RHC TA Conference Call Transcript

Moderator: Bill Finerfrock
February 5, 2008
1:00 p.m. CT

Operator: Good day and welcome to the today’s RHC Technical Assistance call. This conference is being recorded.

At this time for opening remarks and introduction, I’d like to turn the conference over to Mr. Bill Finerfrock. Please go ahead, sir

Bill Finerfrock: Thank you, Operator. I’d like to welcome everyone to today’s presentation on “Implementing an EHR: Now What?” Today’s call is part two in a two-part series on EHR. Part one: Selecting an EHR was addressed during the call held on Tuesday, January 8.

My name is Bill Finerfrock, and I’m the Executive Director of the National Association of Rural Health Clinics and the moderator for today’s call.

Our presenter today is Marian Weber, a principal with Health Consulting Strategies. Marian was also the presenter for part one – our part one call on selecting an EHR. Marian will address steps for implementing electronic health records, medical records system and will answer your questions at the conclusion of her presentation.

Today’s program is scheduled for one hour. The first 45 minutes will consist of the speaker’s presentation. And the remaining time will be dedicated to questions and discussion. This series is sponsored by the Health Resources and Services Administrations Federal Office of Rural Health Policy, in conjunction with the National Association of Rural Health Clinics. The purpose of this series is to provide rural health clinic staff with valuable technical assistance and RHC-specific information.

Today’s call is the 22nd in this series which began in late 2004. There is no charge, as you know, to participate in this series. We encourage you to refer others who might benefit from this call series to sign up and receive our announcement. If they want to do that, they can go to www.ruralhealth.hrsa.gov/rhc.

In the future, if you have questions, you can e-mail us to info@narhc.org and put “RHC questions or topic” in the subject line if you’d like to recommend a topic for us. Please follow along in the PowerPoint presentation. The link was sent to you by e-mail, or to those who are signed up for this series, about today’s call.

At this point, I'd like to turn it over to our speaker today, Marian Weber, who’s going to talk to us about “Implementing an EHR: Now What?” Go ahead, Marian.

Marian Weber: OK. Well, good afternoon everyone. I’m very excited to be able to talk about this topic. It’s pretty hot topic out there in the world of practice management and in the world of medicine, overall. The first slide, the selection of system, I’d like to review some key points that were brought up during our first presentation.

The process for selection of your system usually takes about 12 to 36 months. And it all depends on the size of your organization, whether or not you’re looking for a fully integrated system. You know, several different things that will affect how long the implementation process will actually take.

An important thing to do is not to rush the process. Recognize that is point to take time, that anytime that you take now doing your thorough research and making sure that your system that you choose is going to be effective and in point to meet all your needs. It will pay off in the end.
Also, look at this as an opportunity to improve your processes. This is a perfect time to be able to step back, look at how your office is functioning, look at those areas perhaps needing some reengineering, and take the opportunity to do so through the implementation of your system.
The collection of the committee members for this is crucial. You want to make sure that you have a good mix.

You want to make sure that you have committee representation from all aspects of your operation at front office, your medical staff, your provider staff. If it’s a larger organization, someone from administration, so that everyone has the opportunity for input and to share ideas. Make it sure that you follow the process. Don’t take any shortcuts. We went through quite a few of the steps that you need in order to be successful in collection of the process. And make sure you follow the process thoroughly, that even though it seems that it’s taking an awful lot of time, that you go ahead and you set up the paperwork.

You do your evaluations. You make your phone calls. Because, once again, these things will really prove to be critical once you get to the point of actual implementation of the system. And overall, make sure you communicate. With our – and continual communication with each other, the members of the committee, with the staff, with the leadership of the organization if it’s a larger organization.

This is one of the things – communication has always been the most difficult thing to do well. So, I just wanted to stress that in this process, just like anything else, it’s very important that you continue to do that. And sometimes you feel like you’re over-communicating but it still makes the whole collection process go much more smoothly.

Implementation design. There are several key points that are going to determine the strategy and how you go about the actual implementation of your system. You want to make sure that you all have clear understanding of the organizational goals that you set up during your committee process. You want to make sure that you understand that your specialty.

In other words, are you a one-shop organization, are you a multispecialty collective? What are all of the different components? You want to recognize the size of your practice. You know, larger practices are going to take much more time to implement, typically, than smaller practices. And also, have a multispecialty mix will also take longer.

You want to look at the complexity of your software. You want to make sure that you understand your software and everything that’s involved in getting it up and running. You want to have a thorough understanding of the type of equipment needs that you may have.

Make sure that your wireless system is functional, fully functional, before you begin implementation. Test your connection, have your IF team involved. And if you don’t have an IF team and you’re contracting for this service, make sure that you have someone come in and test those connections before you actually go live.

