Coming out of our in-class case study this week, Team Jefferson left with more essential questions to acquire more information around, than we can realistically address in this post. However, we did identify some of the key questions that we felt are necessary for healthcare organizations to ask when implementing an EHR system, and developed answers to those questions in the following paragraphs. This is, by no means, an all encompassing guide to EHR implementation, however it can serve as a starting point for organizations or project managers who are beginning the process of acquiring and implementing an Electronic Health Record.
Intro: What is EHR and what should you do before deciding you need one (readiness assessment, etc.)? And then what you should ask prior to picking and implementing one?
An electronic health record (EHR) is a digital version of a patient’s paper chart. Having a patient’s chart in a digital format allows it to be more easily (and cleanly) updated, does not require physical space other than the electronic device on which it is being viewed, and can keep all information organized. Now these are just the basic benefits of what digitalizing anything would provide you, but what about healthcare-specific features? According to Health IT, EHRs can:
- Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results;
- Allow access to evidence-based tools that providers can use to make decisions about a patient’s care;
- Automate and streamline provider workflow; and
- Be shared with other providers across more than one healthcare organization
This last point is one of the most important features as it can dramatically improve the care that a patient receives. Prior to EHR, if a patient had an appointment with a specialist then they would have to contact their primary care doctor and ask for records to be faxed to the specialist. This would be the best case scenario. A more problematic scenario might be if an unconscious person was taken to the emergency department and the ED physician knew nothing about them. The patient could have allergies to medication or latex, be on blood thinners, have a heart condition, or maybe even have a metal plate, screw, or pin in their body from a past surgery. With an EHR system you are much more likely to be able to find vital information that could save that patient’s life.
Most, if not all, healthcare organizations should one day transition to an EMR system, but appropriate timing is essential. If a hospital, group, clinic, or other healthcare provider risks implementation without first ensuring organization preparedness, they will likely fail. Both Health IT and AHIMA provide great preparation guides that every organization should consider utilizing. You can find the Health IT guide here, and AHIMA here.
If it is determined that an organization is ready for their first EHR system, they have a few questions to answer, such as: How do I know which system to acquire? How do I implement it? How do I overcome some of the challenges I might face? What are the future goals and objectives of our organization, and will this EHR system help get us there? More questions to be considered can be found here, but for now we will start by helping you answer these few first.
How do we make decisions about what systems to acquire and how to implement them once acquired?
Once the decision to acquire a new piece of technology has been made and it has been scoped and budgeted the next step is to determine exactly which version to acquire. For most products there are numerous vendors available that offer a wide range of possible options. In order to make a decision an organization must first determine what criteria are most important to them. In the case of a new EHR stability, cost, interoperability, and user satisfaction among many other factors may all be important but priorities must be determined. If a system is cheap but has no interoperability it may be viewed as superior to an expensive EHR with supreme interoperability in the eyes of one organization but not to another. If these criteria have all been settled before evaluation it will prevent the possibility of a decision being swayed by something that is not necessarily in the best interests of the organization.
With selection criteria in hand an organization can reach out to vendors that appear to have a potentially viable product with RFPs. This will allow them to gain the necessary information to make a selection. Thorough vetting is a must before a final decision is made. Site visits to locations that have already implemented the technology to gain insight into how it is used and customer satisfaction can prevent being misled by sales staff. Once the buying team feels comfortable with the decision they will provide their recommendation and if approved, contract negotiations can commence. Depending on the finances and needs of the organization the technology may either be leased or purchased outright.
No matter how great the acquired technology, without proper planning and implementation the effort will ultimately fail. Depending on the scale of the product there may be significant capital expenditures to accompany the main purchase. For example, for an organization purchasing their first EHR system they would also need to purchase numerous computers and monitors in addition to any facilities upgrades needed to handle the increased power demands.
With the resources in place it is time to focus once again on the people element. Most major technology upgrades must be used by non-IT staff and so it is absolutely essential that they have both the ability and desire to use the technology effectively. As mentioned previously, before any purchasing goes forward there must be communication with the front-line staff that will be asked to operate the system with their requests and expectations kept in mind during each step along the way. If these steps are followed it will make the training step much easier. Most major organizations have a training department who will work with departmental heads to select super users. These users are given more thorough training and serve as extra support during training and implementation but with a better sense of day-to-day operations.
If we want to achieve population health and establish a care network, we will need to share data with network partners. Will our EHR be able to communicate with the other systems in our area?
The degree to which interoperability is important will depend upon the organization purchasing the EHR system. For a rural hospital which is the only healthcare provider within many miles there should not be much concern over the ability to communicate with other systems. A small physician group in a competitive market should be aware of the possibility of partnering with a local hospital down the road and consider adopting an interoperable system. Securing referrals is much easier through the same EHR than relying entirely on faxes and phone calls in the modern day and age.
