Last time I described that when thinking about clinical staff facing the move from paper to an EMR, I find it useful to think of three groups of people and ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

I went on to write about "the Excited:" the younger clinicians who bring computer skills, a positive attitude, energy and impatience to an implementation.  Now comes the group to which I, myself, belonged at the outset of my journey from clinician to EMR implementer.  I call this group the More or Less Willing.

These clinicians are bit older. They still have kids at home, so they are exposed to the contemporary computer world. They use email and shop online. In their professional lives, they have longer tenure at the organization and in their professions. They are used to established roles and methods in their work. This group is computer comfortable.

When facing an EMR implementation, they have an open attitude about the contribution of computers. They understand the advantages of computers in terms of accessibility and legibility. But they also have important concerns. They fear the therapeutic process will become dehumanized. They worry about the loss of authority over the flow and content of their work.  They are concerned about threats to client confidentiality. How about the impact on their time? Maybe they are skeptical about the organization’s capacity to actually pull it off. And more…

The wise implementer will address these concerns. Every stage of the implementation process offers opportunities to woo, communicate, engage and reassure.  I’ll be writing about my experiences, strategies and ideas for each stage.  It just occurred to me that this group is the equivalent of the independent/swing voters and that the crucial goal is to help them to become confident and positive enough to “vote” for and maybe even work for the implementation. Without them, you cannot win.

I’ve been writing about “the clinician” as if this word represents a homogenous group of people. Of course, this generalization is not correct, especially when it comes to individuals facing the move from a paper chart to an electronic medical record.  So I like to divide my one big generalization into three smaller ones.  I find it useful to think of three groups of people and ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

This blog will focus on the third I call “the Excited.”  These clinicians are younger, computer-philes from our modern computer culture.  They are the kids of the organization. (Is my age showing?)  They are newer to their work and not greatly invested in established roles and methods.  They are also newer to the organization, and less identified with the organization’s history and culture.

When facing an EMR implementation, the excited group will probably be – well - excited.  A wise implementer will draw their enthusiasm and knowledge into the implementation effort.  Make sure they are represented in planning groups and tapped to be local champions. I enjoyed a mentoring relationship with two of our up-and-coming clinicians who became great boosters of the EMR in their clinical units.

But, no surprise, with the energy and computer skills comes impatience. These computer-philes are used to interacting with action packed graphics, to intuitively following their bliss through hyperlinks and to expressing themselves extensively on MySpace.  The content of the EHR is structured and controlled through required fields and software procedures.  They need help to be patient with the restrictions of the software.  They need help to see that the content designers are not dolts and to accept that there are legitimate clinical and compliance reasons behind design decisions.

It is the implementer’s job to ensure that these two last statements are correct.

I recently had two useful pieces of information come to me that illustrate my thoughts on achieving user buy-in to an electronic health record.

One was a tip on blogging from our blog host. It introduced me to the acronym WIIFM. The tip reminded us that readers search for and look at blogs, asking, “What’s in it for me?”

The other information was told to me by a nurse turned techie/implementer in a large system with over 10 institutions. She described the implementations in two of their facilities. In one, the implementation focused on creating reports for the needs of the top managers. In the other, the implementation team created reports designed to meet the needs of the clinical staff. For example, they created a shift change document for nurses and a report showing treatment permissions coming up for renewal. She described that in the first facility, the implementation had a difficult time winning over clinicians. In the second facility, the clinicians had a much more positive attitude and the implementation went much more smoothly.

I believe WIIFM is an absolutely legitimate attitude for a CEO, a supervisor, or a clinician using an EMR. After all we’re talking about the relationship of a user to an electronic health record system It may be long-term but it is not an intimate relationship.  WIIFM is OK. So, implementers, ignore it at your peril!

I’d love to hear more stories about where WIIFM fits into your implementation.

Computer Fluency of Users

Do designated users of the e-Prescribing application have basic computer knowledge? Experience has shown that users familiar with using a computer, whether at home or at work, tend to learn the application at a faster rate than those who do not. To accommodate staff members that are not computer-savvy, your e-Prescribing application should have an intuitive, user-friendly interface, and should offer as much consumer-specific data as is possible to the prescribing physician.