The worst thing that can happen is to have system interruptions. With your provider (state) tend to get a little bit some frustrated with that, which is very understandable. You want to make sure that you have available support.

And that includes someone, you know, different individuals who understand the system so that during the implementation process, if a provider has a quick question, you’re available to answer that question. If support, so if all of the sudden you have a system shutdown, you have someone available to help with that to get you back up and running as soon as possible. And you also want to make sure that the staff within each area have been well trained and are there and able to support each other.

Cost of the implementation. You don’t want to forget about the cost of the implementation including the training cost. And typically they’re between 20 and 35 percent of your overall investment. Although this seems like a pretty large sum, it’s extremely necessary in order to be successful during implementation.

You want to make sure that you don’t cut any corners. That even though the training cost may seem high, that’s one area you don’t want to skimp on. You want to make sure that you understand what’s involved in the training process, what the system – what the actual bender is going to do for you. In other words, you know, what different types of training cost do they have? What is the cost of their on-site training? What is the cost of your online support?

You want to know all the (infenals) of that before you actually begin implementation of the system. And then you want to make sure that you provide sufficient staff time. For the implementation process, that you have support individuals available.

For the provider team, that you have thoroughly trained your provider team. That you carved out time and scheduled ahead of time to do the training. And that everyone feels fairly comfortable before you actually begin the process. Or do the – go live within your organization.

Some common strategies that are very helpful in any implementation system process or any EHR systems, you want to make sure that you identify a physician champion. And this physician champion needs to be someone who is going to be fairly cool, calm, and collect in collective

It’s going to be someone who’s fairly comfortable with technology, that their fellow providers know and respect; that is very approachable. That, you know, if you have a physician who knows technology very well but isn’t very good about being able to express ideas or ways to do things, then perhaps, you know, that isn’t the ideal person.

You’re more apt to have success with someone who’s calm, collected, has the ability to be able to teach others, and doesn’t mind, quite honestly, quite a few interruptions during the implementation stage.

The provider staff, overall, needs to understand the commitment to this process, that it’s going to take time. It doesn’t happen overnight. That feeling frustrated in the beginning is common and that it’s going to be painful in the beginning but in the end will pay off. It’s what we need to make sure that all of your provider staff are on board before you take the lead.

You’re going to find different levels of that. You’re going to have some physicians that actually can’t wait and (challenge) you a bit. You have some that are dragging their feet and have never used a computer before, are very rarely.

The implementation team. This is the core team that’s going to be responsible for setting up processes and actually evolving the system that you go live. Before you begin the implementation you need to, as a team, clearly define your goal. What are the things that you want to be able to – how do you want to succeed in this process?

Develop timelines and targets for the implementation process, you know. Where do you want to be 90 days from now? Where do you want to be six months from now? How long do you feel that this process is going to take overall? So that everyone else has a clear understanding of the amount of time that will evolve during the transition.

Successful teams have stamina and focus. You’re going to have individuals on here that don’t give up easily, that stay fairly focused, that are able to stay in track, that are organized. Its’ very easy, as you’re going through the implementation phase, to get side tracked. It’s very easy to get discouraged.

During my own personal experience with this, we always had team members that, at one point or another, were having little breakdowns. And that’s OK. You know, as long as you know that you don’t all break down at the same time.

And as a team, you will grow to become pretty strong. You’ll learn that you have certain people that you can approach, that it’s OK to complain or to vent your frustration as long as it’s not in front of the entire staff. And it’s just, you know, you need to be able to mesh and work together very well.

You need to develop clearly defined roles. In other words, who’s going to be in charge of most of the clinical processes? Typically, that’s someone who has a fairly strong clinical background. And it’s usually not going to be a provider. It will be, either you’re office manager or, in a larger organization, your operations manager. But someone who really understands the ins and outs of the day to day process that place in all of your practices.

You need to agree upon methods. In other words, how are we going to go about doing things? What is that process for making changes? How are we going to communicate changes to the rest of the staff when they occur?

You want to make sure you have adequate information systems support. If you’re in a small organization, that may mean contracting for the service during this time. In a larger organization, it means identifying an individual from your information systems department who’s actually going to sit on your team.

And then you want to make sure that you have the support of administration. In smaller practices, of course, that’s going to be your clinician group, whoever it is who has ownership in the organization. In larger organizations, such – you know, in a hospital setting, that will be your leadership, your hospital leadership.

It’s going to be a team approach. Everything needs to be agreed upon before implementation. It’s very important to make sure you share successes, that you meet on a regular basis, that you have set up time, carved out time of your schedules in order to reconvene as a group. You want to make sure that you problem-solve as a team and not individually. And this is also extremely important.

