a jewish kids view of the christmas season


My daughter hates Christmas. I wish there was a better way of saying it, maybe something more pleasant, less controversial or more politically correct, but there really is not. It is not the weather, the sleeping Santa at Wal-Mart or not getting the 16 gigabyte Ipod so she can watch Lost under her covers at night (every nine year olds dream). But rather a very interesting look into the divide between Christians and other religious groups, the prevalence of non religious Christmas symbols that really are religious, even if somewhat innocuous, and how a little girl who is Jewish sees the world as Christian and feels left out of the party.

It really started as a somewhat innocent comment, along the lines of why are there so many Christmas trees and no trees for Hanukah or Kwanza? Why is there Santa Claus on every corner and why is Target putting up decorations before Halloween, and most importantly why are there aisles of decorations for Christmas and one shelf for Hanukah? It was not enough to explain simply that there were more christians then jews, or that stores needed to market to their larger customers which, for better or worse are in fact Christmas shoppers, or that well, this was just the way it was and we should celebrate our own faith. To her it was a slight, a recognition that she was a minority and that her faith, reform, or conservative, was irrelevant.

Try as her mom and I did, we have been unsuccessful in explaining to her how the season works and why we see Christmas everywhere and only small mentions of other faiths and their celebrations this time of year. What has been the most interesting is to see how a nine year old, perhaps a little precocious, deals with her version of perceived prejudice. Target is not out to get her or slight Judiasm, however it may seem those who want crèches on city property by legal mandate do not hate other faiths, they just seemingly prefer their own. But to her, it is prejudice, it is a slight, it is a lack of recognition of other faiths and that in and of itself demeans hers, religiously and culturally.

But this got me to thinking about prejudice and about being in a minority that is really not persecuted and in dealing with my daughter’s conceptions of being in a minority and what lessons we, and hopefully others can take from it. First, she through this she has taught me to recognize that her feelings of being in a minority are real, and that our first attempts to laugh them off in essence reinforced her feelings, basically saying that this is just the way it is, and deal with it, rather then address what was really bothering her and how we could make her feel better about herself.

Which is the next point. To me, it seemed, this was effecting her self esteem, that society was making her feel less like a person because she did not celebrate Christmas. This should have given her mom and me an opening to discuss her faith and how it impacts her life, and how it differs from Christianty, but how both are important, and different, and despite a few evangelicals to the contrary, important to how we exist, a lesson I wish I had learned at 9, instead of 41. We make efforts, even divorced, to have an occasional Shabbat dinner, attend family Temple events, high holiday services and reinforce who we are and some of the values of our faith . But what we did not do was explain to her why we have faith, how it can play a role in our everyday lives and why and how we can address the issues of being a minority without having it make us feel bad or left out, especially at this important time of year for all religions so that she does not express sadness at feeling left out, which then becomes anger, which then becomes disenchantment and being disengaged from religion, which happened to me and which I hope does not happen to her and her brother.

Finally, it got me to thinking about those that want to enact laws that force a government to recognize one religion over another. It is all well and good to say that this is not the case, that it is simply recognizing our heritage as a Judeo Christian nation, or that they are simply reinforcing the values that made our country great. But that’s a lie, maybe not a conscious lie, but a lie. Those values, as honorable as they may be, are based in one religion, the placing of religious symbols on government land, as ordered by law, violates what we are about. As an admitted liberal, mostly, it does not bother me if a government throws 20 symbols on their front lawn, frankly it’s pretty laughable and makes it look like a farce. But when citizens band together to say that a government must place the religious symbols of one religion, on government property such as city hall or a police station, well, it’s gotta make people think, like it did my daughter who may not have completely understood why she feels like she does, but that she does, and is this the message we want to pass on to our kids.

Take the time this season to explain whatever your religion is, what values it may teach and how it impacts our lives and more importantly, how all religions fit together, whether through love or hatred, through peace or violence or simply through “being”, and how we need to take these values to our kids and both teach them and learn through them.

