Article Date: 1/1/2011

The Challenges of EHR Implementation
EHR implementation

The Challenges of EHR Implementation

To make your EHR system a success, avoid these stumbling stones that have befallen other practices.

Jeff Grant, Shell, Wyo.

In any discussion on addressing the challenges of implementing an electronic health records (EHR) system, you should remember three critical points:

► Implementing EHR is a process, not an event.
► There is no one “best way” for implementing EHR that applies to all optometric practices.
► You should learn from the mistakes of others.

It's important to recognize the magnitude of the project you're undertaking. Implementing EHR is a complicated, time-consuming process. This article is meant to help you identify the steps you need to take to make your implementation a success and to help you avoid the stumbling stones that have befallen other practices.

If your EHR implementation project is done well, the benefits of EHR to your practice are huge (e.g. improved efficiency, improved patient care, an improved patient experience, increased revenue, a decrease in costs, etc.)

If your EHR implementation project is done poorly, however, the costs can be catastrophic, as I'll illustrate.

Some studies reveal that 50% of all EHR implementations fail. That may mean these implementations failed completely or simply that they didn't meet the practice's expectations. Either way, the message here is that you need to treat this project with the care and respect it deserves.

The following is a list of the most common reasons for EHR implementation failure:

► No implementation team or plan exists.
► The doctor isn't part of the implementation process.
► There isn't 100% buy-in by the doctor.
► There is no road map, or electronic workflows have not been defined in advance.
► The doctor and staff undergo too little training on the EHR system.
► No plan exists for continuous updates.
► Doctors underestimate the costs of going electronic.
► There is a lack of measureable goals (no milestones or dates set).
► Doctors’ use of EHR was optional at go-live date.
► No written penalty exists for staff non-compliance to the implementation plan.
► IDDUINEM: “If Docs Don't Use It Nothing Else Matters!”

I'm going to touch on a few of these topics and provide you with methods of avoiding these “stumbling stones.”

STONE #1: No implementation team or implementation plan exists.

You need to assemble a team to create a specific implementation plan with a specific time line. The team needs a project manager (usually a clinician, not a low-level employee). Set aside adequate time to both assemble and work with an EHR implementation team. The implementation team might include only two or three people if you run a small practice or a dozen or more people if you operate a large practice.

The team must be able to meet regularly (bi-monthly at first and then weekly) so they can:

1. coordinate pre-implementation decisions.
2. ensure the training program meets the practice's needs.
3. coordinate any software modifications that are necessary to meet the practice's specific needs.
4. ensure that the clinical team has time to practice on the new software.
5. prepare for any other issues in going live.

The implementation team also needs to create an open forum that allows all staff and physicians to voice their concerns and fears about EHR implementation so they can be taken into consideration.

In addition, the team needs to report its progress back to the staff. Some practices develop an implementation team that operates secretively, and the rest of the staff doesn't know what's going on. This leads to fear, uncertainly, and doubt — all of which can lead to EHR implementation failure. As a result, allow your implementation team to hear from everyone, create a positive environment, and get all your staff members excited about the implementation.

As the practice leader, communicate regularly about your expectations.

For example, the medical records clerk probably fears for his/her job once the practice goes “paperless.” Assure this person that the position will still be needed, even though the job description may change (to include scanning internal and external documents, for instance).

The implementation team should also develop a specific timeline that all staff can access/view. Without a specific timeline, your staff will not understand where the practice is in the process of EHR implementation and what is expected of them. Further, no one will know whether they've made acceptable progress with their individual tasks.

Many practices struggle with or don't know whether their implementation is successful because they never defined “success” at the start of the implementation process. They wonder: “Will we be successful when the doctor is fully utilizing EHR?” “Will we be successful when all the doctors in the practice are fully utilizing EHR?” “Will we be successful when the patient volume is back to the 100% level pre-launch?” You have to define what you consider to be a “success” and communicate this to your staff.

I've seen practices that didn't follow any of this advice either: 1) go live without being properly prepared, or 2) let their implementation process linger for months and months, exhausting everyone in the process. These implementations ultimately failed.

An implementation team and the project manager, can't be successful unless they have adequate time and resources.

STONE #2: No doctor involvement in the implementation process.

Not having involvement from the doctor(s) can lead to project disaster. Ultimately, if doctors aren't using the EHR system, even if everyone else can, you will have failed. The reasons: To make your EHR system run smoothly, your staff needs a doctor's perspective on issues related to EHR modifications, patient flow changes and information flow. The worst thing you can do is “go live” on EHR on a Monday morning and have that morning be the first time you or another doctor has seen the EHR system. That might be impossible for you to believe, but it happens. And, when it happens, you end up with a problem “of biblical proportions.”

For instance, one doctor in North Carolina told me that at the end of his second “live” day, his staff was in tears and ready to quit, patients were furious and threatening never to return, and he and his fellow doctors were devastated as a result.

Bring a doctor into the implementation and going back to a point made in “Stone #1,” make sure the doctor, as a member of the implementation team, has adequate time set aside to devote to working with the team.

STONE #3: No analysis of your current work flow and processes in order to re-design or modify those processes for EHR.

