Some 10 years ago, when I first started covering health IT, a lot of the talk was about the “modular” approach to EMR adoption, i.e., put in a piece at a time during a transition period. Much of that had to do with the state of technology at the tail end of the dot-com bubble, when companies developed applications to address one small problem, often in the hopes of getting a larger firm to shell out big bucks for their idea. (Wouldn’t you know, that’s how many vendors, most notably GE Healthcare, put together end-to-end enterprise systems.)

Implicit in any step-by-step transition to EMRs was the idea that there would be an interim period where providers would have to run dual electronic and paper systems. It’s a notion that’s always been with us, but how many people still think of it?

I got a reminder this afternoon when I spoke to Ken Rubin, Iron Mountain‘s senior VP and GM for healthcare, who was talking about results of a new survey on progress toward meaningful use. (I was ostensibly doing that interview for InformationWeek Healthcare, so look there tomorrow for coverage. Here, I just want to talk about one aspect of the conversation.) Rubin noted that there seems to be a sort of “no-man’s land” between the paper and digital. “I don’t see a real, well-defined way of dealing with the hybrid world,” when hospitals and medical systems are switching to EMRs while still retaining old paper records.

Obviously, Iron Mountain would like to sell some scanning, data management and shredding services to healthcare organizations, but Rubin has a point. The rules for meaningful use Stage 1 don’t say a thing about what you’re supposed to do with existing paper files, and it doesn’t appear that Stage 2 will address that issue either.

Do you scan all the old files immediately, or wait until each patient’s next visit, then chart electronically going forward? What do you do with the files of inactive patients? Do you archive records in house or offsite? Do you still need rows of files taking up valuable square footage that could be put to better use? What do you do with clerical staff?  Do file clerks become managers of electronic health information, or do you need to replace those people with others trained in HIM?

Rubin noted that this limbo often works against organizations trying to overcome physician resistance to change. “The faster you can get to the other side, the faster you’ll get physician adoption,” he said.

That all makes good sense to me. CIOs and practice managers, what do you think? Have you addressed hybrid workflow during this transition period, or is the siren call of federal dollars for meaningful use too strong?

I’m always interested in interacting with the readers of this blog. Plus, I like to help people out that email me asking questions. Plus, I’m swamped preparing for HIMSS and putting the finishing touches on my EMR selection e-Book. So, here’s one that I think was more than worthy of a discussion:

I am concerned with some of the specialty medicine aspects of EMR, specifically those of Oncology. Do you think there would be room for discussion of the different types of workflows different types of practices face? I would love some outside views of how different Oncology practices plan to convert their workflows to an electronic form.

I am also interested in learning more about different in-house architectures.

-Nick

I’d love to hear people’s comments about this as well. You know I think workflow is one of the keys to a successful EMR implementation. So, what type of special workflows have you created to make EMR work for a specific specialty? Has anyone had experience implementing an EMR in oncology? Let’s hear your thoughts.

I’m a HUGE proponent of mapping your current workflows and evaluating how that applies to your EMR implementation. It’s absolutely essential to be able to do it right. It’s not an easy or necessarily fun task, but it pays big dividends when you go live with an EMR.

However, far too many people get caught up with “my workflows” versus the “EMR workflows.” Some people like to argue that an EMR vendor should be able to customize their software to be able to support my current paper work flows. Other people argue that you should toss aside your current workflows and adopt the “best practices” standards of your EMR vendor.

Of course, the real answer is as it should be: somewhere in the middle. The EMR should be built so that you can customize many of the features to match the way you see patients and the way you practice medicine. In fact, this should be part of the evaluation process when selecting an EMR vendor. However, let’s not also be naive enough to think that some things in the electronic world won’t be easier to do than they would have been in the paper world.

You better hope that your EMR implementation does change some of your current processes for the better. That’s part of the reason why your implementing an EMR. You want to improve something about your clinic. If nothing changed, then where would the improvement come from?

Like everything in life, workflow customization just requires balancing your current workflow with the EMR vendor’s suggested workflow and the features of the software.

I saw an EMR demo today and they made a really interesting point about workflow. In fact, I was impressed that the EMR vendor admitted up front that you would need to change your clinic to work with their EMR software. I’ve said this a number of times on this site, but it was kind of refreshing to hear an EMR vendor admit it. I’ll have more on the rest of the demo/presentations in future posts.

What was most interesting was that after admitting that you would need to change the way you work to use an EMR, he made a really interesting and powerful point. The basic concept was that if you don’t have an EMR, your current workflow is bound by the paper world in which you now live. Hopefully, adding an EMR to the mix provides some new ways to serve patients that were impossible to accomplish in the paper world.

I think you could also add that implementing an EMR removes a bunch of paper queues. For example, we use to have a half sheet of paper that was filled out by the patient follow the patient throughout the entire visit. What were we going to do without that half sheet of paper? This is one of those workflow changes that isn’t a deal breaker, but just had to be considered and planned for.

Also, don’t confuse changes to your workflow with changes to how you treat a patient. Your workflow will absolutely change. We’ll save how an EMR affects how you treat a patient for another post.