Phased or Bridge

Implications of the Phased Approach to EHR Adoption

The opposite of the "All at Once" approach is the "Phased" or "bridged" approach to EHR adoption. This is the more common approach, as it is perceived by many to be safer than the do-it-all-at-once approach. It may be safer (at least financially) but it isn't a road that always leads in the end to where you thought you were going when you started down it. There are usually some twists in the road and along the way a few crossroads may be encountered, or worse yet the road will fork and you will have to decide which "fork" is the fastest, safest and cheapest way to your destination. There are many advantages of the phased approach. It requires less money "up front"; it is generally perceived as "safer" as it allows more time for those impacted most by the changes to become accustomed to them and make the transition to the new electronic way at their "own pace". In some systems you can even plan provisions for those practitioners who will never change.

If They Don't Have It Now - They May Never Have It!

In multiple phased approaches, the group practice has some vision of what they want do with, for example, their paper charts - generally, a fully-integrated, fully electronic, paperless practice. The questions is, where to start and how to get there from here (usually rooms full of paper charts). Those less ambitious practices will settle for electronic charts going forward, while the more idealistic will delve into the deep water of converting some of their current paper into some form of retrievable, marginally indexed electronic representations of their current paper charts. Even the idealists in the end usually end up with some compromise where the oldest charts disappear to some off site storage bin, to collect dust for until the termites discover them.

Challenges With the Phased Approach

The major challenges with the phased approach overall include: 1) Finding a vendor that can deliver all the Phases needed as part of a single, integrated solution; 2) Determining what combination of capabilities to implement first; 3) Completing all phases before the EHR vendor's product line undergoes a technology or hardware platform "generation change" and you end up with new components of a now "legacy" system. None of these are insurmountable problems; they just take planning.

What Is The "Low Hanging" Fruit?

With all the emphasis on reducing medical errors, meeting quality standards and enhancing workflow, pick components for your phase 1 roll out that help to achieve some of these objectives. Many younger docs are already carrying around personal digital assistants (PDAs) so converting them to a practice-wide solution for Rx interactions lookup in real-time, a disease-drug cross-reference, decision support for antibiotic therapy or other components of a medication error reduction effort, (often lumped together under the title of CPOE -- computerized pharmaceutical order entry) may be one area to look into. While ePocrates and Patient Keeper move into the desktop space, there are some EHRs that are already there. Most EHRs that implement CPOE use a drug-interactions database licensed form 3 or 4 major vendors. Gold is our favorite at the moment, and also one of the newer ones. The Grand-daddy is First Databank, a Hearst company. There is also Multum (which Cerner acquired) and a couple of more. The point is, make sure any EHR you are looking at has ONE of these 3rd party, drug interaction modules embedded in it. Stay a million miles away from small EHR vendors that have embedded their own proprietary Rx interactions or information systems into their own EHR. There is simply no way a small EHR vendor can keep these current, with the rare exception of a vendor that designs systems for one clinical specialty where drugs are a minor part of the practice. Systems designed for mental health or for radiology or pathology might be exceptions, but the general rule for doctors working in most practice specialties is, restrict your attentions to vendors that license a viable, well-maintained drug interactions database from a third party.

Computerizing Those OLD Charts

Some EHR companies, like SRS and Dictaphone, delve right into the problem of those old charts. Their approach is either to:

1) extend transcription into the arena of voice-recognized, structured EHR (through the miracle of remote, centralized natural language processing) or

2) scan in existing records in such a manner that elements of the chart are at least indexed, and new information dictated by the physician at least, become (and are stored as) structured text.

Both of these companies are worthy of physician attention if the approach appeals to you. Recognize that there are downstream issues to be considered, as some would argue that neither approach yet leads to a fully electronic, fully structured solution that achieves all the goals of EHRs. Look closely at longitudinal, cross-office, cross-patient outcome measures. Remember, documenting quality and outcomes to the 33 different organizations that are developing pay-for-performance (P4P) incentives, is one of the major reasons and driving forces to adopt EHRs in the first place. Make sure with any approach that you obtain a system that can achieve this as its end-point, no matter how neatly it captures and stores information on each patient electronically. The MSP Reality EHR Selector™ has filters that differentiate those vendors that approach EHRs as an extension of either record scanning or voice recognition approaches. These can be enabled and disabled to evaluate how overall EHR objectives are met by various vendors. If you want to learn more about this tool, now would be a good time to Register now.