And I have to say that this is the one area that, for me, sometimes was more difficult because I happen to be the operations director of a very large practice. And I was used to going out and, a lot of times, having to make decisions on the fly. And in this case, I really had to set back and say (“Dash”), you know. Before we go ahead and just make this change, I really need, we need to take this back to the team, have it reviewed, and then we’ll get back with you.

But I always make sure that there are the clearly defined timelines. In other words, I’ll let them know, you know. I’ll be able to get back with you tomorrow. I can get back with you next week. You know, this is something that’s probably going to take a little longer. We need to research it before we actually make a decision.

So, it’s important to remind yourself, as you’re out there working with the system, that you really can’t do that. You need to make sure that everybody’s on board and informed before any changes are made. It’s a (cordy) of open and honest dialogue. As I mentioned earlier, a lot of tense frustration levels can be very high.

You want to make sure that you let someone know. Oh my goodness. When this happened, I got really frustrated. Next time, can we make sure that we handle that a little differently? I think it’s difficult to do that. But in the end, the success rate will be much better because you’ve learned how to communicate those feelings of frustration with one another.

Another thing you don’t want to do is sugarcoat issues. I found this specially when working with provider staff and, many times, they had to be very honest about an issue.

If they were frustrated about the capability of the system, it was – a better approach was to say to them, “I’m sorry. The system can’t do what you’re asking it to do. This is why it can’t do that, that particular process. And this is why, you know, we need to have you follow this approach.”

Sometimes, that – it is like this very well at first. But in a long run, I think they had a better understanding of how the system actually functioned. And I think they had better respect for the team (of raw).

I keep mentioning planning but it’s so critical. It needs to be thorough. You really need to think through processes. You need to go through dry runs. You need to look at every step of your day. In other words, you know, what happens at eight o’clock when the front office comes in, turns on the computer, it’s got three people standing in front of them.

How are we going to make sure that the process for updating demographic information becomes as efficient and smooth as possible? How are you going to notify the front office ((inaudible)) the back office, the clinical staff, the patient is here?

When you’re on a paper system, many times you need to put the chart insert in file or you print off on (counter) sheet. You do something that triggers the back clinical staff that they know that that person is there. You really have to think through, whether or not your system has the ability to do that online. Or whether you have think of another way to be able to let the staff know that their patients are there.

Team members must be responsive to staff needs. When you’re going to the implementation phase, many times you do get frustrated. And you want to be able to say, “Oh, my gosh, you know, that’s just a petty concern.” Or, “No, I can’t talk about this right now with that 16 calls ahead of me.”

You have to remember to let the staff know what’s going on, when you’re going to be able to get back with them, and then follow through. You have to understand this so work flow on the organization, every single step of the way.

Sometimes it’s really important, or actually, most of the time, it is very important to actually, either do a flow chart or an algorithm, map out what happened during the encounter process from the from the time the patient present at the front desk until the time they check out. And, as I mentioned earlier, you may need to reengineer some of those process (to state) and the way that your electronic health record system work.

Training and support. You need to make sure that you establish a very solid relationship with all of the users. And that includes not only your clinical staff but your front office staff, your clinical support staff team, all the different personalities and different functions of the health center needs to be brought into this, into the workflow.

You need to make sure that you take a realistic approach to change. People hate change. I know it’s not my favorite thing. And many times, you need to be able to pause back aside and say, “You know, it really doesn’t help when you’re continually putting down this system.”

You know, we need all to be on the same team. If you’re really frustrated, you know, come and talk to me about it, instead of, you know, (dancing) in front of patients or staff.
You need to make sure that your support team has shared goals, which we mentioned earlier. And that everyone has a mutual interest in learning from one another. And it’s really interesting, once you get going with this, you’ll find that your best teachers are staff members themselves.

That when someone really learns the system, they like nothing better than to say, “Oh, hey, you know, (bally) I see you’re having trouble with that. Let me show you how we do that.” It really helps to build the team, the clinical team as a whole.

At most organizations, you do the train the trainer concept. And what we mean by that is that you have key staff who are – who participates in a very formal training and becomes super users of the product. In other words, they know the process inside and out and you’re able to turn around and show that to others.

So, part of the implementation preparation is to identify key staff for hands-on training. You got a cross-section of managers and clinicians and front line staff that are going to participate in the training process. You want to make sure that you have, like I said, providers, clinical support staff. I know that in our clinical settings, we involved the – we had site managers that are trainee-trainer, people for each area.