Nursing Staff

How many nursing staff will be using the system? What is their receptivity to adopting electronic prescribing? Nurses should be made aware that organizational efficiency may not immediately rise at the point of transition, but over time, e-Prescribing can greatly assist them in a variety of areas, including reducing the number of call-backs from pharmacies, eliminating the need to transcribe medication orders, and improving risk management efforts.

Hardware Setup

Does your organization have adequate computer and printing resources for the project to be successful? There should be a computer available for each prescriber to use during appointments. Computer monitors should be positioned so that it is not necessary for the prescriber to turn his/her back on the consumer to issue a prescription. Also, a printer must be stationed nearby to instantly produce prescriptions or collateral information. Experience tells us that the first thing users will complain about during the introduction of new applications is the hardware (e.g., “The printer doesn’t have ink in it so I can’t use the new program”).

IT Support

Do your information technology leaders and staff endorse the project? Are your IT specialists working on other projects concurrently? The effort required to implement new systems should not be underestimated, especially in a setting that will bring technology to the desktops of all clinic staff. Assignment of adequate internal IT resources is mandatory to assure project success. 

Current Consumers on Medications

How many of your active consumers are on medications? A typical estimate is 60-70% of active charts. Your organization will need to determine the most efficient way to input consumers’ current paper-based medication information into the new system. Many organizations use data entry to do this; but keep in mind that it takes an average of three minutes to enter each consumer’s current medication information.

Pharmacy Communication

Have you let all routinely-used community pharmacies know your organization will begin e-Prescribing?  Notifying pharmacies in advance will reduce the number of phone calls that may originate from inquiries regarding the new prescription formats (e.g., confirming authenticity).

In Conclusion

More and more behavioral health providers are adopting e-Prescribing as technological advancements and government regulations drive the healthcare industry towards wholly automated processes. Early experience indicates that the benefits of e-Prescribing are real, and by far outweigh the risks and costs of implementation. Transitioning to an electronic prescribing system requires a dedicated investment of your organization’s time, money and resources. Good planning and proactive communication with all internal and external stakeholders will help assure a successful implementation, which, in turn, will result in higher quality care for your consumers.

At a workshop a couple of years ago, a behavioral health executive contemplating an EHR implementation asked me, “How can I get my clinicians excited about this implementation?” My short answers are “Be realistic” and “It depends.”

Clinicians have different needs for information and a different relationship to an EHR than executives. Managers need information to lead the organization. I would also add that they do very little of the direct data input, so they get the benefit of the reports without much personal effort.  Not so for the clinicians who, along with support staff, are the main sources of the content being entered into the EHR. So what might get a busy clinician excited about an EMR implementation? Let’s think about this question from the point of view of salaried clinicians in a behavioral health organization.

Such clinicians are not much interested in organization finances, compliance and other executive concerns.  They too want information, but of a very different sort. They want an efficient method to capture relevant client history.  They would appreciate tools that could help them define the treatment and track progress. They need to communicate with themselves and with other staff treating the client both currently and in the future. Approaching these needs will be experienced as helping them do their core job, providing the best care they can for their patients. So far, so good.  Clinicians further need to capture data and document their work to satisfy all the various data masters of the universe, eg payers and accrediting entities. This is experienced as extraneous to their core job. (They feel grumpy about doing it and will feel grumpy about the EHR that ensures they do it.)  And, of course, they want EHR content to be easy to access and navigate.

If you are an implementer, don’t set yourself up for disappointment by expecting clinicians to be excited about the EHR implementation itself. Moving from paper to computer involves lots of changes for clinicians. A well-executed implementation is critical in getting the EHR off on the right foot. Do understand, though, that the long-term success of the EHR you are implementing depends on how well the system you deploy serves the work the clinicians are doing.  It depends on their having ready access to a computer, on the functionality of the software you have chosen, the design of the content, the usefulness of the outputs, the adequacy of the supports.  None of this is magic. Digging down into the details and finding good solutions at the level of the clinicians at their jobs is the work of the implementation.

I’ll write about my experiences and thoughts on these challenges in future blogs.

