Buyer Beware - the MD and the EMR: You Can't Have One Without the Other

Eiman Al-Jafar, PhD, Jennie Campbell, CPC, CCS-P, Rosemarie Nelson, and  
Harry Starnes, MD

Introduction

Due to significant advances in technology and increasing pressure on physician groups for improved efficiency and care delivery, electronic medical record (EMR) systems are gaining popularity. There are hundreds of products designated as EMRs available in today's market, making it difficult for a physician group to effectively evaluate its options and choose the best product for their group. The selection and implementation of an EMR system is discussed herein, along with a study that explores implementation of an EMR system from the perspective of physicians.

A recent survey by Modern Healthcare¹ of more than 1,000 medical practices reports that 17 percent of respondents are currently using an EMR system. In addition, 10 percent of respondents are in the process of implementing an EMR system, 9 percent plan to implement an EMR system in the next year, and 38 percent will implement an EMR system sometime in the future.

Another study by Modern Physician² reports that hospital-owned groups have a higher level of EMR penetration (22 percent) compared to physician-owned groups (15 percent). The study also showed that larger medical groups have a higher EMR usage rate; although only 17.8 percent of the total survey pool is currently using EMR systems and another 9.3 percent are in the process of implementing an EMR system--60 percent of practices with more than 200 physicians fall into one of these two categories.

EMR System Selection from Point of Interest to Purchase

How many physicians are thinking about implementing an EMR in their practice? Consider your practice's strategic planning objectives. Look at your current practice management, appointment scheduling, billing, and accounts receivable solutions during the process. Get physicians and administration on board and decide as a group to move forward with the selection, acquisition, and implementation of an EMR solution.

The key steps start with a kickoff planning event to uncover users' "top 10" features and functions. Focus on the goals you are trying to achieve. Identify the work processes you want to affect. Educate your group to the possibilities by looking at products available at conferences, trade shows, and via the Internet.

Who is leading the project?   Identify a project manager who can spearhead the activities in the early education and selection process and lead the implementation planning that starts even before a vendor contract is signed. Develop a multidisciplinary team from each of the functional departments in the practice, such as nursing (RN, LPN, MOA/MA), appointment scheduling, billing, HIM, reception, transcription, and management. Identify physician champions to participate on the team as well.

Consider how your top 10 list can develop into an RFI or RFP (request for information or request for proposal). Use this type of tool to query the vendor as to how its solution will assist you in meeting your needs and how much a comprehensive solution will cost to meet your needs.

Host demonstration sessions for your project team as well as other interested group members. The demonstrations can be most effectively managed by requiring your participants to evaluate and score the products formally with a written tool. The development of a scoring tool starts with your needs list and includes clinical work flows and clinical scenarios that are typical in your practice. During your preparation, the elements on the scoring tool are weighted by your team for relative importance in the evaluation process.

Solicit a reference list from each vendor under consideration and assign team members to contact their peers at the reference. A formal de-brief of these reference phone discussions is essential to share knowledge gained across the disciplines. The next step is an analysis of the demonstration evaluations, the responses to the RFI/RFP, and the telephone reference discussions, as well as a review of the vendor's materials provided during the sales process.

The selection process should be narrowed to finalists for reference site visits. It is essential to see the solution in use at a practice with some similarities to your practice to fully insure the applicability of the product. Interview the vendor's installation, training, and support team to ascertain their industry knowledge--how well do they understand the nature of your specialty and those functions that are required based on your specialty?

During the contract negotiation process, service standards and implementation roles must be clearly defined. Identify gaps in the solution that must be filled prior to a go-live and include the scope of work in the contract document. Successful contract negotiations result from following a thorough selection process.

EMR Implementation in the Physician Practice

Physician groups who choose to implement an EMR system want not only the newest, best, and most cost-effective product, but also an assurance that the vendor they select will be with them through implementation and beyond. The financial commitment to implement an EMR system is large, and because many of the EMR's benefits are either non-financial or difficult to quantify, it is often difficult to demonstrate the exact return on investment. However, studies of physician groups who implement EMR systems have been able to document both the qualitative benefits (easier access to information, greater patient and provider satisfaction, etc.) and the quantitative benefits (increased savings and revenues) of an EMR system.