And when we set up the formal training, they participated in all training sessions. When we actually – what lies in the different areas, they were relieved that a lot of their normal duties in order to be able to help out with the online, the (gold life) implementation process.

You have to recognize that different staff are going to have different training needs. You’re going to have all different levels of comfort with technology within your staff. And you need to recognize that and be patient.

And, for some people, you know, they don’t use the computer much at home. They’re not familiar with it so, they need to be able to develop some comfort with that. And if you know that I have the time and you can identify who those individuals are, you are able to give them a little extra support.

Make sure you identify a project manager, someone who’s going to be the person who is in-charge of this project. They have the final say. They know when they need to pull the team together as a whole, if there are some angling issues that need to be dealt with immediately.

Identifying the project manager decrease the chance for miscommunications. It’s just like – I don’t know if any of you watched the reality show on TV with – oh, gosh, I can’t even think of his name but where they have different project teams. The first thing that they do at the beginning of each show is pick out their project manager. And many times, the success or failure of their team really falls on who that person is.

You want to make sure that they have the different characteristics that you’re looking for, the ability to lead, they’re a great a communicator, that they have the ability to be that collaborative person that can bring people together when things get a little bit scary.

There’re going to be, like I mentioned previously, the gatekeeper of the system. You want them to be someone who had a fairly politically-correct approach, that they’re able to deal with all different types of individuals without becoming offensive.

You need to understand in advance how much vendor support is available. Depending on the size of the system that you’re implementing, you may have – if you’re implementing a smaller system they may be very great about the actual go live hands-on support. But when it comes to long range systems support for IT problems you have, they might not be, you know, as great in that area support.

Once you – we have a clear understanding of that and you know how you’re going to be setting up your training. In other words, how many hours of formal training are you going to have? How many times are they going to be on-site? How many Webinars are you going to have available?

The system that we chose, we actually were able to go on periodically via the Internet and shared up that path and go through many of the processes with the trainer on the other end of the telephone line. And that was extremely helpful.

If they have that capability, that is one that I will highly suggest that you use. You want to know, OK, when they come on this day, if you’re going to have in-person training and support, you need to make sure ahead of time that that training day is set up and organized and everyone is aware of where their trainers are going to be, what the focus is going to be. If the schedule needs to be changed at all, that all of those things are done well in advance.

The project manager. The project manager wears many hats. Like I mentioned earlier, they’re the person that’s going to keep the project on schedule, who is going to be assisting in training of the staff, that’s going to also assist in development of customized templates.

When you look at your EHR system, we mentioned in the first presentation that we did, the importance of looking at the systems and see what its capabilities are in terms of pre-defined templates. So you need to make sure that you know what your system capabilities are in terms of template processing. In other words, if you want to make changes to those templates, can you do that yourself or do you have to have input from the vendor in order to be able to do that?

The project manager is, typically, the person who oversees all of that. Because it’s critical that any changes that are being made in template are done correctly. Otherwise, it’s going to affect all kinds of components. In terms of your compliance components of your documentation, your billings whether or not the data element is going to pull over into your billing screen, all kinds of issues. So, this person, typically, is the one who’s going to be in-charge of overseeing that.
They’re also going to be on the forefront of intense systems training, to be part of every single training session, you know, from the front office desk, the clinical staff to the billing staff. And they need to knowledgeable regarding all aspects of the practice system.

A phase – there are different approaches that you can take with the EHR implementation. And the one that’ most often recommended is the phased in approach. In other words, you’re not going to have your office and go live, you know. Everyone’s not going to be starting at the same time.

You’re going to be looking at your provider staff in your schedules and determining ahead of time who’s going to be the first provider to serve on the systems, how many appointments that day they’re going to be doing in EHR. You’re going to have a very good idea of how that’s all going to be set up ahead of time.

You need to make sure before you ever go live that you have all of your non-provider staff up to (see). Your clinical support staff, it’s really critical that they understand the system themselves. They’re the ones that are putting things into the record like vital signs, chief complaint. They do a lot of the upkeep of the medical rec – the medication list.

They’re going to be doing a lot of the patient messaging, call routing, results reporting for lab tests. So you want to make sure that they’re all comfortable with the systems before you go live.

Start out with processes that don’t interfere with the actual face to face encounter in the exam room and many of those things that we just mentioned. You know, when a patient calls in and wants to leave a message for the physician, how’s that going to work with the EHR system? When you get a lab result back, how are you going to process that within the system? Those types of things, it’s really going to affect the flow once go live starts.

It’s important to train your support staff to enter vital signs, medications, allergies, all the things that they currently do on paper or in that paper chart. You need to train them to do an electronic health record. And you need to make sure that they’re comfortable doing that.

