not in this setting.
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The lack of adaptability and flexibility costs the clinics and its providers in more ways than just patient
care. While it is not a comfortable conversation; clinics are businesses, in this case, one that employs full
or part time over 20 people, has an onsite pharmacy and is a valued member of the community.
It pays property taxes, enhances the community and serves a vital role in an area where a clinic is more
likely to close, then to remain open. When a doctor goes from seeing five patients an hour to just two,
people do not get seen, diagnosis and treatments do not happen and the staff gets frustrated. In some
cases patients leave, who may or may not come back and quite frankly, revenue decreases.
The staff gets especially frustrated when they are confronted with technology that they were told would
make their jobs easier, but in reality makes them harder. EMR companies need to be aware that there is
a “flow” to an office that cannot be generalized. Those patients who have been coming to the clinic, in
some cases for fifty years, generations of families, do not like change and loyalty can be short lived.
When doctors have to take time away from patients to enter information into a computer, they lose the
interaction, the face to face, that can be so critical to a diagnosis, or to just a personal relationship that is
so valued by a patient. What was learned is that the technology did not address the human side of
treatment. People who went to the doctor as much for treatment as they did for personal well-being, were
faced with a doctor who now had to stare into a computer, try and find a template, try and take notes, all
in a way that works for both practice management and patient care. With this system and others that
were looked at after, this simply was not possible without a great deal of changes.
Junction Clinic went through four different sessions, each between three and four days, of on-site training.
However, there were different trainers, each with their own philosophy and frankly, their own interest and
ideas on how such a system should work. One of the things that we questioned right off, was why was
there not just one person assigned to the Clinic, who would learn the flow of the practice, the patient
population, how things work in this Clinic, who could be a constant resource? The greatest improvement
we would suggest to EMR providers is to tailor the training to the clinic, use people with a background in
family practice (or whatever specialty), in a similar setting, who will understand the needs and wants of
the providers-not just show what the system is capable of, which is nice, but of little practical value. The
other issue is the sessions are spread out often by months, so one person comes in, trains for a week
and then three months pass. Unless the staff is ready, which they rarely are, the system breaks down and
what was learned is long forgotten.
The Clinic has now gone through four training sessions and has forty hours of paid time left. No one from
the vendor has called to see how we are going to use that, or even just checked in, which is something
even a car salesman does once a year. When we had serious accounting issues that most businesses
would be able to reconcile in days, it took four months to simply get an accounting of the money that has
gone in and out. The Clinic largely feels abandoned, with no one and nowhere to turn, to help make that
determination of where do they go from here. Or do they go at all? Most importantly, as a customer, they
did not feel valued.
It is this lack of continuity, usability and accountability that has left Junction Clinic in a middling grey area.
Its first Medicaid incentive payments were received. Now the Clinic is faced with the question of whether it
is worth the time and the effort to continue to use the system, or frankly any system, or simply let the
chips fall where they will and suffer any financial penalties imposed.
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The incentives offered are helpful, but in many ways do not even begin to offset the financial and human
costs that have been incurred and as a long term commitment. A decision has to be made whether or
not to simply scrap the project and incur the penalties that may go along with that.
The clinic may well be willing to suffer the financial loss that this would entail, but would not have to
undergo the hassles and hardships that even attempting to implement the system has caused.
It is clear that the government mandates to implement EMR systems into offices are well intentioned, but
lacked foresight and practicality for many physicians today for this type of primary practice office.
Changes need to be made, from fewer government mandates, to greater financial incentives, to
extending deadlines and more awareness of patient impact. It is not a liberal or conservative bent but
rather a practical one. People in Congress and the “experts” they use, simply cannot understand the
needs of a medical office to not only be technologically up to date, but to combine that with patient care.
This is something that has been lacking in the end game.
