Over the past 10 years, I have expanded my experience with information systems starting out on the inpatient side and then moving into the ambulatory world with my first NextGen implementation. There are similarities between the inpatient and ambulatory worlds with one of the hardest obstacles in both being how to bridge the gap between the focus of IT technicians and that of clinicians, which is on workflow. What is the best way to deliver a product that will not only be a technically easily to use, will enhance patient safety and will increase clinician productivity?

Productivity is a big issue for clinicians. There is usually a significant loss of productivity, a critical component of reimbursement, in the first few months following an EHR implementation. This loss should be discussed and planned for in the EHR implementation process. In many implementations, I have seen physician schedules around the Go-Live trimmed by as much as 30-50%. I’d like to discuss how we can help our clients keep productivity much higher during an EHR implementation by making decisions that help them manage a more robust patient load.

In my opinion, there are two major issues that impact productivity. There is a learning curve as to how long it takes end users to become proficient with new skills and roles. This is impacted partly by the complexity of the software’s related training and partly by end users’ knowledge of general computer skills. An end user who struggles with the basic concepts of right-clicking a mouse is going to have a much more difficult time than a user that grew up in front of a computer. After that, the biggest productivity hit is the amount of abstracting of the historical paper chart that is completed as the organization rolls into an EHR Go-Live.

There are some key steps that not only aid in achieving an increased productivity level at Go-Live, but can also give end users a more thorough electronic patient chart. These will give clinicians more time to spend with a patient on a visit rather than spending “face time” with a patient abstracting meds, problems, allergies, medical/surgical history, etc.

1.    Paper Chart Organization (Chart Summary)
The first important step is to organize the existing paper chart in preparation for abstraction. This process can be put into place before a full project ‘kick off’ even begins. Start by reviewing the chart and collecting key elements such as the patient’s current medications, problems, allergies, med/surg/social history, immunizations and health history onto one legible form. Doing this will greatly decrease the time spent digging through the chart during abstraction. If the office or site you are preparing for Go-Live has a current ‘intake’ form that includes the above items, it is beneficial to transfer this information into a form that is specifically formatted for ease of use in abstracting into NextGen.  Another option I’ve seen used with success is to have the physicians verbally dictate this information and have transcription staff complete the paper form that is placed into the patient chart. Whether it’s completing a summary form or using dictation, this process needs to be clearly communicated to the physicians and monitored for progress. While any trained staff can complete the abstraction into NextGen, it should be the doctors and other providers who complete the chart summaries.

2.    Scanning Decisions
The next step to consider is how much information you want to scan into the system. When you scan a document into the NextGen Image Control System (ICS), it’s attached to the patient’s electronic chart as an image file. You don’t have discrete data. You cannot report or trend on this data. So, how much to scan is an important decision because you have to face the fact that the paper chart is going to go away at some point following the Go-Live. There will be historical items you will want to have access to for review. One option would be to scan in the entire paper chart. This is the least efficient option. Not only is it extremely labor intensive if using current staff time, but it can be expensive to hire a third party to completely scan all the charts in the office or clinic. I’ve heard it reported that less than 30% of the images are ever reviewed after initial scan. Another option is to scan nothing and pull charts as needed. While this would save money, it’s not very efficient when a ‘retired’ chart needs to be pulled from an offsite location to aid in patient care. My recommendation, and where I’ve seen the best outcomes in costs and patient care, is somewhere in the middle but closer to having less information scanned in. Set some guidelines for staff as to what is the minimum and the maximum number of items to be scanned (last set of lab results, last few office visit progress notes, any pertinent consult notes, etc.). Let providers have access to the historical paper chart for the first 2-3 visits with a patient following Go-Live. This gives providers time to decide during a visit which items they referenced and what they know they will want, so they can mark them in the chart for scanning following the visit. Also, remember to stay flexible based on the patient; for example a provider may require a lot more information scanned in for a cancer patient than someone who comes in once a year for a wellness check-up.

3.    Electronic transfer/load pros and cons
Now the decision needs to be made about what electronic information can be loaded from older systems. This could include data from a number of places including a prior EMR/EHR, a practice management system, state registries (specifically regarding immunizations), etc. This is an important decision for many reasons. First, you need to make sure the integrity of the data is solid and you can match patients based on more than just name and date of birth (DOB). You need to make sure you have an experienced database team, and you should do extensive testing before pushing old data into the new system. If completed successfully, this process can be hugely beneficial to your Go-Live. Not only will it save time and costs, but the information pushed in will be discreet data that you can report and trend on. What you want to avoid is moving bad data or data that is not well matched with the patient ID into the new system.

4.    Resources necessary for abstraction
It is important to think about what type of resources you are going to engage to complete the chart abstraction. While I’ve encountered mostly unanimous sentiment that providers/clinicians should be the ones to complete summary of the paper chart, there are multiple views as to what the skill set should be of the  resources who actually abstract the data into NextGen. While it’s beneficial for the office staff to participate in the abstraction process; for an office that sees 30+ patients a day, it’s not practical to expect current staff to be able to handle their regular workload and to abstract all the office charts prior to Go-Live. It’s best to bring in a small group that will focus only on abstraction. Their skill set does not have to be extremely high because no matter what is abstracted into NextGen, the provider is still going to review the information during the first visit following Go-Live, make any changes/additions necessary, and sign off on the chart. Following the 80/20 rule, even if 20% of the information is not entered or possibly entered incorrectly, you are still saving a huge amount of time for your providers at the time of Go-Live. This will not only give your providers extra time to spend with their patients, but also should increase the number of patients that can be seen during the initial weeks following Go-Live.

From the team you put together to the stability of your network and hardware, there are an array of items that all come together for a successful EHR implementation. I hope these steps will help you to implement a solid abstraction strategy prior to Go-Live. This can greatly improve clinician and patient acceptance of a new EHR and increase productivity during the initial weeks following Go-Live.

To learn more about how Santa Rosa Consulting can assist you with a successful EHR implementation, email us at contactus@santarosaconsulting.com.