The files are electronic, but the staff is only human
From the January-February ACP Observer, copyright © 2006 by the American College of Physicians.
By Janet Colwell
At Greenhouse Internists in Philadelphia, getting patients' phone messages to physicians used to be a fairly simple process. The receptionist would write the message down, pull the patient's chart, clip the message to the chart and place them both on the doctor's desk. The physician would record the conversation in the chart and then send it back to be filed.
Converting to an electronic health record (EHR), where all the physicians and staff would have simultaneous desktop access to everyone's files, promised to make that process even easier. But after the office went live with an EHR in mid-2004, taking a phone message—along with every other office routine—became a source of missteps, errors and tension among the once-compatible staff.
At Greenhouse Internists in Philadelphia, Melissa G. Schiffman, ACP Member (left), and Richard J. Baron, FACP, discuss the best use of patient data recorded in their tablet laptops. The group implemented an electronic health records system in 2004.
"Just responding to a patient's question or phone call became difficult," said Richard J. Baron, FACP, one of the group's four general internists. "Everyone had to do things differently, and no one knew exactly how to communicate with everyone else. How did the people taking the message communicate with the people in the file room if there wasn't a piece of paper moving around? Where would the doctors look for information to support telephone decision-making?"
While physicians anticipate rough spots in adapting their clinical workflow, many groups underestimate the level of disruption—and just plain stress—that staff can experience during an EHR implementation. At Greenhouse, the 15 staff members, all of whom had been there for at least five years, suddenly felt incompetent, Dr. Baron said. Well-established work patterns had to be re-tooled and collegiality temporarily evaporated as staff members wrestled with new roles and modes of communication.
'We didn't anticipate the group tensions and that was one of our biggest surprises.'
—Richard J. Baron, FACP
"We went from an environment of productive, happy employees who covered for one another to one where everyone was more resentful and had a shorter fuse," said Dr. Baron. "We didn't anticipate the group tensions and that was one of our biggest surprises."
There is, however, light at the end of the tunnel: According to Dr. Baron, morale will recover and office routines will be even more efficient than before in about three to six months. But he and others who have weathered the implementation process warned physicians to expect morale to get worse before it gets better—and they offered some tips to make the transition a little easier.
Living in two worlds
When implementing an EHR, a practice initially lives with both paper and computer records, gradually moving information from patients' paper charts into the new electronic system as patients come in for appointments. That approach places an extra burden on staff and physicians just when they are getting used to new procedures.
"Just the physical act of working back and forth from a paper chart to a personal computer is actually quite challenging," Dr. Baron said. Staff had to spend twice as much time as before checking in patients as they flipped between their old paper file and the computer screen. Nurses struggled to figure out how to record things like vision checks and purified protein derivatives.
Patient reactions can add to staff stress, pointed out Guillermo Tirado, MD, an internist based in San Juan, Puerto Rico, whose four-physician group switched to a new system in November 2004. "At the beginning it was a traumatic transition, especially for our secretary and nurse," he said. "Patients had to wait while staff entered new information into an electronic record, and they got impatient."
A heavier workload, unfamiliar routines and uncomprehending patients can lead employees to get defensive—and start blaming each other for mistakes. "They didn't know what was going on," Dr. Tirado recalled. "They started thinking that they would lose their jobs."
Dorothy A. Bradford, ACP Member, a solo practitioner in Cleveland Heights, Ohio, pointed out that lack of clear instruction only makes stress worse. When she switched to an EHR in the fall of 2004, tension grew in her office over file retrieval.
She had hired two high school students to scan documents into the new system but hadn't told them how to systematically name and store those files.
"People were saying, 'I downloaded this, now where is it?' " said Dr. Bradford, who employs a physician extender, a medical assistant, an office manager/front desk receptionist and a network administrator. "I didn't pay much attention to naming the files or where they were going—so when we started to retrieve the information it was a nightmare. And I couldn't blame anyone but myself, which caused even more tension." She now assigns all scanning to the network administrator.
Clinging to the status quo
According to Dr. Tirado, his staff and colleagues eventually embraced change, but the office suffered at least one casualty. One of his support staff—a nurse who'd worked there for close to nine years—ended up resigning.
"She left because she preferred paper records," he said. "In the beginning, not everyone thought it was important to move to an electronic system."
