Over the past decade, more and more medical practices have implemented electronic health records (EHR). Now even holdouts have a tempting reason to take the plunge.

Under changes authorized by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, part of the American Recovery and Reinvestment Act (ARRA), physicians and certain other practitioners may receive financial incentives for using electronic health records (EHR). Eligible practitioners may qualify for up to $44,000 over five years in incentive payments from Medicare, or they may receive up to $63,750 over six years from Medicaid. Practitioners may participate in one incentive program; enrollment in both programs is not permitted. Incentive payments for eligible practitioners will start sometime in 2011.

The U.S. Department of Health and Human Services (DHHS) released two final rules on July 13, 2010. One rule, issued by the Centers for Medicare & Medicaid Services (CMS), defines the minimum requirements that providers must meet in order to qualify for EHR incentive payments. The second rule, issued by the Office of the National Coordinator for Health Information Technology (ONC), identifies the standards and criteria for the certification of EHR technology.

EHR vendors have seen medical practices lining up for both new product implementations and product upgrades needed to meet incentive requirements. Is your practice among them? Should it be?
What can you do to ensure that your implementation is a success, and not the disaster that occurs in so many medical practices? The physicians in one Philadelphia internal medicine practice compared their conversion from paper to electronic health records to flying an airplane without a pilot! You can have a positive experience through careful planning.

Here are a dozen practical suggestions.

1. Be honest about your technology readiness and receptivity
In most practices, physicians' attitudes toward technology vary greatly. Some love it, and others hope they will never have to fiddle with it. Structure your software selection, staff training and implementation to accommodate your workforce. The primary purpose for introducing EHR into your practice is to provide better patient care and enhance outcomes; it’s not simply to claim incentive payments or buy the hottest new gizmo. Make enhancement of practice value the goal. New associates who have recently completed their training seek environments with EHR and the ability to exchange information within referral networks. Physicians who plan to retire within a few years can enhance the attractiveness of their practices by adding these capabilities.

2. Designate the right leader(s)
Identify the appropriate individual(s) to lead the decision and implementation processes. The leader should have both an interest in IT and the ability to manage people and change. In some situations, a physician can do the job—provided that he or she is given adequate time to accomplish the task. In other situations, an administrative person may be better suited to the role. Or, a physician/administrator team may work best.

3. Involve employees at all levels of the practice
Your EHR will impact staff at all levels of your practice, so physicians and other clinicians, as well as administrative and clerical staff, should be part of your implementation team. People who are involved from the outset are more likely to support your ultimate decision and make it work. Be sure to include IT skeptics in the mix. The speed of your success as an organization will be measured by the progress of its slowest learners. You may be surprised to find your skeptic transformed into an IT advocate.

4. Identify your needs
Clarify your own mission and goals before investing in expensive technology. A small practice with one location has different needs than a large practice with multiple sites and aggressive growth plans. Do you receive or send large images and files? What are your communication needs? Reach consensus on your future direction and choose technology that supports you.

5. Fix problems in your current workflow
If you assume that automating specific aspects of your practice operations will correct current problems in your workflow, think again. You cannot computerize chaos. Transitioning from paper to electronic health records won’t fix human resource problems or poor financial management. If you automate malfunctioning processes, you’ll compound the problems. Fix what doesn’t work before you automate.

6. Consider EHR as part of your total IT strategy
For maximum benefit, your EHR should interface with the other major components of your practice's IT system, such as the practice management system (PMS) and patient Web portal, if you have one. Select an EHR vendor with the total picture in mind. Here's an example from a family practice physician who wants to purchase EHR and replace his current PMS. The physician likes the software from two different vendors, and if he decides on this option, he must pay for a two-way interface of several data sets both at the outset and on an ongoing basis. From a financial perspective, a better option is to select a single vendor that can provide an integrated solution, where software for two or more applications is built off the same operating platform. With the integrated solution, there are no cost add-ons and there's no question about where to seek technical assistance when it’s needed. E-prescribe is another good example. If you select an EHR that includes an e-prescribe feature (as opposed to buying a separate e-prescribing application) prescription information automatically links to your EHR without your having to take extra steps to enter it into the patient record. Taking the time to make EHR work harmoniously with all your systems from the outset will save your practice headaches—and money—over the long haul.

7. Educate yourself about recent legislative changes
To qualify for incentive payments from Medicare or Medicaid, a practice must use EHR, meet requirements for submitting information on clinical and health information quality measures, and be able to demonstrate interoperability with other healthcare facilities. Practices will also be required to demonstrate they meet requirements for “meaningful use” of EHR in the practice. That may sound simple, but practices must meet very specific criteria set by the federal government in order to qualify. Look at the new CMS website that contains current information on the EHR incentives —www.cms.gov/EHRIncentivePrograms/.

