Too Much Too Soon

The Implementation of Electronic Medical Records in an Urban Primary Practice

Written by Scott Sitner and Stacey Marie Chapman October 2011

The decision to buy and implement an Electronic Medical Records system is, in and of itself, a major undertaking and practice altering decision. Financial considerations, legal ramifications, practical concerns and patient and practice management concerns all go into the decision to make the leap or to accept the financial ramifications if you dont. This articles intent is to give physicians in a primarily Medicaid/urban setting, a grasp of the issues they will encounter, the problems that are inherent in starting with electronic medical records in general, and the concerns that this type of office will have to address, which are vastly different than more modern, suburban settings. While EMR systems are at the forefront and cutting edge of medical technology and may hold the promise for a safer, more secure patient care, our experience is clear: buyer beware before jumping in. I was asked by the Clinic, partially owned by family, to act as general legal counsel for the contracts and implementation issues and any issues that would arise regarding privacy and patient care. Additionally, I was also to act as a Project Manager, as the Clinic simply had no one who could step into that role, without impacting their day to day operations. I have learned as much about practice management as I ever thought I would need, but despite 20 years of business consulting and management experience, nothing I had done could have prepared me for the role and actions I would be undertaking.

The Clinic
Junction Clinic PC, is by its own admission, a unique entity, having begun fifty years ago by two young Osteopaths, both born and raised in Detroit Proper. Having gone to school there and graduated from Des Moines College of Osteopathic Medicine and Science in the early 1960s, both doctors were committed to having a private practice in Detroit Proper, which was at that time, thriving. The auto factories were the center of the local economy and just a few miles away, employing tens of thousands of workers. The neighborhoods were bastions of middle class, with small well-kept homes, good schools and nuclear families. It was a perfect place to take over a small family practice and make it their own. The practice has now survived for 49 years, celebrating its fiftieth year in 2012. It has seen the changing face of Detroit and society. The neighborhoods went from middle class to impoverished, the factories closing and its residents moving out to the northern and western suburbs. After the riots of 1967, the doctors, who actually crossed into the city during the riots to stay open, had to make a decision whether to stay in Detroit or follow their fellow doctors to the suburbs. For many reasons, they elected to stay where they were, even upgrading in 1973 to a brand new building only two blocks from where they had started and where the practice still exists to this day. (The old office which was vacant for years, is now a trendy restaurant.) Over the following decades, the Clinic has not only survived, but thrived, providing Primary Care services to an urban population, now largely on some form of public assistance, a substantial majority of which, are Medicaid and Medicaid HMOs.

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The clinic has thousands of office visits a year, employs three doctors, two physician assistants and over a dozen office staff, some of whom have been with the clinic for decades. Also included is this writer, who has helped out with legal and consulting advice over the years and was now charged with being the project manager for the EMR roll out. Needless to say, the Clinic knows how to operate, changes only if and when it needs to and is secure in its place in the medical hierarchy. It is not fancy, there is no plasma TV in the waiting room, it takes no appointments, and up until recently only used computers for billing, checking email and the news. It was, and is actually, a system that worked, so, as the doctors asked many times before agreeing to implement an EMR system: why? The answer to this came in two parts: 1) Because you will have to; 2) Because you will get paid something; The first answer was the least satisfying, and as the clinics project manager and occasional legal counsel, it was left to me to explain to them, with the help of its partner hospital, that in some sense, they had no choice. It would just be a question of how and when it would happen and how bad it was going to be. The second answer provided a little bit of relief, but at the end of the day the amounts they would get back, spread out over so many years, did not come close to offsetting the totality of its actual cost. Quietly disregarded were the physical costs, employee downtime, training and the amount of aggravation to both doctor and patient that would go into making the decision and going forward with what was and is, a substantial change to how the practice had run, and run successfully, for close to fifty years. But at the time, the decision, although slightly forced, seemed reasonable. In September of 2009, in what was really not much more than a sales pitch in hindsight, the Clinic decided to sign the contracts to implement a system for the office, personally obligating the doctors to over $100,000 in financial liability and the practice to a fundamental change in its operation. The system that was chosen (a word used with a touch of sarcasm), was not based on what was best for the doctors or patients, but instead on what was presented to them by the hospitals chosen vendor, and the hospital itself, which was offering a subsidy (although to this day no one seems to know exactly what it actually covered or how much) and a well-meaning sales representative from the vendor. No one actually took the time to look at the clinic, evaluate the practice, what is the patient population, and most importantly, how does the clinic work and what does the Clinic need? While the word workflow is a grossly overused one and in some sense, one no one really seems to understand, in this case no one even asked about it, the conversations taking place in the doctors private office and not out on the floor where it should have. Lost in the shuffle was the simple question; should this clinic, even with the incentives, obligate itself not only to this company but to an EMR system at all? What are the benefits, what are the costs, and is it, at the end of the day, something that would ever work in this setting? After all was said and done, the decision was made, the contracts signed and the process begun. The clinic is, as are many clinics in a similar urban low income setting, technologically challenged. Its infrastructure consisted of a number of old PCs, some still having floppy drives, a broadband internet