A recent study by KLAS Enterprises, LLC, names the following factors (listed in order of importance) that physician groups evaluating EMR systems look at: cost, feature/function, technology, sole source vendor, relationship, and vision. However, those physician groups who have already selected an EMR cite feature/function and sole source vendor as the top two criteria used in selecting the EMR, followed by cost.³

Once the appropriate EMR software has been selected, the physician practice will work with the selected vendor to implement that software. Careful planning and execution of an implementation plan will increase the overall success of the EMR system and shorten the time in which the practice sees a quantifiable return on investment.

Critical Success Factors for EMR Implementation

1. Identify an Implementation Team

Creating a project team responsible for overseeing implementation of the EMR system is one of the keys to successful implementation. The project team should identify a leader or project manager (ideally a physician or office administrator) who will coordinate the implementation issues, decisions, and tasks, and who will serve as a contact for any questions that arise. The project manager must be allotted sufficient time dedicated solely to the EMR implementation. The project team should also include senior staff with access to upper management and a representative from the selected vendor. The project team's goals should include:

• Set realistic project management processes
• Raise awareness and enthusiasm for the EMR throughout the practice
• Be accountable for the successful execution of the implementation plan

2. Clearly Define the Practice's Goals

The practice's objectives for the EMR system should be detailed well in advance of the EMR system selection process. The implementation team should create a comprehensive list of the problems or issues that the practice's ideal EMR system will solve. Engaging in this step prior to selection and implementation of the EMR system will allow the practice to clearly communicate to the EMR vendor exactly what it wants the EMR system to accomplish. The practice's objectives should be defined clearly enough that the scope of the project will not be altered during the implementation process. Once the practice's objectives have been defined, the project team can communicate to the members of the practice the benefits and value that the EMR system will bring to each of them.

3. Plan before Acting

Implementation of an EMR system will require changes in the day-to-day processes of the practice. Some practices have found it useful to employ project management software that details the steps in the implementation process as well as the cost of each step. According to an article in Family Practice Management, factors that need to be considered in the planning stage include:

• Work-Flow Analysis and Redesign
• Facility Modification
• Hardware Selection and Installation
• Software Configuration
• Security
• Laboratory Data Management
• Templates
• EMR Backup System
• Training⁴

4. Develop a Strategy for Existing Data

Each practice must determine for themselves what portions of existing patient charts will be included in the new EMR system. In addition to deciding what information to include in the EMR system, the practice must determine the best method for entering the data into the EMR system. The amount of data that a practice chooses to convert to the EMR system may depend on the amount of time and funding available, as well as the overall objectives of the practice.

5. Dedicate Time to Training

EMR implementation experience has shown that "one of the leading indicators of success is a familiarity with where things are located in the system, and this is only done through individual hands-on experience with the [EMR] product".⁵  Each physician practice will set up training based on the EMR system selected and the amount of training needed by the practice employees. The physician practice highlighted in May 2003 issue of Family Practice Management used a three-tiered training approach:   (1) initial basic skills assessment three months before going live, (2) basic skills training two months before going live, and (3) application-specific training one week before going live.⁶ Training will give employees familiarity with the EMR system and allow the practice to work through any problems or issues that arise.

6. Allow Time for Adjustment

Many physician practices have found it useful to conduct a "dry-run" of the EMR system prior to going live. This practice session allows the practice to get a feel for the EMR system and identify any problems or areas for concern. During the first few weeks of live operation, it may be beneficial to structure EMR buffer time into the physician's schedule to account for the extra time it will take to use the EMR system on the forefront.