My contact with Stacey, who has authored the second part of this paper, arose out of my own need and
after having acted as a project manager for the clinic, to see if other clinics were, in fact, encountering the
same obstacles. As Stacey points out below and we wholeheartedly concur, using resources not offered
by the vendors, such as Independent Consultants, can be of great assistance to the clinic-not only in the
implementation stage, but also in the initial acquisition. I have no doubt that had the Clinic been
presented with options, rather than being told, essentially, what they had to buy, we would be in a much
better situation than we are now. To that end, it is, I think, critical that readers of this paper, whoever they
may be, learn from this Clinic’s experience, but also takes the following to pay heed to her sound advice.
What Scott describes in the previous pages is indicative of the struggles that so many practices
experience and is especially synonymous with small ambulatory practices. It is also the catalyst for how
Scott and I met and now have come to be working together. It is through his and Junction Clinic’s need to
remedy and redesign an implementation, which cost an extraordinary amount of money, with little return
for its investment, that we embark on this venture.
With that, let’s start from the beginning.
My name is Stacey Marie Chapman, with PTS Consulting, and I’ve been working in the EMR industry
since 2007. Since that time, EMRs have evolved remarkably, though sadly, the struggles with the
implementation of them have not.
The implementation of an EMR is a very expensive endeavor, both financially and emotionally. It changes
the very cultural backbone of a practice and requires tremendous commitment and patience from all
involved. While I certainly am thoroughly aware of Meaningful Use and the incentive money, it cannot be
the only reason given why a practice should implement an EMR. I encourage practices to focus on the
benefits of a properly installed and fully functioning EMR such as: continuity of care, patient safety,
patient satisfaction, additional space, saved expenses on office supplies, time saved, practice resale
value AND additional incentives from programs such as P4P, Quality Reporting, ePrescribing and
Meaningful Use-not to mention the avoidance of penalties through Medicare.
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The undertaking of such a volatile process needs to commence with the practice having a clear
understanding of the journey they are about to embark upon.
Proper preparation is critical for practices and a crucial first step I often see overlooked. Some practices
can prepare in a month, some can take 6 months or longer.
When working with a practice, one of the first things I do is to sit with them to understand their reason for
implementing and offer a solid roadmap for the course they are to proceed upon. No one wants to feel
lost in a process, especially when it comes to a foreign one. Sitting with the individual members and
discussing their goals, pain points, ideas, and fears offers insight into the practice and allows a Project
Manager to offer a customized solution and a roadmap that is crafted with the clinic at the heart of it. It’s
your practice, your livelihood and your process-for long after a consultant walks away, the practice will still
remain.
When Junction Clinic began to investigate their options, hospital subsidies offered discounted pricing.
While this may be enticing, the saying “the most expensive EMR you’ll purchase is your second” rings
true. One time subsidized pricing will not matter if the practice can’t keep pace with patient load and
properly bill for their services rendered. Understanding their needs and goals is a critical first step in
identifying the potential vendors. The step of choosing an EMR platform can be arduous but is well worth
the effort. Focus should be placed upon things such as customer satisfaction, practice culture, technical
proficiency, IT support staff, as well as usability, specialties served, and workflow. Does it meet the
needs of the practice? If Meaningful Use is an objective, is the platform ONC-ATCB certified? Working
with a trusted Consultant through these steps can help provide guidance and negotiate price.
When navigating your way through demos, make sure that the salesperson targets the demo to the needs
of your practice. Come up with scenarios and questions specific to your practice to ensure the product
can deliver to your specifications. Observe things such as ease of use, speed and the number of clicks
you have to go through to perform a common task. Ask your questions and ensure they are answered to
your satisfaction. Remember, this is a vendor’s sales demo given by gifted salesperson and you will likely
be impressed by all of them. While what you see is impressive, does it suit your practice? Can the
platform be successfully manipulated or customized to suit the needs of your practice? Ask the
salesperson to step you through some of your “typical” visits, demonstrating all of the features pertinent to
your use. Keep checklists and notes of each demo, providing yourself with a means with which to later
weigh out the pros and cons of each.
