PDF File: 

HCT3_wp_schreiber.pdf

RSM McGladrey

The key to a successful implementation lies not so much in the system itself, but in the overall abilityof the organization to manage the change.

The implementation of an EHR (electronic health records) system in an ambulatory care environment must be done carefully and utilize a disciplined approach. This approach should involve multiple phases and begin with in-depth planning. In planning, organizations must define the project structure, roles, responsibilities, detailed work plans, staff assignments, communications and administrative details. Ongoing administration and management of the project continues throughout and beyond the project and includes project management, status meetings, status reporting and quality assurance reviews. Components of the implementation include project management, change management with workflow redesign, technical services and end-user training. Each project phase requires planning, execution and evaluation phases. Essential to project success is a robust project team and an atmosphere of partnership among all entities involved.

Many modern practice management and EHR systems contain similar functionality, are easy to use and address virtually all aspects of the organization’s requirements (e.g., registration and scheduling, billing, clinical reporting and workflow). Thus the key to a successful implementation lies not so much in the system itself, but in the overall ability of the organization to manage the change. Essential elements of change management are planning, communication, organization and resource allocation.

Planning

During the early phase of the implementation, the vendor and/or consultants work with the client project team to systematically plan the implementation, assign the needed resources, and begin work on needed tasks. At first, the client project team members will have limited knowledge of what they will be expected to do. As the project evolves, they will learn their roles and responsibilities, and become increasingly comfortable with making EHRrelated decisions.

The final outcome of a well-planned implementation is the transfer of accountability for the system to the organization. By the end of the project, organizational lines of responsibility for the EHR should be well-defined and accepted. There should be a clear procedure in place for EHR support, both for technical and clinical documentation and care management issues, and also for communicating enhancement requests to the vendor. Additionally, postimplementation strategies such as monthly EHR staff meetings should be employed consistently, as should planning for training new employees.

Throughout the planning phase and beyond, it is important for the organization to have a clear vision of its purpose for making the change, and to articulate its goals for the new system. These goals should be concrete, measurable and relevant both to stakeholders and staff. The key to success is to develop shared goals that everyone understands and supports. Having a shared vision helps everyone overcome the rough spots that inevitably will occur as the project is implemented.

Goal-Oriented Project Planning

Project goals should be realistic and related to sound business practices. It is a truism that a computer system cannot improve business processes that are fundamentally unsound. It is worth the time in the beginning of the project to examine the organization’s business processes and determine how the EHR will fit in. If challenges at this juncture are not addressed, they will likely be raised at a later time; during training, for instance, when the resolution will be much more problematic.

When an EHR is implemented, every employee is affected in some way. For example, front desk staff may be asked to change the way they register patients, because the new EHR system needs different information to be entered. Providers will have to change how they write a progress note in the EHR. The daily routine will be disrupted by the training schedules, the need to accommodate implementation consultants in clinic areas and having reduced access to resources and people who are newly busy with project tasks. As a result of these demands, it is natural for the staff to expect an immediate, direct benefit from their sacrifice.

Including short-term staff goals during project planning will help to address this expectation. For example, announcing the increase in the number of EHR visits per day motivates those staff responsible for the task, and helps everyone to appreciate the progress being made. Project leaders should frequently revisit the project goals and inform staff on the organization’s progress. Regular reporting of progress toward goals helps everyone stay on board. At the same time, staff input should be solicited, valued and answered. Clearly, a rapid and effective response to problems is an important strategy for keeping the project progressing in a goal-oriented direction.

Planning for Change

An EHR implementation creates a significant organizational change. It is an intense process, because doctors and nurses are being asked to perform their work in a new way. Often change engenders reactions, such as fear or resistance, even anger. Thus carefully managed implementation support and effective change management are critical. Experience has shown that the most successful implementations demonstrate three key features: topdown organizational support for change; well-managed teams that share the tasks of the implementation; and support for the end users who are new to the system by providing them additional time to learn the system while not overburdening them with patient appointments.

Going Paperless

The prospect of going paperless should always be viewed as a long-term goal when adopting an EHR. Although reducing certain paper outputs may be an early outcome, several implementation criteria must be met before a paperless system can be safely instituted. For example, network connectivity must be stable and system downtime minimal, if not absent. Telecommunications, printing, scanning and electronic interfaces must be tested and reliable. Billing and workflow issues must already be evaluated and fine-tuned in the electronic environment. Lacking any one of these criteria could result in a situation in which a paperless deployment would be inconvenient and frustrating, if not counterproductive.

Achieving Full Utilization

If the organization does not achieve 100 percent utilization, the EHR implementation is not complete. Resources will continue to be split, both in workflow and in clinical output. For example, when providers create electronic progress notes and then print the notes and place them into paper charts, there is no reduction in the use of paper (in fact, there may be an increase). The new standard must be that all information is to be entered electronically.