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connection, aged dot matrix laser printers, no scanners, and a billing connection set up, which, while familiar, was quickly becoming unusable. There were no laptops; nothing could be done on the computers except for billing and some patient insurance verification. Even more importantly, was a fact that our clinic, similarly to other urban clinics, typically have staff simply not trained or educated in the changing face of modern practice management. The staff are all very skilled in what they do, mostly medical assistants, and very capable, but not trained in modern medical office practices, nor even really trained in basic computer skills except what was needed for billing. Adapting a sophisticated, challenging and totally new EMR system in such an office would turn out to be one of the biggest challenges the clinic had faced since it opened. The clinic is a paper office. With thousands of patient files behind the front check-in counter, mostly in alphabetical order, doctors and assistants would simply write notes in the file, order tests and put the file back when done. Billing information would be on the front of the manila folder, a chart of vaccines for the kids, vital statistics and then, for the most part, just blank record forms where notes would be taken and put back in the file. Nothing fancy, but at the end of the day, it worked and worked for them. Records were easily located, information was accessible, and everyone simply knew where everything was. To make a wholesale change to electronic records flew in the face of the established practices that did not seem to need changing. It was, it seemed, change for the sake of change, without really examining whether in this setting, such a change would offer any benefit to the clinic, its doctors, and most importantly, and to this point largely lost, its patients. Or was this just something they had to do? The first issue the clinic faced was the lack of any upgraded technology. As Junction Clinic is self-funded, it has only a loose affiliation with a hospital and does not get the benefit of the hospital buying equipment. The clinic was told, again without really an evaluation being done as to what right for them, to purchase four tablet computers, six net books, and a scanner. Of course it had to upgrade its network and infrastructure as well. At the same time, as part of the overall purchase, a new server had to be put in for the software (which was part of what was purchased initially). All told, the cost was over $25,000 in equipment purchases, again, out of pocket for the clinic, which was already seeing a reduction in revenue. The office was then told that the physical setting for the new server was not good enough, there was no place in such an older office that was safe for the server, and that the desktop computers were too old and needed upgrading. $2500 later for an electrician and networking expert and two visits from the EMR Companys designated network person to get things set up, the system, six months after the contracts were signed, was in theory, up and running.

Training and Implementation

The largest issue the clinic has faced and the one that had the biggest disconnect between the EMR providers history with other clinics and Junction Clinic, was in the training and the actual use. First, the sheer number of people who were on our team from the system side was amazing. What was more amazing was that none of these people was very good at responding to issues and none of them, as a general rule, would take a phone call, once going so far as telling the Clinics doctors, not to call, but to e mail. This told to doctors who did not e-mail and just wanted someone to talk to and get answers from. It was almost shocking that it was so difficult to get anyone to assume responsibility, with each person saying, no that is not me, but I will get you to the person who handles that on your team.