Next, do your homework! Ask for reference sites from the vendor-practices that are similar in size, staff,
patient load and specialty. Call and speak with them and if possible, ask to do a site visit. Visit forums,
blogs and conferences to hear the positives and the pain points of practices. Speak to colleagues who
have “gone live” to get their experience and how they like the system that they chose. All of the
aforementioned will give you a better understanding of how the company conducted its processes once
the contract was signed.
With the decision made and the contracts signed, Junction Clinic begins the process of an EMR
implementation. First stop; hardware assessment. Or, in the case of Junction Clinic, its lack of hardware.
Hardware selection is an aspect that needs to be carefully considered on many different levels; the
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computer proficiency levels of the practice, IT support structure, and functionality and of course, the
budget.
When implementing, for any practice, the procurement of the hardware should always commence the
same way: assessing the technical proficiency of the practice. This part of the process is invaluable for
understanding the culture of any organization. As Scott mentioned, the practice is very good at what they
do; skilled and capable, resigned to their own way of doing things. On paper. When I explain to a practice
why I administer a computer proficiency assessment I reflect on and highlight those very same points.
The providers, clinicians and staff have all been providing exemplary care without the need for
computers, so without that dependency; why do they have to know how to use computers? Surprisingly,
many healthcare professionals lack basic computer skills. Before we can expect a staff member to use a
complex program such as an EMR, they have to know the basics of how to point and click, surf the web,
type and send an email and create a document in Word. Knowing this is a sensitive issue; a “back to
basics” approach can eliminate great frustration and empower individuals too embarrassed to admit their
need for preliminary preparation.
When making purchasing decisions of this magnitude you must consider the culture of the practice.
Besides cost being a factor, you must also consider the skills of the persons using the hardware. Is it
necessary to go with the latest and greatest touch screen tablet with a stylus? Or in Scott’s case-four
tablets and six net books? For a practice entering its fiftieth year, desktops; properly and strategically
placed would have been my first suggestion.
As the procurement process continued, Junction Clinic was faced with what little hardware they have
being outdated, a server room and network infrastructure that is not up to specifications and a hardware
bill quickly growing out of control. The thought now comes to mind as to why a SaaS (Software as a
Service) model was not introduced. Hosted by the vendor, a SaaS model eliminates the need for servers,
server rooms and construction. It allows the vendor to host the solution for its client, allowing web based
access for the practice with the use of an internet connection. For a practice with a culture such as this, a
SaaS model would have been ideal and would have come at an enormous cost savings. While not for
every practice, consideration needs to be given to the actual practice at hand and what is the most cost
effective, convenient model that can be utilized.
For the client-server model, once you buy software, servers and network hardware you are obligated to
maintain them, which means you need to have IT support. Whether you hire staff or enter a contractual
arrangement with an integrator, it is an area in which you were likely unprepared for and a cost you
weren’t accounting for in your budgets. Since your practice now relies on IT, that person or organization
you employ becomes critical and a potential single point of failure. You need to trust them implicitly and
they need to be competent and dependable. Do you know how to screen these candidates? Or how to
negotiate favorable terms and conditions for your practice? Like it or not, you’re now in the IT business
too.
With a SaaS model, you are relieved of much of this burden, however, at the expense of another long
term monthly bill.
Moving along, we come to the implementation team introduction. Scott mentions the people throughout
his implementation “on his team”. I’ve worked on one of those “teams” having spent two years working for
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an industry leading EMR vendor. I worked very hard, long hours and was very dedicated-as I know were
all of my colleagues. I have the utmost respect for everyone there and their tremendous work ethic.
However, I also know that there is not enough time in a day for these teams to manage all of their day to
day tasks easily. Scott’s experience is not uncommon. This is not to say that Junction Clinic’s frustration
isn’t justified and they are not alone. A practice deserves answers and assistance every step of the way,
when making such a sizeable investment, in a product they do not know, on a path that is not clear.
Having one point of contact, both from the clinic and the vendor is essential to clearer communication.