8. Seek outside help when you need it
Most practices don't select and implement IT solutions on a regular basis, so they are less experienced in the process than they are in other aspects of practice management. Independent practice management consultants without financial ties to vendors can guide you, introduce you to vendors, set up site visits to practices that use different products, provide criteria for vendor selection, and review proposed vendor contracts. The Carolinas Center for Medical Excellence in Cary offers an excellent series of webinars on ARRA and the stimulus package. The North Carolina AHEC Program recently received federal funding to provide on-site consulting to primary care practices that need to prepare for, select and implement certified electronic health records. The NC AHEC Program will also assist primary care practices using electronic health records and ensure that they meet criteria to qualify for the financial incentives. For information on AHEC services in your community, go to www.ncahec.net and click on the county in which your practice is located. Finally, the High Performance Physician Institute (HPPI) offers multi-day CME seminars throughout the country on information technology for practicing physicians. HPPI also provides programs that are customized for communities and medical associations. For more information, visit www.highperformancephysician.com

9. Do your homework before bringing in vendors
Research the big picture about EHR systems you are interested in before talking with specific vendors. Then specify exactly what you want each vendor to tell you so you can easily compare. Give the vendors background information on your practice, a list of questions about the software, the company, training and technical support, and the criteria that you will use to make your selection. Having guided many practices in their selection of various IT solutions, I put training and technical support—not cost—at the top of my list. Avoid vendors that want to provide a quote without taking the time to listen to and understand your needs.

10. Select a vendor(s) appropriate for your practice’s needs
Independent national organizations such as the AC Group or KLAS regularly test and rank EHR vendors according to specific criteria. Professional associations can be good resources too. For example, the website of the American Academy of Family Practice (www.aafp.org) includes a section with feedback from practitioners who have shared their experiences, both positive and negative, using EHR and other IT systems.

11. Make the most of site visits
Ask each vendor to provide the names of three practices that match your size and specialty. Contact each practice and offer a stipend of a few hundred dollars (they are likely to refuse) to observe their workflow for a few hours. Visit the practice without the vendor present, and be willing to travel as far as you need to go. Ask both the lead champion and most vocal skeptic physicians to participate in your visit. Bring examples of common scenarios in your practice and ask your hosts to show you how the equivalent situation is handled in a digital environment. "The site visit is absolutely the most important part of the vendor selection,"says Allen Wenner, MD, of West Columbia Family Medicine and a principal with High Performance Physician Institute, a group that trains physicians on the use of EHR.

12. Don’t skimp on training
My clients' experiences with EHR have taught me an important lesson regarding training. Many vendors offer Web-based training as a way of reducing costs. But remote learning doesn’t work for everybody. If you need on-site training for both the super-users and everybody else in your practice, buy it—even if you have to pay a premium. You are already spending a significant amount of money on the software, so learn how to make it work for you. Don’t be like a surgical practice I know that was one of the first to purchase EHR so it could be ahead of its competitors. When I asked this group how it uses data, the physicians confided to me that they had no idea how to use the software and, in fact, continued to use paper records!

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Resources
Centers for Medicare and Medicaid Services
CMS has created a Web page on its Internet site to help healthcare professionals interested in receiving financial incentives for using certified EHR systems.
www.cms.gov/EHRIncentivePrograms/

Carolinas Center for Medical Excellence
Offering a series of webinars on the federal stimulus package as it pertains to healthcare professionals.
www.thecarolinascenter.org

NC Area Health Education Centers
NC AHEC received grant funding to provide on-site consulting to primary care practices preparing for, selecting and implementing certified electronic health records. NC AHEC will also help primary care practices already using EHR ensure that they meet criteria for incentive payments.
www.ncahec.net

High Performance Physician Institute
Offers multi-day CME seminars nationwide on information technology for practicing physicians; also provides customized programs for communities and medical societies. www.highperformancephysician.com

American Academy of Family Physicians
AAFP’s website includes feedback from physician practices already using EHR systems, and other information technology.
www.aafp.org


Acknowledgments
Thanks to the following for their input and assistance with this article: Holt Anderson, Executive Director, North Carolina Healthcare Information and Communications Alliance, Inc., and State of North Carolina lead for the Nationwide Health Information Network (NHIN); Ann Lefebvre, Associate Director, Statewide Quality Improvement, North Carolina AHEC Program; and Allen Wenner, MD, West Columbia Family Medicine, West Columbia, SC and High Performance Physician Institute.