EMR Success Factors
Make the move to an electronic medical record (EMR) system and you’ll wonder how you ever worked without it. That’s the overarching message that comes from a research-based series of 20 case studies sponsored by the Canadian Medical Association and Infoway. Patients and their care teams — including physicians, nurses, office administrators — all see the benefits EMRs bring to the delivery of health care, making it better, and making the business of health care easier. Getting there, however, is a little harder.
A significant focus of the case studies research was on success factors. What is needed to successfully integrate an EMR system into a clinical practice? What do you have to do? How should you do it?
In studying 20 diverse clinics across Canada, from project inception to execution, it is clear that there are factors common to every successful EMR system implementation. Here are five such factors:
- Leadership and Commitment
- Funding
- Change Management
- Payment and Practice Model
- Collaborative Culture
Leadership and Commitment
Every EMR system implementation needs a champion. In each case study there was at least one person who not only thought an EMR system was the way to go, but also insisted on it. The fact is there are a number of barriers to EMR system implementation that can only be overcome with leadership and commitment.
Clinical practices tend to stick with routine. Without someone pushing for innovation, pushing for a better way of doing things, there won’t be any change.
Not everyone likes and embraces technology; quite often people resist it, even in a technology-driven field like health care. You need someone to step up and show colleagues how the new system will function, how simple it will be to work, and how much easier it will make daily tasks.
If it ain’t broke, don’t fix it. That attitude has always been a big barrier to EMR adoption. Without someone to point out clearly and forcefully that electronic medical record keeping makes more sense for both providers and patients, there will always be people content to stay with paper records.
Case in Point
The Family Health Clinic in Calgary began using an EMR system in 2002. Today, the clinic’s eight physicians, rheumatologist, clinic manager and several office staff report the move has simplified office workflow, improved office communication and made it easier to provide quality care and patient education.
The adoption of an EMR system was the brainchild of Dr. Norman Yee. Dr. Yee had both a deep interest in information technology and a background in business, and he understood the importance of increased efficiency and improved service.
Without Dr. Yee’s leadership, the Family Health Clinic’s EMR system implementation would almost certainly not have happened. He drove the project from the beginning, convincing his colleagues and staff that an EMR was the way to go, and helping them through the process at every step. He ensured that a change management plan was in place, helped create a budget for the project, and suggested the hiring of a clinic manager with the business and organizational management experience needed to help guide them through.
You need somebody who will take charge, provide the vision, provide the ongoing business case, and provide the ongoing champion. That’s how it gets done. It’s very much a pull, and often a push. Left to their own devices, groups will not move.
Dr. Norman Yee, Family Physician
Funding
Along with having a champion, clinics moving to an EMR system need money. There is no way around it: computers, hardware, software and technical support all require significant investment and ongoing maintenance.
While the initial investment into an EMR system can prove to be a costly undertaking, the return can be felt in the long term through productivity increases and workflow efficiencies. Most importantly, no dollar figure can be placed on having information available to you when you need it to make the best patient care decisions.
The case studies indicate physicians are willing to bear some of the expense of an EMR system, both for the sake of their patients and their practices, but that a cost-sharing arrangement with government is almost always a necessary component.
Case in Point
The Raymond Medical Clinic in Raymond, Alberta, moved from paper records to EMRs in 2004. The team was looking for faster access to important information and saw the EMR system as the way to get it.
Dr. Clayne Steed, his three physician colleagues and nine staff found the transition to an EMR system to be largely problem free, and feel they are now delivering better care thanks to improved and more efficient handling of information.
To assist with the cost of introducing the EMR system, the clinic obtained funding from Alberta’s Physician Office System Program. That funding, combined with the clinic’s own investment, was enough to get an EMR system the team feels has improved the services they can offer their patients – and that is a great return on their investment.
The cost-benefit balance is that it’s worth every penny. Whatever hassles we may have experienced...we’ve probably had some blips, but none of them were a significant enough obstacle to justify changing our mind. No way.
Dr. Clayne Steed, Family Physician
Change Management
The move to EMRs is a big one. No question. It involves doing a great many things in ways you’re not used to. It means installing new equipment. It means learning to use it. Above all, it means becoming accustomed to the fact that your job description — and how you do your work — has suddenly changed. For the move to EMRs to be successful, you need to have a change management plan in place, one that adapts the workflow of the clinic not only to accommodate, but also to leverage, the EMR system to everyone’s advantage.
