From Selection to ImplementationA Q&A with Berkeley Cardiovascular Medical GroupRead about this practice's experience in the following areas: EHR Vendor SelectionWhat was Berkeley Cardiovascular Medical Group's vision for EMR implementation and how did your practice realize this vision?Dr Edelen: It came about because we were in a situation where we were buried in paper. We had a stack of lab reports that was about two feet tall and we were way behind in filing. Our office days were getting held up because we couldn't find data. We were also having trouble with our refill requests because we were receiving multiple phone calls from pharmacies daily, and the patients were complaining about the long delays getting refills back.
At this time the practice seemed broken and we were getting busier and busier. One day, we had a meeting and it seemed like the answer to all the issues was an EMR system. At that point, as a group we made a list of all the goals that we wanted our electronic medical record software to accomplish and then started shopping around. How did you select NextGen?Dr Edelen: We called the vice president of IT at Sutter because we knew the hospital was committed to going to EPIC, and we had talked to a bunch of cardiologists on the West Coast for ideas as well. Sutter suggested three vendors. We then went online and I looked at all the certification services that gave out awards every year and NextGen's name kept coming up. Also, NextGen was one of the names that Sutter suggested, and it seemed to be something that would work for our size practice. As a group we went to visit a cardiology practice in Michigan that had an EMR and EPM. We spent the morning at the practice, meeting and discussing the NextGen EMR, and in the afternoon got a chance to observe the application in actual use with the patients. The system seemed more robust that we had seen before, and it seemed to have everything that we initially set goals for. Did NextGen facilitate communication with other practices concerning lessons learned?Sandra Washington: NextGen provided resources and reference sites, and then we took what little we knew and came back to the practice and began planning. It became reality as far as planning for an EMR and EPM. Technical AssessmentWhat NextGen application did you roll out first?Sandra Washington: We began with a rollout of EPM about a year before EMR. We also started out with the Fat Client servers and now we have transitioned to the Thin Client which is connected to our in-house servers. We use Thin Client for the front office reception area. For the responsibilities of the call center, they required the use of the Fat Client servers as well. As a result we've combined the use of our Thin and Fat Client servers. How and why did you select the specific server you are currently using?Dr Tsang: From the server requirements given by NextGen, we purchased the HP business server. We decided on a Thin Client solution because changes made on a centralized server would affect all computers connected to that server. We thought this would be an ideal solution for how we were set up. We already had PCs in the office, so we put the NextGen EPM and EMR applications on the Thin Client server. How did you decide on the direction you wanted to go with an implementation of the hardware and support of the hardware?Dr Tsang: We have an outside company managing our needs and they were familiar with implementation. We decided on a top tier service agreement that would support us in the long run. Was it difficult selecting an IT partner?Dr Edelen: No, because the local NextGen representatives recommended ConnectionsIT as a local partner that would help us with the technical infrastructure design and implementation of the NextGen EPM and EMR. Do all clinicians have their own notebook PCs?Sandra Washington: No, but there are enough PCs for each provider and we rotate them among us. We just started off with the notebooks because they are easier to manage. What have been your biggest IT challenges thus far?Dr Wang: Sometimes we have trouble connecting the wireless network. With a tablet, we have individual user accounts and some people are not logging off. It appears that the next person who signs on as a user is not connected to the network. Sometimes users forget to log out, and other times the battery just runs out and there is no way for the person to log out. Operations ManagementHow was the change to using the EMR? How did the staff manage this and did you lose any people because of it?Sandra Washington: No, we didn't lose people but it was tough during the change. I began to prepare staff three years ago by telling them to extend their skill sets. I told them to look into other areas while providing them the tools to do so. You just can't work in one area; you need to be able to do something else. So with that in mind, the change began with cross-training people. We did not stagnate our time. We went live and they did not have a chance to sit back and complain. It came down to the goals and the mission of the organization, and wanting each and every employee to be a part of the organization. Your current goals are to improve quality service for your patients and to reduce overhead; did you add to or redefine the goals due to the implementation of NextGen EMR?Sandra Washington: We did not redefine the goals because we had a five-year plan. We agreed as a group to move forward knowing that you have to do what you have to do to move forward. It's a tough transition because it is a group call. Training & ImplementationDo the physician champions do the training?Sandra Washington: Yes. For training, what I have in place is a minimum of 12 hours of one-on-one training with two physicians. It's a good balance for physicians and they can choose who they want to train with and how they want to roll out their own plan. What goals have you set per physician after they complete their training, and do they jump in and start seeing all patients in an electronic manner?Sandra Washington: The goal for the week after they complete their training is to have half of their patients seen electronically. In the forthcoming days, the expectation is to see all patients electronically. Tell us about your roll out of the NextGen EMR.Sandra Washington: We rolled out in phases. We are currently in phase 2A and phase 2B will be the roll out of the Lab Interface in mid-November. Phase 3 will rollout charges and billing. Roll out date to be determined later. At this point, the timeframe for each of these roll outs is contingent upon the success of each. According to our timeline, we are approximately three months behind due to hiccups with the lab interface. Dr Tsang: Phase 3 is when everything comes together with the front office and the back office, with all charges going through