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Published 11/1/2018
Douglas W. Lundy, MD, MBA, FAOA; Jeffrey M. Goldberg, PT, CMPE

MACRA-compliant EHR Implementation Can Challenge Even the Best Practices

In 2016, the leadership at Resurgens Orthopaedics determined that the electronic health record (EHR) system we were using in our practice was suboptimal in engaging and complying with Medicare Access and CHIP Reauthorization Act (MACRA) requirements. We decided to undergo the exhaustive process of analyzing every EHR available to find the best product for our physicians and employees, and in 2017, we went “live” with our new platform.

It had been more than 10 years since our practice deployed a new EHR system, and the transition was unbelievably stressful. We had previously undergone an EHR implementation at our practice, which prepared us for some of the challenges. However, this time, we were responsible for the conversion, making it an entirely different experience. A senior partner at our practice offered sage advice: “As copresident of our group, you will never switch EHR systems more than once.” We couldn’t agree more.

Here, we offer insight into what went wrong, what went right, and how to successfully implement a new EHR system of your own.

What we did right

We did our due diligence in evaluating the different EHR systems, which proved to be important. We selected the best existing system for our practice, despite second-guessing our decision when implementation struggles arose. Leaders should emphasize to their organizations why a change is necessary and why a new system was selected. Optimism is an important trait for an effective leader, and reiterating the clear facts that outline the benefits of an EHR conversion can help move the process forward.

We participated in multiple demonstrations of the final slate of selected systems, along with internal stakeholders and content experts. Many of these complex systems integrate the electronic record with the practice management system; therefore, we recommend having your revenue-cycle employees present and engaged during this process. We also made several site visits to orthopaedic practices currently utilizing the systems we were considering to gain feedback from real-time users. Getting input from trusted colleagues at other practices was the key to receiving unvarnished truth about their EHR experiences.

In addition, we established a comprehensive implementation team from our practice, and we hired a project manager. An implementation process will be extensively more disruptive and time-consuming than expected and can get in the way of our ultimate purpose: patient care. Medium or large practices cannot expect full-time employees with multiple responsibilities to add project manager to their list of duties. We recommend hiring someone whose sole job is to oversee this process.

We tested the EHR system extensively before the launch to identify areas of concern and to preempt any issues that could arise. Although you cannot mirror the actual impact of the go-live experience, it is important to test the system and train your employees on the new system thoroughly. New EHR systems demand different physician and staff workflows. Physicians and staff should identify the pain points in the new system during testing, because the impact of these issues on go-live are substantial. You also should have a central go-live command center that is ultimately responsible for communication throughout the organization. Although this is well known from an academic and common-sense standpoint, the actual implementation of this process is far more challenging than it seems.

The varying departments and groups in our practice collaborated extremely well during this period. The resilience and optimism of our staff were amazing and reaffirmed our status as an annual Top Workplace in Atlanta, according to The Atlanta Journal-Constitution. We hired the right people, and they stepped up to the task. They deserve the credit for our success.

What we could have done better

Although vendor advice and guidance concerning implementation were valid and integral to our success, we felt that the vendor training was inadequate. A vendor’s standard cookie-cutter approach to implementation may not work well for your practice for a variety of reasons. Although vendors implement their systems frequently, they do not know your practice or staff like you do. Workflows differ greatly among physician groups, and a one-size-fits-all approach will add stress during implementation. In retrospect, we should have demanded more customized prelaunch training.

Gaining and maintaining physician buy-in are among the biggest challenges during the conversion process. Although we focused on the benefits and necessity of the conversion, the impact on our physicians’ workflows and enjoyment of their work was significant. It is important that physician leaders throughout the organization encourage the process. Unfortunately, we did not use physician champions as well as we could have.

Lastly, it is important to focus on communication throughout the implementation process. We believed that we over-communicated during the conversion process, but some departments in our organization did not agree. Our practice has 102 orthopaedic surgeons and physiatrists and nearly 1,000 employees covering 23 locations. In an organization that large, it is not surprising that some felt that communication was lacking. We realize we could have done more.

Tips for success

During conversion to a new EHR system, it is important to emphasize training and practice during the testing phase—you’ll need it much more than you think. Realize that although everyone knows that the process will be disruptive, the impact at the local level can be significant. And interfacing with third-party vendors can take much longer than projected, so start early. Lastly, communicate until you think you’ve overdone it, and then communicate more. Do everything you can to make the conversion the right one. You will not want to do it again any time soon, so it’s imperative that it is done correctly the first time.

Douglas W. Lundy, MD, MBA, FAOA, is copresident of Resurgens Orthopaedics and a member of the AAOS Now Editorial Board.

Jeffrey M. Goldberg, PT, CMPE, is a physical therapist and chief operations officer of Resurgens Orthopaedics. He is a certified medical practice executive and president of the Georgia Association of Orthopaedic Executives.