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On one hand it was nice so many people were involved, on the other it was not so nice that none of them seemed able to answer questions as simple as how many hours of training are left or when training could occur or why were we being charged for something we did not use? It was also clear from day one, that from the first roll out phone conference I had, that Junction Clinic was nothing that this Company had encountered and that it clearly did not fit the mold for which the system was developed. The questions that were asked by our team to get the system up and running were designed for suburban clinics; ones who had the ability to shut down for three days to train, that makes appointments and keeps them and has a staff that is technologically advanced and trained and computer savvy from the start. More than one time, the clinic was asked how it makes and keeps appointments and how it handles no shows. More than once they were told that no appointments were kept, as the no shows would be so large in number, it was pointless to do so. The trainers were also not at all ready to handle a staff that was very well versed in their jobs, and knew how to handle the patients, but did not have a lot of technical training and did not use words like reach out. There was an inability to deviate from the training script and to make changes for the clinic on the fly, changes that were needed for the system to work in this setting. If something did not work, there should have been a way to make quick changes, especially given that the providers, who are also customers, are spending a large amount of money every month- over $2000 for the system and another $1000 for software upgrades and other mandatory fees. But there was not. The trainers, who were all well-meaning, and clearly well versed in the system, were not able to wrap their hands around this Clinic, as it was such a different animal. Junction Clinic, as with most Medicaid/Urban Clinics, has to see people fast, make decisions and evaluations based on what is front of them, and move on to the next patient-or they do not survive. With reductions in reimbursements, increasing demands on staff for reporting requirements, increasing time to bill and general office work, urban clinics must see patients fast to survive. EMR systems, just by their nature are slow. Doctors must type, flip through different screens, load a patient into the system and then check the patient out, all the while trying to be a doctor; communicating and diagnosing. It just cant work in this setting; especially with physicians who are older, not as familiar with technology and are resistant to using it. The system was great for evaluating and treating a patient when there is unlimited time to do so, and 45 minutes blocked out per patient, but for us, for dealing with a mom and her two kids coming in for a preschool checkup or the sniffles and a fever, it was actually substandard. Flow charts that usually ended up far away from the reality, turned a cold into cancer and were just not at all suited for a family practice. Quick office visits were the expected norm but unrealistic. The templates, valued and propounded by the vendor, simply had too much information in them, too many steps to go through, for things like the flu or a virus and could not easily be adapted for a primarily Medicaid/almost exclusively family practice clinic. Most critically, those templates were not at all user friendly. Clinics are not cookie cutter offices, which is how the system is set up; one size fits all. Practices such as this are different and need a system that can see people, allow the doctor to take notes and record vitals and make conclusions, doing so quickly. The system now in place is simply not adapted for this type of setting. The information may be there and the ability in certain settings is acceptable, but not in this setting.

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The lack of adaptability and flexibility costs the clinics and its providers in more ways than just patient care. While it is not a comfortable conversation; clinics are businesses, in this case, one that employs full or part time over 20 people, has an onsite pharmacy and is a valued member of the community. It pays property taxes, enhances the community and serves a vital role in an area where a clinic is more likely to close, then to remain open. When a doctor goes from seeing five patients an hour to just two, people do not get seen, diagnosis and treatments do not happen and the staff gets frustrated. In some cases patients leave, who may or may not come back and quite frankly, revenue decreases. The staff gets especially frustrated when they are confronted with technology that they were told would make their jobs easier, but in reality makes them harder. EMR companies need to be aware that there is a flow to an office that cannot be generalized. Those patients who have been coming to the clinic, in some cases for fifty years, generations of families, do not like change and loyalty can be short lived. When doctors have to take time away from patients to enter information into a computer, they lose the interaction, the face to face, that can be so critical to a diagnosis, or to just a personal relationship that is so valued by a patient. What was learned is that the technology did not address the human side of treatment. People who went to the doctor as much for treatment as they did for personal well-being, were faced with a doctor who now had to stare into a computer, try and find a template, try and take notes, all in a way that works for both practice management and patient care. With this system and others that were looked at after, this simply was not possible without a great deal of changes. Junction Clinic went through four different sessions, each between three and four days, of on-site training. However, there were different trainers, each with their own philosophy and frankly, their own interest and ideas on how such a system should work. One of the things that we questioned right off, was why was there not just one person assigned to the Clinic, who would learn the flow of the practice, the patient population, how things work in this Clinic, who could be a constant resource? The greatest improvement we would suggest to EMR providers is to tailor the training to the clinic, use people with a background in family practice (or whatever specialty), in a similar setting, who will understand the needs and wants of the providers-not just show what the system is capable of, which is nice, but of little practical value. The other issue is the sessions are spread out often by months, so one person comes in, trains for a week and then three months pass. Unless the staff is ready, which they rarely are, the system breaks down and what was learned is long forgotten. The Clinic has now gone through four training sessions and has forty hours of paid time left. No one from the vendor has called to see how we are going to use that, or even just checked in, which is something even a car salesman does once a year. When we had serious accounting issues that most businesses would be able to reconcile in days, it took four months to simply get an accounting of the money that has gone in and out. The Clinic largely feels abandoned, with no one and nowhere to turn, to help make that determination of where do they go from here. Or do they go at all? Most importantly, as a customer, they did not feel valued. It is this lack of continuity, usability and accountability that has left Junction Clinic in a middling grey area. Its first Medicaid incentive payments were received. Now the Clinic is faced with the question of whether it is worth the time and the effort to continue to use the system, or frankly any system, or simply let the chips fall where they will and suffer any financial penalties imposed.

