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This is the fifth article in a series dedicated to uncovering the best practices for an EMR implementation. The information presented has been developed by the author as part of a research project.
EMR Implementations
As EMR systems become more prevalent, more information is being made regarding the success or failure of the final integrated system. According to Hoffman (2007), systems implemented at the Harbin Clinic based in Rome, Georgia had been delayed due to cultural issues including resistance by the physician staff to adopt the new system. Due to the issues, the implementation has increased from two and a half years to over four years. Harbin Clinic is the largest privately owned multispecialty clinic, has 20 locations and employs 135 physicians. This large implementation had significant support from the executive team, however, they found that a number of specialists within the organization did not like the aggravation of keying information into the system because it was not tailored to them. Implementation obstacles identified were the lack of process mapping due to the large number of specialties, lack of a change management strategy regarding adaptation of specialty processes to the new system. The effect of the obstacles led to the extension of the implementation window while increasing the cost of the overall project by a half a million dollars.
Bellevue Family Medicine Association (BFMA) in Bellevue, Washington is a healthcare provider with over 100 patients in daily care. Additionally, they had over 10,000 active patient charts. BFMA implemented a new charting system that took two years. BFMA's implementation succeeded due to the flexibility they gave their physicians on entering data into the system. The use of tablet PCs allowed the user to either type or write into the system. BFMA paid particular attention to how people would utilize the system and accounted for those aspects in their planning and implementation (Schock, 2007). BFMA also utilized structured training on the use of the new charting system. Additionally, BFMA leveraged an outside IT firm to implement the technology in order to free up their own resources.
Dominican Hospital located in Santa Cruz, California, implemented an electronic charting system called CareConnect. Dominican is part of Catholic Healthcare West. Dominican utilized formal training as well as CareConnect provided technical support. Dominican also leveraged "super user" groups to help with subject matter expertise. Despite the training and super users, the rollout impacted the nursing staff significantly. There appeared to be a lack of process analysis to understand how the nursing staff utilized the paper charts to administer medication and care. The end result caused significantly more work for nurses to review and validate patient history. Additionally, system issues such as missing or duplicated data undermined trust in the system by the users (Everitt & Hwang, 2007). The system implemented was not analyzed properly to understand whether it was user capable or not. Lack of user involvement, data integrity and usability were significant factors in this failed implementation.
Thomas Jefferson University Hospital (TJUH) in 2001 implemented a computerized provider order entry (CPOE) system. A byproduct goal of the project was the building of lifetime electronic health records (EHR). Over 950 physicians enter information into their CPOE and related systems. TJUH took an overarching approach to addressing the realignment and standardization of processes and procedures across the hospital. TJUH involved users at every level of the organization to help redesign workflows and tailoring the system to the appropriate audiences. Strong backing from hospital executives provided credibility that lead to significant buy-in from hospital staff. TJUH implemented an Interdisciplinary Workflow Group to assess departmental processes and make changes where necessary to ensure that the new processes and systems aligned.
TJUH leveraged the use of a pilot to test the new system and processes. The pilot allowed them to evaluate progress and then adopt at a pace they could effectively support. As the pilot became the implementation, TJUH leveraged the experience pilot participants to assist with integration of the other users (McGurkin, Hart, & Millinghausen, 2006). TJUH utilized a number of opportunities to ensure the success of their rollout by heavily integrating the stakeholders into the entire process. The integration and change management strategy contributed to the success of their implementation.
Yakima Valley Farm Workers Clinic (YVFWC) is a multispecialty community practice. YVFWC operates 18 clinics in Washington and Oregon. YVFMC purpose for implementing an EMR system was to improve patient care and portability of medical information between the various clinics. Patients would commonly visit multiple clinics depending on where they were located at the time they needed service. Without access to all of a patient's records, it became difficult to keep them synchronized. YVFWC decided it was time to implement an EMR system that could be accessed by all sites. TVFWC conducted research to determine the best way to implement their EMR system and discovered that "big bang" approaches were to be avoided.
They leveraged a pilot approach to ease the transition to the EMR by implementing just one module at time. Doing this, they were able to avoid the frustration that quick change brings on along with the unintended consequence of user resistance and distrust. The pilot approach allowed them to continually refine the implementation tactics and overcome obstacles before the larger organization was affected. TVFWC did run into issues related to the lack of standardized processes from site to site. This led to some resistance at local site. They overcame this deficiency by leveraging a consistent rollout team to help train new and consistent processes in the local sites. Training regimens were utilized before, during and after implementation (Simmons & Tschauner, 2006).
Dean Health System (DHS) is located in Madison, Wisconsin. DHS is a multi-specialty healthcare system that provides a network of 60 multi-level ownership clinic that provide a wide range of care in the southern part of the state. DHS deployed an EMR system from EPIC Systems using a a phased approach leveraging a pilot phase to work out issues. Their rationale for the pilot was to gain committed users to help with future expansion. Additionally, DHS leveraged additional tools to help with adoption like speech recognition and integrated transcription services. The combination encouraged greater adoption of the technology (Cordio, 2007).