It is important to enter as much data as possible before the first visit. In other words, when in practice, I was involved with – we actually went through and entered in medication list, problem list, like I said, any previous data that we found, their flow sheet. Because that makes it very easy for the providers, when they go on to the electronic record and they see that the foundation is there.

And it’s critical before these dictations that a lot of bit information is already in there. Otherwise, they’re going to be putting back and forth between electronic and paper. And it just makes the process a lot more difficult.

You need to – not if they went (that test) but, overall, you need to allow your providers to start out slowly. They do much better if they’re not feeling under a lot of pressure. You know, let them do, like I mentioned, one or two visits at a time. And the, if they, you know, gradually become more comfortable with the product then they can increase the number of encounters that they to the electronic health record everyday.

The template, you need to make sure that you modify those templates according to the agreed upon approach. What we ended up doing was we developed a request sheet. And the request sheet was circulated amongst all of the provider staff.

And when they were in a particular template and they saw something that they want to change, they documented that on the request sheet. And that request sheet was given back to the project manager, or whoever that person is that’s been identified to assist with template changes, for input into the system.

So, that person would receive the request. Once the requests were done, it was documented on that same piece of paper that the change was implemented. And then it was given back to the provider staff.

We did a weekly update and listed for just any changes, overall changes that were made in the systems so that everyone was aware what have been done. That’s extremely important also. And then, large practices, many times it will start in one specialty area and then spread.

If you have several sites or if you have several different types of specialties that they – we had family practice ((inaudible)) internal medicine we had (several) aid of specialist. We started out in one area. First is we started out in our family practice area. We spread within that areas of providers, made sure that everyone within that specialty area was comfortable with the systems before we started in another area.

When we had – we didn’t happen to have multiple sites. We did have an urgent care but we had a very large clinic for most of our specialty practices were located. If you do have numerous sites, you will more than likely want to phase in side by side. In other words, you want to keep things under control on one site before you spread to another.

Usually, you determine the site that’s going to start by level of comfortable, you know. If you got staff there are comfortable with technology, your physical layout is good, IS supported and then they’ve made the changes, they’ve done their task and things are running well, then you probably want to start in that area first before you spread to any other area. Or you’re going to find out about that area where you begin your implementation and if that’s going to be the area where you’re going to work out all of your (bugs) so make sure that you think about that when you do your selection.

(Scanning). (Scanning) is another big traffic area for electronic health record transition in scanning and (taking) all those paper records and turning them into an electronic format and there are several different approaches that you can take with this. But the one thing that you do have to do no matter what approach you take is make sure that you decide upon your process before the implementation begins.

It’s critical that you pull your provider staff together and decide as a whole whether or not you’re scanning the whole chart, if you’re going to do a partial chart, how many visits do you want to included, what labs do you want included, what pieces of current information that you have that you want scanned into that chart. And what we did was we pieced the actual physical paper record at the first meeting and went through it, and then developed little sub-committees that looked at different areas and then, when we came back together as a whole group, they had their recommendations for each area and then it was voted upon so, it’s pretty diplomatic.

You’re going to meet to determine as a group whether or not you’re going to be scanning the whole record and then shredding the paper, whether you’re going to be just scanning pieces of the medical record and then storing the paper record. You may be storing onsite, you may be storing offsite, these are different things that you need to be thinking about before you begin the (go live) process.

You need to agree upon if you’re going to get rid of the paper chart or if you’re going to store it offsite, how long do you want to hold on to that paper chart, do you want to say “Gosh, the patient really needs to have three visits before we get rid of that chart,” or if you’re going to be doing the full chart obviously, you need to make sure that the chart has been completely scanned and that the patient has actually been seen before you get rid of that paper chart record. And I want to make sure that that was one thing that we found out the hard way, just because the paper chart is fully scanned in the system, you really don’t want to get rid of the paper and so, the patient has been seen at least one time and the provider has had the opportunity to go through it and review the record.

You want to make sure that all the important data that we mentioned previously is entered into the paper chart before the chart is moved and then you also want to examine your staffing needs. You’re going to find that you may need to hire some temporary staff to assist with the scanning. It’s a pretty time intensive process.

Template building. You want to make sure that your providers review the templates before implementation. Most systems have a cafeteria plan, in other words, they have templates that are part of their system that are already built in before you get started. You want to make sure that your provider staff has a chance to look at those before they actually start using them. Like I mentioned previously, make sure you have guidelines for making changes in the templates. You want to make sure that the provider staff understands the impact on building data, in other words, their documentation in that electronic health record is going to be passed on and it’s going to have an impact upon the coding levels in the system.

