1. Jacob Persily
Professor Robert Irwin
Information Systems for Healthcare Organizations
20 November 2014
Executive Summary on EMR Implementation
EPIC. Medhost. TAPS. Soarian. MyAvatar. Cerner. Allscripts. Depending on who you
are speaking to, you may be told that these words are the names of rock bands, video game
manufacturers, adventure films, or young adult novels. However, anyone in the medical world
would immediately tell you that these are all brands of major EHR, or Electronic Health Record.
However, for the purposes of keeping spell-check satisfied, from this point forward, I will be
using the abbreviation EMR, Electronic Medical Record, the phraseology more often used in
conversation. The process of implementing an EMR in a healthcare organization is often a
challenging process, and, as will be demonstrated below, often does not go according to plan.
It would be difficult to discuss EMR implementation without defining this concept. EMR
implementation is the process of a medical facility putting an electronic medical record system
into place for everyday use in their facility. Simply, it is the culmination of what has often been a
years-long process of selecting the proper EMR for usage in the facility.
The Meaningful Use guidelines from the federal government set out a step-by-step
process for a successful EMR implementation process. The first step is to assess the
practice/facility readiness for the implementation of a EMR, meaning that the organization needs
to take the time to ensure their facility is ready for an EMR, including evaluating the internet
connection for the software, physical needs for the installation of computers in exam rooms, and
envisioning the future of the operation in the digital era. The next step is planning the

2. implementation process. Step three is to select an ONC-certified EMR. Step four is training and
implementation. Step five is achieving meaningful use, which will be detailed fully in another
presentation, and step six is continuing quality improvement in the usage of the EMR.
Let’s now take a closer look at some of these steps. The first is the selection process.
While is essential to select an ONC-certified EMR system to be eligible for Meaningful Use
reimbursement, it is also important to choose a system that will work well for your organization.
The first step to put out a Request For Proposal (RFP) for vendors to bid on the contract. After
bids have been received, the next step in the selection process to rank the pros and cons of each
vendor, and narrow down to the top three choices. References should be checked, and product
demonstration should be scheduled. In particular for the EMR it is also important to discuss the
importance of onsite and remote end-user support, to address issues that come up at any hour of
the day or night.
The next step, after selection, is to decide on an implementation model. There are four
major models used in healthcare. The first is the Parallel Approach, where the new software is
used in parallel with the old methodology, whether paper records or another EMR, for a period
of time, to cover any issues in the new software. The second is the Phased Approach, where
different components are brought online at varying times, to allow the operation to adjust to each
component without all of the new technology active. This is a cost-effective alternative to the
parallel approach, as each phase of the digital roll-out replaces an equivalent portion of the paper
record. The third method is the Pilot Approach, where the EMR is rolled out in a smaller facility
first like an off-site urgent care, before implementation in the main facility. The final is the
Cutover Approach, where a cold-turkey turnover date is chosen for the go-live of the new EMR,
with no going back.

3. Another component of an effective implementation process is provider training. It is a
known fact that many physicians are afraid of the EMR, so it is important to give them enough
training to feel comfortable with the software. There are several components to an effective
training process, including both online and in person before the rollout of the EMR, onsite
support during the go-live process, and ongoing training once the software is fully implemented.
The next step, after training the physicians is the Go-Live phase, where the software is
implemented. This is often where things begin to go wrong. 96% of physicians surveyed by
Health Economics indicated that the implementation process took excessive time, 89% indicated
that they felt the implementation was disruptive to their practice of medicine, and just 37%
indicated that they truly felt ready or the Go-Live day.
There is one concept, which has been majorly developed in the past few years, to make
the Go-Live process flow smoother for the physician. That is the concept of the Scribe.
America, the nation’s largest medical scribe contractor, defines the scribe as “essentially a
personal assistant to the physician; performing documentation in the EHR, gathering information
for the patient's visit, and partnering with the physician to deliver the pinnacle of efficient patient
care.” Scribe America has real, calculable success. At St. Peter’s University Hospital in New
Brunswick, NJ, the implementation of ED scribes yielded both a 8.5% increase in patients seen
per hour and an 87% decrease in down-coded charts.
I spent this past summer working as a Scribe America scribe on a Go-Live of an ED
EMR for a community hospital in upstate New York, and to say the process was rocky would be
a grotesque understatement. The concept of the scribe during Go-Live is to have someone in the
room who knows the software. Having only been hired four weeks before, and with a truncated
40 hour version of a 120 hour training program, my first exposure to the TAPS EMR was on the