electronically. After you signed with NextGen, did they do a practice assessment, workflow analysis, and overall evaluation of services prior to implementation of the product?Dr Tsang: We had a project manager who made suggestions for implementation and practice set up, and they let us know that our workflow would need to be reevaluated. In terms of a formal evaluation of the practice operation, however, there wasn't one. It was left to us to assess our practice and we drove the direct changes and completed the build out. How do you do your abstracting? Are you scanning everything from the charts?Sandra Washington: We are pulling out the pertinent information such as procedures, hospital discharges, and devices to apply to the charts. Have there been any issues with the rollout so far?Sandra Washington: We rolled out our patient contact and medication modules, which were our biggest problems. From the nurses' perspective, it is a problem when physicians are not filling out the problem list and or the medication lists because the nurse has to go back to the patient or physician to confirm the medications and problems, and input the information into the medication template as an additional step. Describe you workflow and patient flow.Sandra Washington: We have MAs assessing vitals and the patient flow coordinator starts to record the data on the electronic chart. What we are doing now that we didn't do before is completely registering the patient. We now validate and check for eligibility. With the EMR piece, we now know when a patient has presented and has been registered and, if we did real-time, we can see how long they have been in the exam room. How is the patient flow compared to the old methods of practice?Sandra Washington: The patient flow has not changed. What has changed is the physician's ability to know from his or her desk whether the patient is here or not. It is wonderful. Tell us about the templates you created and standardization across the board.Dr Wang: We tried to stick with the standard templates that were provided by NextGen. We don't have an onsite IT person to make those changes. We took the templatesout of the box and began using them and then made changes as was seen fit to improve our workflow. Dr Tsang: NextGen offer various ways to input information in a combination, part free text and part drop down usage to capture pertinent positives and negatives. And now we will be using voice recognition to make us more efficient. Providers who are less savvy with computers tend to gravitate toward voice recognition. Tell us about the how the system allows you to capture data.Dr Wang: There are many ways to capture discrete data. When you enter the encounter information, it sounds like an elementary person wrote in the detail. For the most part, when documenting the physical, most of us just write in notes. It really depends on the comfort level of the physician or the nurse entering the data. Dr Tsang: I don't think we are losing a lot in using voice recognition because most of that information is not rich for data generation at a later time. That data will come from test results and labs. Dr Edelen: Most of voice recognition will be captured in the history and the plan, which are individualized for the patient. Application UsageDid you have customized templates other than the NextGen Cardiology KMB templates for cardiology?Sandra Washington: No, we didn't customize, we tweaked the templates. The lead physicians on this project, Michael Tsang and Sam Wang, are the computer physicians. They went through advance EMR training with NextGen in Irvine. They prepared and paved the way and are now handling the template editor themselves. What efficiencies did you hope to gain or are you gaining with this solution?Dr Edelen: It does change the way you work; for example, phone call tasking. To me, rather than having a stack of pink slips on you desk, it's a much more orderly way to do things. It brings a sense of order to that process; it creates a documentation process that wasn't there before, and an accountability process that wasn't there. Sandra Washington: From an administrative perspective, it's helpful to know whether or not you completed a task, rather than running back to the doctor's office, searching on their desk. It is a more manageable process. The staff can see the outstanding tasks and identify what is happening with the patient. What were your experiences, challenges, and first impressions of the system once you finally began using it?Dr Wang: Initially, it takes a lot of time to input the data into the system. It is quite easy to see a new patient rather than old patient, because with old patients you have to abstract all information from prior visits, as well as important lab information, procedures and past medical history. Sure we can hire a person to abstract the data but it is the physician who sees the patient most often who knows the important information most intimately, so we can make sure nothing gets missed. Did you increase you scheduled appointment time to see patients?Dr Tsang: At the training for EMR, they suggested we extend patient visit time from 20-minute to 40-minute appointments. AssessmentWhen did you set a baseline for FTE and time it takes to gain efficiency?Dr Edelen: We don't really have an answer because our processes are changing. It's hard to see where we're going to be because all of our processes are changing. Most likely we will be reallocating staff time. Our office's workflow requires for an employee to be cross-trained. What would you suggest to a group just starting out?Sandra Washington: Assess your greatest needs first. Dr Tsang: The biggest issue is to have the right group of people driving the implementation and having enough people on board to drive change. Dr Edelen: Appoint a ZAR that makes decision about software, hardware, etc. Another tip to those starting: be prepared to spend more on staff time. The only thing the salesman didn't tell us about is the IT costs and obtaining the IT service. Dr Tsang: Administrative, billing, and clinical representation are most important to have support. One big misconception I think people have is that once you have an EMR in place, it will somehow magically do things for you, when that is not the case. But it's really what you put in and that's what you get. It is not going to suddenly send out prescriptions for you. Dr Edelen: One of our minor goals was to have an integrated system. One of the quality issues that we brainstormed about was that we wanted to be able to query patient data. We wanted to query our database to find patients associated with drug recalls and pacemaker recalls. Our biggest thing was a pacemaker recall. We had to contact hundreds of patients one by one. The process was horrible. |
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