The Newhan Primary Care Trust in East London and Nuffield Orthopedic Centre at Oxford implemented a system from Cerner, a U.S. based company. After the implementation several issues with appointments being mailed out to the incorrect people were found resulting in people missing appointments and people showing up for appointments that did not exist. People working on the project associated the many problems with the speed at which the systems were being implemented. The velocity of the changes being thrown at the medical staff made it difficult to be successful (Collins, 2006). Other implementations related to the same program have also been plagued with issues. The system dubbed "Choose and Book" provides electronic patient records and appointment booking services as indicated above. The system is
17.3 billion British Pounds over its original budget of 2.7 billion pounds (Wilkinson, 2006). Causes of failures identified in the article include lack of stakeholder involvement, the sheer scale of the project (country wide implementation) and turnover in program management.
A case study analyzing two Danish installations of the same EMR system at two different locations illustrates the approach and subsequent successful implementations of the case study locations. The case study covers a cardiothoracic surgery ward and an orthopedic surgery ward at two different Danish hospitals. Both sites adopted the same EMR system. The system is a standard system providing a shared electronic patient record. The implementation of EMR system was organized by a project manager who created several diverse workgroups to develop integration plans. Super users were identified and leveraged to help with the design of new work processes to support the EMR system. Additionally, the super users provided localized support and answers to questions. User training consisted of 6 to 8 hours in general IT and EMR prior to implementation. Super users were provided with more detailed training to assist in supporting the EMR. Management led meetings were leveraged to ensure users were informed about the project. All of techniques identified above contributed to the successful implementation of the EMR system within the two surgery centers (Jensen & Aanestad, 2007).
Cayuga Family Medicine in Ithaca, New York, is a small practice consisting of pediatrics and obstetrics employing two physician partners and a nurse practitioner. They implemented an integrated practice management system and electronic chart system when they opened in 2000. The system served primarily to provide electronic versions of the patient chart until one of the partners realized that the software could do more through the use of date entry templates. Once he gained understanding, the physician created a number of electronic forms to facilitate data entry and coding. The effect of this activity provided immediate benefits to improved workflow and data entry. Additional gains in billing were achieved due to the more accurate data (Loehr, 2006). The ultimate improvement in the system utilization came from a small scale version of process engineering and showed that it can work even on a smaller level.
Herb Smaltz of the Ohio State University Medical Center (OSUMC) uses a support "S.W.A.T" team to help with EMR implementations. When moving to a new EMR system, OSUMC leveraged steering committees designed to address the process and procedure changes necessary to implement the new system. Leveraging support teams pre and post implementation helped support those users that needed help. OSUMC leveraged staff in the selection process to encourage buy-in for the new system (Havenstein, 2007). Also covered in the article was Citizens Memorial Healthcare (CMS) in Bolivar, Missouri. CMS leveraged the support of the company's executives along with the IT group working directly with staff and physicians through all phases of the implementation. CMS spent 8 million dollars on their EMR project and have over 95 percent of patients on electronic charts (Havenstein, 2007). The JKL Healthcare system operates three acute care hospitals and five ambulatory locations. JKL also operates a research institute and a 450 employee physician group with 50 local offices and a home care services company. The article focuses on one of the acute care hospitals recently acquired.
JKL began their implementation in 2001 to install an EMR system. JKL chose EPIC and had a budget of 35 million dollars. JKL leverage process re-engineering and certification to help facilitate the integration of the new system. JKL made physician certification required in order to refer patients to the hospital. To help compensate for the training required, they waived their professional staff dues as an incentive to participate in the training and continue to refer patients to the hospital. JKL leverage super users to facilitate integration of the systems after staff members received training. The day that JKL went live, they assigned each physician a personal trainer that completed rounds with them. Additionally, super users were stationed at every patient unit to assist with questions or procedures. Ninety percent of the physicians using the system believe it is beneficial and made it easier to do their work (O'Brien, 2006).
Healthcare Partners Medical Group (HCP) located in California moved from an older EMR system to a newer product offered by Allscript Healthcare Solutions, Inc. called Touchworks EHR. HCP operates 38 sites, and four urgent care centers serving half a million patients. The overall project cost 4 million dollars and was scheduled to last 3 years. HCP leveraged a multifunctional team to identify requirements for the new system and break them down into "must haves" and "nice to haves". The team was also leveraged to evaluate and select the new software package. Vendor considerations were heavily weighted in selecting the new product. HCP focused on ensuring vendor stability and ability to support such a large implementation. HCP analyzed workflows in order address changes to fit the new system and also completed performance testing to ensure the systems could handle large amounts of data transfers. Training was a critical focus for all the users of the systems and included e-learning, instructor led training and individualized training. HCP adopted the use of super users to help field questions during and post go-live. The rollout of the software was accomplished using a pilot method bringing up each location independently. Prior to each location go-live event, managers conducted dry runs of the implementation to ensure that systems and personnel were ready (Yocum, 2006).
A study conducted by Miller and Sim (Miller & Sim, 2004)analyzed survey data provided by 90 respondents regarding their use and perceptions of their EMR installations. It was noted that physician's attitudes were of utmost importance in determining the success of an implementation. Those practices that had an "EMR champion" were more successful and had higher usage of the EMR systems. In contrast, those practices where there wasn't a champion of the technology, the use of the system was minimal. Also noteworthy was that larger practices with more staff tended to be higher users than smaller practices and the authors associated this phenomenon with the ability of the practice to absorb implementation costs with regard to additional personnel needed to integrate the project.
The next article(s) will delve into additional reference material and best practices related to EMR Implementations.
All references can be found at
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