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Running head: IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS
Implementation of Electronic Medical Records in a Suboxone Clinic
Tonya Anderson
Auburn University/Auburn Montgomery
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Running head: IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS
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Abstract
The ultimate goal of change within an organization is improvement. This process is
usually triggered by a reaction to a specific problem or an opportunity that the
organization is facing. With the implementation of the Affordable Care Act which was
passed in 2010, health care will be making many changes to meet the new health care
policy requirements. The Affordable Care Act will refocus health care providers and
system to improve quality, education, and self-management of illnesses. There are
many influences of change. This paper assesses at the implementation of electronic
health records within a small clinic. It analysis the assessment for change, the
implementation of the change including the identification of the stakeholders, reason for
change, vested interests, human drivers, and resources, and the evaluation of change.
As health care providers we must be leaders as our profession undergoes many
changes. The preparation and assess for change is as important as the actual change
process.
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Implementation of Electronic Medical Records
With the implementation of the Affordable Care Act which was passed in 2010,
health care will be making many changes to meet the new policy requirements. The
Affordable Care Act will refocus health care providers and system to improve quality,
education, and self-management of illnesses. The Institute of Medicine and the Future
of Family Medicine have both recommended the use of electronic medical records
systems and information technology as tools for the improvement in quality of care and
for patient safety (Crosson, Stroebel, Scott, Stello, & Crabtree, 2005).
Legislation created a 2015 deadline for all medical facilities and providers who
receive reimbursement for Medicare patients to incorporate electronic health records
(EHR) in their system (Milstead, 2013). This requirement will also allow for data to be
shared among health systems. Other advantages of the EHR are to increase continuity
of care, increase efficiency of care and billing, increase job performance, and improve
quality. This technology will assist in the reduction of reduce duplicate orders, drug
interactions and allergy check, assist with educational information, and decision making.
The American Recovery and Reinvestment Act of 2009’s (Recovery Act) goal is to
further the implementation of health information technology which will modernize the
health care system through meaningful use (Process Begins, 2011). Meaningful use is
a set of standards defined by the Center for Medicare and Medicaid Services Incentive
Programs that guides the use of electronic health records and will provide providers and
hospitals to earn incentive payments be meeting specific criteria (Process Begins,
2011).
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Needs Assessment
This paper will be assessing the need and implementation of electronic medical
records in Dr. Jay Darji’s Suboxone clinic in Thomasville, Alabama. This clinic consists
of the physician and one nurse. The Suboxone clinic is open on the second and fourth
Wednesday of each month in which Dr. Darji commutes from Atlanta, GA to treat
approximately 60 patients. As a cash only clinic, insurance filing is the responsibility of
the patient if they are a carrier. Patients do not schedule appointments and are free to
come during office hour on those two days. Prior authorizations for the purpose of
medication coverage are done by the nurse in the clinic. Dr. Darji provided his patients
with his personal phone number for any problems or concerns with treatment when the
clinic is not open.
Suboxone (buprenorphine) is a medication used in a clinical setting to help opiateaddicted patients withdraw from and stop the use of drugs. In order for a physician to
prescribe and treat a patient with Suboxone he/she must take and pass an eight hour
course along with other qualifications. It is important that Dr. Darji treat each patient in
accordance with the established guidelines.