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The incentives offered are helpful, but in many ways do not even begin to offset the financial and human costs that have been incurred and as a long term commitment. A decision has to be made whether or not to simply scrap the project and incur the penalties that may go along with that. The clinic may well be willing to suffer the financial loss that this would entail, but would not have to undergo the hassles and hardships that even attempting to implement the system has caused. It is clear that the government mandates to implement EMR systems into offices are well intentioned, but lacked foresight and practicality for many physicians today for this type of primary practice office. Changes need to be made, from fewer government mandates, to greater financial incentives, to extending deadlines and more awareness of patient impact. It is not a liberal or conservative bent but rather a practical one. People in Congress and the experts they use, simply cannot understand the needs of a medical office to not only be technologically up to date, but to combine that with patient care. This is something that has been lacking in the end game. My contact with Stacey, who has authored the second part of this paper, arose out of my own need and after having acted as a project manager for the clinic, to see if other clinics were, in fact, encountering the same obstacles. As Stacey points out below and we wholeheartedly concur, using resources not offered by the vendors, such as Independent Consultants, can be of great assistance to the clinic-not only in the implementation stage, but also in the initial acquisition. I have no doubt that had the Clinic been presented with options, rather than being told, essentially, what they had to buy, we would be in a much better situation than we are now. To that end, it is, I think, critical that readers of this paper, whoever they may be, learn from this Clinics experience, but also takes the following to pay heed to her sound advice.

What Scott describes in the previous pages is indicative of the struggles that so many practices experience and is especially synonymous with small ambulatory practices. It is also the catalyst for how Scott and I met and now have come to be working together. It is through his and Junction Clinics need to remedy and redesign an implementation, which cost an extraordinary amount of money, with little return for its investment, that we embark on this venture. With that, lets start from the beginning. My name is Stacey Marie Chapman, with PTS Consulting, and Ive been working in the EMR industry since 2007. Since that time, EMRs have evolved remarkably, though sadly, the struggles with the implementation of them have not. The implementation of an EMR is a very expensive endeavor, both financially and emotionally. It changes the very cultural backbone of a practice and requires tremendous commitment and patience from all involved. While I certainly am thoroughly aware of Meaningful Use and the incentive money, it cannot be the only reason given why a practice should implement an EMR. I encourage practices to focus on the benefits of a properly installed and fully functioning EMR such as: continuity of care, patient safety, patient satisfaction, additional space, saved expenses on office supplies, time saved, practice resale value AND additional incentives from programs such as P4P, Quality Reporting, ePrescribing and Meaningful Use-not to mention the avoidance of penalties through Medicare.

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The undertaking of such a volatile process needs to commence with the practice having a clear understanding of the journey they are about to embark upon. Proper preparation is critical for practices and a crucial first step I often see overlooked. Some practices can prepare in a month, some can take 6 months or longer. When working with a practice, one of the first things I do is to sit with them to understand their reason for implementing and offer a solid roadmap for the course they are to proceed upon. No one wants to feel lost in a process, especially when it comes to a foreign one. Sitting with the individual members and discussing their goals, pain points, ideas, and fears offers insight into the practice and allows a Project Manager to offer a customized solution and a roadmap that is crafted with the clinic at the heart of it. Its your practice, your livelihood and your process-for long after a consultant walks away, the practice will still remain. When Junction Clinic began to investigate their options, hospital subsidies offered discounted pricing. While this may be enticing, the saying the most expensive EMR youll purchase is your second rings true. One time subsidized pricing will not matter if the practice cant keep pace with patient load and properly bill for their services rendered. Understanding their needs and goals is a critical first step in identifying the potential vendors. The step of choosing an EMR platform can be arduous but is well worth the effort. Focus should be placed upon things such as customer satisfaction, practice culture, technical proficiency, IT support staff, as well as usability, specialties served, and workflow. Does it meet the needs of the practice? If Meaningful Use is an objective, is the platform ONC-ATCB certified? Working with a trusted Consultant through these steps can help provide guidance and negotiate price.

