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Overcoming resistance: Towards the Electronic Patient Record conference
■ Deciding what information technology software to buy could be easier than getting your practice to use it. Experts offer some advice.
- WITH THIS STORY:
- » Avoiding failure
- » Making the right choice
- » Lessons learned from the field
Mark Fracasso, MD, a gynecologist in Alexandria, Va., can tell you that his two-doctor office is proof that not every physician, even in the same office, uses information technology to its fullest extent.
Dr. Fracasso said he uses electronic prescribing technology to handle 80% of all the prescriptions he writes, putting the other 20% on paper because of patient preferences. Meanwhile, his practice partner usually uses the technology only for refills.
"I just want to emphasize that just because one physician is interested in using [technology], it doesn't mean that the other will do it." Dr. Fracasso said. "That's going to happen but it's not going to happen right away."
Dr. Fracasso made his remarks at the recent Towards the Electronic Patient Record conference at the Baltimore Convention Center, where about 3,000 physicians, physician office managers, consultants and vendors gathered. They were there, in part, to brainstorm for answers to the question: How do you make sure physicians are getting the most out of their technology?
The broad answer is that physicians must prepare themselves and their staffs well before the purchase of a system for changes, both positive and negative, that will occur with the implementation of new information technology. A theme that ran through many of the educational sessions was that, as difficult as it is for physicians in small practices to drop $20,000 to $30,000 for electronic medical records software, writing the check is actually the easiest part of automating a doctor's clinical practice. The tough part is getting everyone in a practice to use the technology, considering physician and staff resistance not only to the new system but also to changes to the day-to-day routine that system brings.
It's not unheard of for a practice to go through the costly process of deinstalling their EMRs down the road -- junking the system after staff members have stopped using it -- according to some physicians who spoke at TEPR, held in mid-May. With advance preparation, the chances a system will fail or merely be underused go down significantly, experts said.
"A lot of times you see offices trying to put in computers when they don't know what they are doing to start with," said Allen Wenner, MD, a family physician in Lexington, S.C., and a vice president of clinical applications for Columbia, S.C.-based Primetime Medical Software. "That's why education is so important. I recommend a minimum of 50 hours of CME in [medical informatics] before a physician even considers looking at buying an EMR."
That instills confidence in physicians that they made the right decision to get an EMR and makes them stick with it when problems inevitably arise, Dr. Wenner said. "They think they can just write a check like they would for a practice management system and as a result, we see a disaster and we see resistance because they are going to tell all their friends about how much they spent for a system that [they think] doesn't work."
John C. Joe, MD, MPH, assistant medical director of information services at Texas Children's Hospital and medical informatics specialist at the NASA Johnson Space Center in Houston, said many doctors think that EMRs should reflect how they work. But Dr. Joe said that mentality is wrong because "most clinics have flaws in their processes, and if you don't identify and fix those first, we have two pitfalls."
"One is that you automate a faulty process and do the wrong thing faster in the EMR. The other thing, which can potentially be worse, is that you don't identify a faulty process, and then when you automate and people run into problems, they start blaming the software rather than the flaw that existed before."
To successfully implement and use an EMR, physicians must figure out all their and their employees' workflows before buying a system, Dr. Joe said. To identify workflow processes that have to be redesigned, outside experts can offer an objective evaluation, he said.
Small practices also can educate themselves about EMRs by arranging for medical schools to send a medical student to spend the summer helping them understand, implement and use EMRs in exchange for the student seeing how doctors work, Dr. Wenner said."It's wonderful for the student because he gets to see how [doctors] practice medicine and gets to understand the workflow. The older physicians get to learn from the medical student the techniques of information management that only a medical student or other physician could teach," Dr. Wenner said.
For a practice to implement an EMR successfully, both the lead physician and office manager must be on board from the get-go, said Michael C. Tooke, MD, chief medical officer of the Delmarva (Md.) Foundation, a quality improvement organization that has a federal contract to help small practices in Maryland and the District of Columbia select and implement EMRs at no cost to the practices. That's why Delmarva requires the lead physician and office manager of a practice to sign a statement declaring that they are committed to and will devote resources to implementing an EMR before it will agree to help any practice, he said.
"When there's a difference of opinion of what needs to happen [or physicians are humoring a colleague who's gung-ho on EMRs], you are really pulling the stopper out of the bottle -- and hope -- before you can really get started," Dr. Tooke said. "If the partners aren't on board with the transition ... it's going to make this a very difficult situation for [an implementation] to succeed."
To give resistant physicians and staff time to come around, practices should set a date by which everyone will be expected to use an EMR, Dr. Tooke said. If they don't get on board, "at some point ... you just have to say, 'This is what our practice is going to do. If you want to be part of our practice, this is what you're going to do. If not, good luck.' "