Many organizations have already had an EHR system in place for many years but for one reason or another are considering a change in order to have systems communicate. Health systems using different EHRs for outpatient and inpatient care have finally realized that the internal workflow headaches caused by two different systems eventually outweigh the problems of yet another purchase and implementation. Making this move is a serious financial burden in a time when profit margins are shrinking in many hospitals across the country. However, putting the move off in the hopes of a more stable future environment is a risk that not every organization is willing to take.
Beyond collecting patient data, what are some of the capabilities that we hope to achieve with this technology in the next year? In five years? Or in 10 years? In other words, how can we ensure the technology we implement today is able to meet our future goals and objectives?
In order to achieve the required capabilities needed now and 10 years from now, organizations must take a business driven approach. At the business level there should be a strategic approach that encompasses: growth plans, action plans to meet objectives, spending plans, revenue targets, and any plans to merge with other healthcare organizations. This business driven approach, when executed in a strategic manner, will follow a set of defined activities. These activities should include: setting priorities, focusing energy and resources towards a beneficial system or application that will then strengthen operations. With this long range plan, the organization will ensure that employees and other stakeholders are working toward common goal, thus establishing an agreement around intended outcomes and results. With this strategy, the technology implemented will provide a constant and ongoing assessment and allow for an adjustment of the organization's direction in response to a changing environment.
Now that EHR is implemented, what problems may you run into and what should you do (going to the vendor, use internal support, redo training, setting up a communication plan, and the like)? What will be improved? In short, what are the pros and cons, the challenges and barriers, and how to will you overcome them within first 6 months to a year after implementation?
Kevin Helmrick, MD, CMIO at Methodist Healthcare in San Antonio led the “disruptive and transformative” implementation of their EHR in 2012 and found that while the basic EHR functionality is working, it is causing difficulty and pain for physicians. He believes that the user interface and the EHR’s support of clinical workflow could both be improved, although they are capturing data much more reliably and efficiently than before EHR implementation (Becker’s Hospital Review). Other CIO’s and CMIO’s commonly report disruption to workflow being the most significant challenge to post-implementation EHR adoption, so are finding ways to improve usability and productivity at the same time. The industry generally agrees that involvement of physicians and nurses is critical for gathering useful information on user interface satisfaction and potential issues prior to implementation.
Training of clinicians is a formidable task for any healthcare organization. While administrators should expect to receive pushback from their clinical staff on new difficulties and problems introduced by EHR implementation, administrators should expect to invest heavily in initial and ongoing EHR training and user support. EHR vendors can be leveraged to provide initial EHR training through vetted training models and “super user” staff to provide internal training to clinicians and non-clinical staff members. HealthIT.gov, in conjunction with the National Learning Consortium, suggest training through various methods, such as “super user” training, internal role-based training, and specific process training. HealthIT.gov is a federally sponsored resource that health IT/IS managers will want to peruse.
While healthcare organizations are on the path to achieving Meaningful Use stages 1 and 2 standards to collect incentive funding, new questions continue to be asked, regarding improvement of operational processes and systems. William Spooner, Senior VP and CIO of Sharp Healthcare in San Diego publicly stated that, “One of the biggest challenges we are facing is the aggressive meaningful use program we are on. We are seeing pushback around the industry. It takes a lot of time to define, create and refine IT, and these two year increments are really aggressive especially when we are trying to create a good product.” Spooner advocates on behalf of the health IT industry to extend the length of limited time that CMS has allotted for healthcare organizations to meet the current Meaningful Use criteria, by speaking on the difficulty of intentionally cautious and incremental transitions made to EHR.
What other incentives motivate health care organizations to pursue HIT projects?
Up to 70% of HIT projects fail. When organizations try to rebuild from a failure, it is an uphill battle to regain the excitement and enthusiasm once promised of adopting an electronic medical record system. Organizations often face a culture of mistrust and must overcome this. A way to ensure organizations are headed in the right direction is by ensuring meaningful use of its EHR technology. Many organizations aim to achieve meaningful use in their EHR technology to qualify for CMS incentive programs. The goal of meaningful use is to ensure better clinical outcomes, improved population health outcomes, transparency, and opportunities for data research. EHR technology should strengthen care coordination, ensure security of patient health information, engage patients, and improve the overall quality, safety, and efficiency of care while closing the gap of health disparities. Although these qualities are logical, they cannot all be focused on simultaneously together.
CMS has organized meaningful use into three stages. These stages are spread out for years starting with Stage 1. Here, health information is captured electronically in a standardized form. This helps track key clinical conditions and allow for coordination to improve care coordination. This coordination also includes the engagement of the patient and their families and allows for contribution to the growing reports of clinical quality measures to improve public health. Stage 2 moves on to transmitting health information through exchange. This includes e-prescribing and using lab results allowing patients to be able to control more of their health data along with being able to transmit this information across numerous settings. Stage 3 looks at health outcomes through populations. Through health information exchange, more comprehensive data is accessible and allows better support to make decisions on priority conditions leading to improved quality, safety, and efficiency.
What should the implementation process consist of? (so pretty much like the exercise we did in class) What do we need to do? Are there other similar organizations that we can learn from? Who might be resistant and what should we do in order to get them onboard first? Etc.
