In our previous article about the functions of an Electronic Health Record system, we explained what options you have when going for an EHR. We then went on to explain the problems hospitals face in operating EHRs. This time we’d like to tackle the implementation itself. Where to start, how to select the software suiting your practice’s needs, and how to get the system up and running while smoothing the introduction for the staff.
We describe the EHR implementation lifecycle in eight steps:
- First, you need to assess where staff stands in terms of technical skills and mindset.
- Then, you move on to mapping out your current workflow.
- During planning, you put your ideas down on a roadmap.
- The fourth step is to select the appropriate EHR solution.
- Once it’s done, you get down to setting up the system and adjusting it to your processes.
- Next goes the implementation itself.
- Then, it's time to educate the staff about the EHR system.
- Finally, you can estimate the initial results, act on this data, and make necessary improvements.
Eight steps of the EHR Implementation LifecycleNow, let’s zoom in on each step in the EHR Implementation Lifecycle.
Step 1: Measure your EHR readinessYou know you are in need of an EHR system but are you prepared for it? Before diving in, assess your organization’s readiness: IT infrastructure, staff skills as well as attitudes. You can conduct a practical assessment in the form of a survey. For example, taking a computer skills survey will help you identify the available expertise as well as the gaps to be filled in by training.
Stratis Health made an Organizational Readiness Assessment (.doc) for the leadership team. It spans five main readiness aspects:
- leadership and management
- workflow and process improvement
Snippet of the Organizational Readiness AssessmentThe form lets you evaluate your readiness on a scale of “Not Yet Prepared” to “Moderately Prepared” to “Highly Prepared.” The more checks in “Moderately” and “Highly Prepared” you have, the more prepared you are. If there are still many checks in the “Not Prepared” column, use statements from it to understand the problem areas and work on them.
Stratis Health also offers an EHR Beliefs Assessment (.doc) designed to understand the attitudes and beliefs of both administrative and clinical staff. Its outcome also affects training and helps figure out how to encourage sustained use of the software in the future.
Step 2: Workflow analysisDerived from the previous step, workflow demands specific attention. Clarifying the processes in your organization, you’ll be able to determine the exact organizational and technical criteria for your future EHR software.
We can identify two key actions to take:
- Document your current workflow by mapping out how patients move through your medical practice.
- Plan your future workflow with an EHR implemented
Planning future workflow. Now, think about the ways EHR features will technically support your practice and boost its productivity. Identify the EHR features you need to boost your processes.
Let’s map the office visit workflow, as an example. A patient arrives at the office and checks in through the encounter close out in the EHR. Then, the staff interacts with the patient. EHR reminds them of any patient considerations so they can improve the quality of care and patient safety. The staff navigates the patient to the doctor who measures the patient’s vital signs, updates medications, and gathers complaints, and then - examines the patient. In the end, the doctor enters all the info into the EHR.
That’s a general workflow description but we can already see how EHR’s front office management tools together with the physician support tools greatly upgrade the patient’s experience.
Office visit workflow mapped out, Source: National Learning Consortium (doc.)
Step 3: Create an EHR implementation roadmapIf the assessment stage confirms that you’re ready, start planning. At the planning stage, the primary task is to outline all the processes that need to be executed by your team of physicians, practice managers, IT staff, and even patients. For this purpose, you can use a roadmap.
A roadmap is a table-like document where you can put down the stages of your EHR product’s development. Having a roadmap will help you align EHR technology with the actual needs of your hospital. As a result of filling out a roadmap, your EHR implementation strategy and utmost goals are taking shape.
Example of an EHR Implementation Roadmap, Source: HealthInsightA roadmap is where you also diagram all your tasks and risks and calculate the expected implementation budget. Read on how to create a roadmap in our dedicated article.
Depending on the complexity, it can also be a checklist, a matrix, or a template. You can use tools like simple Google Sheets or more advanced ones for flexible project management like Trello, Wrike, and Asana. If you’re working with an IT consultant to drive your implementation efforts, they will suggest the most fitting tools and will prepare a roadmap with you.