Many vendors offer “Account Managers” to alleviate this very concern. Does the vendor you’re choosing
dedicate account managers? If you don’t know, add this question to your list. As mentioned, I worked for
the vendors and had this exact role. Clients had my cell phone number; days, nights, weekends, and
holidays-I was always available to answer questions on a first name basis with my clients.
We’ve already touched upon practices that are not technically savvy and that maybe this is part of the
practice culture, but each practice has its own workflow that likely took years to evolve. Workflow is a key
consideration in the implementation plan, but it is key for different reasons and in different capacities. It is
important for the workflow to be mapped out, even if simply in a Word document. This workflow should be
mapped out and dictated by the actual workflow of the clinic. Not the way it is perceived, or desired to be
operating, but its present tense operations. It is important to determine this for two reasons; so that the
vendor understands the practice’s needs and so that the trainer can prepare effectively and understand
the processes prior to arrival. As the use and understanding of the EMR improves, mapping the before
and after workflows will improve processes. As a consultant, when working with a practice in training, it is
important to know the workflow processes in place, to effectively manage the training process, but also to
work with the practice so that it is understood, that while their current flow is important, it will also alter as
it becomes electronic.
This divide between paper and digital can often be difficult to understand and envision. If explained and
illustrated, a practice will be more acceptable of letting go of the old and slowly embracing the new. As we
embark on that embrace- albeit the standoffish embrace you give your 90 year old aunt who always
leaves lipstick marks on your collar and smells likes Vicks, embrace, remember this: EMR is not paper. It
is more time consuming, especially in the beginning, and more thorough. It will also never be an “out of
the box” solution, a phenomenon we’ve all come to expect in today’s culture. Templates need to be
discussed, created, modified, deleted and reborn again, in an iterative manner. As with anything new,
there will be a learning curve and templates are no exception. With vendors that allow the manipulation of
templates; it is an additional process for the clinical staff to undertake, but one that must be explored to
best align software and process. Taking a “practice specific” approach to the design and augmentation of
these templates, while time consuming, will allow the practice to determine best practices for them.
Additional means of input should also be assessed, such as Voice Recognition and transcription (through
various means). The trick with workflow, templates and data input is that there is no one size fits all, as
Scott has learned.
Change can be difficult for a practice, but often overlooked and equally as important, change impacts the
patients of a practice as well. I advise practices to engage their patients, inform them and prepare them
for the modifications the clinic is about to make. As an implementation comes to a close, I bring in posters
for the practice to hang in various places throughout its locations. Explaining in English and the most
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predominantly spoken language of the patient demographic, the posters illustrate the changes they will be
witnessing and that they are a result of an initiative to improve patient care.
No one likes longer wait times at the doctor’s office, including me, but if patients are prepared for the
changes and are informed and engaged as they arise, their level of tolerance will be better than
inexplicably standing in long lines at check in.
As efforts are made to inform and include patients in your process, ensure that considerations are also
made for their benefit. Keep design in mind as you make procurement decisions. There are a variety of
hardware choices to ensure that clinicians do not lose face time with their patients. No one wants to look
at a doctor’s back while they click on the keys. As EMRs have evolved, so have their method of delivery
and usage. Wall mounts with arms, carts on wheels, tablets, iPads and more, have been designed to
incorporate the ability to input data, while maintaining the face to face communication necessary to see
patients. Again, each practice is different and can use one or all of the aforementioned, depending on
personal preference.
All considerations made should include input of key staff members on an internal team, to champion the
successful adoption of an EMR. This team should be determined early on, taking team members that are
technically proficient, ready and able to undertake the challenge and to do so with a positive, encouraging
attitude with which to mentor other members. Referred to as Champions, it is an important and
fundamental role in the success of the process. Champions take all of the items mentioned in all of these
pages into consideration and represent the clinical, financial and technical components of the practice.
They are the cheerleaders of the implementation and help guide the practice internally through the
training. Their role will be ever changing as the implementation, adoption and use of an EMR progresses.