And an occasional Ipod does not hurt either.

Electronic medical records in a real world setting-Scott Sitner



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 have to 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 EHR 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.

            I was asked by the Clinic, which is also partially owned by family, to act as legal counsel for the contracts and implementation issues, together with the issues that would arise for privacy, patient care and general legal, but also to act as a project manager, as the Clinic simply had no one who could step into that role, without impacting the day to day operations.    I have learned as much about practice management as I ever thought I would need, but I also took into thos project 20 years of business consulting and management experience.  Nothing I had done could prepare me for the role and actions I would be undertaking.


            Junction Clinic  PC is,  by its own admission, a unique animal, having begun fifty years ago by two young osteopaths, both born and raised in the 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,  the center of the local economy, were 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 were changing and from middle class to impoverished, the factories closing and 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 started 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 years 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 Medicaid and Medicaid HMOs.    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 and this writer who has helped out with legal and consulting advice over the years and was charged with being the project manager for the HER 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, takes no appointments, and up until recently used computers for billing and for 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 EHR system:   why?

The answer to this came in two parts:

  • Because you will have to;
  • 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 actual physical costs, the employee downtime and 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 seemed reasonable but also slightly forced.

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, but no one who 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 phrase “workflow” is a grossly overused one, and in some sense one no one really seems to understands, 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 question of, simply, should this clinic, even with the incentives, obligate itself not only to this company but to an EHR system at all?  What are the benefits, what are the costs, is it, at the end of the day, something that would ever work in this setting?

But 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.   A number of old PCs, some still having floppy drives, hopefully a broadband internet connection, dot matrix and aged laser printers, no scanners, a billing connection set up, older and comfortable billing system even if becoming unusable.  But no laptops, nothing that could be done on the computers except for billing and some patient insurance verification, and even more importantly, and a fact that similar clinics see, a 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 they not trained in modern medical office practices, or not even really trained in just basic computer skills except what was needed for billing.  Adapting a sophisticated, challenging and totally new EHR system in such an office would turn out to be one of the biggest challenges the clinic 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 note would be taken and put back in the file.  Nothing fancy, but at the end of the day, it worked and worked well.  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 again, 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 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; it 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 and of course upgrade its network and infrastructure.  At the same time, and 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, over $25,000 in equipment purchases, again, out of pocket for the clinic, which was already seeing reduced revenue.  The office was then of course 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 then the desktop computers were too old and needed upgrading.  $2500 later for an electrician and networking expert and two visits from the EHR 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.


The largest issue the clinic has faced and the one that had the biggest disconnect between the EHR 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” on 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, going so far as telling the Clinic’s doctors, not to call, but to e mail.    This being 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.’”  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 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 works 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 just general office work, urban clinics must see patients fast to survive.  EHR systems, just by their nature, are slow.  Doctors must type, flip through different screens, and load a patient into the system and then check the patient out, all the while trying to be a doctor and communicate and diagnosis.  It just can’t work in this setting, and especially cannot work with physicians who are older and not as familiar with technology and are resistant to using it.  The system the clinic was using was great for evaluating and treating a patient when there is unlimited time to do so, and 45 minutes blocked out per patient, but was and actually substandard for dealing with a say a mom and her two kids coming in for a preschool checkup or the sniffles and a fever.   Flow charts that usually ended up far away from the reality turning a cold into cancer and were just not at all suited for a family practice, quick office visit 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.  But practices such as this are different; they are not cookie cutter and need a system that can see people, allow the doctor to take notes and record vitals and make conclusions, but to do so quickly.  Systems in place now simply are not adapted for this type of setting. The information may be there and the ability in certain settings is acceptable, but in this setting.