4. floor of the emergency department. This was not very helpful, as I was learning the software
while documenting on patients. The TAPS software was also an interesting EMR. It is designed
to be used on a tablet, yet places importance on the right click, which cannot be achieved with a
stylus or touchscreen action. We were also given physical laptops to work with the software, not
tablets as it was designed. The software made it difficult to indicate common historical facts, like
a tonsillectomy, which was five templates deep in the software, and does not feature spell-check.
Most notably, however, the only training held by the TAPS representatives occurred during the
Go-Live week, while I was working in the ED, so I had no formal training on the software.
I reached out to providers in different settings for their thoughts on EMR implementation.
Drs. Persily each responded with pages of content, when asked for a few sentences, clearing
showing their investment in the concept. Their full thoughts are in the appendix of this summary.
Dr. Eric Persily, anesthesiologist with General Anesthesia Services, Inc., which operates
at Charleston Area Medical Center, WV, and at every other medical facility in Charleston, WV,
indicated the following about the Siemens Soarian Clinicals EMR. “Our hospital implemented
Soarian about ten years ago. At the time, we were promised it would never go down; of course,
that hasn't proven to be true…We are literally the first hospital to use this system so they have
customized it for us, but there were a lot of bugs at first. I wish our hospital had used an
established system.”
Cynthia Persily, Ph.D., MSN, FAAN, President and CEO of Highland Hospital
Association, an 80-bed psychiatric hospital with outpatient services had this to say about the
Netsmart MyAvatar EMR, a common EMR in psychiatric settings. “Our implementation has
been less than smooth. We have been working with the company since 2011 and thus far have
spent about 500k on implementation, not counting the time and cost of my staff and loss of

5. productivity. We just began implementing in our outpatient department in January 2014. We are
intending to implement in our hospital, beginning in January 2015.”
Dr. Jerry Weissman, Associate Professor of Rehabilitation Medicine at the Icahn School
of Medicine at Mount Sinai, based out of Elmhurst Hospital in Queens, had some more positive,
and concise, thoughts than the other providers. “The major implementation of our current system
called Quadramed was several years ago with periodic additions and modifications. Between
formal classes and plentiful onsite assistance at times of major changes and an ongoing 24 hour
telephone help desk the implementation has been relatively smooth and effective. We are now
preparing to switch to a new system called Epic with intensive input from the clinicians which,
hopefully, will result in a user friendly system.”
Though Dr. Weissman had a more positive opinion on his most recent EMR
implementation process, he brings to light a major issue of the implementation of technology in
medicine. Until the entire country is using the same EMR, likely at some point in the future to be
based on the EPIC framework, organizations will find new EMRs that will suit their interest
more effectively and efficiently, and every few years go through the entire implementation
process again. Hopefully, those going through the process again will have a smoother time than
some of the providers interviewed here, but, as in life, things in healthcare IT are never perfect;
there will always be places for improvement, and this often only becomes apparent when the
software is put to the test in a hospital of other facility.

6. References:
"Get Started! Here Are the EHR Implementation Steps." HealthIT.gov. United States Department
of Health, n.d. Web. 15 Nov. 2014.
Harris, Russ, and Mark Switaj. "Are Medical Scribes Worth the Investment?" Becker's Hospital
Review. ASC Communications, 13 June 2013. Web. 15 Nov. 2014.
McNickle, Michelle. "The 7 Deadly Sins of EMR Implementation." Healthcare IT News. HIMSS
Media, 7 Sept. 2011. Web. 15 Nov. 2014.
Ritchie, Alison, and Donna Marbury. "EHR Best Practices: Surviving the Go-live Stage."
Medical Economics. Modern Medicine Network, 24 Feb. 2014. Web. 15 Nov. 2014.
Tan, Joseph K. H., Fay Cobb. Payton, and Joseph K. H. Tan. Adaptive Health Management
Information Systems: Concepts, Cases, and Practical Applications. 3rd ed. Sudbury, MA:
Jones and Bartlett, 2010. Print.
"What Is a Medical Scribe?" Scribe America. N.p., 2014. Web. 15 Nov. 2014.

7. Appendix: Full Provider Comments
Dr. Eric Persily
EMR systems are very hard to transition to. Most of us who trained by writing on paper find it
hard to transition to computerized note writing and order entry. A complaint I hear frequently is,
" this is so much quicker if I just write it on paper." What they don't realize is that when we
write it on paper, we are done with it, but then a Health Unit Coordinator (HUC) has to take our
orders and transcribe and enter them into the computer so while the doctor saves time writing on
paper the time to put them into the computer is still spent, just by someone else. Now when I
order a lab test or an x-ray of a medication I place the order once and it gets transmitted instantly
to the department that needs it (lab or x-ray, etc.) There is one less step when a transposition
error can take place. And no one has to interpret my handwriting, which should, in theory, cut
down on mistakes. For instance, if I order 20 mg of a drug four times a day, abbreviated 20 mg
QID, if my handwriting is sloppy or if the HUC makes a mistake, it may get entered as 20 mg
QD, which is 20 mg once a day. And if I am a little sloppy my order for a left hip x-ray (L hip x-
ray), may come out as R hip x-ray. You get the point.
Remember I don't have an office in the traditional sense, so I can't comment on the use of an
EMR for patient charts in a pediatrics or internal medicine office. I only use the EMR for
inpatients at my hospital. It has two components, one for active inpatients and one for archived
records of all of our patients. When they implemented the current system someone spent a lot of
time scanning old records going back to around 1995 or so. We have access to them directly
from the computer system available at every nurses station in the hospital. This is a great
convenience. If we really need to get something older, we have to request it from medical
records and they can get us the old paper charts. I haven't had to do this in a long time. It is