The Drug Addiction Treatment Act was passed on October 17, 2000 by congress
and permits qualified physicians to dispense and prescribe Schedule III, IV, or V
medications that have been approved for detoxification or maintenance treatment of
patients that are narcotic dependent. The Drug Enforcement Administration (DEA) is
responsible for seeing that the physicians comply with recordkeeping, security, and
other requirements for the administration including dispensing, and /or prescribing of
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these controlled substances under the Controlled Substance Act. (McCance-Katz,
2010)
Assessment Theories
Chaudron (2010) describes a four step process in the assessment and improvement
in an organization. The steps involves are the following: get started, assess, choose
treatment and use them, and periodic evaluation. The steps mimic the assessment and
treatment process of a healthcare provider. (Chaudron, 2010)
This is an assessment using the Chaudron’s (2010) steps. In the get started stage a
problem or need is recognized also known as a symptom. In the Suboxone clinic a
need to organize and simplify was identified by the physician. In the next stage called
assess, the initiator determines the depth of the need. In the clinic the need was not a
mandate or detrimental but more of a need to provide better documents and bring better
organization to the clinic to meet the guidelines of the DEA, have remote access and
increase the quality of care. Stage three is choosing a treatment and using it. As this
stage evolves the physician selected the EHR that best sued the facilities needs and
budget, educated his small staff in the EHR program, and stated implementing the new
system. The final stage described is to periodically evaluate. The evaluation of the
implementation of medical records has been and will continue to be evaluated by
accuracy of documentation, success of e-prescribing, and improves time and quality for
the patients in the clinic.
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Facility Assessment
A needs assessment should be used when making a significant change no matter
how small the business. An upfront plan will assist in the prediction of reactions,
outcomes, and how staff member react to the change. This will also allow for planning
how to handle these reactions.
Change
The ultimate goal of change within an organization is improvement. Change is
usually triggered by a reaction to a specific problem or an opportunity that the
organization is facing. When change is implemented there are several parts of an
operation that may be affected. These may include the organizations processes,
systems, organization structure, and job roles. (Creasey, 2007)
Change Theories
Kurt Lewin’s change theory is often used in nursing and involves three stages that
Lewin refers to the unfreezing stage, the moving stage, and the refreezing stage. This
theory focuses on the presence of driving forces and resistant forces. The resistant
forces are usually the employees who oppose the change while the driving forces are
those who are pushing the change forward. The success of the change is dependent
on which force is stronger. (Kritsonis, 2004-2005)
The unfreezing stage is about getting prepared for the change. At this stage the
driver understands that the change is necessary and begins to prepare others for the
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change (Medley & Akan, 2008). This may also include preparing equipment and
supplies needed for this change.
The moving stage in Lewin’s theory refers to the process of transition. This stage is
making the changes that are needed. This may be the hardest stage because
employees having to learn a new task and routine that they are unfamiliar with.
Training, coaching, and mistakes are also a part of this process. (Medley, et al, 2008)
The refreezing stage is about establishing stability when the change has been made.
At this stage the change becomes normal and employees are comfortable with the
change. The refreezing stage may take time. It is important that the change be
reinforced to insure that it is fully accepted so that it will be maintained in the future.
(Medley, et al, 2008)
Rogers’ change theory is a modification of Lewin’s change theory and referred is to
as “Diffusion of Innovations” that includes five stages. These stages include knowledge,
persuasion, decision, implementation, and confirmation. This is a theory that applies to
a long term change in an institution or organization (Orr, 2003).
During the knowledge stage the person becomes aware of an innovation. Then, in
the persuasion stage that person forms some type of attitude toward the innovation
whether it is good or bad. In the decision state the person begins to engage in activities
that lead to a decision to choice to adopt or reject the innovation. In stage four, the
implementation stage, the person puts the innovation into use. The final stage is
confirmation. The person then evaluated the results of this innovation that has been
made. (Orr, 2003)
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Each stage Roger’s diffusion of innovation can be seen in the implementation of
medical records in the Suboxone clinic. As part of the knowledge stage Dr. Darji was
aware that EHR would assist in the organization of information to ensure that the DEA
standards are met by his practice. In the persuasion stage he researched and found a
system that would meet the needs of his small clinic. The decision stage the doctor
registered for the EHR system and begin training in the system. When implementing,
Dr. Darji and his nurse entered all patient data into the system creating a data base.
The next clinic day the system was started. Copies of labs and other forms were
scanned and attached to the patient’s electronic chart. Dr. Darji created templates that
would allow easier charting of required information to meet requirements of DEA. As
confirmation he evaluated the use and accuracy of the system.
