Your EHR Go-Live should be the culmination of months of research, evaluation and planning by a multidisciplinary team comprised of a cross representation of business, clinical and provider management and end-user representatives. But sheer effort alone does not ensure success. The lack of a comprehensive and coordinated approach to preparing for Go-Live could result in negative satisfaction, adoption and sustainment—as well as perhaps harmful financial outcomes. You do not need to be in the industry long to know that hospitals sometimes experience revenue challenges soon after implementing EHR systems. It commonly takes months for clinicians to get back to their pre-Go-Live patient care loads and for revenue to increase.
The sooner you plan, and the more detailed your planning, the more likely you will avoid the perils of a poor implementation. Identifying leaders for each department or specialty ahead of the build phase not only ensures involvement across the entire hospital, but allows your project team members to have a direct link to concerns that may arise later in the project that need to be addressed quickly or have a high level of complexity. It’s also imperative that you capture information on key pre-live business metrics (such as CPOE percentage or actual revenue vs. expected) in order to provide concrete data on how well, or poorly, your staff are coming along; your vendor may have information to show them how it relates to their peers elsewhere as well.
In this section, we look at how comprehensive, proactive management can help you to speed adoption and preserve revenue integrity.
Hospital administrators are vital to set the tone, momentum, and expectations for the entire hospital/health system’s acceptance of electronic charting. They must first believe in the product and the process of converting legacy documentation to modern methods for electronic charting, then stand by the chosen vendor through all stages of the transformation. This may sound simple and obvious however there will be challenges during the phases of adoption that will test even the strongest supporters. Hospital administrators will set an example and motivate others within the hospital system who expect to have their work lives and practices respected and managed properly.
A Lesson in How Not to Go-Live
Poor adoption by physicians and the ensuing problems that it caused for a small hospital in California underscore the implications of weak support by administrators.
There were the usual training opportunities in place, with lots of time to get the staff and physicians up to speed with the product, from a well-established and dependable vendor. However physician training was not mandatory, and ultimately they were not required to use the system. Essentially, administrators for the hospital, which was part of a larger healthcare system, didn’t provide any tangible expectations for the physicians.
As imagined, without training or commitment to moving from paper to an electronic system, the process of implementation deteriorated rapidly. Right away during implementation bright and technically savvy physicians found fault with the software. Reportedly it couldn’t do what they expected and they felt it was too time consuming. In spite of every effort to bring in developers, software engineers, and additional trainers the physicians would find little they could appreciate about the product and quickly lost interest.
Despite efforts by the hospital administrators to rally the physicians back into the system’s use, the physicians eventually mounted such intense resistance that the members of the hospital’s medical board deemed the vendor’s product “unsafe”. Overwhelmingly, the board voted to prevent its use until the vendor could meet certain demands to prove there was no risk in using the product, which by the way, had been proven multiple times with multiple clients over multiple years. Nevertheless, no amount of reassurance would help bring them back. Ultimately physicians at that particular hospital still charted in whatever way they pleased paper or electronic, or sometimes both.
Through this example we see hospital administrators made great attempts to bring the process back into focus, but eventually couldn’t hold their ground. Lesson learned: In a conversion from paper to an electronic system, it is proper for administrators to establish a commitment from the end users by encouraging a contract, and by mandating the training and use with the physicians. They should also ensure expert and effective support from the vendor. Hospital leadership must stand firm, within reason, alongside the vendor, in support of the process during this kind of change.
Time-tested EHR businesses are best suited for providing the most predictable and reliable services throughout the process of implementation. Companies like these have developed databases, established a degree of standardization, and are best equipped to provide skilled resources to support implementation. They know what’s expected for them to provide a product that will satisfy client needs and meet the demands of government regulation. Vendors must be willing to work with new client sites in engaging physicians as early as they can in the process so nothing comes as a complete surprise at the time of implementation. In addition, customization of the product is one way to draw physicians’ interest. Reasonable expectations can be outlined in software demonstrations. Furthermore, an honest description of what can and cannot be modified could remove any unrealistic demands from the end users.
Vendor representatives must also manage users’ expectations. For example, though time saving is the most sought after quality of any EHR, users typically do not experience it right away because of the very nature of changing the process from paper to electronic. Your vendor’s representatives should clarify that change is hard, particularly if users fret about compromising productivity.
Here are some particular trigger points for users’ pain and suggestions for how your vendor can alleviate the response:
Give users the difficult news up front; Initially using an EHR does slow the work flow down.
Ways that vendor representatives can alleviate initial change in productivity from a physician standpoint include a couple practical steps if hardware budgets will accommodate the need.
Voice recognition software to speed up data entry to replace typing.
Have devices in close proximity and have enough for use, physicians will not go out of their way to find a device.
The application will never be “perfect” for everyone, and change typically doesn’t come quickly with EHRs, but vendors should welcome suggestions for improvement. They also need to offer reasonable customization to the existing software. Showing clinicians how the software can enhance patient care—rather than detracting from it by taking away time—can also be helpful. Vendor representatives may want to integrate a computer into the experience by showing clinicians the patient screens that display graphic trends, or screens that illustrate a point about the importance or severity of a condition, for example. Demonstrating that patient privacy is better protected than with paper systems is beneficial as well. Ask your vendor’s representatives to demonstrate how every electronic entry has a date/time stamp that states which provider/clinician opened the record. This is better than currently, where anyone can open the paper record and anonymously view any details.
