Electronic Medical Records Implementation
Frequently Asked Questions
What are the Goals of the EMR implementation process?
The EMR implementation process will migrate your physicians and staff from a paper system of managing care and documentation to an automated one. To make this transition as smooth as possible, your practice will need to identify physicians and staff who will champion the process. You will also need to be ready to invest time in system configuration and training and to respond flexibly to recommendations for new ways of managing clinical care and documentation. When successful, the EMR implementation process will lead to patient care improvements as well as increased physician and staff satisfaction.

How long will the entire EMR implementation take?
Most EMR implementations will take twelve to sixteen weeks from contract signing. Much of this time is spent preparing for the EMR by building interfaces, ordering hardware, analyzing practice patterns and building training plans. Since these activities generally involve a small number of individuals, most of your practice staff will only feel the impact of the implementation process for four to six weeks prior to the start of daily EMR use.

How much EMR training do we need?
Training is a process whereby an expert familiar with the software comes to your practice, evaluates your current work processes and makes recommendations on how you might use the software to best fit your current processes. If there is an opportunity to change current processes to create more efficiencies, the expert may recommend those changes as well. Following your acceptance of these recommendations, training can begin. This training will focus on the way you and your practice plan to use the software's features.

Many providers don't value software training and are reluctant to set aside time for it. These providers believe they will be able to "learn it on the fly". While that may work for a few providers, it doesn't work for most. Without adequate training, the providers grow frustrated in the use of the new system and come to believe that the system isn't able to support their work process. And, once this negative attitude develops, it's hard to overcome. Make provider training a priority!

How can we maintain productivity during initial EMR use?
Many practices worry that the transition to an EMR will make each patient visit longer and reduce the overall number of patients they can see. While experiences are varied, it does seem that most practices experience a "settling in" period of six to eight weeks when providers are getting comfortable with how to best document a patient visit. There are a number of strategies you might consider to lessen the impact on productivity during this period including:

At the risk of repeating a recommendation... make provider training a priority!
If your practice has multiple locations, sequence EMR transitions by location so that you spread out over time any potential impact to productivity.
If your practice uses a transcription service, keep the service in place during the EMR transition and upload the transcribed notes into the EMR. As you grow more comfortable with the EMR software, start documenting some of the patient visits directly into the EMR. Increase this over time until all of your notes are going directly into the EMR and transcription services can be eliminated.
Focus your training on EMR features that speed visit documentation (e.g., templates and macros). Getting these features properly set up and training all of your providers in their use is another important reason to invest in training.

How many templates or macros will we need for visit documentation?
Many EMR systems use templates and macros to speed visit documentation. Some physicians favor the creation of dozens of templates one for each condition they frequently treat. These might include a diabetes template, an asthma template, a hypertension template and so on. Others favor the use of a few generic templates that cover a range of visits. These might include a new patient template, an annual exam template and a sick visit template. While the temptation to create a lot of specific templates may be great, the time involved in creating and maintaining templates can be significant. Therefore, the more prudent approach may be to create a few generic templates and one or two disease specific ones to start. Over time, you'll be better able to assess your documentation needs and adjust accordingly.

How much data should we carry forward from our paper records into the EMR?
Unless you are new to medical practice, you probably have rows and rows of paper charts. When you make the transition to an EMR, how much of the patient information stored in those charts should be transferred into the EMR? All of it? Some of it? None of it? Plus, who's going to do that work?

Most successful EMR implementations involve the transfer of some information from the paper charts. These data conversions usually focus on key data elements that are likely to have an impact on the patient's future care. Typically, they include the patient's allergies, active medications, active problems, and for pediatricians, prior immunizations. Converting less data can make initial use of the EMR frustrating for providers. So little information is present, the old paper chart must be pulled and the temptation to continue documentation in the paper chart is strong. Converting more data is not very cost effective. You will spend a lot on labor to convert detailed information from past visits that may not be critical to the patient's future care and thus never accessed.

The conversion of data from paper to EMR is usually performed in advance of the patient's first visit following the start of EMR use. This way, the data is converted for only those patients who are making a return visit to the practice; the charts from patients who never return to the practice are left on paper.