So, they really need to know the flow. It’s a completely different mindset. With paper, it’s all there, it’s all in front of you, you have your routing script. Also last minute, if you decide “Hey, wait a minute, I forgot to do that, I forgot to check the (UA),” they can grab it back and make their changes. It’s really a completely different way of thinking so, staff need to be able to understand that.

There’s an issue at (free Teximals, Winmalls), yes, both systems. Many times, when the provider’s going in, they use the (free text) option, the coding component that’s associated with the data elements that are in the complex with (free texting) won’t be pulled over. So, they need to understand that if they choose to do a lot of free (texting), if they’re going to have go in there and carefully review their ENM coding and make sure that they haven’t neglected to put something in there that was done to make sure that they agree upon the level, all kinds of things.

We actually did compliance reviews with each provider when they first started into EHR and we had our certified coders going in and look at their documentation and look at the ENM level to see whether or not the documentation supported the level of coding, which can also be fairly time intensive but well worth it down the line. And that’s another thing that you want to be thinking about as you’re thinking about the whole process for implementation.

Some key issues. We mentioned impact on the staff. You may have temporary staff needs in terms of additional staffing in your medical records department for scanning, for assisting with retrieval of records. It can have a long range impact and usually where you see that is in the same department so, you may not have the same need in your medical records department that you had previous to going electronic.

This may give you the opportunity to redefine roles. You may not have the same need for medical records that you had before in terms of handling paper charts but you have an awful lot of scanning to do because paper really doesn’t go away. You also need to bring in the behavioral component on all of this and understand that there’s really – I can’t (struck) this enough. There’s definitely going to be a psychological effect on your current staff and make sure you’re prepared for that.

There will be an impact on productivity. There’s a question, I believe before we have this session that was sent to Bill regarding “How do you prepare for the decrease in productivity and perhaps, the decrease in cash flow during the implementation phase?” I would encourage any organization to make sure that they build into their budget, whether that’s going to be a percentage of the current budget based on the number of providers that are going to be going ((inaudible)) at one time. Usually, that’s anywhere between 20 to 25 percent. We found it to be very minimal. The initial impact perhaps is somewhat about within, usually within 30 days of (go live) in each area, those providers were up and running and doing just as well and a lot of them were actually more productive than they were prior to HER implementation.

In terms of smaller practices, they don’t have a financial backbone to fall back on. You might want to look at developing or establishing a line of credit for your initial base before you go into EHR, you may need to borrow money until you really get things up and running. As I said, we didn’t experience that. In a lot of the research that I’ve done, I found that most practices don’t find that they have a very critical and (past time) cash flow. But the key is you want to be prepared. You want to make sure that you understand your providers’ comfort level and that we developed a tool for our providers prior to implementation that all feel about letting us know what their level of comfort was with technology.

Paper will not go away and you need to make sure that you have strategies developed for addressing incoming paper, those lab reports, those x-rays, from systems perhaps outside your office that aren’t digital yet, processes for outgoing requests from patients. You have a patient, your electronic that you’re going through an office test paper.

Develop formal written policies and procedures related to any of the processing that you do, this is very important also. Make sure that you as you change processes that you have someone assigned to actually formalizing those and putting them on paper and making them part of your policy and procedure book. That’s the place many people are going to be referred to when they’re not fully understanding how something is supposed to work. When you have it in black and white, it’s a lot easier for staff.

Recognize change management issues, that your staff is made up of several different kinds of personalities. You’re going to have extroverts, introverts, thinking types, the people that process everything over and over again and that feeling type, the ones that typically, they just react. With extroverts, you want to make sure that you provide them an opportunity to talk about what is happening, that they’re being heard, that they’re involved and they have a visible role. These people, these staff members, these are the ones that typically want to be involved, want to be in the committees and I suggest that you take advantage of that.

Introverts, you need to give them space and time to think. You need to provide them with written communication and you need to make sure that you give them time to assimilate changes before they actually need to do them.

Thinking types, for these people, there has to be (latch) behind the decision. So, many times, when you’re explaining something to them, why you’re doing things a certain way, you need to make sure that you go through the whole process and they fully understand it. You need to make sure that your leadership skills are pretty (whole) and that those people you have in charge are confident because these types of individuals will find a flaw if there’s a flaw to be find. They also want to make sure that any change that’s made is fair and equitable.

Feeling type, they tend to react. They think about the impact on people. These are the ones that are going to be worried about their (numbers) losing jobs, they’re going to be worried about everyone else and what’s going on, not necessarily the process but how everyone will be affected. They want to make sure that leadership actually shows that they care about the employees, that there’s a value assessment in place and that appreciation and support is being shown to the staff throughout the process.