When navigating your way through demos, make sure that the salesperson targets the demo to the needs of your practice. Come up with scenarios and questions specific to your practice to ensure the product can deliver to your specifications. Observe things such as ease of use, speed and the number of clicks you have to go through to perform a common task. Ask your questions and ensure they are answered to your satisfaction. Remember, this is a vendors sales demo given by gifted salesperson and you will likely be impressed by all of them. While what you see is impressive, does it suit your practice? Can the platform be successfully manipulated or customized to suit the needs of your practice? Ask the salesperson to step you through some of your typical visits, demonstrating all of the features pertinent to your use. Keep checklists and notes of each demo, providing yourself with a means with which to later weigh out the pros and cons of each. Next, do your homework! Ask for reference sites from the vendor-practices that are similar in size, staff, patient load and specialty. Call and speak with them and if possible, ask to do a site visit. Visit forums, blogs and conferences to hear the positives and the pain points of practices. Speak to colleagues who have gone live to get their experience and how they like the system that they chose. All of the aforementioned will give you a better understanding of how the company conducted its processes once the contract was signed. With the decision made and the contracts signed, Junction Clinic begins the process of an EMR implementation. First stop; hardware assessment. Or, in the case of Junction Clinic, its lack of hardware. Hardware selection is an aspect that needs to be carefully considered on many different levels; the

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computer proficiency levels of the practice, IT support structure, and functionality and of course, the budget. When implementing, for any practice, the procurement of the hardware should always commence the same way: assessing the technical proficiency of the practice. This part of the process is invaluable for understanding the culture of any organization. As Scott mentioned, the practice is very good at what they do; skilled and capable, resigned to their own way of doing things. On paper. When I explain to a practice why I administer a computer proficiency assessment I reflect on and highlight those very same points. The providers, clinicians and staff have all been providing exemplary care without the need for computers, so without that dependency; why do they have to know how to use computers? Surprisingly, many healthcare professionals lack basic computer skills. Before we can expect a staff member to use a complex program such as an EMR, they have to know the basics of how to point and click, surf the web, type and send an email and create a document in Word. Knowing this is a sensitive issue; a back to basics approach can eliminate great frustration and empower individuals too embarrassed to admit their need for preliminary preparation. When making purchasing decisions of this magnitude you must consider the culture of the practice. Besides cost being a factor, you must also consider the skills of the persons using the hardware. Is it necessary to go with the latest and greatest touch screen tablet with a stylus? Or in Scotts case-four tablets and six net books? For a practice entering its fiftieth year, desktops; properly and strategically placed would have been my first suggestion. As the procurement process continued, Junction Clinic was faced with what little hardware they have being outdated, a server room and network infrastructure that is not up to specifications and a hardware bill quickly growing out of control. The thought now comes to mind as to why a SaaS (Software as a Service) model was not introduced. Hosted by the vendor, a SaaS model eliminates the need for servers, server rooms and construction. It allows the vendor to host the solution for its client, allowing web based access for the practice with the use of an internet connection. For a practice with a culture such as this, a SaaS model would have been ideal and would have come at an enormous cost savings. While not for every practice, consideration needs to be given to the actual practice at hand and what is the most cost effective, convenient model that can be utilized. For the client-server model, once you buy software, servers and network hardware you are obligated to maintain them, which means you need to have IT support. Whether you hire staff or enter a contractual arrangement with an integrator, it is an area in which you were likely unprepared for and a cost you werent accounting for in your budgets. Since your practice now relies on IT, that person or organization you employ becomes critical and a potential single point of failure. You need to trust them implicitly and they need to be competent and dependable. Do you know how to screen these candidates? Or how to negotiate favorable terms and conditions for your practice? Like it or not, youre now in the IT business too. With a SaaS model, you are relieved of much of this burden, however, at the expense of another long term monthly bill. Moving along, we come to the implementation team introduction. Scott mentions the people throughout his implementation on his team. Ive worked on one of those teams having spent two years working for

