EHR lessons learned from small practices: Part 1


With impending deadlines for physicians to attest for meaningful use incentives, the inevitable and harsh push towards EHR adoption is well underway. However, despite government mandates, many small-practice physicians remain steadfast in their opposition of the transition from paper to electronic medical records.

As I mentioned in my first post, our organization worked with the Mayo Clinic Center for Innovation to develop an EHR solution designed specifically for small practices. One of the major objectives of this project was to first determine exactly why many small-practice physicians were wary of implementing an EHR system in the first place. In my next few posts I will highlight the findings from this story that shed light on some of the most common and significant barriers impeding EHR adoption in the small-practice setting.

I will also offer suggestions for identifying and selecting an EHR that can help to not only overcome these barriers, but also significantly improve clinical efficiency and quality of care.

Loss of efficiency
Over the course of our research, we discovered that many physicians in the small-practice setting see EHR adoption as a significant threat to their current workflow and, therefore, a threat to their practices’ efficiency. A small practice’s success is highly dependent on its ability to maintain a high panel of patients per day, while still providing high-quality clinical care. On average, physicians at a small practice treat upwards of 30 patients a day, dedicating approximately 16 minutes to each patient -- statistics which must be maintained throughout the course of their EHR adoption in order to avoid any revenue loss. Despite the misperception of many outside of healthcare, physician practices often operate within rather narrow margins. The threat of an EHR interrupting what is typically a well-oiled workflow to begin with represents an immediate and real threat to these narrow margins.

Fortunately, there are EHR systems that contain the features needed to overcome this fear. For example, in our research, we noticed that many small practices maintain a very specific layout of paper records, allowing for quick and easy access to essential patient information.  A practice’s unique style of setting up and displaying paper medical records can be easily mimicked by an EHR that has a customizable electronic clipboard. This type of clipboard can display prioritized patient data, determined on a case-by-case basis pending the preference of the physician, as opposed to an EHR that employs a standard clipboard display, forcing physicians to adjust to it rather than it adjusting to them. In addition, an EHR that offers a longitudinal view of patients’ medical history (similar to the recently introduced Facebook “timeline” view) can be extremely advantageous as physicians can view a patient’s entire clinical history in one glance, as opposed to viewing only a single snapshot of an individual occurrence. This feature enables a physician to both diagnose and treat patients faster and oftentimes, better.

Another major challenge of EHR adoption for small practices is the need to learn a new technology’s user interface. Most small practices have developed a workflow style and language all their own, which often consists of a series of post-it notes, paper-based records, and other non-verbal signals that may not be obvious to anyone outside the practice, yet are critical to complete each day’s tasks. For example, at one of the observed practices , the nurse would place a post-it note on one of three lotion bottles of varying size. The size of the bottle the note was placed on would indicate the relative importance of the message. While this may sound silly, most small practice physicians and staff have developed a great deal of faith in their current system, and fears of having to learn complicated technical processes and symbols associated with using a new EHR can understandably be quite overwhelming.

It is not difficult to draw comparisons between what small practices need in an EHR and what people want in cell phones and tablets -- those technologies that have the easiest navigation and allow the user to customize its appearance and functionality so that it is compatible to their current work style and personality -- are most desirable. An EHR with a highly intuitive user interface will demonstrate its functions and capabilities immediately, eliminating time spent reading manuals or in training sessions. Physicians have enough on their plate already to worry about learning how to use new technology. Furthermore, customization also allows a transitioning practice to mimic its existing paper-based system.

Clinical staff, as well as patients at a small practice, are in constant motion, meaning the EHR needs to be equally agile. As previously mentioned, small-practice physicians see many patients a day, requiring clinical staff to move between waiting rooms, exam rooms, offices and clinical spaces in order to provide the efficient, high-quality care that their patients expect and deserve. An EHR that can keep up with the perpetual motion of a small practice needs to support streamlined team login capabilities, so that regardless of where a member of the staff is, he or she can quickly access all necessary patient data. A truly mobile EHR should also utilize flexible search methods and intuitive categorization of clinical information in order to cater to different staff members’ work styles. Finally, an EHR that is tablet-compatible (such as one that is designed for an iPad) is perhaps the most mobile of all EHR solutions. A tablet-compatible EHR that can combine all these described features and functions will not only allow physicians to continue to practice in the fashion that they are accustomed to, but may even reduce the need for some of the current space trading and “running around” required of small practice physicians, while ensuring all critical patient data is literally at their fingertips.

While efficiency was typically at the top of mind for small practices during our study, there were certainly some other substantial concerns uncovered through the course of the research. In my next post I will continue this line of discussion and focus on additional barriers to small-practice EHR adoption.

Can you think of any other issues related to EHRs and small practice efficiency? Please share your comments in the space below.

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