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Part IV: Lack of a Practice Analysis and Not Following the Plan

Here is the fourth installment of WRS Health’s 10-part series dedicated to Dr. Lawrence Gordon’s recent white paper, “10 Implementation Mistakes to Avoid: Why Practices Fail.” Each segment of the series examines one of the 10 most common implementation mistakes by medical practices when implementing electronic health record (EHR) systems.


Engaging in a practice analysis is essential. It’s imperative to know where you want to be and to outline your goals. Frequently, it is the medical practices’ old processes that are carried out by poorly trained or inexperienced personnel that lead to the failure to achieve a practice goal. By going through a rigorous practice analysis, goals can inform what tasks need to be addressed and priorities can be set. When issues inevitably arise, there is a context for understanding whether it’s a software problem or a problem with the practice personnel and processes.

In an article appearing in The Annals of Family Medicine, “Implementing an Electronic Medical Record in a Family Medicine Practice: Communication, Decision Making, and Conflict,” researchers studied a private family medicine practice that had recently purchased and implemented an EHR. According to the researchers, members of the practice reported differing perspectives regarding the value and appropriate use of the EHR. It is clear from the study’s findings that a practice analysis outlining the practice’s goals from the get-go is imperative so that everyone is on the same page.

The study’s researchers explain, “The senior partner in the practice saw the EHR as a tool to increase efficiency in the clinical encounter by eliminating a recurrent problem with lost charts while providing better management of complex patient data. For him, “the more information that’s in there, the more reliable it is … and there are complex patients I have in here who have 12 medications and 12 diagnoses, and I come into the room and I am saving immeasurable time … I am plotting out blood pressures to show patients, and weights and heights and things and … that has been very well received I think, by the patients.” The junior partner in the practice also saw the EHR as improving efficiency, but his focus was on how the system affected patient flow through the practice. As he put it, “We always wanted to … help prevent some of the congestion … signing in vs. checking out.… Well, we cannot expand the office … [and] the only place that was deemed removable would be the charts.… The hope is … that now we can collect co-pays when the patients are coming in, which was harder to do before, because the person who would be checking in, would also be getting checked out … [and] having to answer the phones.”

The study’s researchers conclude, “Although both physician owners focused on efficiency, during the observation period, they did not discuss with each other or with other practice members their competing goals of managing complex data efficiently during the clinical encounter and managing practice space more efficiently.”

The right way to engage in a practice analysis

  • According to the Office of the National Coordinator for Health Information Technology (ONC), building an EHR implementation plan becomes critical for identifying the right tasks to perform, the order of those tasks, and clear communication of tasks to the entire team involved with the change process.
  • One effective first step in the planning process is for the team to segment tasks into three categories: What new work tasks/process are we going to start doing? What work tasks/process are we going to stop doing? What work tasks/process are we going to sustain?
  • The start/stop/sustain exercise helps clarify what the new work environment will be like after the change and helps the team prioritize tasks in the overall EHR implementation plan, advises ONC.
  • ONC also advises practices to do the following during the EHR implementation planning phase:
  • Analyze and map out the practice’s current workflow and processes of how the practice currently gets work done (the current state).
  • Map out how EHRs will enable desired workflows and processes, creating new workflow patterns to improve inefficiency or duplicative processes (the future state).
  • Create a contingency plan – or back-up plan – to combat issues that may arise throughout the implementation process.
  • Create a project plan for transitioning from paper to EHRs, and appoint someone to manage the project plan.
  • Establish a chart abstraction plan, a means to convert or transform information from paper charts to electronic charts. Identify specific data elements that will need to be entered into the new EHR and if there are items that will be scanned.
  • Understand what data elements may be migrated from your old system to your new one, such as patient demographics or provider schedule information. Sometimes, being selective with which data or how much data you want to migrate can influence the ease of transition.
  • Identify concerns and obstacles regarding privacy and security and create a plan to address them. It is essential to emphasize the importance of privacy and security when transitioning to EHRs.

Not following the plan

In addition to the mistake of lacking to engage in a practice analysis, many electronic health record implementations also fail because practices do not follow a plan.

In order to avoid an implementation debacle, you need to develop a project plan and follow that plan to fruition. If certain foundational tasks are not completed, it is difficult to achieve other dependent goals.

  • Clearly articulate a set of goals and standard implementation tasks
  • This includes the identification of roles and responsibilities, the assignment of tasks to specific persons (vendor and practice), priorities associated with those tasks and due dates for completion. Once the project plan is set, regular meetings are required to ensure task completion and problem-solving of other issues. Dr. Joseph Cramer, a pediatrician in Utah wants practices to learn from his practice’s mistakes. “Once we signed, the EHR committee stopped meeting. Instead that was the exact time everyone, the clerks, Medical Assistants, business office, and especially the docs should have starting meeting regularly. Because of this, we all have to learn, one mistake at a time all over again. The list of errors goes on. We bought something too big to fail without a trial period and escape clause. We hired internal IT personnel without the clinic management having the technical expertise to audit their work.”
  • If the vendor fails to provide project plan leadership organization and tools, then this is a warning red-flag. If the vendor or practices fail to adhere to a project plan, this is also a reason for implementation failure.
  • One of Dr. Raymond DeMoville’s goals for his practice, Mid State ENT was to find an EHR that had the tools to help him attest for Meaningful Use incentives. So, prior to selecting his current EHR, Dr. DeMoville considered an EHR that was being developed by a Memphis physician. “We were almost ready to buy his system, but it didn’t meet the federal requirements yet for Meaningful Use. He said he’d have it by January, but he wasn’t sure,” says Dr. DeMoville. He adds that he chose a different system that “made it easy to meet the criteria for MU and it was set up to have the data available to push the buttons to pull up reports that I needed. It went very smoothly. We got our first check a month ago. That was a pleasant surprise.” says Dr. DeMoville.