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AAOS Now

Published 11/1/2009
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William J. Mallon, MD

Are you ready for HITECH?

By William J. Mallon, MD

Tips on making the transition to EMRs

According to a national survey of physicians in 2008, only 4 percent of practices had a “fully functioning” electronic medical record (EMR) system, and 13 percent had a “basic system.” But that’s about to change.

Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, medical practices must make the transition to using an EMR system under a timeline that begins in 2011 and concludes in 2015. Failure to meet the published timelines will result in payment reductions from any government payor.

But how do you choose which EMR is best for your practice? And once you’ve made a decision, how should your practice begin the transition?

Selecting a system
The AAOS Primer on Electronic Medical Records, developed in 2007, is currently being updated and will be available at the 2010 Annual Meeting in New Orleans. The 2007 version, however, is still available online and contains a great deal of information on EMR systems, including implementation recommendations.

The Primer provides guidance on how to develop a request for proposal (RFP) for vendors, a list of questions to ask, and an evaluation form. Once you’ve completed your evaluation of the various systems available for orthopaedic practices and made your selection, the next step is managing the implementation process. Typically, the vendor will deliver and set up the system and conduct a training program for your physicians and staff.

Be certain that your vendor is prepared to provide a customized training program, tailored to meet your office’s specific needs. The remainder of this article describes elements of an effective training program.

Step 1: Know your audience
For a customized EMR training program to be successful, you (and the vendor) must have a thorough understanding of the personalities and technical skills of the persons who will be receiving training. Most practices will have a range of people in both of these arenas; some trainees will be gung-ho and tech savvy, others will be uninformed and resistant to change.

Start with a short survey of your practice physicians and staff. (See “Sample EMR implementation survey on page 37.)The survey responses will enable you to determine your users’ training needs.

Step 2: Work with your vendor
Include a requirement for a customized training program in your RFP. Do not agree to any proposal that provides only a standardized training program and offers training sessions of minimal length. The typical 4- to 8-hour training session will not produce the results needed for successful implementation of an EMR system.

Develop a training program with multiple stages to allow time for learning and practice, then more learning, followed by additional practice. Practices that want to implement EMRs quickly to qualify for maximum Medicare or Medicaid incentives must devote significant internal resources to education and training.

Under HITECH, $44,000 in incentives per physician over 5 years is available for practices to implement an EMR and meet meaningful use standards. In some rural areas, up to $65,000 is available. Incentive payments will begin in 2011, and physicians who do not meet the “meaningful use” requirements will see their Medicare payments reduced.

“Meaningful use” seems to be a moving target, however, lacking a strict definition. (See “The meaning of meaningful use” on page 39.) To gain the maximum incentives, you will need to work with your vendor to develop a customized training program.

Step 3: Take the time needed
A five-physician orthopaedic practice will invest more than $200,000 in an EMR system. At that price, you will want some assurance of achieving a successful implementation. Because physicians are often resistant to investing the 16 to 20 hours of training required for successful implementation, you will need a strategy for overcoming their objections.

Training should be divided into two parts: before the go-live date and on the day of system implementation. For the first part, consider a 2-day intensive training program with hands-on activities. Create patient scenarios for the training, based on a typical day in your practice. Be sure to include scenarios involving new patients, returning patients with the same problem, and returning patients with a new problem.

Work with your nursing and practice administration staff to identify various patient types.

The training on the day of system implementation is critically important. Ideally, your vendor should provide staff who will work onsite in your offices, assisting your physicians and other healthcare providers. The first day is the most difficult with any new system, so include this requirement in your RFP. You should also ask if vendor support will be available for several days during the implementation process.

Plan ahead because schedules will need to be reduced as the system is rolled out. Because taking time for training will cut into the clinical day, practice revenues may be affected. This may add to the indirect costs of implementing EMRin your practice.

Step 4: Training
Your training program should cover the following topics:

  1. General system overview
  2. Specific system features
  3. Hands-on training using patient scenarios
  4. Independent learning with instructors available for questions
  5. Mock go-live event without instructors
  6. Remedial training

The mock event will help you identify training gaps and any individuals who need additional one-on-one training. Family members or other volunteers may pose as patients with typical orthopaedic conditions.

The training program will also help you identify changes that need to be made in practice processes. Training will help you determine whether your practice is well-organized to deal with using an EMR system effectively. Typically, well-organized physicians adopting EMR technology may actually improve process, but those who are poorly organized may find it difficult to adopt EMR technology.

Having one or more physician champeons drive the process can facilitate successful implementation. An EMR system doesn’t just replace the paper chart; it will change your practice processes, patient interaction and communication, and patient documentation.

Step 5: Keep communicating
If you have multiple practice sites, consider rolling out the EMR system in stages to manage implementation. Develop a set of practice expectations based on input from all practice physicians, other healthcare providers, and office staff. You want everyone to buy in to this new way of practicing, which will become a necessity in the future.

As you move through this entire process from evaluation to RFP to selection to training and implementation, be sure to communicate, communicate, and communicate. Create a detailed communications program reporting on each step in this process. A newsletter might facilitate your communication effort.

The use of EMR systems in our practices will soon become a reality, despite any objections your doctors may have. Failure to start planning now could affect your practice’s bottom line significantly in a few years. The first incentives and penalties begin in 2011, so don’t delay.

William J. Mallon, MD, is a member of the AAOS Board of Directors’ Project Team on Electronic Medical Records. He can be reached at bill1729@gmail.com

The meaning of “meaningful use”
In the HITECH Act, the term “meaningful use” of EMR systems is quite important. The Centers for Medicare & Medicaid Services is currently preparing a definition of “meaningful use.”

The AAOS Project Team on EMRs is developing a set of recommended standards for orthopaedic surgeons that should be included in any “meaningful use” definition for the Office of Health Information Technology. The project team is also attempting to exempt orthopaedic practices from some standards that are principally aimed at primary care practices and have little relevance to orthopaedic care.

Regardless of what standards are finally adopted, when looking at vendors, you should mandate in your RFP that the vendor’s products fulfill the government’s “meaningful use” standards, when they are published.