In the Brown et al. (2013): Case Study - Zenith Internal Medicine (p. 58) by Win Phillips, In this selection and implementation, what should have been done differently? How can the current situation at Zenith be fixed?

Case study:

Zenith Internal Medicine is a large multioffice practice, with 14 separate offices located in rural areas and small cities and staffed with one to three physicians and other office staff. The central office has ten physicians, and the practices administrative, financial, and IT staff members are located at the central office. Overall, Zenith has 53 physicians, 12 nurse practitioners, 5 physician assistants, 12 registered nurses, and 18 licensed practical nurses. The full staff (a total of 300 people) includes managers, med techs, schedulers/receptionists, IT/tech support staff, and billing/ coding specialists. For a number of years, the practice has had a combined comput- erized scheduling and billing system from a single vendor. The CEO, Martha Lee, decides now is time to get an EMR. She calls an old college friend who works as a healthcare executive in a nearby hospital; the friend advises her to contact EMR Solutions, Inc., to see if its system might work for Zenith. Martha arranges a visit with an EMR Solutions sales rep, watches a demo of the system, and then signs a multiyear contract to have the vendor install the EMR in all Zenith offices. The price of the system is several million dollars and includes both up-front and yearly maintenance and upgrades. EMR Solutions delivers three servers to be installed on the network by Zeniths IT staff with help from the vendors engineer. One server contains the proprietary database and the other two contain the actual EMR application. The clinicians hear about the purchase through an announcement e-mail sent out to all staff by senior management on a Friday afternoon. According to the e-mail, the new system will be ready to use in ten busi- ness days and can be accessed through an icon that will appear on every Zenith computer. Clinicians are asked to take a 30-minute tutorial, which would be available as a menu option on opening the EMR interface. Ten days later, on a Monday morning, another e-mail announcement is sent out by senior management to inform the clinicians that they are expected to now use the EMR and can no longer carry out dictation for their chart notes. On the go-live date, most branch offices are reluctant to use the new system. The office managers inform the nurses and med techs that they must enter the results of lab tests into the EMR. One lab is con- figured to send test results directly into the system, but the other labs continue to transmit results by fax, leaving the techs and nurses to manually enter the data into the EMR. This takes time. Meanwhile, many physicians completely ignore the EMR directive and continue to jot notes on paper during patient visits and dictate notes after each visit. Only a handful of physicians agree to start using the system, but they encounter problems with finding the patients they are scheduled to see. The existing scheduling system is supposed to be linked to the new EMR, so in theory the days schedule of patients can be pulled up for easy access. That is not the case. Manual data entry and searching before each patient visit is required. The physicians notes-taking processes vary. Some type notes directly into the system, while others dictate to med techs during the visit and the med techs enter the notes later. Patient visits fall behind as a result, and some patients wait an hour or more to be seen. A few physi- cians jot down extensive handwritten chart notes during each visit and then after 5 pm enter the notes themselves by using the special templates in the EMR. But many of the templates are set up for pediatrics, not internal medicine or other specialties, making most of the categories and tabs not applicable for other physicians purposes. The EMR has an ordering module that allows physicians to enter prescriptions online. But the module is not populated by medication names, which forces users (specifically, the nurses) to manually enter the drug name, a practice that introduces misspellings that remain in the sys- tem for other nurses to choose inadvertently when selecting drugs from a general medication list. Prescriptions entered in the system are not trans- mitted electronically to any pharmacy but rather must be printed out and then either handed to the patient or faxed to the pharmacy. Finding the correct fax numbers for the pharmacies is also time consuming. Clinicians also have trouble incorporating the EMR into their patient-visit workflow. Computers are available in exam rooms, but physi- cians cannot log on to use the EMR installed in these computers because the user name and password required for EMR is different from those required by the regular network. On first visit, the EMR requires the user to change his password and answer a number of security questions in case of a forgotten password. Physicians who do push through the log- on requirement encounter other problems. When they try to call up old chart notes, they (and their patients) are surprised that the EMR contains no patient records whatsoever. As a result, a mad scramble to retrieve the paper-based chart notes becomes a constant during patient visits. When paper charts cannot be located, the physicians have to ask patients about the history and purpose of their visit. Furthermore, the medication lists are also a source of problems. Sometimes the patients existing medica- tions have been entered into the EMR and are thus visible on the screen, but other times the nurse who takes the patients vitals has to hand the physician a piece of paper that lists these drugs. Figuring out which nurse does what and how is difficult. The EMR has a problem management module to help clinicians keep track of patient illnesses and diseases, but physicians cannot find the ICD-9 codes for diseases they do not personally manage. Some physi- cians enter all patient problems, while others enter just the patient-specific problems they are currently treating. Some nurses enter problems before the patient arrives, but this is not uniformly done. Physicians are also unclear about how to handle billing. Some continue to fill out paper billing sheets, but others assume that enter- ing ICD-9 codes into the EMR automatically sets off the billing system. However, this assumption is false, because the EMR and billing system are from two separate vendors and thus are not integrated to exchange data. When the finance department realizes this confusion during the first days of EMR implementation, they start to brainstorm solutions to the billing process. Even before the first (go-live) day is over, the branch offices are in chaos. Someone has terminated half of the transcriptionists in anticipa- tion of their services no longer being needed. This causes an outcry from physicians, many of whom are still dictating their notes and thus argue that the mass layoff means their notes will not be available until weeks after their patients visits. Some clinicians, including several physicians and nurses, are openly cursing and threatening to quit. Meanwhile, Zeniths IT department is flooded with phone calls and e-mails about the prob- lems: the system is slow or inaccessible, computers have crashed, patient records are not available or lost, user names and passwords do not work, a tech is needed immediately to fix an error or to do a quick training, and so on. One IT employee walks out for lunch and does not return. Martha is holed up in her office, refusing to take any calls. At the end of the first week, she sends out an all-staff e-mail informing everyone to stop using the EMR until further notice and for clinicians to go back to their paper charts and dictation.