The lack of adaptability and flexibility costs the clinics and its providers in more ways that 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 staff gets frustrated and in some cases patients leave and may or may not come back and 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.  EHR 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 patients.  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 training sessions, each between three and four days of on-site training.    However, there were different trainers, each with their own philosophy and frankly 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 and who could be a constant resource.  The greatest improvement we would suggest to EHR 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 showing 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 than three months pass, and 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 provider has called to see how we are going to use that or even just checked in, which is something a car salesman does once a year. When we had serious accounting issues that most business would be able to reconcile in days, it took four months to simply get an accounting of that money that has gone in and out.  The Clinic largely feels left in the lurch 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 feel not valued.

It is this lack of continuity and usability and accountability that has left Junction Clinic in a middling grey area.  Its first Medicaid incentive payments were received.    But 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.  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 EHR systems into offices are and were well intentioned but lacked foresight and practicality for many physicians today for this type of primary practice office.  Changes need to be made, from less mandating of implementation 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 “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.  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 th clinic, to see if other clinics we in fact encountering the same obstacles.  As Stacey points out below, and we whole heartdly concur, using resources not offered by the vendors such as independent ocnsultants, 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 presentd with options, rather then 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 the Clinic’s experience, but also take the following to pay heed to her sound advice.


(need a headline, was not crazy about the enter, but it works)

I wish, sadly, that I could say I haven’t heard this before, or that it’s atypical, but if I did, I would be lying.

My name is Stacey 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 struggle with the implementation of them has not.

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.

The implementation of an EMR is a very expensive endeavor, both in expense and in kind. It changes the very cultural backbone of a practice and requires tremendous commitment from all involved. While I certainly am thoroughly involved in Meaningful Use and the incentive money, it cannot be the only reason given in why a practice should implement an EMR. I encourage practices to focus on the benefits of a properly installed and fully functioning (remember these key terms) 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 for programs such as P4P, Quality Reporting, ePrescribing, Meaningful Use. Not to mention the avoidance of penalties through Medicare.

The mere undertaking of such a volatile process needs to commence with the practice having a clear understanding of the endeavor they are about to embark upon. Proper preparedness is key for practices and a crucial first step I often see overlooked.

When working with a practice, one of the first things I do is to sit with the practice to understand the 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 individuals members and discussing their goals, pain points, ideas, plans and fears offers insight into the practice and allows a Project Manager to offer a customized solution and 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 install is your second” rings true. Subsidized pricing does not always work to the advantage of the practice. Understanding your needs and goals is a critical first step in identifying the preliminary candidates. The step of choosing an EMR platform can be arduous-but is well worth the effort. Focus should be placed upon things such as platform certifications (for use in attesting to Meaningful Use), customer satisfaction, practice culture (such as technical proficiency, IT on staff) usability, ability to meet the needs of the practice, specialties served, workflow and of course price.  Working with a trusted Consultant through these steps can help provide guidance.

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 number of clicks as you go through. Ask your questions and ensure they are answered to your satisfaction. Remember, this is a Sales Demo! Most demos that you see will impress you- that is the skill of a gifted salesperson. While what you see is impressive-does it suit your practice? Can the platform be successfully manipulated to suit the workflow 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 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 the processes once the contract was signed.

With the decision made and the contracts signed, Junction Clinic has now embarked on the process of an EMR implementation. First stop; hardware, or in the case of Junction Clinic, lack thereof. Hardware, for me, is a process I plan delicately; it is an aspect that needs to be carefully considered on many different levels; the computer proficiency levels of the practice, usability, need, and design-never mind overall cost.

When implementing, for any practice, the procurement of the hardware always commences the same way: assessing the technical proficiency of the practice. This is a process that is invaluable in understanding the culture of any organization and critical in ensuring a smooth implementation, training and eventual adoption of an EMR. 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; do they know how to use computers? Surprisingly, many members of a practice do not have computer proficiency. Knowing that and carefully and delicately approaching who needs basic skills training will enable people to train on a system far more comfortably then they would if they didn’t know where the power button was. A back to basics approach can eliminate great frustration and empower individuals too embarrassed to admit their need for preliminary preparation.