8. great to have a patient in the hospital and coming to the OR and I can see every lab test, surgical
procedure, medical imaging study, consult, etc. going back 20 years. For instance, I can see a
cardiac catheterization from two years ago instantly and know if the patient has coronary artery
disease. I can see consults from specialists, etc. at the touch of a button. Many anesthesia
departments have automated operating room records that keep track of vital signs during an
operation and have places where anesthesiologists can make manual notes about events in the
OR. We don't have that yet. We are hoping to buy one in the next year or two. So in my
practice, I don't have to make notes in an EMR yet. I do enter orders directly into a computer for
my post op patients (recovery room orders) and my labor and delivery patients (for continuous
medication during labor.) But I do use the hospital EMR every day to look at patient records,
both the records from the current admission as well as old data. Our system is called Soarian. I
don't know the vendors name, but I know they work closely with our hospital and make changes
we request regularly. It's not a very widespread system. Some of us suspect that our hospital
uses them because they get a kickback from the company. But we don't have any proof. haha..
Our hospital implemented this Soarian system about ten years ago. At the time we were
promised it would never go down; of course that hasn't proven to be true. Whenever they roll
out a new version or add some new features they try to do extra training and they have available
in the building extra trainers from the company at least for the first week or two. The doctors
fight every new thing they make us do on the computer that we previously did on paper. We
never win. So it's best to take the attitude I have. No one said we are doing this to make things
easier on the doctors. But we are going to do it anyway. Usually, within a month or two you can
get as fast on the computer as you were on paper. For new people, students and residents who
never used paper charts, they have a much easier time using new EMR services and

9. versions. My hospital uses a system called Soarian which is software by a company that had a
relationship with our hospital for other tech services, but I'm not sure which other services. We
are literally the first hospital to use this system so they have customized it for us, but there were a
lot of bugs at first since they never did this before. It's very frustrating to reinvent the wheel
every time we have to make a change. I wish our hospital had used an established system.
Dr. Cynthia Persily
Our product is called MyAvatar and the company is called Netsmart. It is a product frequently
used by psychiatric services.
Our implementation has been less than smooth. We have been working with the company since
2011 and thus far have spent about 500k on implementation, not counting the time and cost of
my staff and loss of productivity.
We just began implementing in our outpatient department in January 2014. Thus far I have about
20 providers using the EMR. We are intending to implement in our hospital, beginning in
January 2015. We had intended to begin in July except that the EMR company decided, after
working with us since 2011, that the system they were planning for us was not going to work.
So, we have gone back to the drawing board and only now have a solution and a new timeline.
Here are the things that we did to have a smooth implementation.
1. We have one designated expert in EMR on staff. He is our Project Manager and the key to
having one person who knows the entire system. Our entire IT team is involved, but we
needed one person to provide oversight of the project.
2. We trained "super users" and "trainers" early and often. Our trainers are on call for rapid
response. If an outpatient provider is having a difficulty, they message the trainer who

10. responds within minutes. This reduces frustration in providers.
3. We continued to run our back up system throughout so that no data were lost during the
transition. This has increased our costs considerably BUT we cannot afford to lose data
for billings etc due to user error or system error.
Here are the problems we've experienced from the IT company which I think anyone in the
business should learn from:
1. We have had 5 project managers from the company in the last 3 years and are staring with a
new one now. Every time we get a new PM, we get a new team, and we have to start over
essentially teaching them our health system and our needs. This has increased our time,
costs, and frustration.
2. Promises made are not kept. Contracts are 40-50 pages long with multiple addendums and it is
difficult to keep track of where we are (by design I believe).
3. Reports are difficult to access so difficult to use to analyze quality, etc using the EMR data.
I could go on, but you get the picture. Our experience is not unique--many of my colleagues have
had similar problems regardless of the company.
Big picture-- EMRs have not lived up to the promise. Because everyone uses something
different, the smooth transition of data electronically between providers is not a reality-- which
impacts quality of care as patients transition across sites of care and systems. The cost to even
small organizations like ours (80 bed hospital and large outpatient center) is exorbitant for the
results received and can be crippling. Meaningful use dollars barely touch the cost.
Not a rosy picture but the "on the ground" reality which is what I think you wanted!