7. Develop an On-Going Plan for Support

Once the EMR system has been successfully implemented, there must be an on-going plan for support of issues or problems that will inevitably arise. The practice may choose to delegate an EMR "power user" who is highly trained and able to troubleshoot various problems. This person can also be the main point of contact for anyone with a question regarding the system. The support person will also maintain a close relationship with the EMR vendor.

EMR Selection and Implementation Summary

Selection and implementation of an EMR system for a physician practice requires substantial time, planning, and support. Physician practices that have implemented EMR systems sit on both sides of the table to speak of their success or lack of success related to their individual investments in an EMR system. The groups who have struggled most have lacked strong physician leadership to guide change and physician adaptation of the new technology. It is clear that a strong selection and implementation plan is critical to the success of the EMR adaptation by a group, and the weakest plans are those that are solely vendor based. The critical factors for success outlined herein are essential to helping the physician practice realize the qualitative and quantitative benefits of its EMR system.

Factors Affecting Diffusion of Electronic Health Records (EHR): Physicians' Perspective

Introduction

With the era of information and communication technologies, Ministry of Health, Kuwait, initiated a new step toward using information technologies (IT) in improving the healthcare system. The top management at the Ministry adopted a plan to introduce an integrated EHR in the different healthcare facilities in Kuwait. A partial implementation of the EHR system already took place at the Primary Health Care Centers since year 2001. The healthcare top management at the ministry eventually recognized the importance of the medical record and it effects on the provision of quality healthcare services.

This study is considered the first in Kuwait to explore physicians' perspective toward implementing an EHR. A qualitative design was used in an attempt to investigate pre-defined factors by Rogers, Moore, and Benbasat, and examine their affect on diffusion of innovation with EHR innovation. Furthermore, the study investigated physicians' perspectives toward other factors that may influence the diffusion process.

Literature Review

Many researchers consider Everette Rogers as a pioneer in diffusion studies. Roger's landmark book published initially 1962, and followed by three editions, Diffusion of Innovation (DOI), discussed the DOI concept, elements of diffusion, and attributes of innovations and their rate of adoption. DOI is defined as "the process by which an innovation is communicated through certain channels over time among the members of a social system."

Rogers outlined in his book, five attributes of innovations that affect rate of adoption of an innovation. The five attributes included relative advantage, compatibility, complexity, trialability, and observability. Nearly 49 percent to 87 percent of the variance in the rate of adoption can be explained by these five attributes. These attributes of innovation were found to have an impact in the diffusion process of an innovation.

Rogers defines relative advantage as "the degree to which an innovation is perceived as being better than the idea it supersedes." The second attribute in DOI theory is compatibility. Compatibility is the "degree to which an innovation is consistent with existing values, past experiences, and current needs of potential adopters." Complexity is the third attribute of innovation; however, the use of complexity was replaced by ease of usage by many of the IS diffusion researchers. Ease of usage is defined as the "degree to which an innovation is perceived as relatively difficult to understand and to use." Trialability is another attribute discussed by Rogers in his book. It is "the degree to which an innovation may be experimented with on a trial basis." Trialability reduces uncertainty and greatly increases the rate of adoption. Observability or result demonstrability is "the degree to which the operations and results of an innovation are observable to others."

Information technology (IT) researchers approved on the five attributes stated by Rogers. However, different characteristics were also found to be important when testing diffusion of IT innovations. For example, Moore and Benbasat (1991) suggested two additional attributes besides Rogers' attributes of diffusion to be included: voluntariness of usage and image. "Voluntary of usage" is defined as "the degree to which use of the innovation is perceived as being voluntary, or have free will." Image is related to the "degree to which use of innovation is perceived to enhance one's image or status in one's social system."

Several studies discussed physician's perspectives toward implementing an EHR. Wagner et al (1997) studied EHR systems from the users' perspective. Results revealed that 60 to 70 percent of physicians are now using computers in their offices mainly for billing and administrative purposes. On the other hand, only 10 percent are using computers to maintain the patient record system.