Implementing Change
The Suboxone clinic changed from the use of paper charting to using an electronic
medical record system. This was a complex change due to the multiple steps that must
be taken to accomplish the goals of the change. A large amount of time, learning, and
evaluating must take place to make a complete transition to EMR. The system used is
called Practice Fusion. This EHR is an ad-supported model which provides the program
for free. It is a web-based program which is accessible from any computer. The
features of the system include charting, scheduling, e-prescribing, billing, and a
comprehensive EHR and practice management tool. This system was created to assist
physicians in the improvement of practice efficiency while increasing security,
productivity, and quality of care and meets The Department of Health and Human
Service “meaningful use” criteria. (Electronic Health, 2012)
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Barriers.
Implementing an EHR system can have several barriers. These should be identified
prior to implementation. One barrier is that the older paper charts must be incorporated
into the new EHR. This may be done by scanning the file and attaching the file. This
can be very time consuming and very difficult to read depending of the quality of the
scan. This is a process that was implemented in the Suboxone clinic and was a large
task although the clinic opened in May of this year. The quality was fortunately good on
each scan. Another barrier is privacy which is a priority with both paper and electronic
records. By using Practice Fusion the software is insured to have a highly secure
environment as part of the package. The limitation of hardware is another barrier that
was also considered and seen as a barrier. Practice Fusion is web-based so the clinic
does not have to use expense or hardware space to update the program. Cost can also
be a barrier and identified before implementation of EHR. With a small clinic like the
Suboxone Clinic it was not feasible to incorporate an expensive system. Practice
Fusion was the right software for the clinic and selected after research by the physician.
Another barrier is internet downtime. This must be considered and planned for with
back-up paperwork in order to continue without interruption to patient flow. Fortunately
there were no major problems with the change process. It was well planned by the
physician and nurse.
Stakeholders.
A stakeholder is defined as “a person or group that has an investment, share, or
interest in something, as a business or industry” (Stakeholder, 2012). Dr. Darji is a
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stakeholder in this change. He has implemented this change in order to make it easier
to meet the documentation criteria of the DEA, improve patient care, and for
conveniences such as e-prescribing. Electronic health records are also providing
remote access for the physician who does not live in the area of the practice.
E-prescribing allows the physician to send prescription requests directly to the
pharmacy of the patient’s choice. This eliminates the physician from having a
prescription pad that may become lost or stolen. It also requires the patient to be
consistent with the use of one pharmacy and decreasing the chance of error by the
physician. Many times pharmacies will alert the physician because the patient is using
multiple pharmacies.
The software company is also a stockholder in the success of its use. This company
is an ad-driven company the drives its product through its success. Many software
companies must be purchased and are very profitable. Overtime the systems must be
upgrades with also comes with a price. Software companies must ensure that their
product is efficient and meets that needs of the institution to stay viable.
Reason for the change.
The main reason that this change was necessary is to assist in meeting the
guidelines of the DEA for the distribution of Suboxone. In this case the change is not
being implemented due to the policies for Medicare or Medicaid reimbursement nor is it
a mandatory change. This change will help meet the goals of the Institute of Medicine
by ensuring health care to be effective, safe, efficient, and individually focused on
specific circumstances and needs. EHR gives many more benefits by providing more
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accurate data with fewer mistakes, higher quality due to speeder service as the all
records are at easily accessible, allows the doctor to have more time with the patients
and less time making and filing noted, the records are easily adaptive to how the
physician documents, provides lower supply cost with less paper, ink, coping, ordering
forms and files, and provides lower staffing cost giving practice higher revenue.
Vested interests.
The implementation of the EHR system is a gain for the physician. The physician
will have access to medical records at all times even in remote locations in case of a
need to call in a prescription or if the nurse needs to submit prior authorization for
medications. With Suboxone being a regulated medication with guidelines for
prescribing, the DEA can come to inspect or audit a clinic at any time. According to the
Drug Addiction Treatment Act of 2000 the physician must comply with recordkeeping,
security of records, and the requirements of prescribing the medication (McCance-Katz,
2010). If an inspection or audit does occur the DEA will be looking at prescription
records, dispensing records, and adherence to patients limits. As a prescriber the
physician may only treat 30 patients in the first year of licensure and may increase to
100 patients after that first year McCance-Katz, 2010). With EHR the physician can
easily monitor the number of patients, the prescriptions, and treatment plan for each
patient. The physician is wise to implement the EHR to protect his practice. No one
was identified as losing in the change.