Without 100 percent utilization of the EHR, there are risks. For example, if one provider adds an allergy note to a patient’s EHR, but a second provider does not use the EHR, there is a risk that the allergy may be missed. Also since EHRs provide automated drug alerts, providers who do not use the EHR at the point of care may inadvertently create an unsafe practice environment and could be held liable in the case of an adverse event. A topdown, consistent, focused drive toward 100 percent utilization reduces the unstable transition time during the change from the paper to the electronic record.

If going paperless is a long-term goal, 100 percent utilization of the EHR should be considered a primary short-term goal. Only when the system is fully utilized can the expected return on investment be realized. Maintaining parallel paper and electronic systems is not a productive model. It’s important to have top-down support for a consistent drive toward full utilization on the part of all users, particularly providers.

After the system has been operational for several months and the learning curve and impact of activation has settled, an assessment can be made to determine if the original objectives of productivity and accuracy have been met. Further enhancements and adjustments are often identified and could result in considerable increase in the benefits of the system.

Categories of Change

Organizing a major change process requires both structure and flexibility. While planning provides the foundation, the process itself will inevitably vary from its predicted parameters. The project team’s ability to communicate effectively, provide change leadership and promote organizational goals, will be challenged by the day-to-day demands of the implementation process.

An EHR system enables change in several important areas of ambulatory care: information capture and documentation (including orders and results management); decision support; administrative support; patient support; and public health reporting and management. Most project tasks are organized around making these potential benefits become reality.

Information Capture

An EHR is only as good as the information entered into it. Project leaders must organize their current information sources such as lists, reports, flowsheets, order slips, letters and forms, and determine how the EHR will capture, store, manage and report the data automatically. Personal and departmental agendas must be put aside, and reasonable priorities must be set. Efficiency, access and documentation quality are the goals. Sometimes research will be required to determine whether associated entities will accept the new information outputs (reports, prescriptions, standard referral forms, etc.) that the EHR can produce. Categories of information to be documented in an EHR include:

• Patient information entered directly or indirectly into the EHR;
• Demographic information entered into the EHR directly or obtained via interface or integration with a practice management system;
• Clinical information entered by providers, nursing staff or associates;
• Historical information transferred from paper charts; and
• Documentation from other sources, via scanning, file transfer, interface, integration or email.

For each type of information, consider the automated capabilities of the EHR and select a preferred method for entering the information (e.g., document scanning, point-and-click, keyboard text, templates, system interface, file transfer, voice recognition, etc.). Methods selected for entering data should correspond to the methods chosen for obtaining needed reports on the data that has been entered.

In organizing the workflows needed to deliver the information to the EHR, consider the role of every department, from registration through billing, and eliminate unnecessary documents, tasks and processes.

Reorganizing orders and results management is a daunting task. Implementing an automated system may expose the degree to which the existing system is a patchwork one. However, no matter how flawed the existing orders management system may be, providers and nursing staff are often loathe to change it. Careful assessment by project leaders of the EHR’s capabilities, and a consistent plan for implementing orders and results processing, will help prevent glitches.

Decision Support

Because an EHR system is designed to support clinical quality standards, the implementation forces a review of the organization’s current clinical quality status, processes and leadership. Because of its capabilities to affect decision making and, ultimately, patient care quality, the new system will influence both formal and informal relationships and hierarchies within the medical and administrative groups. Thus project management and leadership are critical to the resolution of change issues as they arise. The medical staff should be included in the definition and measurement of clinical goals, tools and resources throughout the project. Provider buy-in requires provider participation. A goaloriented approach will help to focus the medical staff’s participation when the going gets tough and when they are first using the EHR while seeing patients.

Administrative Support

Ambulatory healthcare organizations are characterized by unrelenting administrative burdens, such as insurance eligibility checking, management of paper charts and billing based upon paper encounter forms. In addition, they face clinical burdens associated with busy staff caring for an increasing number of patients per day. Last they face communication challenges such as verbal orders that are often not effectively documented and captured for billing. To cope with these challenges, real-world clinical workflows have evolved to a conglomerate of workarounds. For example, to ensure that charts are not misfiled or lost, providers hide them in desk drawers. Another example is nurses calling the pharmacy to refill a prescription before the physician has signed it, because waiting for a signature delays the patient too long.

In comparison an EHR is designed to follow simple if-then, cause-and-effect rules. Because the EHR introduces this element of logic into the clinic workflow, home-grown solutions and informal hierarchies of influence, authority and power within the organization are challenged. The organization’s ability to cope with these changes determines the eventual success of the system implementation.

Patient Support

An important aspect of change with an EHR is the shift in the notion of data ownership. The electronic chart allows both caregivers and patients expanded access to patient data. Soon patients will maintain custody of their personal medical data via personal health records, and continuity-of-care records will be standard in EHRs. Furthermore patients will increasingly participate in the entering and viewing of medical data in the electronic chart, via pre-admission histories and chief complaint recording, and viewing of graphs, patient education and other automated features, shared by the provider in the exam room.