In a cross-sectional study conducted at a large Health Maintenance Organization (1998), investigators were examining the attitude of clinicians toward the effect of an outpatient EHR system on the quality of patient care. The researchers surveyed physicians and conducted interviews with physician leaders of the clinical departments. The results revealed that 72 percent reported an improvement with the use of the results reporting system, and 60 percent reported an improvement with the use of the online charting and ordering system. Overall, "clinicians feel that the Electronic Medical Record system has improved the quality of the patient-clinician interaction, the ability to coordinate the care of patients with other departments, the ability to detect medication errors, the timeliness of referrals, and the ability to act on test results in a timely manner."

Methodology

The qualitative design used in this study was qualitative case study, which is the most common qualitative method used in information systems. Qualitative research offers insight into emotional and experiential phenomena in healthcare to determine what, how, and why.

The selection of participants' healthcare institutions was based on their experience in dealing with EHR systems and their approval to participate in the study. A total of 12 healthcare institutions were included for the purpose of the study. A total of 18 physicians were included: eight from two govermental primary healthcare facilitities, four from the private hospitals, and six private practitioners. Combinations of qualitative techniques for data collection--semi-structured interview and observation at fieldwork--were used. The researcher followed a detailed procedure for data analysis provided by Creswell (1994). First, a quick read through all interview data for each participant and general notes were taken on what each interview included. This was done to get familiar with the material given by the subjects. Second, much closer reading was performed again for all interview responses and more details related to demographic data of participants and background information were considered. At this point, similarities and differences among subjects were written in detail. A third reading was performed to get a closer look at certain statements, highlighting them with attention to detailed explanations and reasons given by the subjects.

After performing three thorough readings of all answers, the researcher developed a conceptual framework including identifying major topics withdrawn from subjects' answers. Answers were classified into three different categories: by sector including government and private, by different healthcare professional perspectives, and the type of system used--either developed in-house or ready made by vendor.

Results and Discussion

In testing different attributes of innovation specified by Rogers (1995), and Moore and Benbasat (1991), participants responses from government and private sectors, to different interview questions related to these attributes were studied. Thorough interpretations of responses reflected adequate evidence that these factors greatly affect the diffusion of EHR innovation from physician's perspectives.

Results showed that there is a difference in responses based on the type of system used and the amount of the physician's involvement in system development. Users at the government sector specified two types of systems: an EHR system developed in-house based on users involvement and needs and an EHR system provided by a vendor from the Kuwait market. The responses of physicians to each of the diffusion attributes questions depended greatly on these two factors: type of system and user involvement factors. This was noticed especially with relative advantage, compatibility, result demonstrability, and image attributes.

When testing the relative advantage attribute of using EHR innovation, relative advantage indicated economic profitability (as seen by private sector), social prestige, and benefits of the system. These were the same indications discussed by Rogers's studies. In addition, it is important to mention here that only physicians who worked in the private sector explained economic profitability advantage.

As for compatibility and complexity attributes, using an EHR provided by a vendor without user's involvement did affect responses to these two factors. Physicians who used this type of system and had no involvement in development of the product saw the system as incompatible and difficult to use compared to those who had opportunity to participate in system development and modify the system based on their needs.

Testing trialability was associated with the training period provided to users. IT innovations tend to be too complex; therefore, longer periods of experimenting did affect satisfaction with the system, hence adoption of the system. Trialability reduces uncertainty and greatly increases the rate of adoption. Availability of training was positively correlated with the extent of implementation of innovation.

In addition, the results reflected that the observability attribute was influenced by the type of system used and amount of user's involvement at the system development stage. Physicians using ready-made EHR systems and who were not involved in system development find it difficult to observe results of using such a system. Again these two factors did affect diffusion of innovation and satisfaction of users with the innovation.

For all participants, except for private practitioners, usage of the system was compulsory, but it seems that it did not affect their acceptance of the innovation. The reason for this conclusion is the enthusiasm that was noticed working with the system and satisfaction as expressed by most users especially in the government sector, during observations, interviews, and field notes.

