Implementing Electronic Records

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Personnel need to have a complete understanding of current workflow and set specific goals.


The first part of this article, which appeared in the August issue, discussed the benefits of the electronic health record, how to decide whether it is justified for a particular practice, and how to select and purchase a system. This second part provides guidance for installation and implementation.


Once a practice has purchased an electronic health record (EHR) system, it is important that it be installed properly. One way to prevent installation problems is by establishing an internal committee consisting of the right people. This EHR team must set a realistic transition plan that incorporates changes in workflow and explains how the practice plans to use the new technology—whether it is phased in or implemented all at once.


A phased-in plan gives the staff time to get used to the new system by setting increasingly higher goals or controlling the number of features available at one time and slowly adding more features as the staff becomes more comfortable. Implementing the system all at once keeps the practice from having to manage electronic and paper processes simultaneously and gets everyone up to speed at the same time. But the transition should be well prepared.


The preparation for installing the system must include gaining a complete understanding of the current workflow of the office, and setting specific, measurable goals. The AmericanCollege of Physicians (ACP) provides a checklist in its practice management center to help analyze your workflow. Decide what portions of existing charts will be included in the EHR and develop a strategy for entering that data.


Customized templates that fit your practice's operations can speed data entry during daily use of EHR. The software will come with pre-designed templates, but taking the time to customize them to match your practice's workflow will ensure more efficient use of the system. Your practice should decide whether the templates will be developed as a group or individually, balancing flexibility and structure to ensure the maximum amount of data is made available for reports while allowing for each physician's style.


“No matter how many demos you see or other practices you visit, until you start hands-on with it, it's difficult to understand all of the bells and whistles,” noted Larry Lehrner, MD, of Kidney Specialists of Southern Nevada and board member of the Renal Physicians Association, who

has been using an EHR system since August 2005. Dr. Lehrner, helped customize the EHR system at his practice by designing nephrology-specific forms to replace the forms the vendor provided. While most of the custom forms were created before the practice began using EHRs, he said, developing the templates sooner could have provided staff with more time to train.

Basic implementation

Implementation usually requires about three to six months of preparation and about two months of actual “start-up,” when the EHR replaces the paper system. It is advisable to leave a safety buffer for everyone on staff, perhaps by scheduling fewer patients the first day the system is up. Your practice should create an ongoing plan for support, ensuring that everyone knows where to get answers.


Dr. Lehrner said his practice followed the vendor's recommendation to see fewer patients initially, but that there was still a big adjustment for some physicians.


“Productivity drops off tremendously,” explained Dr. Lehrner, adding that drop-off continues to affect some physicians. Some have even extended their appointments from 15 to 20 minutes, and lengthened their workdays to allow time for the new procedures, Dr. Lehrner said. The doctors in his practice use the system to fit their comfort level. For example, Dr. Lehrner completes his notes and enters data in front of the patient on a tablet PC in the exam room, while other physicians take handwritten notes and enter the data into the system later.


One way to achieve success during implementation is by finding balance between disruption of workflow, and putting features and functions in place, stressed Franklin W. Maddux, MD, former president and chairman of the Danville Urologic Clinic in Virginia.


“Balance is always something that will need to be reassessed because the practice will go through times when it can accommodate more or less speed, based on other things going on,” Dr. Maddux added. For example, during some of the implementation time when his practice went paperless, the practice also was building two dialysis units, so some progress was slowed down to accommodate the disruption, he said. 


Improved data access in EHR systems can also help practices participate in pay-for-reporting/pay-for-performance programs. Pay-for-performance (also known as value-based purchasing) encourages quality improvement and high-value patient care. It can be expensive to submit paper claims to the Centers for Medicare and Medicaid Services (CMS). A system with a reporting capacity that will allow a practice to report its performance will be indispensable as federal requirements for Medicare reimbursement change.


An EHR system also pulls different pieces of a database together in a reporting format. The type of analysis Dr. Lehrner can do with electronic records would be difficult and time-consuming to do on paper, he noted. But now, he can retrieve the data he needs with a few keystrokes at his computer, and improve the quality of patient care.

This information was provided by the Renal Physicians Association of Rockville, Md. (, which has partnered with Renal & Urology News to create this department. This article, which is the second of two parts, is based on material that appeared first in RPA's newsletter, RPA News.

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