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The Five Biggest Mistakes of EHR Implementation

Vol. 18 •Issue 6 • Page 18
The Five Biggest Mistakes of EHR Implementation

Five facilities share their stories of EHR disasters so others can learn from their mistakes.

"Learn from the mistakes of others. You can't live long enough to make them all yourself."

The above quote by Eleanor Roosevelt is the theme of our article and the hope these five facilities had when they opened up to ADVANCE and bravely shared their stories of EHR disasters and downfalls. One facility watched as money drained out of its practice and its patients switched doctors; another made its physicians' workday even more cumbersome than it had been in the paper world; and a third unknowingly put its patients at great risk just by updating its system. In the end, however, all shared one remarkable similarity: they never gave up on their EHRs.

Here and continued on our Web site are their full stories of EHR disaster, failure and subsequently, triumph.

Disaster at the Start

In December 2004, Siouxland Women's Health Care, PC, Sioux City, IA, decided on an electronic medical record (EMR) to put its five physicians and one nurse practitioner on pen-based tablets.

As the go-live date approached, Julie Barto, BS, MS, administrator, started getting nervous. Absolutely nothing had been scanned in. They hadn't made a single template, and no one had any idea what their EMR tablets even looked like.

Barto called the value-added reseller (VAR) responsible for the EMR's sale and implementation, who assured them he'd train everyone on site 2 days before go-live. Barto didn't like that idea. "When we're talking 'live,' we're talking no paper," Barto said. "We told him 'No. We have to have things scanned; we can't have any downtime, we're an OB/GYN!'"

As the clock ticked down, the VAR finally arrived. He had promised to make them paperless and fully operational within 5 days. The VAR, Barto realized, was delusional.

"We had older physicians who didn't know how to use a computer—they hadn't even e-mailed before this! Things like how to turn on the tablet, we didn't even know that," Barto said. "We knew nothing, absolutely nothing."

Without templates, physicians had to start from scratch with each patient rather than being guided with yes/no checkboxes. They were soon moving so slowly that each provider was only able to handle one patient per hour.

"That's when the disaster happened," Barto said. The VAR hadn't told them to scale back their operations. The practice got so backed up; they had to cancel every appointment on the schedule and accept only emergencies. In the weeks that followed, they continued to call and move hundreds of patients back to different times.

"At first [our patients] were tolerable, but soon became less and less so," Barto recalled. "We definitely lost patients over this. We took a hit financially that first year."

To find out how Barto's practice bounced back, and how you can learn from this mistake, visit Lesson #1 on our Web site.

Physicians Get Sneaky

Spending some time hybrid as you transition from paper to the new electronic technology is necessary. Not setting a date to leave paper for good will keep you stranded.

In May 2005, the five physicians at Northwest Family Physicians in Plymouth, MN, were about to move from paper charts to Misys' wireless EMR tablets. Now, instead of jotting down notes or dictating, physicians would have to tap, search and scroll their way through a patient visit using the EMR.

This was about to disrupt their routine so drastically, the system's clinic manager, Brenda McNeill, RN, thought it would be best to ease them through: the physicians could keep the paper records, she decided, as long as they captured at least two patient visits per day directly into the EMR.

That was in May. Seven months later the number of visits per day the physicians were entering into the EMR rose to—wait, it was still two. It seemed that rather than mastering the system, the physicians instead had become experts in learning how to trick it.

"They'd look over their list in the mornings with their medical assistant (MA) and we'd hear them say, 'Let's do this one and this one,'" referring to the two patients they thought would be the easiest to template, McNeill recalled, laughing.

McNeill had given them a guideline; what they needed was a goal. Otherwise, "they'll linger in the middle ground forever," she said. McNeill also realized if she wanted them to become comfortable with the EMR, she had to make sure the technology was in their hands at the start of very visit.

Currently, the physicians were walking into some visits with paper charts and others with the EMR tablet, depending on which they told the MA to start with at the beginning of the day. McNeill changed it around so that the MAs started every patient visit—the vital signs and notes—directly into the EMR.

This then forced the physicians to decide, on the spot, whether to continue in the EMR and add to what's already there, or physically ditch the EMR tablet and go back to paper.

This small change proved helpful. "Even if they wanted to dictate they had to hit a 'see dictation' button in the EMR, which least got them to look into the electronic record." McNeill said. "It was a matter of getting the paper chart out of their hands right away and getting the computer in their hands."

The second boost for the physicians came more in the form of a shove. To see the ultimatum the physicians were given, visit Lesson #2 on our Web site.

Workflow, What Workflow?