The image factor was considered by most of the participants in the government sector as the only incentive they had for working with an EHR system. The incentive is non-monetary. Participants discussed image factor as very important to their self-esteem and to gain prestigious status compared to those who did not have the opportunity to work with the EHR system. In addition, participants of this study were considered pioneers in working with EHR systems in Kuwait, therefore, this positively affected their image. Therefore, results reflected that considering this attribute as independent factor by Moore and Benbasat, rather than include it under relative advantage attribute as seen by Rogers, was crucial in studies of diffusion of IT innovations.

After investigating additional factors affecting the diffusion rate of innovation by physicians, the researcher classified results in three main themes: organizational factors (planning, decision making, communication, and management support), technological factors (IT manpower, technological infrastructure, and compatibility), and economical factors (resource allocation).

Recommendations for future studies would include exploring attitudes of different healthcare professionals toward implementation of EHR systems. In addition, patient satisfaction with quality of services provided after implementing the EHR systems is worth inclusion for research studies.

References

Alavi, M & Carlson, P. "A review of MIS research and disciplinary development." Journal of Management Information Systems (8:4), 1992, pp. 45-62

Ash, J. "Cross-Site Study of the Implementation of Information Technology Innovations in Health Sciences Centers." Journal of American Medical Information Association Symposium Supplement. 1995. pp. 795-99.

Carter, Jerome H. "Implementing an EMR? Five mistakes you should avoid." ACP Observer. (December 2003).

Creswell, J. Research Design: Qualitative & Quantitative Approaches. SAGE Publications, 1994.

Giacomini, M. Cook, D. "Users' Guides to the Medical Literature: XXIII. Qualitative Research in Health Care: Area the Results of the Study Valid?" Journal of American Medical Association Vol. 284 (2000): 357-362.

Marsharll, P. Chin, H. "The Effects Of An Electronic Medical Record On Patient Care:   Clinician Attitudes In a Large HMO."  Proceedings of the Annual Meeting Of the American Medical Informatics Association (1998): 150-4.

Moore, G., Benbasat, I. "Development of an Instrument to Measure the Perceptions of Adopting an Information Technology Innovation." Journal of Information Systems Research. Vol. 2. (1991): 192-222.

Orlikowski, W.J. & Baroudi, J.J. "Studying Information Technology in Organizations: Research Approaches and Assumptions." Information Systems Research (2) 1991, pp. 1-28.

Rogers, E. Diffusion of Innovation, (1995). 4 th Ed., New York: The Free Press.

Rogoski, Richard R. "Enhancing the Enterprise." Health Management Technology. (May 2004).

Wagner, K. Ornstein, M., Jerkins, R. "Observations and Opinions." MD Computing Vol. 14(5), (1997): 334-6, 338.

Endnotes

1. "Physician Affairs." Modern Healthcare, Volume 34, Issue 6 (February 9, 2004): page 26.
2. Versel, Neil. "Connect the Docs." Modern Physician (February 23, 2004).
3. KLAS Enterprises, LLC. "Ambulatory EMR Perception Report." (January 2004). Available at http://www.healthcomputing.com.
4. Smith MD, Paul D. "Implementing an EMR System: One Clinic's Experience." Family Practice Management, May 2003.
5. Mysis Healthcare Systems. "Critical Success Factors for Practice-Wide EMR Implementations: Ten Steps to Maximize ROI." Available at http://www.misysemr.com/.
6. Smith MD, Paul D. "Implementing an EMR System: One Clinic's Experience." Family Practice Management: (May 2003).

About the Authors

Rosemarie Nelson, MS, is a consultant with the MGMA HealthCare Consulting Group.

Jennie L. Campbell, CPC, CCS-P, is a senior manager with Pershing Yoakley &
Associates.

Eiman Al-Jafar, MSc, PhD, is assistant professor at the Department of Health Information Administration, Faculty of Allied Health Sciences & Nursing, Kuwait University.

Harry Starnes, MD, is a family physician at Starnes Family Clinic in Clinton, AK. He implemented an EMR in his practice in 1997.