Your vendor’s representatives are key in spreading adoption. Requiring them to advocate on behalf of your EHR implementation as vigorously as they do their product will increase the chances of the EHR success and the latter’s use.
Before you Go-Live, trainers have one obvious responsibility: they’re around to teach and instruct classes and keep your instructional designers from working around the clock. However, they can also help out in a variety of other ways.
An experienced trainer can be a real value add if they’re around during the preparations for training. All applications design and build must be completed prior to training in advance of Go-Live to provide a place for users to work during classes, and often times there are difficult steps that must be completed to do so (like setting up labs to result automatically or dropping charges on training patients for your users).
Since these steps are usually time and order sensitive they must be done right the first time—doing them incorrectly can set an application back days. Additionally, there are so many materials needed in classroom training that it can be difficult to keep them all straight. Quick start guides, training companions, tent cards, and barcodes are just a few examples of materials you would typically see.
Creating poor quick start guides or tent cards can be extremely detrimental to training as any time wasted in class will have a negative impact on the attitudes of your students and the perceived success of the installation; if training is this much of a mess, what are your end users to expect at the Go-Live? This principle extends also to the people teaching the classes—if your trainers aren’t strong in the classroom it certainly won’t look good. By making sure that your trainers are excellent teachers you can make for a smoother class, which not only builds goodwill but instills good habits and end-user preparedness.
Hospitals must have the right floor support resources available to manage the needs of the clinical and ancillary staff. Go-Live team members must be capable of providing both solid technical expertise and high-quality customer service during those first critical weeks.
As you begin to plan for your EHR Go-Live, you will need to consider how much staff training has been accomplished prior to the Go-Live and if you will be able to contribute internal full-time super users during back-load and activation. Understanding training and available resources at your facility will greatly impact the numbers, type and requirements of the resources you will need to augment your project. The idea is to accomplish your goal, cover hot spots and maintain patient safety. Overall adoption rates are much faster on floors with strong and engaging support. So, it’s always better to slightly overestimate your support needs and have the contractual flexibility to draw down resources as project leadership determines.
At-the-elbow support resources are the front line for the hospital staff and the face of your project. As such, your resources must be knowledgeable in their modality and radiate a teaching spirit.
Whether organizations are installing their electronic medical record system or adding enhanced functionality to meet regulatory demands, most of them have a few key goals in mind: increasing revenue, a smooth transition, and happy patients. Just as organizations are feeling the pressure to implement at a faster pace, physicians are also feeling the pressure to improve quality, reduce costs and maintain a stable revenue stream; often in multiple settings. One sure-fire way to help ensure all of those goals are met is to create engagement with your staff throughout the duration of the installations, and nowhere is that more important than with your physicians. Involve them in designing the things that affect them most—the order sets, documentation tools, and workflows. They are the ones using the system and should be the ones who determine the content within the constraints of policies, procedures, and regulations.
Include dissenters in the process. You know the ones—those physicians who are most vocal in meetings and to their peers about their vehement distaste for an EHR and how it may be detrimental to their provision of patient care. Persuading one or two of those people, especially if they are in diverse specialties, to help with the build and design the system the way they want to see it, is the best thing that can be done. If done correctly, this process can turn dissenters into allies.
As important as getting involvement from dissenter is, also getting it from other influential, knowledgeable physicians is a must: it is imperative to identify those who will invest themselves in the process, those that will ask tough questions and push back if necessary, those that are viewed as leaders throughout the hospital and the ones with the trust of their staff. This is also important during the decision making process pertaining to your organization’s workflows. By bringing them into the decision making process early, you ensure that questions and issues which could be raised with little preparation are brought to the forefront early, and that the involvement of leaders will create buy-in and excitement before you eventually Go-Live.
Once a framework for designing order sets is established and a smaller number of prototype orders sets are designed it’s time to engage end users in some testing, which will help get them acquainted with the software’s look and feel. Over the course of time for this analysis, design, development and testing users will gain confidence and experience with the product and can be early in identifying how it flows with or interferes with their work process.
Lastly, remember that most physicians have not been sensitized enough to the idea of a “work flow”. These are more like buzz words: recognized, but not necessarily understood. Likewise, many technology professionals don’t recognize the culture of the medical community and their lexicon. Nevertheless, they must work closely with the physician to identify best practices; understand the day in the life of a physician and how the work gets done and how departments collaborate with one another to serve the patients. By standardizing as much of the work flow as possible, with close attention to the sequence of events to get work done, the burden of Electronic Medical Recordkeeping and the practice of Computerized Physician/Provider Order Entry (CPOE) can be made lighter and increase the momentum of physician acceptance of this technology.
Familiarity and experience with the software will enhance the use of the strengths of the application in conjunction with best medical practices, and with greater efficiency and value physicians will find CPOE adoption streamlined and more valuable to patient and population health.