This could mean, for instance, looking at any number of regular processes involving several specific steps when dealing with paper, and realizing that with the EMR system several of the steps could be eliminated and others changed.
Something as simple as the placement of a printer can have a significant impact on efficiency and atmosphere in a clinic. If you don’t think carefully about it in advance, you will more than likely install the printer in a place that some may find inconvenient.
The new equipment that has appeared in your office can make your life much easier if you know how to use it. By the same token, if you don’t, it can make life frustrating and miserable. To avoid that, you need training at the outset and technical support on an ongoing basis. And finally, you have to be prepared for changing staff roles and allow time for staff to adapt to new, and temporarily, unfamiliar jobs.
The changes needed will vary from clinic to clinic however, the case studies clearly demonstrate that a good change management plan will greatly ease the transition from paper to an EMR. Those clinics that carefully review their work practices and workflow, before getting an EMR system will find the entire process much easier.
Case in Point
The Great Slave Medical House in Yellowknife implemented an EMR system in 2005. The clinic employs six physicians, several nurses and nurse practitioners, a mental health specialist, a community outreach worker and medical office assistants.
Great Slave Medical House provides its services in a remote setting, and coordinating information across multiple sites and care providers is critical. The EMR system has been a huge success in this regard, but there was a steep and difficult learning curve.
Initially, the clinic did not put a change management plan in place. However, it soon became obvious that workflow changes would have to be made. Once that happened, the transition became much easier. Gail Morse, a Medical Office Assistant at the clinic, says adjusting workflow is critical to managing a change over to EMRs.
Some people don’t do this, and then they lose functionality. They lose everything that the EMR can do for them, and it becomes an expensive filing cabinet. I’m so passionate about that because we realized it on day one.
Gail Morse, Medical Office Assistant
Collaborative Culture
An EMR system is a tool for enhancing the efficiency of health care delivery by improving health care interactions within a patient-centred interdisciplinary approach (e.g. physician to patient; physician to physician; physician to pharmacist). It encourages many forms of online partnerships to support patient care. It should come as no surprise then that a key factor in the success of EMR system implementation is collaboration.
The case studies show the clinics with the most team spirit, those most willing to approach EMR system implementation with a sense of enthusiasm and cooperation, were the clinics where the transition was the smoothest.
Case in Point
Central Interior Health Services is a multidisciplinary clinic located in downtown Prince George, British Columbia. The clinic implemented an EMR system in 1996. In 2003, with the introduction of a primary health care coordinator, the clinic became a showcase on how an EMR sytem can be used to support not only physicians’ work but also the work of nurses and other health care providers and community workers.
Today full spectrum and coordinated care is being provided by the clinic’s four physicians, three medical office assistants, two nurses, two social workers, one nurse practitioner, one Aboriginal support worker, one addictions worker, one office administrator and one primary health care coordinator.
The fact that all members of the team use it is very useful, especially because many clients have a variety of health issues – some are medical and some are more to do with their social circumstances, their addictions, whatever. We all need to be aware of and deal with all that, regardless of our particular focus. So it’s great to have this information in one record…
Primary health care coordinator, Central Interior Native Health Services
Payment and Practice Model
EMR efficiencies help support appropriate health services, reducing duplicate tests and patient visits. Care is focused on patient needs, moving to proactive rather than reactive care. In response to this, research in other jurisdictions, such as the United States, has indicated the benefits of EMRs are better realized in health care systems where the payment model tends more towards capitation or rostering than fee-for service.
That’s because, in a capitation model, the organization would take in the same amount of money regardless of the number of services delivered. It was notable that many of the case studies do not operate in a full fee-for-service model. Some use a blended model of capitation and incentive payments, while others are simply salaried.
Case in Point
The Willowdale Family Practice adopted an EMR in 2006. The physician leader on this project saw the EMR as a means of increasing efficiency in almost every aspect of her clinic’s operations. What she has found is that efficiency in patient care is a benefit to her patients, and the physicians treating them.
The biggest benefit for me: efficiency...I’m a Family Health Network doctor, so I get paid per roster patient. I don’t get paid for a visit. It really pays me to do everything I can in one visit and to make sure patients are managed whether I do it by phone, by nurse or by email. This blend of capitation, I think, is a good fit for the EMR.
Family physician, Willowdale Family Practice