During this electrifying political season, there is a flurry of attention being given to Electronic Health Records. Nationwide implementation of  EHR’s is a core component of candidate plans to reform the American health care system. The main reasons put forth include to save money, reduce medical errors, avoid redundant testing, identify previously ineffective treatment,  and provide access to current medications from any point of care.   The media is high profiling phrases such as “interoperability,” “RHIO’s” and “Personal Health Record (PHR).”

Adding to the intensity of the EHR discussion, the federal government is proposing penalties for EMR non-adopters. Our largest technology companies, namely Microsoft and Google, are charging into competition to capture the hot property of the PHR.

Some of the enabling technology for these high level goals is in place. Some crucial components are not. What are the providers of healthcare to do? More particularly, how can those contemplating software for behavioral health, addictions, MRDD and public health approach the question of why should they embark on such an undertaking? Here is my thought. To borrow a saying:

Plan globally and for the future………Act locally and for the present

An organization’s top planners must be aware of the national vision and policy trends concerning EHRs. They must be informed about technology trends. Only then can they define their own plans and make decisions. For example, they should not cast their lot with a vendor which cannot demonstrate its ability to lead or at least keep up with technical developments over the long haul.

The person leading an Electronic Medical Record (EMR) implementation must know both the clinical and IT terrains. Since these two sets of knowledge don't ordinarily come in the same individual, who is best prepared to lead the EMR implementation effort, a clinician or a techie? I vote firmly for a clinician. Here's why.

At its heart, an EMR implementation should be a clinical and business processes undertaking, not an IT project. While an EMR crucially depends on technology, the ultimate purpose is to advance the quality and efficiency of care provided by people for people. The essential  knowledge underpinning an EMR is an intuitive grasp of the flow of the clinical enterprise: how to think, what to ask, how to decide, how to plan, execute and document. Next in line of importance is understanding the requirements of the complex business environment of health care. Then comes technical knowledge: how to exploit the rich computer systems toolkit to capture and enhance the flow and requirements.

This is NOT to say that technical knowledge is unimportant. It is essential for an EHR implementer to grasp the core concepts of networks, client-server, databases and reporting. When I began my transition from practicing psychiatrist to EMR implementer, I identified my computer naïveté to be a serious deficiency. So I promptly  enrolled in the introductory computer science course at a local college. I learned about hardware, networks, operating systems, reporting… I even became competent at very basic programming. On my own, I studied databases and taught myself MS ACCESS. I participated in many IT meetings. With focused effort, I learned enough to be an effective member of our IT team. To my surprise I found that computers are great fun – and very useful.  

I have talked with many people embarking on an EHR implementation. I routinely ask, “ Is it easier to teach a clinician the technical side or a techie the clinical side?” The answer is always, “It’s easier to teach the clinician.” What's your vote?

I  began my career in the 70's as a community psychiatrist. I was part of a team out in the field working to engage people with Serious and Persistent Mental Illness. The work was challenging and creative. It demanded a wide scope of thought and action. I loved it. In the late 90's in what seemed a sudden shift, I found myself confined to an office and the managed care driven 20-30 minute med check. I wrote the prescriptions, while others were gifted with out-reach and the therapeutic relationship. I felt cut-off, suffocated. As a community psychiatrist I was a dinosaur, an unhappy one.

Then our CEO suggested that I take on the leadership role in the implementation of the newly purchased electronic medical record (EMR). My response: a startled "Me?!" "Yes, you," he said. "Think about it." As a clinician I focused on the human rather than the technical dimension. Why would I join the dark side of the business managers and number crunchers? I was a novice computer user, how could I lead a computer software implementation? The "Why?" answer is short and simple. I'll tell it now. The "How" answer has many, detailed parts and has to wait for later blogs.

So OK, why? I knew enough of trends in the larger world to be totally convinced that computers in clinical care were inevitable. It followed immediately from this realization, that the urgent call was to make the computer serve the work. Another question emerged: "Who better than a senior clinician to try to make this happen?" I pondered this new question. I acknowledged the importance of the goal. Then before my mind’s eye, the question flipped to "Why not me?" I saw the timeliness of the opportunity. The challenge energized me. Yes, indeed, why not me. It became clear that I must try. I accepted the job. My personal buy-in was complete.