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Human drivers.
The physician again is the driver of the change to EHR to maintain compliance with
the DEA, improve patient outcomes, minimize paper, ensures privacy, and allows
remote access of medical records.
No resistors have been identified in this change. The only persons involved in the
change and transition are the physician and nurse. Both were equally willing and
excited about the transition and agreed that it was the right choice for the practice and
the patients.
Resources.
Resources are needed to implement change. In the implementation of electronic
medical records in the Suboxone clinic the following resources were needed: two
computers, EHR program, internet, a scanner, and a printer/fax. Most clinics have
computers that can be used for documentation. In this clinic the physician and the
nurse use their personal computer for documentation. This minimized cost and with the
EHR being web-based no software had to be downloaded to the personal computer.
The software, as mentioned before, is called Practice Fusion is a free, web-based,
ad-supported program. The program is ideal to meet the needs of the clinic and budget.
The program features charting, scheduling, e-prescribing, billing, and a comprehensive
EHR and practice management tool. It also is adaptive to the physicians charting
needs by allowing the physician to create templates. Internet service is necessary for
the program to work. Other resources identified were a scanner to incorporate any hard
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charts into the EHR and a printer/fax for the need to print medical records for the
purpose of medication insurance prior authorizations.
Evaluation
Before closing a change, an evaluation should take place. An evaluation is the
systematic collection and assessment of information related a change to assess the
outcomes and operation of an organization. By using this process the organizations
quality of service and productivity can be explored.
Evaluation Theories
The Input, Process, Output, Outcome Model (IPO) is an approach used in the
evaluation of a change. The input stage is an evaluation of the system performance
indicators. These may include the qualifications of the trainee, the availability of
materials, and appropriateness training. The process phase is embracing the plan,
design development, and delivery of the program to train. In the output phase we
gather result from the training evaluation. In the outcome phase long term results
associated with improvement are assessed. This is the bottom line, results, profits, and
even competitiveness. (Eseryel, 2002)
Kirkpatrick’s Learning Evaluation Model provides four levels of the evaluation of a
training which can also be applied to change. These four levels include the reaction,
learning, behavior, and results. Kirkpatrick’s model follows a goal-based evaluation
approach (Eseryel, 2002).
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The first evaluation level is reaction. The reaction evaluation is how the participants
felt and their reaction to the training experience or change. The next level is learning.
This level is the measurement of the increase in knowledge before and after. Level
three is behavior evaluation. This is the extent of applied learning back on the job or the
implementation. Over time change, relevance of change, and sustainability of change is
assessed. The final level is results. Results evaluation is the affect that the change has
had on the business or environment. (Clark, 2012)
Kirkpatrick’s evaluation model can be applied to the Suboxone clinic. The first
evaluation is the reaction stage. The physician and nurses were both involved in this
stage were both excited about the transition. Each felt that the transition was easy. In
the learning level both the physician and the nurse adapted well to the software. The
system is user friendly making it easy to make the transition. In the behavior evaluation
the physician was able to adapt the system to include templates for the patients to
include the proper documentation for care and implement the e-prescribing properly. As
the use of the EHR is used over time the physician and nurse will continue to learn
more features of the system. The results level in this case has been positive with the
improvement in documentation, prescribing of medication, and ease of use in the EHR
system. The level will continue to be evaluated as the clinic continues its use.
Conclusion
Change is unavoidable and many times constant within health care. With the new
policies established by the Affordable Care Act health care facilities at all levels must
prepare for change.
This paper provides a base for assessing, implementing, and
Running head: IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS
evaluating change.
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The process begins with assessing a need for a change and
continues through the evaluation process. As health care providers we must be the
leaders and drivers of this process.
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