Taking The Ego Out Of EMR Implementation

Compiled by Jennifer Dennard

Ego can derail an EMR implementation, but communication, honesty, and a strong physician champion can ensure success.

Chinese Community Health Care Association (CCHCA) is a non-profit, independent practice association (IPA) that serves the Chinese community in California’s San Francisco and San Mateo counties. The association’s 201 physicians provide care in several Asian languages to patients, many of whom are senior citizens living in Chinatown. CCHCA physicians work at 36 private practices and four community clinics in the area, which feed into six hospitals, including the 54-bed Chinese Hospital – the only facility of its kind in the United States.

Jonathan Everett, director of health information technology at CCHCA, has helped the association’s physicians through the process of EMR selection and implementation, including a first-of-its-kind NextGen upgrade, and is gearing up to prepare everyone for Stage 2 Meaningful Use and the transition to ICD-10.

Juggling the wants, needs, and personalities of dozens of physicians at multiple locations, all the while managing an IT budget of more than $2 million with a team of 10, has given Everett a unique perspective on what the ideal EMR implementation looks like. He shares his thoughts on how to get there, and how to keep an organization moving forward after Meaningful Use incentive checks have been cashed and other IT deadlines loom. Everett also chimes in on the debate around EMR ROI.

Q: When did CCHCA begin implementing EMRs for its physicians?

Everett: We’ve been doing gradual rollouts for the last five and a half years. CCHCA is an IPA, and so it was the physicians themselves who made the decision to move to EMRs. That decision was made about six and a half years ago, and then it took them a year to go through the process of looking at different vendors, conducting site visits, and ultimately deciding on a system.

The final choice came down to eClinicalWorks, which has a really strong foothold in California, and NextGen. Our physicians ultimately decided to go with NextGen, which was chosen because it has a strong standing in the marketplace. As one physician explained to me when I came to CCHCA a little over three years ago, NextGen was the winner because it is a strong company with no debt, is going to be around for awhile, and has all the specialty content CCHCA physicians need or might need in the future.

We now have 70 providers on the NextGen system, which covers 65% of our entire patient population. That figure includes 70% of our senior population, a very big deal for our organization because these are Medicare Advantage patients. Because they are in the NextGen EMR, our physicians have access to tools that let them drill down to the exact Hierarchical Condition Category ICD-9 code. These codes determine the amount of “risk” associated with caring for Medicare Advantage patients. The higher the risk, the more funds received from CMS to help care for the patient. These tools make it easier for our providers to document for more accurate reimbursement.

Q: Where are CCHCA physicians with Meaningful Use?

Everett: Because the majority of our patients qualify for Medi-cal, California’s Medicaid program, and because we already had EMRs live at many of our facilities, we attested for AIU (adoption, implementation, upgrade) for most of our physicians in 2011. Last year, we focused on the 90 days necessary for Stage 1, and this year we’re working toward the first full year of Stage 1.

The first 90 days for Stage 2 are going to be interesting, because you can’t really attest for it until 2014. The big focus next year, of course, will be Meaningful Use Stage 2 and ICD-10. In order to build out our upgrade plans to deal with Stage 2 and ICD-10 in the same year, we’ve decided to take a really proactive approach during the first four months of the year, similarly to how we prepared for Stage 1. For example, we built binders that laid out each measure our physicians needed to focus on and built Meaningful Use-specific templates within NextGen. These templates enabled our physicians to do a Meaningful Use check at the end of their patient visit to ensure they hit the necessary points. We run weekly reports on their numbers and place them on their desktops so that they can get an idea of where they stand for the percentage requirements. This has helped them achieve those goals. We plan on doing the same approach for Stage 2. As soon as everyone hits their 90 days after those first four months of the year, we will focus strictly on ICD-10.

A lot of people, in my opinion, are making a mistake and waiting to upgrade. It’s not easy to stay on top of the latest and greatest healthcare IT all the time, but it is the right thing to do. We were the first organization in the country to upgrade from the NextGen 7 Series to the 8 Series, and it was rough but necessary. It didn’t just change a few fields here and there. It was essentially a new EMR. Previous versions were specialty content driven and very good but still had an older look and feel to them. Development on the backend for IT infrastructure was difficult to maintain and upgrade.

In an age of healthcare reform, everybody has to continually upgrade, and fortunately that process is easier to do in the 8 Series. My mentality is to always keep our physicians on their toes, because upgrades are going to happen for at least the next 10 years due to new regulations and requirements.

Q: What barriers to physician adoption, or other challenges, have you seen during implementations and upgrades?

Everett: The first one is physician bias. It’s a huge challenge to get physicians to commit to using a system. If you can get them to buy in, you’ve won 80% of the battle. The second is lack of computer skills. There’s certainly an age gap in which some users are innately comfortable using computers and some are not. I would say about 10% of our physicians are not strong EMR users. That’s neither good nor bad but a reality we have to face. We need to work at getting them comfortable with the EMR.