So in conclusion, I don’t want to sure quote anything. Like I said, it is a very difficult process but it is also an extremely rewarding process. I can say that I went through this process with the group, we happened to be going through real health certification and provider base group at the same time and we were able to go through our initial review.

Our medical component took about 20 minutes. I actually had the surveyor (cert) right next to me, we went through every phase of record review. We took (goal) from visit to visit to visit, we could show flaw, that there is a problem list, that the medication list was thorough, that any meds that were discontinued were documented. It was just absolutely amazing and that particular person wasn’t necessarily an electronic fan but by the time we finished the medical record review, let me tell, I think they went on the other side. So, we found it extremely helpful when we were going through that process.

You want to make that you conserve your energy. It’s very draining, you need to be pretty honest, up front with staff and acknowledge the fact that it’s not an easy process. As a leader, you need to make sure that you create a positive environment and that you give opportunity to see your staff to vent their frustrations because there will be many. You need to be patient. It’s going to take time and you need to make sure that you celebrate your successes.

When each area implemented the (live) with EHR, we had a little pizza party in each of the areas. And then, once the staff once was fully implemented and our group was pretty much on track after a year, we brought everybody together and had a big celebration so, it was very rewarding. They’re still going through the process, they’re still standing, it takes time like I said but when you go through it and you step back and you have an opportunity to breathe and look at what you’ve been able to accomplish, it’s pretty rewarding.

Any questions with that? That’s the conclusion of my presentation so, I welcome any questions at this time.

Bill Finerfrock: Thank you, Marian and operator, if you could give instructions for those who want to ask a question.

Operator: Thank you. The question and answer session will be conducted electronically. To ask a question today, please press star one on your touch-tone telephone. A voice prompt on your phone line will indicate if your line is open. Once again, that is star one on your touch-tone telephone. Also if you’re joining by speakerphone, please pick up your handset and make sure your mute function is turned off to allow your signal to reach our equipment. We’ll pause for just a moment to assemble the cue.

MBill Finerfrock: Also, I’d like when folk callers do come in to ask a question that you identify yourself, your name and where you’re calling from, the state that you’re calling from.

Operator: We’ll go ahead, take our first question.

Bill Finerfrock: Go ahead, caller.

(Toni): Hi. This is (Toni) with (Mercy) in Sioux City, Iowa and I’m just wondering if you’ve had any experience with the process of going up live in a new practice management system as well as an EMR at the same time.

Marian Weber: Personally, our group did not do that. We kept the practice management system that we were currently utilizing that I have worked with clinics and have gone through that phase. And typically, what happens is a lot of times, the billing staff will get up and running and functional and they’ll make sure that they are able to get their claims out, and that that side of the component is fully functional and then, they’ll implement the EHR side.

It’s interesting. They’re (prototons) to that. What I found, when I was actually working with the group that had done that, is that the flow through is very nice. The flow from the electronic health record documentation to the actual coding and the building component was pretty smooth.

(Toni): I was referring to two different systems that are integrated. What are your feelings about that?

Marian Weber: I personally have not had experience with that. In my first presentation, we talked about the need to make sure that those systems can (talk). I would not advise doing that because of many issues and one of them is the fact that documentation and billing really rely on each other and as the systems can’t talk to each other, you’re just (up) into a lot of issues and a lot of work around that you’re going to have to develop as a result of that.

Bill Finerfrock: I had this (meant) to (limit) when their question was asked of somebody building a bridge, one person starting on one side of the river and the other on the other side of the river, trying to meet in the middle and finding that they’re off by about four or five feet.

Female: Right.

Female: Thank you.

Marian Weber: I don’t think that that would be advisable and if they’re not the exact same system, there are many systems out there that do talk to each other, they interface. But like we mentioned in the previous presentation, you need to make sure that you get a very reliable source to verify that, and if you’re able that you do some testing with that and that you call practices that are using those two systems to make sure that really do work.

(Toni): Thank you.

Bill Finerfrock: Thanks, (Toni). Next question.

(Charlene): This is (Charlene) from Montana. We’re in a small outline really health clinic trying to adjust to an EMR system. I’m trying to find more places that are using an EMR or certainly the one that we have, (E Clinical Works), trying to find out how they’re doing different components of the day to day events because this had not done before the system went live. So, we’re a little scrambling trying to figure things out.

Marian Weber: I would suggest using, and I hope it’s OK if I say this, the rural health lister, many times they’re able to put the question out there, give the group an either e-mail contact or phone number and then, they can contact your personally and I think that’s a good way of doing that. What we found with our vendor, they’re not always as willing to give you names of other practices to contact.