Four years ago, Denver Health began a pilot project to implement computerized provider order entry (CPOE), but at go-live, the physicians were learning there was more the CPOE couldn't do than what it could.

The types and times of lab orders a doctor could select were limited. The CPOE didn't know how to create a final order summary report or take into account requirements of electronic signature. As far as the nurses were concerned, well, the CPOE didn't take them into account at all.

"We just kind of left the nurses out of the loop completely," said Mary Beth Haugen, MS, RHIA, the HIM director at the time. "Nurses have to do verbal orders, view them or change them; we didn't consider any of those factors into their day. We called it 'physician' order entry." (It's since been changed to 'provider.')

The problem, it turned out, was that the EHR project was lead almost entirely by IT, one of the only groups in the hospital that doesn't live, breathe and walk the daily routine of patient care. Workflow—creating an EHR to fit in with, and simplify, a provider's daily routine—was missing completely.

"A couple days in, things were looking ugly," Haugen said. "There were things in place that made the provider's job harder. It took them 2-5 minutes to log onto the system. Doing this 30 or 40 times takes a huge chunk out of their day. We just created havoc in our opinion."

To see why Haugen wants you to rip out this page, visit Lesson #3 on our Web site.

"We Can't Find Our Patients!"

In Oct. 2001, Children's Medical Center in Dallas, TX, was in the process of upgrading to a new hospital information system. As all of the names from the old master patient index (MPI) filtered into the new one, it was acting something like a virus—everything looked fine on the surface, but was spiraling out of control underneath.

Because the new system was configured to have an exact match search, every patient coming in as "Miller, Catherine" one time and "Miller (space) Catherine" another was unknowingly creating a duplicate, explained Katherine Lusk, RHIA, HIM manager.

What used to be a manageable duplicate problem, now, in the blink of an eye, became an overnight explosion. Soon, physicians would be treating patients and have to stop. "I know I saw this patient recently," they'd write in the record. "Where is that lab result?"

"The medical staff was in an uproar," Lusk said. "We bought this big expensive EHR and the physicians were yelling, 'We can't find our patients!'"

This wasn't just a headache, it was an emergency. Duplicate records are a risk to patient safety. Lusk reacted. She threw five full-time equivalents (FTEs) on the sole task of cleaning up duplicates around the clock, 24/7. She created a hotline.

But Lusk was only patching up cracks in a dam about to burst, said Beth Haenke Just, MBA, RHIA, CEO and president of Just Associates Inc., who was called in to the rescue and found that Lusk's department was drowning in 250,000 duplicates.

It took Just 10 months of clean-up, consulting and training, but now, 5 years later, Lusk continues to keep a low duplicate rate of 0.14 percent, and those five FTEs are now down to less than one. "There's something to be said that still, so many years later, they have an extremely low duplicate rate," Just said. "If you identify and address the causes up front the problem pretty much goes away down the road."

To find out how Just fixed their duplicate problem and how you can avoid this completely, visit Lesson #4 on our Web site.

Out With the Old

A major dilemma when going paperless is deciding what to do with the old paper records. Do you store them; scan them or shred them? The choice this clinic made turned out to be the wrong one.

When St. John's Clinic, Springfield, MO, started planning for a clinical EMR in 2005, its EMR team made a simple but crucial decision not to back scan.

The team reasoned that the EMR should have only the most recent information; old records would simply "muck up" and bog down the database, explained Whitney Gregg, HIM manager. Not to mention, a record that had been inactive for 5 years likely meant one thing: the patient isn't coming back.

This sounded reasonable—until a coincidental event highlighted just how bad this decision was. That same year the HIM department decided it was time to pull the clinic's old paper charts out and store them off site. A physician who wanted an old chart now had to call the off-site vendor, and the vendor had to fax it over.

Tedious? Absolutely. But the more physicians complained, the more they highlighted an undeniable fact: wow, physicians were requesting these older charts—a lot.

"Until those charts came out of the offices, no one really realized how much they physicians would want [them]," Gregg said. "They've since realized that past info is vital, whether it's 3- or 5-years old, it's relevant to the patients' history and care."

The truth is, just because a patient hadn't been to the clinic in 5 years, didn't mean they'd stopped coming. "It might be that they are a cancer patient that had been in remission but recently had a recurrence," Gregg said. "In this case, the history is crucial. You'd need to see the patient as a whole."

The EHR team changed their plan to include a back scanning piece. To see how HealthPort helped to keep the old records out of the EMR, but still only one click away, see Lesson #5 on our Web site .

Ainsley Maloney is an assistant editor with ADVANCE.




     

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