By Mark Newman
At some point in every electronic health record (EHR) implementation, the question is asked, “How do other practices configure their EHR?” It’s natural to want to know what others have done in order to take advantage of what has worked in the past and avoid what hasn’t. While every physician practice is unique, there are common themes that run through almost all EHR implementations. These lessons learned are based on those themes and represent the successes and scars of many practices working through their EHR implementations.
These lessons apply to all types of practices, whether they are large or small, primary care or specialty, academic or private, part of a larger health system or an independent practice. While the emphasis of this article is on the lessons learned in EHR implementations, practice management applications (billing, scheduling, registration, etc.) are often installed in tandem with EHRs. Most of these lessons apply to both clinical and practice management implementations, though the remarks in this article are directed specifically toward EHR implementations. Finally, these lessons learned are presented in the order in which they are typically encountered during an EHR implementation.
Lesson 1: Effective Governance is Critical – develop a quick and decisive decision making process at all levels
Time is money. Make decisions in a timely manner that will not delay the implementation, yet ensures buy-in from clinicians and administrators. Put in place a process that allows major stakeholders to set goals and direction, yet allows a knowledgeable team to nimbly and quickly configure the EHR with governance oversight. Large organizations may need several levels of governance to accommodate many stakeholders (e.g., physicians, nurses, hospitals, clinical and financial leadership, information services, revenue cycle, patient access, administration, legal, etc.), while smaller practices will have a more compressed and simple structure. Without proper governance, implementations can flounder, take longer than expected, experience cost overruns, and not deliver an EHR that meets expectations.
Lesson 2: Leadership Counts – get clinical and business leaders involved and have them send a consistent message
In order to configure an EHR that will actually work in your practice, direct involvement from your clinical staff is essential. An efficient process often involves appointing a clinician to work directly with the implementation team. All too often, though, the newest member of the clinical staff – the new partner, colleague, or division member (who might have been a resident or fellow a scant few months before) – is “nominated” to lead the implementation effort. The logic makes sense; the newest member may have the lightest schedule and is more likely to be “computer savvy,” by virtue of youth. However, computer knowledge is not the critical factor. The most important attributes for an effective clinical lead is knowledge of the practice, and the respect of his or her peers.
Lesson 3: The EHR Implementation Needs To Be Clinically and Business Driven – not seen as an “IS Project”
To overcome the reluctance to adopt new technology, the process must be perceived as being led by clinicians and for clinicians, and not something imposed on them by an Information Services department or the vendor. Ignoring this lesson will lead to a sub-optimal and probably little used EHR.
Lesson 4: The Clinical And Business Transformation Process Needs To Be Codified Before System Configuration Begins – the alternative is a poorly conceived system or major cost overruns
Many practices look at the EHR implementation as an opportunity to optimize their clinical and business processes and workflows. This can greatly aid the conversion to an EHR by correcting inefficient or confusing workflows. Computerizing a bad workflow can make that process even more inefficient. The best time for clinical and business transformation is right now, before the EHR implementation begins. Trying to do it on the fly (or, “when we get to it”) can increase the time it takes to implement the EHR and significantly add to the cost.
Lesson 5: Don’t Try To Do Everything At Once – set the right expectations
EHR implementations are significant undertakings and should typically be implemented in stages. The initial implementation should provide enough functionality for the EHR to be used in a safe and effective manner. As clinicians and staff at your practice become proficient, you can begin to add such items as higher orders of decision support, interfaces to medical devices, and other important functionality. The initial goal should be to get the system up and running to begin taking advantage of EHR benefits (e.g., patient safety and operational efficiencies) and achieving a return on investments in as short a time frame as possible. In our experience, trying to accomplish everything at once is more expensive and increases the risk of failure. Leadership also needs to stress this point so clinicians understand what to expect when they start using the EHR.
Lesson 6: The Process Does Not End With The Implementation – an evolutionary approach of processes and functionality and continuous improvement is needed
Now that you’ve set the expectation that EHR functionality will grow; you need to follow through on that promise. As important, however, the EHR functionality and use needs to “evolve” to better meet your needs. On more than one occasion we’ve heard the EHR project clinical leader state, “if I knew then, what I know now, I would have made different design decisions.” A great initial implementation will better tailor the EHR to your practice needs, but only through experience will you truly understand what works best for your practice. The evolutionary approach allows for fine tunings and helps to optimize the EHR for your practice.
Lesson 7: Define What Constitutes Success Before Go-live, Or It Will Be Defined For You – even if goals are evolutionary and met in stages
A project is proclaimed a success when it meets the expectations of the organization. Defining what constitutes success early is a way to help shape those expectations up front. Stating your success factors in the beginning also serves to get everyone on the same page in terms of what can be delivered. We have seen exceptionally smooth EHR implementations called failures because stage 3 (future) goals were not delivered at stage 1. This could have been avoided if the success factors had been better communicated.
Lesson 8: EHR Vendor Implementation Staff Know The Software, But Are Not Experts On Hospitals and Physician Practices – they’ll help configure any process you ask for (good or bad)
Beyond providing the software, the EHR vendor is often hired to help implement their system. The vendor implementation staff knows what needs to be configured within the EHR, but often does not know how it should be configured for your practice. They will leave those decisions to you. The vendor may have some insight into what other practices have done, but you should augment and verify this information by talking to other practices, including a physician from your group who has EHR experience, hiring consultants who do understand physician practices, etc. Don’t assume that because the vendor has implemented their software at other practices, they know what is best for your practice.
Lesson 9: It Is Challenging To Find Employees Who Have All The Skills That Are Needed – make sure to build in time to allow for extra training and growth
From physicians and nurses, to the clinical and technical analysts who configure the system and maintain the application, to the practice staff that will use the application every day, you will need to hire new staff with specific skill sets or train existing staff to perform new functions, or both. Obviously, a large health system implementation will require more people and specialized skill sets, while the need for more staff in smaller practices will be less. Regardless of the implementation size and scope, it’s important to understand as early as possible what skill sets your practice, hospital, or health system needs in both the implementation and post implementation phase of the EHR project, your current staff capabilities, and how you will close the gap for where you need to be.
Lesson 10: Superior Training Leads To Superior Go-lives – start the training process early and train to workflows, not how to “push buttons”
Productivity often takes a hit when you first switch to an EHR. The faster you and your colleagues become familiar with your EHR, the faster you will obtain or exceed pre-EHR productivity levels. A training program based on your practice’s actual workflow (e.g., patient sign-in, documentation of exams, histories, allergies, findings, procedures, orders, billing, etc.) is far more effective in getting everyone in the practice ready for seeing actual patients than training to a “generic” practice. In addition, depending on the size of your practice, role-based training can also facilitate knowledge transfer (e.g., separate training for clinicians, administrators, billers, etc.). Eventually, your practice will learn the new system, but good training goes a long way toward ensuring a smooth and quick transition. Finally, training should not be an afterthought, but built into the plan from the beginning.
As the philosopher and writer George Santayana is often quoted, “those who cannot remember the past are condemned to repeat it.” Keeping these lessons learned in mind when you implement your EHR will help you avoid some of the deeper pitfalls others have experienced and highlight what has worked well.
Mark Newman is a partner at EHR Associates; a consulting firm dedicated to helping physician practices adopt information technology. He can be reached at 215.690.4133 or firstname.lastname@example.org