With that said, we move to which hardware to purchase. Keep in mind again, the culture of the practice. So of course, cost is a factor-but 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 inclination.

As the procurement process continues, Junction Clinic is now faced with what little hardware they have being outdated, no modernized, up to specification server room 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 the culture such as this, a SaaS model would have been ideal and would have come as 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? I am disappointed that the vendor did not intercede at this juncture.

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 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. Just the same, 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 goes without merit. 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? If you don’t know, add this question to your list. As previously mentioned, I worked for the vendors and I 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. If I didn’t know the answer-I’d find someone who did.

We’ve already touched upon practices that are not technically apt, and that this is part of the practice culture. The culture is also comprised of workflow-a key consideration in the implementation plan, but 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 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 EHR 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 redirect the training, should the need arise, but also to work with the practice so that it is understand 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-all be it the stand offish 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 by design more time consuming and thorough. It will also never be ready out of the box, a phenomenon we’ve all come to expect. Templates need to be discussed and 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. 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, exactly as Scott determined, there is no one size fits all.

Change can be difficult for a practice, but often overlooked, and equally as important, change can be difficult for the patients of a practice. I advise practices to engage their patients. Involve them, inform them, 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 predominantly spoken language of the patient demographic, the posters illustrate the changes they will be witnessing and that they are a result of the undertaking of an EMR-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 prior to them 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 undertaking, 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 EHRs 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 be done so taking the 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 role, fundamental in the success of the process. Champions take all of the items mentioned in all of these pages into consideration. They are the cheerleaders of the implementation and help guide the practice from the earliest onset of goals definition and functionality needs, down to the mentoring of other individuals, and championing the training.  Their role will be ever changing as the implementation, adoption and use of an EMR progresses. Preparatory in design at the onset, they will eventually need to transition to undertake the ongoing training needs of the practice.

Typically vendors offer webinars, videos, tutorials and user guides, to name a few of the ongoing training resources. Capitalizing on the availability of these tools, after the trainers leave, the role of ongoing internal training 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 the 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 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 in an undertaking of a project of this magnitude.  On a daily basis, I work with five practices, not fifty and do not sell features and functionalities to make money. 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 EHR, versus cutting their losses. While their frustration is clearly warranted, I would hate for it to be the determining factor in incurring a monetary and in kind loss of such breadth. 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 EHR. Identifying and aligning the goals, determining the unmet requirements and re-evaluating the processes in place will serve us well, as we embark on yet another challenge.

A challenge to be addressed and illustrated in the upcoming publication of Junction Clinic’s success story.

About the Authors:

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 Bronx Community College in educating tomorrow’s HIT workforce.                                                                            In partnership with BCC, she also created and chairs their HITECH Educational Advisory Board.

Scott Sitner is an independent business consultant, concentarting in the management and oversight of small to meduim sized companies.  He has a Bachelors degree from Kalamazoo College and a law degree from the Michigan State University College of Law.   His experiene is in assisting companies with changes to their structures and management and implementing those changes, together with ensuring legal complaince.

a first hand hernia surgery primer

So after two years I finally decided to see a dr about that strange and mysterious bulge that was coming out of my groin by the bottom part of my chest.  I had had some pretty severe but really random pain for probably two years.  I could go a month or so and nothing but some small discomfort then wake up one day and barely be able to walk.  After a truly crappy day on a high school band trip in Hawaii this past February, that totally ruined one day, it was time to do something.  My symptoms were exactly as above: a small bulge on my right side(inguinal) sort of at the top of my leg just to the right of my pubic bone.