EHR is a fundamentally different way of recording medical record information. A common mistake is to pay attention only to the EHR system itself and ignore all the processes that are affected by the EHR application, Translation: Thinking that you can just drop an EHR system into your current processes is a mistake.

So, one of the most important steps in the EHR implementation process (and even after you have implemented EHR) is to consider business processes and the many ways that EHR affects these processes. In many cases, the impact is neither positive nor negative; it simply requires that you consider how your processes need to be modified to accommodate the electronic flow of data.

To accomplish this, conduct a detailed analysis of your current processes. Specifically, pay attention to the steps, actions and sub-processes that you would ordinarily take for granted. You should analyze the flow of data, paper documents and patients. These are all inter-related; ignoring them will lead to an efficient or a sloppy practice.

A caveat: Don't make the mistake of letting your old habits cloud your process analysis, assuming that there must be a good reason why you do what you do, the way you do it. Instead, you should be objective in your analysis and your documentation of current processes.

A good tactic is to actually shadow another doctor's patient visit through the entire practice from check-in to check-out — and do this for a number of different appointment types, such as comprehensive exam, contact lens fitting and glaucoma follow-up.

You want to be detailed in your analysis and document every discrete action or process. Some of the common processes to review include:

► check-in: forms, actions, documents
► hand off from check-in to clinic
► clinical documentation, including:

● pre-test / H & P
● exam itself
● medications
● handling refills
● handling documents that come from outside the practice
► billing/coding/posting of charges and diagnosis
► scheduling
► in-office messaging
► documentation of all patient interactions
► generation of correspondence
► data/patient hand off to optical and/or contact lens staff

Only after your analysis and documentation are complete should you begin to critically review your findings. Look for opportunities for improved efficiency, designing new work flows that could be accomplished with the tools available in the EHR.

For example, how will the transfer of paperless records during each of the patient hand offs (from check-in to clinic and clinic to optical/contact lens staff) improve office efficiency?

Create new processes which take advantage of the things you do well, and incorporate new or altered processes that help improve efficiency and allow you to incorporate electronic data flow. One of your goals should be to handle things once and to input data only once.

Staff will have to do things differently, and it will take time for them to get comfortable. You might even have to make changes to your physical practice to best accommodate EHR and electronic data flow, and you might have to make physical changes in your exam lanes to accommodate computers/monitors.

For example, since the data will now be electronic, you or a scribe will require a computing device to input data, rather than a paper chart. Also, you might need to make computers available in more places and available to personnel who might not have needed their own computer in the past (this is small investment, compared to the efficiency gains). The fact is that reconfiguring business processes, such as the administration and management of electronic patient records, leads to (often dramatic) improvements in efficiency.

STONE #4: No consideration of your hardware options and IT needs.

Many practices make the mistake of buying whatever “cool” hardware they've seen recently. Be careful. The “coolest” new device might work great at home or in the comfort of your private office, but it might be very cumbersome in an exam room.

So, before you purchase a number of new computers, buy one, and test it in the exam lanes to ensure that it meets your needs. Buying one computer and deciding it really doesn't work as well as you thought it would is a lot less painful (and costly) than buying a dozen and then realizing you need a different technology solution.

Something else to keep in mind: Review your current hardware and networking infrastructure to determine whether upgrades are necessary. As important as financial and billing information is to you, electronic medical records are even more important due to medicolegal and ethical concerns.

For example, I've worked with practices that did everything else right but then loaded the new EHR system on their old, out-of-date server. Speed is going to be important, so a relatively modest expense for faster hardware, a faster switch, etc., can provide a return on the investment literally in days.

Some of the things that practices often fail to consider when upgrading their IT infrastructure are:

► redundancy
► privacy and security
► wiring/switches/routers
► backup systems
► location of computers

STONE #5: Too little or incomplete training and practice.

After implementing EHR, I've never had a practice tell me, “You know Jeff, if I had to do this all over again, I wouldn't have had so much training.” For some reason, practices often feel that they are savvy enough users of IT to skimp on the training recommended by the vendor.

I urge you to listen to the software vendor when they recommend training. In almost all cases, vendors’ recommendations are based on their experiences and on their desire to see you succeed.

The other part of this is practice. Some doctors and their staff make the mistake of going live with little or no practice using the EHR system. To avoid this, spend whatever time it takes for you, your fellow doctors, technicians, scribes and administrative staff to be at about 90% proficiency. Use actual patient charts in practice sessions, doing one or more each at the end of each day until you're very comfortable with the flow of the EHR and with being able to quickly locate any data element in the exam.

A cost-effective approach

While the approach I've detailed may appear too costly, cautious or inefficient, I would argue the opposite — it's the most efficient and effective way to implement EHR in the long run. Here's why: Having to start over after a failed launch costs you a massive amount of time, money and lost revenue, so you want to do it right the first time.

All the stumbling stones I've described are 100% avoidable. By using the experiences of others to guide your project, being careful to avoid the “stumbling stones” that have tripped others, and following the methods I've provided for a successful implementation, you can be much more confident that your EHR implementation will be a success. OM

Mr. Grant is founder of HCMA, Inc., which specializes in management, operations and IT consulting for medical practices. E-mail him at, or send your comments to

Optometric Management, Issue: January 2011