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an industry leading EMR vendor. I worked very hard, long hours and was very dedicated-as I know were all of my colleagues. I have the utmost respect for everyone there and their tremendous work ethic. However, I also know that there is not enough time in a day for these teams to manage all of their day to day tasks easily. Scotts experience is not uncommon. This is not to say that Junction Clinics frustration isnt justified and they are not alone. A practice deserves answers and assistance every step of the way, when making such a sizeable investment, in a product they do not know, on a path that is not clear. Having one point of contact, both from the clinic and the vendor is essential to clearer communication. Many vendors offer Account Managers to alleviate this very concern. Does the vendor youre choosing dedicate account managers? If you dont know, add this question to your list. As mentioned, I worked for the vendors and had this exact role. Clients had my cell phone number; days, nights, weekends, and holidays-I was always available to answer questions on a first name basis with my clients. Weve already touched upon practices that are not technically savvy and that maybe this is part of the practice culture, but each practice has its own workflow that likely took years to evolve. Workflow is a key consideration in the implementation plan, but it is key for different reasons and in different capacities. It is important for the workflow to be mapped out, even if simply in a Word document. This workflow should be mapped out and dictated by the actual workflow of the clinic. Not the way it is perceived, or desired to be operating, but its present tense operations. It is important to determine this for two reasons; so that the vendor understands the practices needs and so that the trainer can prepare effectively and understand the processes prior to arrival. As the use and understanding of the EMR improves, mapping the before and after workflows will improve processes. As a consultant, when working with a practice in training, it is important to know the workflow processes in place, to effectively manage the training process, but also to work with the practice so that it is understood, that while their current flow is important, it will also alter as it becomes electronic. This divide between paper and digital can often be difficult to understand and envision. If explained and illustrated, a practice will be more acceptable of letting go of the old and slowly embracing the new. As we embark on that embrace- albeit the standoffish embrace you give your 90 year old aunt who always leaves lipstick marks on your collar and smells likes Vicks, embrace, remember this: EMR is not paper. It is more time consuming, especially in the beginning, and more thorough. It will also never be an out of the box solution, a phenomenon weve all come to expect in todays culture. Templates need to be discussed, created, modified, deleted and reborn again, in an iterative manner. As with anything new, there will be a learning curve and templates are no exception. With vendors that allow the manipulation of templates; it is an additional process for the clinical staff to undertake, but one that must be explored to best align software and process. Taking a practice specific approach to the design and augmentation of these templates, while time consuming, will allow the practice to determine best practices for them. Additional means of input should also be assessed, such as Voice Recognition and transcription (through various means). The trick with workflow, templates and data input is that there is no one size fits all, as Scott has learned. Change can be difficult for a practice, but often overlooked and equally as important, change impacts the patients of a practice as well. I advise practices to engage their patients, inform them and prepare them for the modifications the clinic is about to make. As an implementation comes to a close, I bring in posters for the practice to hang in various places throughout its locations. Explaining in English and the most