FYI I am a 48 year old pretty healthy man(well save for the diabetes)

I am a horrible, anxiety ridden patient so that’s why I waited until I realized I was being an idiot and my golf game might suffer.  My initial appointment was nothing. The hernia was so obvious, he just touched it, smiled and asked when i wanted surgery.  No ultra sounds, no rectals, no x rays, just a visual and a diagnosis/   he said that most hernias are like that, and laughed when I told him I read some pretty weird diagnosis stories, so that was a welcome surprise.I got the little handbook and the brief lecture, but the bottom line was surgery.  Mine was to be open as opposed to laproscopic. I tend to trust the drs as you read so much garbage on line.But what he said was yes the scope is less intrusive, quicker recovery time and no scar. However, there is more risk to internal organs and complications, and as he had done thousands of these, I decided to defer.

These are so frequent that I could have it any tuesday or friday he was there.  but of course with spring break had to wait a few weeks. You will need pro op blood tests and an EKG, which can be done in your drs office usually, so that was done and normal.Surgery was then set for today, and this is where hopefully people will find this a little useful, as I would have liked to know a lot of the basics.

First I was the first surgery of the day.  Beg for that. After the first who knows what complications may arise that could push back or cancel yours, and if anyone out there is nuts like me, the waiting would suck.  Be first,  no waiting. yeah, getting up at 4:45 not fun,being home by 10:30 was very cool.   Once you do the check in, they will take you back.  While I did mine in Michigan, it seems like the procedure is probably the same.

I got escorted to get all naked, yup all naked, but for my socks.  quick the sight, black socks, pale skin, very attractive but there was a strange security to that. I was then escorted to the bed.  You are hooked up to lots and lots of wire and tubes which maybe I should have known but was not told.  EKG, which is a lot, pulse on the finger, IV was in the top of my wrist. She was going to do it on the back of my hand but I objected and she did the wrist. Much more comfortable which even she agreed. You will also be placed on a blood pressure monitor so I could watch my anxiety level rise.

They will shave you.  My dr likes half shaved which was a lot.  So three women lifted the robe used an electric shaver for ten minutes and cut away.  If you are all embarrassed about showing your private parts, get over it.  The just lifted and went to town. It was so business like it did not even bother me.  But it will itch crazy when it grows back. They used a lint roller to pick up what they cut  that was funny.

You then meet with anesthesia.  I did general, was not given the option of a local.I may be an idiot but did not realize I got the tube down my throat.  Thankfully it is all done when you are asleep, but my throat is pretty sore.  I have NO recollection of going yo sleep. They gave me a valium type drub through the IV which calmed me, but not like being high.  They then told me they were taking me in.My next recollection is waking up.  Which is totally off as 90 minutes of my life is gone, but I have no memory of even seeing the OR. So if that is a concern, don’t.  Like everyone says you just sleep.

Day two

Ok.  It really hurt last night.  All the anesthesia burned off,  could not lie down, spent the night sitting up on my couch surrounded by pillows wallowing in pain and self pity.   Getting up was horrible, the peeing is still more spotty than strong.   But of course, I took Motrin 600 this morning, off the narcotics.    Helped.  Pain there but way down and I feel ok.

Some things to watch for.  Shivering.  Like uncontrollable in the middle of the night.   No fever just shaking.  No one told me about that.   Sucks.

But today ok.   Hurts. Still using ice in my pants and walking really really helps.  No pain when I walk even up the stairs.    Still waiting to poop.   Have until day three til an issue so say a prayer