Other groups have learned the hard way that one size does not fitall when it comes to changing old routines. Stephen J. Wikle, ACP Member, a general internist in a two-physician practice in Irvine, Calif., said he and his partner bought mini-laptops for the two nurses on staff as part of their move to an EHR in late 2004.
"We thought they could take the laptops into the exam rooms and enter patient information in there," said Dr. Wikle, whose practice is part of Greater Newport Physicians, an independent practice association with more than 300 affiliated members. "One likes to do that, but the other likes to get it on paper and transfer it to the laptop."
Those types of problems are compounded by the fact that physicians often are too busy during the transition period to spend extra time training or talking to an employee who may be having trouble.
"The four people who used to do a routine task one way now need to do it another way," said Dr. Baron. "You don't know what to tell them because you're so overwhelmed trying to learn how to use the system and take care of patients."
Dr. Bradford pointed out that at least her office eased into computerization, which helped alleviate some of the stress associated with the new EHR. The office had started using electronic billing 10 years before, and staff had been used to storing data on handheld computers before the EHR arrived.
But financial pressures made the stress of implementation worse for her, she said: She spent about $50,000 on her system and had to cut costs elsewhere to break even, giving up memberships in professional organizations. She also started charging for services like filling out forms and telephone consults that she used to provide for free.
"I pay myself a lot less and my staff, which used to deduct 30 minutes from their paid time for lunch even though we usually took from 45 minutes to two hours, now has to deduct the entire time," Dr. Bradford added. "So there are no more free lunches."
What they did right
In California, Dr. Wikle at least could learn from others' mistakes. He had seen another local group almost melt down during its EHR transition, so he and his partner took notes, planned ahead—and shouldered more of the transitional work in the first few months so staff wouldn't feel so overwhelmed.
"My partner and I put in a lot of effort on the back end," said Dr. Wikle. "If I had 15 patients the next day, I would stay 15 or 20 minutes late the night before to enter information from the paper charts into the electronic record."
The physicians also initially took on the job of making sure that scanned documents, such as lab and consult notes and hospital records, were attached to the electronic record. While that added between 30 to 40 minutes of work for each of them every night, it reduced stress for the staff.
"Every couple of months, we'd give them a little more to do, like attaching different types of records to patient charts or learning how to do a patient intake or registration sheet," said Dr. Wikle. "We worked hard to make sure that workflow didn't dramatically increase for the staff, then we slowly shifted things back to them."
To allow for snafus during the transition, the practice intentionally booked a lighter schedule for the first month. After six months, most administrative tasks had been shifted over to staff, Dr. Wikle said, "and now I'm doing what I need to do."
Communication is another key element in easing staff stress. Drs. Baron and Bradford both held weekly staff meetings so staff could bring up concerns or suggestions. That went a long way toward resolving misunderstandings and making sure problems didn't fester.
Getting everyone engaged in the physical removal of paper files also helped, said Dr. Baron. The practice sank $600 into four self-inking stamps and thousands of custom printed post-It notes. The notes marked and named documents in the paper charts that doctors wanted scanned into electronic format, while the stamps were imprinted with "chart preloaded" and the date.
"The stamps were big and ungainly," said Dr. Baron, who initially balked at paying for them, "but the cathartic act of stamping a chart studded with pink post-it notes and sending it off to the basement not to be seen again was an important step in marking our progress." Over time, the upstairs chart racks got thinner and thinner, and everyone could see that a seemingly interminable task was becoming more manageable.
No amount of training or planning will smooth out all the rough spots—and there are some routines that just won't change. Dr. Bradford's staff, for instance, still won't take advantage of the EHR's instant messaging function, which has led to a Catch-22 argument in the office: They won't use the feature unless she reliably checks her messages, but she often forgets to check because her staff rarely uses the function.
"They still tape messages to my phone," she said. "But then, I've never gotten them to use the intercom on our phone system. We still use yelling."
After making it through all the morale problems and disruption, Dr. Baron said, the payoff is huge, both in workflow and office efficiency.
"Staff love being able to respond to patients' questions without even leaving their desks, and they don't waste time running around the office looking for charts," he said. "It's had a huge impact on our patients and on our own sense of being capable, competent doctors. None of us would go back—in fact, we can't imagine how we functioned without an EHR."
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