The implementation process may vary as much as the potential EHR system that is being implemented. That is to say that there is no one right way to do it. The circumstances, market, and key stakeholders specific to each organization should be considered in the implementation process and will cause the process to vary from one organization to the next. However, there is a general road map that we will present here to help guide the process of implementation, while the details and specifics will have to be worked out to fit the specifics.
To start, we recommend conducting a gap analysis. This entails assessing the current state of the organization as it relates to the technology needed, the cultural acceptance or barriers to change, as well as the infrastructure and processes needed. This will inform the project sponsor of the organization's readiness. Keeping the internal assessment in mind, this should then be compared with the ideal state. That is, what would our organization ideally look like in regards to technology, culture, and infrastructure after the implementation? By asking this question, the project sponsor is able to identify the “gaps” between current state and the ideal state and know what to address moving forward with the implementation.
We recommend, at this point, meeting with all internal stakeholders, as well as the organizational leadership, and assigning a project sponsor to the project. It i is essential to bring everyone to the table early in the project to support buy-in and maybe so far as ownership among those who will be affected by the project. People, naturally, resist change. There will be a number in your organization who will be against the implementation. Understanding this we advise to sit down with these people early and often, listen to their concerns, and do your best to make the why behind the project clear. Further, our reasoning for assigning the project sponsor after the gap analysis is due to the idea that you don’t really know who the best person for the job is until you know what the job is.
At this stage of the process the organization should be clearly able to define what criteria are the essential components needed in the future EHR system, and use that criteria as the rubric in which vendors are assessed against. This is a tedious process with a lot of back and forth with vendors. For clarity, we recommend asking to visit other clients of the vendors whose organizations are similar to your own to learn about their implementation process and gauge satisfaction with the vendor and system. All of these assessment factors combined should lead the organization to selecting the most appropriate vendor for their unique set of circumstances.
Around this point, we identify the organization hitting a milestone. The halfway point if you will, when the Chief Executive Officer signs off on the contract with the vendor. This is where the implementation begins, and as some say, the real work starts because others outside of the project team will be affected by the implementation process and change management becomes a key component of the process. We recommend assembling and implementation team to manage this process, as well as starting small, in a single department or unit to work out any implementation hurdles that were unforeseen before the entire organization is affected. Through the learnings provided by the small implementation process, the implementation team should be able to prepare themselves, as well as others, for the organization wide implementation. This is effectively done, we feel, through the use of “super-users,” development of protocols, standardizing procedures, training staff, and using continuous assessments and review of the process to fix problems on the spot, when they occur.
Finally, at this point on our project roadmap we have hit our final milestone, the finish-line, which we refer to as the system wide go live step. It is noted, that our road map does celebrate this phase with a party. We want to emphasize the importance that this seemingly trivial addition has to the culture of an organization. A celebration will both signal to everyone that this EHR is a good thing that is improving the organization and furthering the pursuit of quality patient care delivery, as well as serving as an opportunity to thank all those involved in the project for their hard work to date.
Our hypothetical in class case study is summarized in our road map below with specific names and titles inserted for clarity. Again, we would like to reiterate, that while to process is not identical by any means, this outline should provide organizations with a general road map that will lead to successful implementation.
Start Point - Project Kick-Off: Larry assume the role of the Project Sponsor
- Define problem (thru gap analysis) and assess current state of technology and current capabilities - paper records, no EMR and compare with the ideal end state (set SMART goals)
- Appoint a project manager.
- Identify and ensure you have strong leadership/identify stakeholders
- Meet with staff to identify what they would want from a system (both clinical, non-clinical providers, and IT department, determine if additional equipment would be needed)
- Meet with Finance to determine budget
- Research vendors (alternative solutions)
- Develop criteria by which you select vendors
- Scope
- Cost
- Timeline
- Desired results
- Cross-departmental impacts
- Interoperability with other organizations (aka MSMC)
- Meeting regulatory requirements
- What are the possible system modifications
- Parameters of system license use
- Negotiate with top vendors
Midway Milepost: Emma, CEO, signs the contract with the vendor.
- Hire and Organize the implementation team
- Create an organization wide communication plan
- Set realistic expectations
- Select “super users” to identify workflows
- Create a steering committee to have representation across the organization, and to help manage scope.
- Assess results of pilot
- Run user experience trials and gather UX feedback
- Quality Assurance assessments
- Create a best practice protocol gleaned from results from pilot (process and procedure changes)
- Developing training process & procedures & educational content (determine if you want continuing education requirements)
- Train people
- Determine what has/can not been implemented and must be addressed after “go-live” - optimization phase
The Finish Line: The system enters “go-live” with a pizza party!
1. Perform a post implementation audit- Is additional training necessary?
HAND OFF - Project end.
- Continuous Performance Improvement
- Meaningful Use
References:
Leviss, J., Hit or Miss: Lessons Learned from Health Information Technology Implementations 2nd Edition.
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