EHR User Series—Part IV

Can you take us through the beginning stages of implementing your EHR and the challenges of adjusting to it?

Initially it was a huge challenge, as is any change. There is so much that goes into the implementation of an EHR at the early stages, including purchasing servers and equipment and hiring an IT person, both of which we had very little experience with in our practice until that point. Then, in addition to finding a more reliable internet provider, we had to get the EHR company and the company that sold us the servers in sync, which took a great deal of coordination. Once those elements were in place, we got into the more logistical details, such as purchasing tablets versus laptops and wiring each room for the equipment.

Once the system was in place, one of the most significant difficulties of the early stages of our EHR was training staff. Not all staff members were fluent with computers, so we had to teach them not only the EHR but also certain functions of the computer. However, after about three months we overcame many of these challenges, and things started making more sense. Roughly from about the three-month point on, it got easier by the day, not just for providers, but everyone else involved including the front desk, billing staff, and even patients.

How has having an EHR changed the way you practice?

Our EHR has changed the workflow of everyone within the practice. After the initial few months, provider efficiency has increased, but we have more support staff now than we did prior to having the EHR. Patient flow took a dip early on, due to learning the new system. Therefore, some practices may need to add more help at the front desk. However, we found that after about three to four months we started seeing the same number of patients as we did before.

Potentially needing more staff members to achieve the same effect is an unsettling reality, and it is just one of the potential drawbacks of EHRs. Another major aspect of EHRs is that they remove some element of control. In the electronic world, you are more dependent on your Internet provider, IT person, and EHR provider than you might wish to be. For example, if you’re using a server-based program and your server goes down, you may not be able to access any of your records for two to three days, which results in greater costs, frustration, and devastation for your practice. Thus, you and your practice are essentially at the mercy of the IT person. If there is a glitch or something wrong with the software, you are dependent on the company to offer assistance in getting your practice up and running again. In addition, if you’re using a cloud-based program, you’re dependent on your Internet provider. You won’t have access to your records if your Internet connection is down.

Can you reflect on other differences between paper-based charts versus electronic charts?

Given the obstacles of implementing an EHR, it’s tempting to see the electronic transition in a negative light. I have learned, though, that electronic is not better or worse than paper-based charts—just different. There is certainly a beauty to the simplicity of paper-based practice and not having to deal with ongoing frustrations of rewiring (physically and figuratively) your practice, but it’s worth noting that paper-based medicine has limitations, too. Sometimes a chart is misplaced or missing, or paperwork within the chart can be misplaced in charts. Sometimes illegible documentation from other physicians made charts nearly impossible to read. These might seem like minor problems, but over time they add up. One benefit of the electronic world is that information is more organized and accessible, potentially enabling better communication in individual practices and in the broader spectrum of the healthcare system. In my opinion, EHRs have in some ways contributed to better patient care since many things that were previously time-consuming are now automated, i.e. generating letters to a referring doctor or the patient’s primary physician, checklists and reminders for labs, etc. I also think e-prescribing allows us to monitor and track patient prescription use a lot better, resulting in better patient care. While there may be a tendency among some clinicians to romanticize the days of paper, change is difficult regardless of what we’re changing to.

Can you discuss aspects of your specific EHR?

I use Encite in my practice and have been very happy with it. What impresses me most about Encite is its versatility and adaptability to many different aspects of a practice. We have two offices with four different providers and all of us use the program differently. Encite is just the kind of fluid program a practice like ours requires. It offers easy-to-use medical, surgical, cosmetic, laser, Mohs, dermatopathology, e-prescribing, and other sections, as well as an effective integrated practice management software, all of which are relatively easy to learn and use. It also allows for easy and quick customization on your own without having to consult or wait for the company to make changes. Pictures and electronic consents integrate into the chart seamlessly without scanning or wasting paper. Having these different modules in one system is much easier than using many different programs to accomplish this. The company regularly updates the software and adds new features based on feedback they get from users, which is a definite plus. Although finding an IT person who’s able to work with the software was initially difficult, we eventually found someone who works very well within the system.

The main drawback of Encite, in my experience, has been adapting to it as well as training staff. However, we have found that it is better to introduce the system slowly to staff, allowing members to learn one aspect at a time instead of asking them to learn everything at once. Have them walk before they run: Teach them one step at a time every one to two weeks. With a larger staff and different providers in our practice, everyone had to learn different styles of using the software, so there has definitely been a learning curve. Other drawbacks of Encite include lack of an inventory-tracking module, patient portal, and smart images, but my understanding is that the patient portal and inventory tracker are in the works and should be released soon. In addition, the automated coding module usually results in upcoding so we manually code but the codes are released automatically from the EHR to the PM.

I have interacted with Encite regarding these and other minor drawbacks, and I am pleased that they have been very receptive to my feedback and are actively working on improving different program features. In addition, while major problems have been infrequent, it bears mentioning that whenever I have encountered a problem, Encite has been responsive and helpful in resolving it.

What would be your advice to colleagues regarding the selection and implementation of an EHR?

The most important thing is to do your homework before you adopt an EHR. Ask as many questions of the company as you can prior to investing. Obviously, the EHR companies themselves are only going to tell you the great things about their programs. That’s why it is so important to talk with fellow physicians who have real-time experience using EHRs in their practices. These dialogues will allow you to gain a better understanding of the problems you may encounter with an EHR, as well as the tech support a company offers, and various other details of what it’s like to use an EHR in action.

How a company deals with problems is key. Try to find out how responsive and quick the company is when problems occur. When you’re speaking with physicians or representatives from EHR companies, learn as much as you can about emergency protocols and what happens when servers go down, and whether problems with the EHR are due more to issues with company, servers, or internet connections, etc. When you are shopping for an EHR, you want to find one that fits well into your practice, but you also want to make sure it does the things you want it to do and with as little downtime as possible.

The issue of cloud-based servers versus in-house servers varies based on the needs of individual practices. In our practice, where our servers are based in our offices, we’ve been with the same IT company coming on two years now and we haven’t had any downtime. The servers haven’t crashed and our IT person regularly maintains servers, so we are not dependent on an Internet provider. However, each practice is different. A small, single practice is going to have different needs than larger practices with multiple locations. Thus, I recommend doing the necessary legwork to find out what works best for you and your co-workers and see what other practices similar to yours have done.

Once you’ve decided on a program, do not change your PM and EM systems at the same time. Go live with the PM, then introduce the EMR four to 12 weeks later. I don’t recommend scanning your paper charts from day one; instead scan charts as patients return so you spread the work over months to years. When you do start using the EMR, I recommend having an assistant in the room with you so you can talk while they type. I recommend doing minimal customization initially until you’ve used the program for at least three months. The program comes with everything you need, you just need to be patient while you and your staff learn where the buttons are and how to use them. Try to refrain from adding new buttons because you’ll be surprised at how well thought out some of the items are, it’s hard to appreciate when you start using the program.

In the end, I’ve found that doctor-to-doctor conversations are essential for all of us to learn about EHRs. Ask your EHRusing colleagues about everything they like and dislike about their EHRs. Visit their offices to see the programs in action. You’ll never find the perfect EHR, but the key is to identify a company you are comfortable with, that fits for your practice, and is responsive to your needs.

Payam Saadat, MD is in private practice in Los Angeles and Burbank, CA.