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predominantly spoken language of the patient demographic, the posters illustrate the changes they will be witnessing and that they are a result of an initiative to improve patient care. No one likes longer wait times at the doctors office, including me, but if patients are prepared for the changes and are informed and engaged as they arise, their level of tolerance will be better than inexplicably standing in long lines at check in. As efforts are made to inform and include patients in your process, ensure that considerations are also made for their benefit. Keep design in mind as you make procurement decisions. There are a variety of hardware choices to ensure that clinicians do not lose face time with their patients. No one wants to look at a doctor's back while they click on the keys. As EMRs have evolved, so have their method of delivery and usage. Wall mounts with arms, carts on wheels, tablets, iPads and more, have been designed to incorporate the ability to input data, while maintaining the face to face communication necessary to see patients. Again, each practice is different and can use one or all of the aforementioned, depending on personal preference. All considerations made should include input of key staff members on an internal team, to champion the successful adoption of an EMR. This team should be determined early on, taking team members that are technically proficient, ready and able to undertake the challenge and to do so with a positive, encouraging attitude with which to mentor other members. Referred to as Champions, it is an important and fundamental role in the success of the process. Champions take all of the items mentioned in all of these pages into consideration and represent the clinical, financial and technical components of the practice. They are the cheerleaders of the implementation and help guide the practice internally through the training. Their role will be ever changing as the implementation, adoption and use of an EMR progresses. While being instrumental to the preparation at the onset, they will eventually need to transition to undertake the ongoing training needs of the practice. Consultants wont be engaged forever. Typically vendors offer webinars, videos, tutorials and user guides, to name a few of the ongoing training resources, but these arent always effective for the newly technical. Beyond the use of these tools and after the trainers leave, the role of an ongoing internal trainer should emerge. Becoming self-reliant in the ability to train and maintain offers several advantages to a practice, such as the ability to train incoming individuals as staffing patterns change. This eliminates the need for additional expenditure on training and allows for a champion to become a super user, modifying and enhancing the use of the software as the practice becomes more refined and sophisticated in its abilities. For practices struggling with the rudimentary processes of training, the Super User can guide the vendors trainer to best make use of time spent on site in subsequent vendor sponsored trainings. As we near the end of Scotts tale, it is sad to me, that he closes not feeling valued or important to the vendor and abandoned in an implementation, that was by and large a very costly disappointment. There is little I can say in response, other than that he is not alone in his sentiment. Were he, then there would not be such value in the offerings of working with a consultant. For when clients ask me what the benefit of working with me AND the vendor is, my response is simple: because youre my first priority. As an advocate for the physicians, it is my responsibility to offer the one-on-one hand holding so desperately needed for a transformation of this magnitude. On a daily basis, I work with five practices, not fifty and do not sell features and functionalities to make money.

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I offer services and solutions to overcome shortcomings and when the practices find themselves here, where Scott is, I offer the insight to improve a process that did not deliver on its expectations. In a more ideal situation, I provide the insight to successfully implement a solution that works for a practice, instead of trying to salvage one that didnt. Junction Clinic now finds themselves at a crossroads, in the position of determining the value of keeping their EMR, versus cutting their losses. While their frustration is clearly warranted, I would hate for it to be the determining factor in incurring a monetary loss of such breadth, not to mention the aggravation they and their patients endured. Instead, this is an opportunity to perform a needs assessment and a gap analysis to determine the present tense state of the implementation and to redesign a path to effective utilization and meaningful use of the EMR. Identifying and aligning the goals, determining the unmet requirements and re-evaluating the processes in place will serve us well, as they transform themselves into a 21st century practice.

About Scott Sitner: Scott Sitner is an Independent Consultant and Advisor concentrating in business development and expansion opportunities for privately owned, small to medium sized businesses. Working across multiple disciplines within the medical community, he specializes in working with clients to evaluate and enhance their infrastructure to accommodate changes in the economics and law inherent to their industry. Scott graduated from Kalamazoo College and Michigan State University College of Law and is a lifelong resident of Detroit. He has been affiliated with Junction Clinic for the past ten years.

scott.sitner@gmail.com

About Stacey Marie Chapman: Stacey Marie Chapman is a Principal Consultant with PTS Consulting, having previously worked as an Implementation Consultant, as well as, for eClinicalWorks, an industry leading EHR software vendor. Stacey recently worked on curriculum development and instructional content for the ONC sponsored Community College Consortia to Educate Health Information Technology Professionals in Health Care Program and continues to work with the Community Colleges in educating tomorrows HIT workforce. In partnership with Bronx Community College, she also created and chairs their HITECH Educational Advisory Board.

Stacey.Chapman@pts-consulting.us

About PTS Consulting: PTS Consulting Group (PTS) is a world class IT Consulting and Project Management company, providing Consultancy, Managed Services and Resourcing solutions to the world's biggest names. Founded in 1983, PTS has built a strong reputation for "substance over style" and is renowned for its impartial, vendor independent advice, the quality of its processes and friendly expertise of its staff. Recognised as the global leader in IT Relocation and Data Centre projects, where its experience, professionalism and quality of service come together in the most demanding of environments, PTS has delivered over 4,500 engagements across the Americas, EMEA and Asia-Pacific. www.ptsconsulting.com

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