Optimizing EHR Implementation Through “Pre-Load Services”: Temple Physicians’ Experience

Relatively speaking, yes. When you implement an electronic medical record in a physician practice, particularly an academic medical practice, there are a lot of expectations that need to be managed or met, per hardware, software, support, maintenance, etc. This is kind of high-risk work for IOD, because you’re talking about trying to make sure all the physicians are satisfied, and of course you know that representing physicians, even when you’re a physician yourself, is not necessarily a homogenous thing to do. So you’re talking about summarizing data that the physician needed, so that when the physician was seeing a patient for the first time after implementing Epic. And we made the paper record available for the first few visits, because you needed to. And there’s a lot of variation in physician practice style; and we had to make sure the average presentation was workable for the docs. And the quality of the work was extremely important.

One of the fuzzy things in doing this work—and we love them dearly—but if you’ve ever thumbed through a paper record, they don’t always follow the rules of how to do things. And we were giving the IOD folks a general set of rules to work from, and then we were giving them every manner of paper chart to sort through and input. So there issues as we went along, but at IOD, they were aggressive about quality control, were responsive as we had issues; and as the physicians began using the record, they got comfortable with that, too.

And from an organizational or management perspective, we knew we were doing this quickly. We signed our contract with Epic in the early spring of 2010; we were bringing up our first practices about six months later; and after that, it was basically a forced march for all our physicians. And I have to commend our physicians, because they absorbed something that was almost like an assault. And any technology expert would tell you that you should do the process rapidly, because the longer you take, the more expensive and difficult it will become, and by the way, you don’t add more value. So that’s a good approach, but is difficult. Epic told us our rollout was something like twice as fast as average. But we needed to put ourselves in the position of optimizing the available meaningful use dollars; and everybody was concerned that the program might not last as long as it was designed to last. I’m thinking of the Cash for Clunkers program that ran out of money.

But we’ve collected so far about $10 million in incentives. We’ve attested for everybody for stage 1. The folks who have been on Epic for two years have attested for the first two years; we’ve got a large number in their third year. And next year, everybody’s on the 90-day cycle for stage 2.

When will that begin?

Fortunately, for us, if you want to get an incentive payment for calendar year 2014, it can occur anytime during the year. As you know, there are some specific requirements for electronic interchange between patients and doctors, and that’s going to be a little bit of a challenge, given our patient base, and their adoption of the patient portal tools we have. So one of our discussions right now is how to increase that communication between patients and their doctors. That will be what actually drives the specific timeframe for the attestation period for docs next year, hitting that 5 percent. It doesn’t sound like a lot, but it isn’t something you can manage directly.

What have the biggest lessons learned been in all this?

This part, the pre-loading of the EMR, is only one of many, many things that you do when you’re rolling out an electronic medical record, and for physician practices, it represents a significant investment in every aspect of training and support—both go-live support and ongoing support. And most physician practices don’t have large medical records/health information management support. Most don’t have large HIT staffs, either; and in our case, we had to grow rapidly to handle all this. But in most cases, you couldn’t expect to have a large enough HIM department to create this transition; so you’d need to identify a partner like IOD that would move forward in a specific timeframe, with the requisite quality, to help the physicians continue to provide quality patient care in an environment in which you’re learning to do everything all over again. So from my perspective, identifying the right partner, working closely with them, and having the requisite mechanics and processes in place, is important.

There’s a lot of basic blocking and tackling required, correct?

Yes, a lot of it. There’s a lot of potential for swirl. And when we have a good partner, as with IOD, you need to think about how to put them in a position to be successful; because if they’re working directly with 100 different practices, it’s very difficult to manage all those relationships, and make sure information is flowing correctly. And that’s why it was important to identify and work with the chief operating officers of all the organizations we work with.

Do you have any specific advice for CIOs, CMIOs, and other healthcare IT leaders around all of this?

I think that you’ve got to keep your eye on this kind of process; but I think any good manager would understand that implicitly as well. But it’s something that bears stressing because of the many different moving parts on a project like this that’s undertaken and completed on such a compressed timeframe.