Step 4: Choose the right EHR productUsing the information gathered in the assessment and planning phases, you’ll be able to select a fitting EHR for your organization. This system should streamline the processes in place and work with them, not against them.
You already know what features are important to you, but you still need to consider technicalities. It includes the following considerations:
Hosting. There are solutions hosted on the cloud (called Software-as-a-Service) and those located on-site. If you want it local, you’ll have to take care of its servers, make sure you have space and resources to maintain them, both financial and IT. Another way is to purchase it as a SaaS solution along with maintenance and support services. You can see a more detailed comparison below. No option is better than the other, but for smaller healthcare providers, it’s more practical to get a cloud product and start using it right away. Larger hospitals aiming for customization will likely choose more expensive options.
Self-Hosting vs. SaaS, Source: Health ITDevices support. Physicians require an easy connection to the EHR system to access and input information. In this case, computer hardware plays a key role for a convenient use. Make sure the EHR is available via different devices like desktops, tablets, or smartphones.
Interoperability. Enabling health information exchange is a critical aspect as hospitals and practices must share data electronically with labs, radiology providers, public health registries, and syndromic surveillance systems. So, an EHR needs to work seamlessly across several platforms and technologies. As interoperability standards and rules become a healthcare requirement, be sure your software supports them.
Compliance. There is a range of rules the EHR app should comply with to enable normal operation. They include HIPAA for the US and GDPR for Europe. Also, there is the ONC Health IT Certification Program aimed at ensuring patient safety and improving the overall usability of EHR apps. So, make sure the vendor you choose is compliant with the standards.
Once you have your pool of suitable vendors, make the final choice. For this purpose, you may use Health IT’s pricing template (.xlsx) and comparison and matrix table where you can prioritize the options by scoring their usability characteristics:
- charting capabilities
- prescriptions and lab results handling
- clinical decision support
- disease and population management
- health records management
- clinical tasks management
- communication within the practice
- patient access to their health data
- entailed finances
- public health reports submission.
Step 5: Tailor EHR to your business processesOnce you’ve settled for an EHR product, the next step is to configure and adjust its functioning to your workflow. This can take up a considerable amount of time, especially for a large organization. The New York City Health and Hospitals Corporation, for instance, faced delays during their second phase of EHR implementation because it took them more time to act on the insights learned from the first phase.
Why is it so difficult to adapt EHR to your practice? It requires rethinking your models of care with regard to EHR technology. The adaptation works both ways. First, you tailor the EHR to match key processes. And then, you modify your non-key operations to work smoothly with the system.
The nuances will depend on your specific practice. Necessary settings range from medication management to patient history settings and billing updates with new codes and consents. Also, your physicians may need specific templates to support documentation.
Don’t forget about integrations. Working closely with insurance companies, laboratories, and pharmacies, you’ll most probably need to integrate your EHR with their software. You should think of external data you’ll need to import such as demographics from the practice management software (PMS), computerized order entry (COE), and treatment regimens/protocols.
Step 6: Prepare for the launchFinally, you can proceed to schedule the implementation. A few weeks before the launch, plan every go-live activity in detail. It involves:
System testing. This includes checking your network speed and reliability, testing the data backup processes, and performing usability testing.
Choosing a launch approach. Launching the system, you can boldly roll it out for all patients and functions on the same day. Although this scenario minimizes time spent managing paper records and the system in parallel, it can be quite disruptive if small problems start popping out. So, many organizations prefer a slower approach introducing one function at a time or implementing the EHR in separate departments first.
Pre-go-live dress rehearsal. Simulating a patient visit prior to the go-live date can help spot unintended consequences and fix unseen problems. Some of the most important scenarios to simulate are patient check-in and check-out, rooming, vital signs collection, lab orders and medication refills processing, immunization orders, referral management, follow-up orders, and billing.