While being instrumental to the preparation at the onset, they will eventually need to transition to
undertake the ongoing training needs of the practice. Consultants won’t be engaged forever.
Typically vendors offer webinars, videos, tutorials and user guides, to name a few of the ongoing training
resources, but these aren’t always effective for the newly “technical”. Beyond the use of these tools and
after the trainers leave, the role of an ongoing internal trainer should emerge. Becoming self-reliant in the
ability to train and maintain offers several advantages to a practice, such as the ability to train incoming
individuals as staffing patterns change. This eliminates the need for additional expenditure on training and
allows for a champion to become a super user, modifying and enhancing the use of the software as the
practice becomes more refined and sophisticated in its abilities. For practices struggling with the
rudimentary processes of training, the Super User can guide the vendor’s trainer to best make use of time
spent on site in subsequent vendor sponsored trainings.
As we near the end of Scott’s tale, it is sad to me, that he closes not feeling valued or important to the
vendor and abandoned in an implementation, that was by and large a very costly disappointment. There
is little I can say in response, other than that he is not alone in his sentiment. Were he, then there would
not be such value in the offerings of working with a consultant. For when clients ask me what the benefit
of working with me AND the vendor is, my response is simple: because you’re my first priority.
As an advocate for the physicians, it is my responsibility to offer the one-on-one hand holding so
desperately needed for a transformation of this magnitude. On a daily basis, I work with five practices,
not fifty and do not sell features and functionalities to make money.
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I offer services and solutions to overcome shortcomings and when the practices find themselves here,
where Scott is, I offer the insight to improve a process that did not deliver on its expectations. In a more
ideal situation, I provide the insight to successfully implement a solution that works for a practice, instead
of trying to salvage one that didn’t.
Junction Clinic now finds themselves at a crossroads, in the position of determining the value of keeping
their EMR, versus cutting their losses. While their frustration is clearly warranted, I would hate for it to be
the determining factor in incurring a monetary loss of such breadth, not to mention the aggravation they
and their patients endured. Instead, this is an opportunity to perform a needs assessment and a gap
analysis to determine the present tense state of the implementation and to redesign a path to effective
utilization and meaningful use of the EMR. Identifying and aligning the goals, determining the unmet
requirements and re-evaluating the processes in place will serve us well, as they transform themselves
into a 21st century practice.
About Scott Sitner:
Scott Sitner is an Independent Consultant and Advisor concentrating in business development and expansion opportunities for
privately owned, small to medium sized businesses. Working across multiple disciplines within the medical community, he
specializes in working with clients to evaluate and enhance their infrastructure to accommodate changes in the economics and law
inherent to their industry. Scott graduated from Kalamazoo College and Michigan State University College of Law and is a lifelong
resident of Detroit. He has been affiliated with Junction Clinic for the past ten years.
scott.sitner@gmail.com
About Stacey Marie Chapman:
Stacey Marie Chapman is a Principal Consultant with PTS Consulting, having previously worked as an Implementation Consultant,
as well as, for eClinicalWorks, an industry leading EHR software vendor. Stacey recently worked on curriculum development and
instructional content for the ONC sponsored Community College Consortia to Educate Health Information Technology Professionals
in Health Care Program and continues to work with the Community Colleges in educating tomorrow’s HIT workforce. In partnership
with Bronx Community College, she also created and chairs their HITECH Educational Advisory Board.
Stacey.Chapman@pts-consulting.us
About PTS Consulting:
PTS Consulting Group (PTS) is a world class IT Consulting and Project Management company, providing Consultancy, Managed
Services and Resourcing solutions to the world’s biggest names. Founded in 1983, PTS has built a strong reputation for “substance
over style” and is renowned for its impartial, vendor independent advice, the quality of its processes and friendly expertise of its
staff. Recognised as the global leader in IT Relocation and Data Centre projects, where its experience, professionalism and quality
of service come together in the most demanding of environments, PTS has delivered over 4,500 engagements across the Americas,
EMEA and Asia-Pacific. http://www.ptsconsulting.com
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