The other side to that coin is that this younger generation of physicians is almost too savvy with computers. They come in with a “been there, done that, I know what it’s capable of ” attitude. Sometimes what they assume can be done in our EMR based on their previous experience at another facility just isn’t the case. This can lead to a lack of enthusiasm to get started and become the super user we had hoped for.

That ties into the back-and-forth ego problems of IT and clinical staff. That’s the elephant in the room. You have to have skill when it comes to talking with physicians on their turf. When computer nerds like me come into a physician’s office and tell them how to practice medicine with an EMR, well, it immediately puts them on the defensive. An old-school practice mindset can be a big barrier to getting a clinical/IT partnership going and trying to use a system.

Another big barrier is a lack of understanding of an organization’s goals. We’ve had to work through some difficulties in getting the physicians to recognize proper coding and the impact that has on their reimbursement. We’ve put prompts into the EMR, but our physicians hate those more than anything. It goes back to the point I made about ego. They tell me they’ve been practicing medicine longer than I’ve been alive, so what do I as an IT guy know? You have to develop a true partnership based on the value this system brings to patient care.

The last challenge is a lack of trust in the EMR. Is it going to be up? Is it going to be down? The word downtime is a scary one when used in the same sentence as EMR. For every time it goes down, it takes away six months of positive user experience. It could go down for 5 minutes, and physicians will start to badmouth it. Something always happens at some point or another. That’s just the nature of technology. We’ve had a few bumps in the road with our data center hosting and losing connectivity to our server farm. I try to tell our physicians not to let a server hiccup judge how they use an EMR or its merits. However, our data center lost power and was down for a few hours during Hurricane Sandy, which led to lots of understandable groaning amongst physicians in the hospital lunchroom.

Q: What benefits have your practices realized as a result of EMR adoption?

Everett:The biggest win for our organization has definitely been the ability of our physicians to communicate electronically amongst all of our offices via NextGen’s Enterprise Chart functionality. It cuts down on duplicate medications, as well as on duplicate testing.

At first, our physicians were reluctant to use Enterprise Chart because it essentially opens up their whole patient story to all the other physicians on the network. Physicians don’t like to talk about it, but it does open up your standard of care and documentation to ridicule from other providers. It was definitely a hurdle that we had to jump over, but it’s turned into the best part of our operation; without question, our physicians love it.

Q: What lessons learned do you have to share with physicians going into EMR implementations and upgrades?

Everett: You have to have a strong physician. A strong IT leader is also ideal, but a physician champion is essential to an EMR’s success. When I talk to physicians about their EMR utilization, they understand what I’m saying but don’t necessarily take it seriously. They’ll pay attention to a peer as opposed to the IT guy. We have a very strong physician in our organization. He doesn’t agree to things just for the sake of doing them. He thinks everything through, explains to me what he goes through on an ongoing basis, and helps me in conversations with our physician offices. It’s a big deal to have a physician helping you make that connection.

You also have to be honest with each another. That sounds like it would be a normal part of the conversation, but it’s really not. Telling people the truth as opposed to what they want to hear doesn’t help when you’re trying to manage a complex EMR project. For example, one of our physicians, who sees maybe a few CCHCA patients a year, asked me recently if he should sign up for our EMR. I looked at how many patients he saw and realized it wouldn’t make sense for him financially, and it wouldn’t make sense for us financially to include him.

Such honesty did leaps and bounds for my reputation within the community in the sense that people didn’t feel like I was trying to sell them something they don’t need. They understood that I recognized the goals of his practice and our organization. That gave me street cred. Being honest and having a strong physician champion is definitely a way to get past 90% of the problems you have with physician adoption.

Q: Speaking of honesty, why do you think so many pundits are criticizing EMRs?

Everett: Issues of EMR dissatisfaction and ROI are going to change over the next 10 years because oldschool physicians who grew up without computers aren’t going to be practicing anymore. Ego is definitely contributing to these pundits’ reasoning behind saying EMRs aren’t working. They may say, “I’m not seeing as many patients as I used to,” or “I spend more time documenting than I used to.” I counter that with the fact their documentation is now much clearer and more concise than it used to be. Many of them haven’t accepted the fact EMRs are here to stay.

The game is changing whether clinicians want it to or not, and they’re going to have to change with it or face failure. EMRs aren’t an option anymore, and that puts clinicians on the defensive, which in turn cuts down on what could be a really positive user experience. I understand both sides of that coin. I call myself physician friendly but not physician sympathetic.

A lot of these dissatisfied physicians have been practicing medicine for 30 years and don’t believe an EMR will make them more efficient. Physicians just coming out of med school, however, start with no paper on day one. EMR ROI is there for the patient, physician, and medical group.