Finally, who will do this conversion work? Much of this is dependent on the quality of your charts. If your charts have a well-organized legible list for the patient's allergies, medications, problems and immunizations, you may be able to hire temporary administrative help to key the data from paper to the EMR. If, however, your charts are not well organized and/or illegible, you may need to hire someone with medical training to extract and transfer the data into the EMR. Regardless of how you staff this function, you should recognize that the data conversion is unlikely to be 100% accurate. Thus, each provider should expect that the first time the open a patient's EMR chart, they will need to review the converted data and ensure its accuracy.

Do we need to buy a personal computer for every exam room?
EMRs are most successful when they are integrated into the care process. In other words, wherever care is delivered, there should be a device capable of displaying patient information and supporting the delivery of care (e.g., prescribing). For many practices, this is accomplished by placing personal computers throughout the office including each exam room, the nurses' station and provider offices. Another approach involves the use of portable computers so that providers can view data and document care from any location in the office.

Can you use an EMR without this level of hardware investment? It's possible, but this approach will limit the value of many EMR features and keep you from achieving the top levels of productivity and associated practice savings.

Should we use stationary, wired computers or portable, wireless computers?
In recent years, the cost of wireless computing has come down while its reliability and speed have improved, thus making it an attractive alternative for EMR implementations. The choice of wired versus wireless needs to be made in consultation with your hardware vendor. Together, you should weigh the issues of total cost, product life, security and support as you make this decision.

Can we migrate to an EMR without investing in system interfaces?
Interfaces are designed to bring important data into your EMR from other systems. Examples include demographic data on your patients, appointment data and lab results. If these interfaces aren't built, you will need to either enter the data directly into the EMR or continue to rely on other paper or electronic systems to present the data:

Without this interface... ...here's what you might need to do
Demographics Double entry. Enter patient demographics into the EMR as well as the practice management system.
Appointments Double entry. Enter appointments into the EMR as well as the practice management system or appointment book, or
EMR work-around. Don't use the EMR's schedule feature (i.e., choose patient records from a general search feature rather than selecting records from the list of today's appointments).
Test results Stick with paper. Continue to refer to paper reports and maintain the paper chart management process

If we are successful with EMR, what happens when the system is "down"?
There are multiple hardware and software components in an EMR system. Failure of any one of them could cause the system to go "down" and the EMR to become unavailable. Practices can minimize the likelihood of this by investing in additional hardware that adds redundancy and fail-over capability, but that expense may be difficult to justify given that a system failure seems pretty unlikely. And, even with these additional investments, the possibility of a system failure is never completely eliminated. Therefore, every practice should develop an EMR downtime routine and practice it. This might involve a daily download of critical data on next week's patients to a personal computer. This data could be printed in the event of a server failure and used along with word processing software to document new visits until the system is back up.

No one seems excited about this - should we go ahead?
Every documented EMR success story involves a strong physician champion. Conversely, every EMR failure cites the absence of a physician leader as one root cause of the failure. So, if experience teaches us anything, don't proceed with an EMR implementation if you don't have a physician leader who is willing to enthusiastically champion the cause.

We haven't talked about this with the staff - should we?
Yes! While much of the discussion of EMR use centers on the automation of the provider's work, the clinical care process involves many staff and their support in this process is essential. Most successful EMR implementations have a staff leader who is an enthusiastic supporter of EMR adoption. Like the physician champion mentioned earlier, moving forward with an EMR without this level of support is ill advised.

How much does the EMR implementation cost?
EMR systems involve three types of expense: 1) the hardware and networking services you need to run the software, 2) the EMR software including the interfaces that transfer data to and from other systems, and 3) the training, data conversion and support services you will need to get the system up and running. Many of these expenses are charged as a one-time fee when you first install the system. Others are charged on an annual basis to keep the system running and up-to-date with new features.

Once the hardware and software have been purchased, the majority of the practice's implementation expenses will involve the services of experts who can work with your staff to setup and configure the system, train your physicians and staff, and support your practice through the "go live" process. Most vendors will estimate the number of hours or days of help you will need and the cost of that time. In addition, you may need to pay for the travel and lodging expenses if the experts are coming from outside the Boston area. If you need more help than what was originally proposed, that help is usually available at an hourly or daily rate.