Health care reform remains a major topic in the news. Even more so with the recent presidential election. (Don’t worry…this is not an opinion piece.)
I think we can all agree that in order for an initiative of this magnitude to be successful you must, of course, have software systems with seamless interfaces in place. In addition, you need a clear understanding of the impacts to all stakeholders and a project implementation plan to roll-out new systems and processes. How many times have we developed or purchased the perfect software solution only to find out very quickly, after the fact, that it adversely impacted a group of stakeholders or they were unprepared to begin utilizing the new system?
One aspect of the Affordable Care Act (ACA), or Obamacare, is the required conversion from paper-based, analog documentation to electronic medical or health records (EMR/EHR) and the compliance thereof by the industry. I would like to share with you some of the lessons I have learned from implementing an EMR/EHR in hopes that your team can avoid some of the expensive errors that I’ve witnessed.
As the related details of the ACA started to come together, it became evident that the workforce to implement and support such a massive effort did not exist. At the time, most medical records were still paper-based. The effort of ramping up this workforce exponential (and quickly) was charged to the Office of National Coordinator or ONC (a subgroup under the Office of Health and Human Services). It became known officially as the Workforce Development Program. For more details, I recommend reading this Evaluation of the IT Professionals in Health Care (“Workforce”) Program prepared by NORC at the University of Chicago.
I was brought in as a consultant for a network of physicians who needed my assistance in making the conversion on their end. Incorporating the new technology and processes into the actual medical offices was not only cumbersome, but it was required as part of the ACA. Don’t forget, many of these doctors and their staff have lived in a paper-based world for a very long time and aren’t comfortable with this new digital effort.
Some of the most critical lessons learned as part of the implementation to make the health care reform successful for our stakeholders were:
1. 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 stakeholders.
For the EMR/EHR project, we put in place a process that allowed major stakeholders to set goals and direction, yet allowed a knowledgeable team to nimbly and quickly configure the EHR/system 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.
Use our Decision Making Process Template to help facilitation and track your project implementation plan decision making.
2. Leadership Counts. Get representative leaders involved and have them send a consistent message.
All too often, the newest member of a group, such as the new partner, colleague, or division member (who might have been a resident or fellow a scant few months before) – is “nominated” to lead an 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 lead is knowledge of the practice/business area, and the respect of his or her peers.
In order to configure an EHR that actually worked in the practice, direct involvement from the clinical staff was essential. An efficient process involved appointing a clinician to work directly with the implementation team.
3. Implementation Needs to be 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 the stakeholders and for stakeholders, 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 system.
4. Identify Process Improvements BEFORE conversion to a new system.
Computerizing a bad workflow can make that process even more inefficient. The best time for transformation is right now, before system implementation 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. 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.
5. Don’t try to do everything at once. Set the right expectations.
The initial goal should be to get the most important aspects of the system up and running to begin taking advantage of core benefits and achieving a return on investments in as short a time frame as possible. Trying to accomplish everything at once is more expensive and increases the risk of failure.
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. Leadership needs to stress this point so clinicians know what to expect when they start using the EHR.
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
7. Define what constitutes success before go-live, or it will be defined for you. Even if your 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.
8. Software vendor implementation staff know the software, but are not experts on your practice/business. They’ll help configure any process you ask for (good or bad).
Don’t assume that because the vendor has implemented their software at other organizations, they know what is best for your situation.
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.
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.
Regardless of the project implementation plan size and scope, it’s important to understand as early as possible what skill sets your practice/business needs in both the implementation and post implementation phase of the project, your current staff capabilities, and how you will close the gap for where you need to be.
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. 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 may need to hire new staff with specific skill sets or train existing staff to perform new functions, or both.
10. Superior training leads to superior go-lives. Start the training process early and train to real workflows, not just how to “push buttons.”
Productivity often takes a hit when you first switch to a new system. The faster your colleagues become familiar with your system, the faster you will return to or exceed pre-new system productivity levels.
A training program based on your practice’s actual workflow (e.g., patient sign-in, documentation of exams, patient 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 will 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 transition.
Finally, training should not be an afterthought, it must be built into the plan from the beginning.
I believe most of these are critical success factors, regardless of the type of initiative being rolled out, and should be considered as part of your impact analysis and transition plan.
While we are uncertain as to the definitive direction of the next chapter of health care reform, many of these lessons can be used again as we implement the new set of pending regulations.