October 29, 2007

It’s the Superusers Who Make the Difference
By Carolyn P. Hartley, MLA, CHP
For The Record
Vol. 19 No. 22 P. 38

Until last month, I was still using a “dumb phone.” Learning how to use my new smartphone came easier for me because the techie members of our team—also known as “superusers”—assisted me during this transition.

They tripped over each other showing me where I was being overcharged for duplicate air time; set up the company’s internal directory into my mobile phone; added Dragon Naturally Speaking Version 9, which interfaces with handheld devices; and hot-synced me to my e-mail. Since my dumb phone also served as the office’s most comprehensive mobile telephone book, they ensured the transition went smoothly so I could take care of other matters.

My newly enabled phone also lets me perform a host of office tasks. I can pay bills; create documents via dictation, scribbling, or typing; and conduct online research. Most recently, my tech team recommended Davis’ Drug Guide for Nurses with integrated dose calculators that also check for contraindications, a system now integrated with my smartphone.

This transition brought to light one of the most important electronic health record (EHR) implementation principles: Discover who and what is available to help you through technology transitions to better understand the impact that smart office technology will have on your workforce. Build a stable of super users first so they’re readily available for others coming onboard.

A good transition plan not only helps prepare your practice to make the change, it also helps you determine the following:

• your motivation to go electronic;

• what you have;

• what you need; and

• what it will take to get you there.

Keep the workforce integrally involved so it is part of the change. Begin with a list of reasons why you plan to make the change.

Right reasons

• To improve the quality of care.

• To have information immediately available at clinicians’ fingertips.

• To reduce the amount of time spent shuffling, losing, filing, and moving paper.

• To know whether a procedure will be approved by the patient’s insurance plan.

• To get paid faster—or, in some instances, at all.

• To gain access to clinical decision support.

• To participate in the process of change that the healthcare industry needs.

• To access patient records, whether in the office or at home.

• To achieve better documentation for reviews, clinical studies, and audits.

• To obtain data that will help build a pay-for-performance program.

Wrong reason

• Everybody’s doing it.

Once you’ve identified your motivation, analyze the workforce’s perceptions about who will be available to them during the change.

Ask staff how the practice will benefit from moving to a digital environment.
Not every office loses or misplaces records, but eliminating lost or missing records is the No. 1 reason why physician practices move to a digital system. You’ve seen the clutter: medical records stacked 20 files deep on the doctor’s desk, at the nurse’s station, or in the medical records room waiting to be filed.

During a recent site visit, the medical records supervisor took me on a tour of the center. We started in the medical records room, where she and I stepped over piles of records stacked in alphabetical order waiting to be filed. Hanging from one records shelf was the day’s dry cleaning delivery.

The tour continued to the nurse’s station, where patient records had been pulled for the day’s visits. But as we made our way through other offices, the supervisor opened cabinet after cabinet filled with files needing various amounts of attention. “When you come back in six months, none of this will be here,” she explained. “We’ll first transition patients with serious chronic diseases to electronic records because our lab interface allows us to download data directly into their file. All new patients will never see a paper record.”

Ask staff where inefficiencies can be improved.
Your staff knows where the practice’s workflow gets bogged down. For example, if the front office is barraged with calls, consider an automated system that immediately reroutes calls to specific departments such as the pharmacy, nurse’s station, lab, and scheduling. It’s also possible to manage calls for location, hours of service, and directions.

The Onebox system offered by j2 Global Communications provides a virtual answering service for practices of two to 20 users without the capital investment of a phone system. Typical costs range between $50 to $100 per month, depending on how many lines are redirected. While callers listen to music on hold, the system redirects them to the appropriate department. A virtual answering system may free the front office to run eligibility checks, fill gaps for no shows, or support the back office. The key to a good virtual phone system is to keep the outgoing message short and concise and have someone regularly answering triaged calls.

Evaluate technical barriers.
Every healthcare provider, regardless of specialty, has overcome a technical barrier, ranging from lack of computer experience to frustration while trying to keep up with the latest software.

Set aside technical fears and you’ll quickly find others in the same boat facing similar areas of discomfort. Once you identify the following barriers, establish training appropriate for adult learning:

• Adults enjoy “community” learning.

• They want to know how their new skills add value to the organization.

• They appreciate the sensitivity and confidentiality of information entrusted to their care and seek measures to keep it safeguarded.

• A host of super users will become coaches as other users come onboard.

Identify your network configuration.
Your move to a digital office will be smoother if you can identify how health information moves through your practice and the amount of space occupied by files. For example, you can send small data files through a dial-up connection, but an image file, such as an x-ray or echocardiogram, is much larger and may require a DICOM-interface system.

Once you know your health exchange partners, you can better assess the amount of bandwidth necessary and the risks in sending or receiving electronic health information. Table 1 lists a sampling of exchange and bandwidth needs.

Identify the practice’s emerging visionary or champion.
Every practice can boast at least one physician who takes the lead with motivating the team to move forward. When changes seem too overwhelming, the physician champion is the person who will listen to frustrations while maintaining a focus on the move to a digital office.

Most practices can identify their physician champion by his or her language, enthusiasm, and lifestyle. This person—often a favorite of EHR vendors—exhibits the following characteristics:

• strong leadership skills;

• good listening skills and the ability to motivate people to action;

• understanding of how information moves throughout the practice and the health community;

• ability to maintain a focus on quality of care and patient safety;

• ability to assist in leading the practice through a long-term plan;

• ability to take the lead on the technology evaluation team;

• understanding of and ability to delegate the adoption and implementation timeline to the implementation team; and

• ability to maintain focus on the outcome.

Being a visionary can be a full-time job. Before assigning one physician as your champion, ask other clinicians the following questions:

• Will other physicians pick up the patient load while the physician champion develops and implements the plan?

• Can you afford to have the champion’s productivity reduced for six months to one year?

• Are other physicians within the practice able to agree on a common EHR solution?

Well-intentioned software vendors can cause internal dissension when they align with individual physicians within the practice or community hospital. As a result, vendors may send the practice into EHR hibernation. If the visionary hesitates, it can cripple the momentum that set the group on a digital path. Will the practice make a commitment of time, finances, and resources to assist the visionary and an HIT team? HIT selection and implementation is a long-term commitment, too much for one person to handle alone. Is there a disruptive activity in place, such as a merger among several practices?

Because the move to a digital environment will exacerbate any existing large-scale event, it is wise to put off EHR implementation until these types of projects are completed.

Commit resources and local support.
Begin with a budget to fund three EHR stages: planning, selection, and implementation. Some practices make the mistake of funding only selection and implementation, but without a planning budget, your chances of getting to the selection and implementation stages are slim to none. For a more comprehensive look at planning, see Table 2.

The transition to a smart office is about people. Workflow process change is acknowledged, but it is also typically undermanaged. Therefore, the transition team will make the biggest difference in cultural acceptance. Things will go wrong, but communicate with the transition team and let them be your heroes. You’ll be amazed what they uncover for you.

— Carolyn P. Hartley, MLA, CHP, is coauthor of the newly released Technical and Financial Guide to EHR Implementation and the president and CEO of Physicians EHR, LLC, in Cary, N.C.