In our small nephrology practice, we started using an electronic health record (EHR) and separate practice management/scheduling suite when we opened our doors six years ago. We changed practice management suites about four years ago and migrated to a new EHR system about two years ago. Both transitions, along with other related experiences, have demonstrated a number of lessons for any practice — nephrology or otherwise.
- Understanding your workflow is the key to understanding your needs. When evaluating EHRs, it is imperative that each physician knows what data is needed, how that data is gathered and validated, and how the data is utilized and reported out for each clinical activity the EHR documents — from new patient visits to the review and filing of external patient data. Then, evaluating an EHR can be an exercise in how well the software being demonstrated matches the practice’s workflows. More importantly, the software’s limitations and necessary workflow alterations will also become obvious. For example, we reviewed about four EHRs in depth when we decided to change software after looking at a total of nine software packages. We rejected a number of the EHR platforms simply because of the way in which lab data was handled — the deviations from our current lab workflows were just too great. As nephrologists, one core element of our practice is ensuring a timely, multi-tiered approach to obtaining, reviewing, and acting upon lab data. Asking the EHR representatives to demonstrate the steps needed to complete our most common office tasks made it easier to compare EHRs and identify options that would least disrupt our workflows.
- There are no perfect electronic health record systems. How a physician gathers, organizes, and utilizes data varies greatly. The best one can hope for is that whatever EHR system is implemented, the user interface and templates are flexible enough to meet the needs of a majority of a practice’s users. An EHR’s flexibility often manifests as customizable views of data (think user-made views of lab or other information), easily generated custom reports, and user-made, editable templates for personalized data capture and review. However, the question, more often than not, is “What trade-offs does a user face when employing an EHR?” You must get your team to accept that every user will need to relearn the basic steps necessary to complete familiar tasks, and will likely have to adapt some of their workflows to the EHR being used. For instance, we have had to revamp some of the steps in our handling of lab data to reflect the fact that some data is sent directly into our EHR and some is still received via fax or paper. The downstream effect of this has been an alteration in how the physicians are notified of the need to review and document about incoming patient lab data.
- Training needs to be focused on the specific data to be gathered. There is increasing tension between the need for discrete data entry (entering specific pieces of data in specific fields) versus narrative exposition in the electronic medical chart. Whether the goal is to report data for incentive programs, research, or internal benchmarking, practices must spend time and attention to ensure the data is consistently gathered, entered in the correct locations, and validated. Understanding and focusing training efforts toward what data is necessary in which fields is key for successful aggregation and reporting of this data. I know our practice’s efforts at collecting and reporting data for stage I of the Meaningful Use program were successful only when we understood how and from which fields our EHR calculated the various metrics.
- Interfaces (the connection between data systems to share data) are the weakest link of the EHR world. Invariably the need to import and export data from a chosen EHR will enhance the usefulness beyond being an electronic form of paper documentation. These most often come in the form of sending lab orders out from and receiving lab data into your EHR. Connections for other data types, including radiology reports, hospital dictations, or pathology reports could be established. Unfortunately, there are too few experts who can effectively connect disparate data systems and too many data systems to connect. Expect a three- to nine-month wait for successful one- or two-way data exchange with the most common lab and radiology systems (LabCorp, Quest, etc.) and maybe longer for hospital systems or smaller service providers. If a secure virtual private network (VPN) or other secure connection is needed, additional local support may be required to interact with your vendor’s interface management team. I know, for our practice, the successful integration of our practice management system with our EHR (ensuring bi-directional communication of appointment and billing data) was expensive and took numerous conference calls and emails over about six months.
- Having local IT support and advice is key. The trend for software is clearly the application service provider (ASP) model, where a practice logs in, usually via web browser, to a remotely hosted EHR. While this makes sense for security, data protection, and to ease multi-platform, multi-location delivery for the EHR vendors, the hardware, installed software (like Microsoft Office or QuickBooks) and operating systems used to access the EHR software still need to be attended to. Finding the right local IT support that balances responsiveness, cost, and the willingness to engage in the troubleshooting of hardware and multiple software products can overcome the “not my software’s fault” answers we often get from our phone-only support. More importantly, getting advice from someone who keeps up with the wide range of fast-moving issues in the IT field can be invaluable. Knowing the latest quirks or issues with an automatic update to Windows operating system or which brand of wireless network router is least problematic can save hours of frustration and down time.
It seems to me that nephrology, and healthcare in general, is increasingly becoming synonymous with data management. I think it is safe to predict that the whole set of goods, services, and policies related to IT systems, the center of which is the office EHR, will increasingly become a focus for physicians and office managers.
Adam Weinstein, MD is a nephrologist in Easton, Maryland. He completed medical school, an internal medicine residency, and a nephrology fellowship at the University of Maryland School of Medicine. Dr. Weinstein and Dr. Anish Hinduja opened The Kidney Health Center of Maryland, PA upon completing their fellowship in July 2006. Dr. Weinstein serves as a member of the RPA Board of Directors.