Thanks for reading

Scott sitner
Birmingham. Mi

Day two and three:
Ok, still hurts.  here are the things they do not tell you.  Lying down hurts.  getting to that position and getting up are worse.  Oh my god,  I feel like a cripple(sorry)   I slept on the couch sitting up the first night, maybe not the best idea, but it did cut back on some of the pain.  I stopped taking the nocor and went to motrin 600(more on that later)  I maybe slept three hours sporadic.  Oh well.   You shiver.  I have now been told this by others.  I do not have a fever, no infection, I get up during the night,  both nights and could not stop shaking.  Last night, second night was a combo of amusing and embarrassing, pretty sure I was shaking so hard I peed on the wall, but did not care.  Just wanted back under the covers.
anyway….the second day was ok.  The anesthesia has worn off, a little burning where they cut me open.  but I walked a lot and ate and did ok.  Walk a lot, take the drugs, eat and try and relax.  I was told this and it’s true.  My kids were home in the afternoon and we had to drive. Thankfully my son has a permit, getting in and out of the car sucked. no way you drive the first few days, just don’t try.
Got a call from the hospital, a little confusing, I think they call just to make sure you are not dead. I was not, she seemed pleased and hung up.   Nice to sleep in bed, I did not try and roll over and again the bathroom thing sucked, but the sleep helped.
now on day three I am in paid, but more discomfort than pain, annoyance. I am thanking god for the shitty weather, do interest in leaving the house at all.
and oh yeah,  ice.  no swelling at all,  really did not want to see those parts swell up for a no good reason. Ice though, well, peas, use em
final update or two tomorrow……Ok, days three and four.

so you know, I had my surgery at 7 am, so day one is that day.

Day four:

sorry to anyone who may know me, but all about the poop.  I woke up feeling ok.  little pain, took a shower, got mostly dressed. About ten am, it it.  Let’s just say they warn you you may got a little constipated.  Oh my god. Pain, discomfort, distension, a scared teen age daughter(or grossed out)  as I told my girlfriend in various e mails and texts and calls, worst day of my life, shoot me, kill me. You stand, you sit, you cry and whine, bend over. Anything  so awful.  I had been taking colace, no effect. I went to the store and got the Phillips. pretty tasty wild cherry.  It did work, but not for about 18 hours I think….

About 3 pm, some came out, as in teeny tiny something,but I felt better, enough to stop being a big baby.  Over the next six hours or so, little by little more came out, but really little pieces, and the pain involved was intense.  I did prune juice(pretty tasty no complaints)  went to bed.Up every two hours, some more came out, peeing was hard, not good. So at 6:25  I wake up.it was time again, went downstairs, and let’s just say the flood gates of egypt happened.  Yeah, some made it to the toilet which immediately clogged up.  and now let’s just say I will never look at this bathroom again and at this moment it is as clean as it will ever be because 45 minutes ago it was as dirty as it could ever be.  It just happened, so prepare yourself.  there is no stopping, you just stand there and amaze at the absurdity of it all.  and then you clean before wakes up or the four sleeping teenagers down the basement.  Wow, awful.

Causalities:  one pair of sweats,one nice towel, one pair of underwear, my dignity.

How do I feel now as day five really start:  great.  Truly great. So live through the above and it is smooth sailing, I hope.


DAY 5-7

Really much better.  The bathroom stuff slowly resolved on Saturday which was day 5.  a few little set backs, but I had lunch at the mall and dinner out.  Had some soreness around the cut site, but really nothing that was not just able to handle with nothing or just with some advil.  Slept decent, one scare during the night, but I made it.  Sunday, day 6 was uneventful.  I only left the house to get my regular drugs from walgreens, and then spent the day pathetically watching golf on tv.  Lunch and dinner at home, quiet night until the kids got home.  I still think my daughter is a little shell shocked from TMI on Friday, but too bad.   She had a sleepover with friends, would have been far worse had one had to pee at 700 am.  So thank god for that.

Day 7-Monday.

Had the follow up doctor visit.  Two minutes, I timed it.  Looked at the scar, coughed(me not him)  chatted about limits and golf, told me to go home.  He seemed quite pleased with his handy work which is I guess better than the opposite.  Spending one more day at home, but right now I feel 80% good, some stiffness and soreness but no drugs.  Will walk outside later if no rain.  Driving was fine, just took it easy.  Stomache almost back, just being cautious for another day or so, but eating normally.

So all in all, I am glad it is done as it was not going to get better only worse, and is something that even if not constant pain, I would have noticed all the time and it would be a centerpiece of daily life. It’s done.  All good.

scott sitner.-Birmingham MI