What Went Wrong with Your EHR Conversion?
If your answer is “almost everything,” it’s time to troubleshoot and fix the issues.
By Jim Strafford, CEDC, MCS-P
In the last decade, we’ve heard a lot about the implementation of or conversion to electronic health records (EHRs). Unfortunately, very little has been said about the aftermath of going paperless and the lessons to be learned from the process. We’ll address that imbalance. Let’s focus on what you may have encountered during your most recent conver-sion, and how to prevent any similar problems next time.
Note: Because many healthcare entities are on their second or third conversion, either to a new EHR or to upgrade their current EHR, we’ll use the term conversion in this article to encompass both.
Learn from Past Mistakes
Your hospital or practice management personnel did all the right things—endless conversion preparation meetings, committees with all stakeholders at the table, and lengthy negotiations with the EHR entity—and yet, the process was fraught with issues. What went wrong?
1. Incomplete Provider Training
Time and planning were lavished on provider and other stakeholder training. Post-startup, provider documentation speed and accuracy suffered, however. Why?
- Adequate time must be allotted for complete provider and stakeholder training. Every EHR is unique in regard to user friendliness and data entry requirements. Major adjustments might be required when converting from paper templates. Even an EHR upgrade (to the latest product) may be a major adjustment for providers.
- Training for EHRs must be organized, well documented, and allow time for providers to achieve complete documentation competency. Hospital and medical practices can learn from AAPC’s certifications and from coding accuracy metrics. This means, prior to conversion, providers should be held to standards similar to those of coders.
Consider developing an EHR course that leads to certification or a completion certificate. Benchmarks can be established for each part of the process (See Chart A for an example). Upon completion, a certification of competence may be offered, such as Certified EHR User (CEHRU) for that specific EHR—just be sure not to get into trademark issues with other certifiers.
In terms of benchmarks, employers typically hold coders to accuracy and speed requirements. This can be built into the EHR training (see Chart A). For instance, the provider might be required to achieve 95 percent accuracy in completion of the history of present illness (HPI) elements and other history elements to move to the next training module.
This training requires time and effort by both EHR entity stakeholders and hospital and practice stakeholders. Because medical records and coding personnel know best what documentation is necessary to code properly from the new or upgraded EHR, their involvement is critical as well.
Are the providers “bought into” using the new or upgraded EHR? Master’s degree level training can be provided, but if a provider has not bought into the EHR, major documentation problems can ensue. The medical practice or hospital may need to prepare for internal marketing to convince providers of the benefits of the EHR.
For example, if the EHR vendor can provide documentation on (hopefully, increasing) billable relative value units (RVUs), and the physicians are RVU incentivized (as most are), the impact on the “pocketbook” can be an effective incentive. Regardless of the approach taken, some providers will resist. These usually are older providers who do not want to deal with one more administrative challenge before retirement (as an older coding consultant, I can relate). This is where you may consider scribes.
2. Did Not Meet Conversion Deadlines
A second problem area for many EHR conversions is meeting startup and ongoing deadlines. I was on the periphery of a conversion at a mid-western hospital that delayed the startup date several times, which often happens. Everything that could go wrong did.
What should have been done?
Flexible/Realistic Deadlines. Having a deadline is necessary for project management and to motivate stakeholders. Unfortunately, often the startup dates are subject to multiple delays. The medical practice or hospital must be prepared and flexible about the startup date. Having a “Plan B” is strongly recommended.
Plan B may mean continuing the current documentation system or template beyond the conversion date. This can be a costly option, particularly in a conversion from one EHR to another. But being without documentation and the revenue delay and losses that go with it will be much more costly than implementing a backup plan. The revenue cycle side of healthcare management already learned from many disastrous “drop dead date” conversions that having a transition period provides greater protection from revenue disasters. Logistically an EHR “run down/phase in” might not be practical, but a Plan B is strongly recommended.
3. You Got What You Paid For
EHRs are very expensive, particularly enterprise-wide EHRs. Despite the high prices already paid, adequate EHR support often is not covered in the contract. I have heard of an EHR being dropped off at the practice like a new laptop, with nothing more than basic instructions and a “Good luck!” wish. The “standard” support may not be adequate for conversion let alone ongoing use.
Sometimes the issue is the quality of support personnel. If this is the case, the medical practice or hospital should have the contractual option of changing personnel. More often, however, the necessary support hasn’t been contracted in the first place. It’s assumed the hospital or practice personnel have the time and expertise to pick up the conversion slack not provided by the EHR personnel. But as implementation problems erupt, enormous amounts of hospital or practice personnel time are burned as they work to get things up and running, often without best practice results.
The “best practice” approach involves contracting for adequate support from the EHR entity and preparing for the time and effort required by personnel. Even with all of that in place, there may be bumps, which is why a Plan B is essential.
Troubleshoot Connectivity issues
A major selling point of super excellent electronic medical record (SEEMR) was that information flow would be improved for internal users, other providers, and outside vendors. Unfortunately, improved flow doesn’t always occur. For example, although an EHR implemented in a Midwest hospital interfaced with an outside vendor (after much information technologist effort), there was one minor issue: The provider signature appeared on the EHR record at the hospital, but did not appear on the image transmitted to the billing company (for reasons still undetermined). Of course, the billing entity could not legally code without signatures, and significant revenue was delayed while finding a solution.
Connectivity issues often occur with outside vendors, other providers (test results, etc.), and other hospital departments (medical records). There is no perfect remedy. To help avoid some of the issues, the EHR entity has to be vetted prior to conversion for its ability to interface. Even more important is testing, testing, testing, and more testing prior to imple-mentation. Perform “dry runs” to test downloads, connections, etc., as much as possible prior to conversion.
Learn and Improve
EHRs are still in their relative infancy and are improving continuously. There are still many bumps in the road on the way to meaningful EHR use, and each conversion is unique. As my colleague Ronald Stunz, MD, medical director at CBIZ, MMP, has said, “If you’ve seen one EMR conversion … you’ve seen one EMR conversion.” Planning, setting realistic deadlines, having a Plan B, ensuring proper support from the vendor, and testing, testing, testing might not assure a perfect implementation, but will minimize delays and disasters on the way to a paperless healthcare industry.
Jim Strafford, CEDC, MCS-P, has over 30 years experience as a consultant, manager, and educator in all phases of medical coding, billing, compliance, and reimbursement. Strafford is a published, nationally recognized expert on emergency department revenue cycle and coding issues.
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