Organizing new strategies in the ambulatory care setting in response to these trends requires support for a more open methodology in customer service. It is worth mentioning that patients generally seem positive about their providers using EHRs. EHRs offer convenience for patients, as well as improved patient safety. Thus enlightened administrators and staff will prepare for the day when patients will enjoy extensive access to their electronic charts.

Reporting and Public Health

In the future, insurance companies and government-funded healthcare entities will require data on healthcare delivery to justify claims payments. Additionally quality standards will become linked increasingly to evidence that can be measured via widespread data analysis. EHRs are key to these initiatives because they enable the collection of massive amounts of clinical data in databases.

When preparing the ambulatory care organization to maximize its opportunities in terms of reporting, it is necessary to consider the data input as well as the data extraction. Technical planning for the storage and reporting of data must be comprehensive. On the front end, it is necessary to decide how to control the data that will be captured. Standard terminology sets (such as SNOMED, ICD, CPT or NDC) provide a foundation. However, more challenging will be the need to standardize clinical terms used by providers. Five providers may describe a fracture in five different ways, but for reporting purposes, this can produce inefficiency. Organizing for change by opting for recognized standards, such as the evidence-based criteria published by the Agency for Healthcare Research and Quality, may help.

Workflow Redesign

There are numerous resources that explain process re-engineering/ workflow redesign, and the project team should be familiar with the basic tenets. In an ambulatory care organization, the redesign of workflow involves several concerns. First is the existing pattern of responsibility and authority for front-office activities. This is because the EHR system will expose inconsistencies in frontdesk operations, so change leadership falls to the leaders in these areas. Billing and medical records departments will also be affected. Often these department leaders are already swamped with work. Finding ways to organize them into effective workflow redesign teams is a challenge. Sometimes holding a brief ad hoc meeting when a problem occurs is effective. However, this is only effective if there is consistent follow-up. Department leaders deserve full respect, and their views and opinions should be solicited.

Another concern is the inclusion of staff in workflow redesign activities. A tenet of workflow redesign theory is to include the front-line workers, because they are the most familiar with how things are done. Staff opinions matter, and many of their ideas are valuable. Needed is a method for organizing their input and assigning responsibility so as to prevent negative reactions when someone’s idea is not implemented. Effective communication and maintaining a goal-oriented, organized approach to change management will help structure the process. Often, in fact, one or more staff members are naturally suited to this work and become innovators or champions for change. The project leaders should take notice and empower these people whenever possible.

Making the System ‘Smart’

An important aspect of the EHR implementation is helping the organization to use the new system in a “smart” way. Taking advantage of system features is key to improving overall efficiency. For example, the automation of flowsheets provides an opportunity to capitalize on the new system’s capabilities. Most ambulatory care organizations rely heavily on flowsheet documents, developed by in-house experts to record and track data that was otherwise getting lost. A flowsheet must be used consistently. Yet the reality is that time constraints, lack of training or simple neglect frequently result in incomplete, outdated flowsheets.

To improve upon this process, an EHR can automate the flowsheet, so that its information is managed automatically within the EHR. The problem arises when staff cannot let go of the in-house flowsheet document and create a flat version of the flowsheet within the EHR without taking advantage of automated features. The result is a “dumb” document with limited value. A better option is to deconstruct the flowsheet, apply appropriate system features, and redefine the workflow that underlies the flowsheet to help end users obtain the same results in a more efficient manner. Helping end users let go of inefficient tools and embrace new strategies is a common challenge for implementation specialists.

Resource Allocation

The administration of an EHR system requires new responsibilities, or new challenges for meeting responsibilities already in place. For example, in the area of security, the electronic record requires additional layers of security beyond those in place for protecting the paper record. A password policy and procedure must be developed, and responsibility for maintaining and updating these procedures must be assigned. To protect patient confidentiality, user access to the EHR needs to be planned and set up. Decisions about which identifying information will be entered on each end user are needed. Procedures for adding new users, maintaining hardware and equipment, preventing theft, managing interfaces and performing regular database back ups will be required. Because most EHRs contain links to the Internet, IT support staff will have new challenges in terms of protecting the internal network from viruses and other external threats, as well as communicating to staff their role in maintaining system security. Auditing system access, protecting data integrity and data archiving are other challenges the EHR will bring about.

At the day-to-day support level of service, the IT department should undertake an annual diagnostic review assisted by an outside independent resource. The objective would be to review the presence, status and adherence of departmental policies and procedures and other professional practices. It is not necessary that an outside resource assist in the review, but it is difficult when being responsive to the day-to-day demand for continuous quality service to be objective in viewing this type of activity.

Once the formal training is finished, the burden of supporting the implementation of the EHR shifts to the organization. Many ongoing changes will occur as the system is integrated into all of the daily processes of the organization.Within a year, an administrative structure should evolve that supports the utilization of the system, provides for IT and training support and identifies the ways the system can now contribute to the overall success of the organization.