The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of patients with the top 10 diagnoses and a sample of acuity of each patient. Use EBM resources to catalog precisely what needs to happen and when for each patient. One of the most important aspects of this is the physician coding. Typically this takes place either at the end of the shift or at some later time (when the head of medical records yells loud enough. By utilizing an instant coding tool, either in the ED or on the acute care floor, a workflow can be designated that does not allow the physician to move forward in the clinical process for each patient until the necessary steps are taken (obviously allowing for the physician to change patients or handle emergencies). The physician cannot transfer patients to the next physician until all is coded. The few modern systems available allow this to happen easily.

Modern revenue cycle/administrative workflow tools will also indicate if either a code is not generated, the code does not match the diagnosis or DRG (meaning that the DRG must be updated), does not match the reimbursement source requirement, or does not match EBM steps. Of course, a physician can do what he or she deems appropriate care, but this way the administration can be aware if the physician routinely is in opposition to either payer standards or Evidence Based Medicine standards. If the coding is not done immediately, the only way administration can be made aware of a gap in care is when the denials for given care begin to impact hospital performance. The administration generally has little guidance about judging whether physicians follow some standards. Immediate coding enables a better understanding, basis for communications, and real time awareness. Tools that enable rapid, easy, and accurate coding are indispensable.