There’s lots of reasons for that so, usually networking with the National Rural Health Association, the National (Association) of Rural Health Clinics, if you have a state association that’s also a good place to start because as you all know, rural health billing is also a little bit different from just regular private practice so, you want to make sure that you connect with someone who has the exact thing makeup.

Bill Finerfrock: (Charlene), are you on the rural health connect and the HRC news lister?

(Charlene): What I’m getting is your Web site.

Bill Finerfrock: You get the announcements about the…

(Charlene): Right.

Bill Finerfrock: But we have a separate – if anybody’s interested, we have a separate lister which is really almost like a chatroom and individuals can post questions on there. Similarly, we’ve had long lines of what you’re asking which is “I’m using this system, is there anybody out there who’s using it?” You can exchange e-mails or phone numbers with one another and talk offline or separately about your experiences with that. If you want to find out, if anybody who’s on this call who wants to be participating in the NARC news lister, send me an e-mail at info@narhc.org. And say you want to sign up for the NARC news lister, we can all take care of that.

(Charlene): I know we’ve been trying to figure out how to reinvent the wheel without any prior opportunity to do that and it’s made the day to day events a little more challenging.

Bill Finerfrock: All right. Thanks, (Charlene). Next question.

Operator: Moving on to our next question.

(Shana): Hi, my name is (Shana). I’m calling from Aledo, Illinois. We have just recently implemented an electronic medical record with our hospital wide, is now moving into the clinic that we have purchased, the electronic medical records.

I guess, my question is, we’re still starting to teach people in the next couple of weeks and I want to know, since you’ve already been through it, what numbers were you finding that your providers were comfortable with as far as – it’s kind of a twofold question. How many were they willing to transfer over the day? You said one or two. And did you start revamping your policy and procedure book before you implemented the EMR or as you were doing it?

Marian Weber: OK. We started out very slowly. We started out each provider with one or two encounters the first day and those encounters were chosen on how to time so that we were able to enter baseline data before they’re actually presented which was extremely helpful. So, we started out slowly.

Now, I do know practices that went live and they just went live. I personally wouldn’t advise that. I know it’s worked in other places but in terms of, I would make sure that everybody was on the same page and everyone knows exactly what points are going to happen that day. Could you repeat the second part of the question, please?

(Shana): I just actually just going through our policy and procedure book because we had state surveyors in a couple of weeks ago so, it’s updating a few things and I heard you mentioned, obviously, the policies you’re going to change relating to the EMR. You may have patience but you’re sending out somewhere going to a paper office. Did you find you’re having to revamp a lot of your policies and procedures or was it just a few? And did you start before or as the problem arose.

Marian Weber: We did end up revamping the majority of our policies and procedures and because it’s a systematic approach it went through initially and looked at anything what could be changed ahead of time, those things that were going to be effective. And then, what we did was we actually and many of the policies, medical records, requisitions, we used a two-phase approach so, the policy would actually reflect what you do with paper record, what you do with an electronic record. And then, as the corrective phase’s over and became all electronic, it was pretty easy to go in and modify it that way and make it a completely electronic policy. So, I would recommend doing it ahead of time mainly because that way, people use that as a resource. It’s very clear and they have a very clear understanding of how it should be done.

(Shana): Thank you.

Bill Finerfrock: Thank you, (Shana). Next question.

Operator: And just as a reminder for your telephone, it is star one at this time. Once again, that is star one on your touch-tone telephone. And Mr. Finerfrock, at this time, there appears to be no further questions. But just as a final reminder to our audience, it is star one on your touch-tone telephone.

Bill Finerfrock: If there are no more questions, then we’re right up. Just about three o’clock and I think that worked well, anyway. So, I want to thank all our participants and I especially want to thank our speaker today, Marian Weber, for doing a great job on implementing electronic medical records. I also want to thank the office of Rural Health Policy for sponsoring this series.

A transcript from today’s presentation will be available on the ORHP Web site hopefully, in near future and then also, we do make a recording of the call available and that should be up in a few days. If you want to listen in again to rehear something, to make sure that you didn’t (or) if you know someone who was not able to be on today’s call who would like to listen in, the next Rural Health Connect Technical Assistance Call will be in March, it’ll be the first Tuesday in March, we’ll be back on to our regular schedule. This was an additional call due to the complexity and the amount of subject matter in this particular area. We will be getting information out of that topic and the specifics on that call next couple of weeks.

If you do have a suggestion for topics, as I said earlier, please feel free to e-mail them to me at info@narhc.org . We encourage folks to try and call in a few minutes before the start of our call so we can try and get started on time.

Again, I want to thank everyone for their participation today and we look forward to talking to you next month. Thank you very much.

Operator: Thank you. That does conclude our conference. You may now disconnect.

END

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