Issue resolution plan. If the staff needs help, they should know who to contact. During the contract negotiation phase, make sure to ask your vendor for support during go-live. Make them aware of your schedule, so they’ll be ready to provide virtual support if needed. In addition, assign leaders among the staff responsible for handling issues.
Go-Live day. The workflow will inevitably face some interruptions, so it makes sense to reduce the patient volume and warn them about the software transition. They’ll be more patient if they face any delay during their visit. Don’t overload your workers; better consider adding additional staff.
Step 7: Develop a training programOne of the primary reasons an EHR system doesn’t bring the expected results is poor user adoption. How practitioners and staff embrace the system hugely impacts the final ROI. A sustainable training program should include role-based training, clear communication channels with the support team, and feedback loops for the project management team to track the adoption progress.
As researchers at Kaiser Permanente conclude, it’s a good practice to base the training curriculum on the frequently asked questions, operational efficiency training content from the health care community, and survey data from expert users. That’s about the content of the training program. And below, we give recommendations as to how to organize the process itself.
Transit gradually. Before launching, start with the basic training to learn the functions. And once the staff has used the system for about a week, hold additional training to improve skills, learn time-saving tricks, and get more comfortable with the technology.
Assign tech leaders in each specialty. Since nurses teach nurses best and surgeons teach surgeons best, having colleagues teaching and tracking their colleagues is a good way to speed up the adoption stage.
Support ongoing training. The length of the training will depend on the usability level of the software. But it’s more of an ongoing process that maintains efficiency and supports updates.
Schedule training beforehand. Consider that training takes time from seeing patients. So, plan training in a way that doesn’t disrupt the practice workflow.
Step 8: Evaluate the quality of EHR implementation and make improvementsFor a solid evaluation of the EHR system implementation, you should choose specific metrics and define success criteria. Using them, you’ll determine whether the system is meeting your expectations.
Feedback. Monitoring your staff and patients, you’ll be able to understand how satisfied they are with the system. Reflecting on the feedback, you can make improvements to the EHR workflow. It’s a good practice to have a system where users can submit EHR suggestions. Based on them, you can later make modifications to your software. Besides feedback itself, you can track how efficiently patients are cycling through the portal.
Metrics. Depending on your goals, choose your target area for evaluation:
- return on investment (ROI) metrics to assess the profitability of the implementation.
- actual numbers of transactions, if wide-scale usage is your priority, and
- turnaround time of orders statistics at various points after the system is fully operational.
Clinical Quality Measures (CQMs). As a healthcare provider, you must report your CQMs to Medicare as part of meaningful use requirements. So, compare the quality of your clinical services now and then to see whether there have been positive shifts.
Common barriers to EHR adoptionThe transition from a document-based storage system to an EHR means investing a lot of your time, effort, and money. We’d like to wrap it up by telling about spikes that make the rolling of an EHR wheel especially challenging. But we also give ways to pull them out.
Data migration. Digitizing paper records can be fairly considered the hardest part of EHR implementation. Especially, if there was no unified paper format in the former system. You can narrow down the scope by prioritizing the essential documents and setting the expiry date for the data you’d like to be backed up into the system. For example, patient records from five years ago may not need input into your new system. Besides, transferring data to a new system, don’t forget to test and verify it beforehand.
Data privacy. Although EHR vendors take care of data security features like data encryption and verification filters, you should also avoid data leakage from your side by enhancing administrative controls. First, guide employees through the privacy and security training process and later run background checks to ensure they are sticking to your security policies.
High implementation cost. Studies estimate the cost of purchasing and installing an EHR system to range from $15,000 to $70,000. Besides, there are ongoing expenses for training, network fees, and maintenance. No wonder, smaller establishments put off this expensive affair. In this case, you could turn to a Regional Extension Center that assists with EHR implementation. The REC not only helps calculate the expenses more accurately but also provides free or reduced price support for eligible practices.
Communication gaps. Establishing effective communication with the EHR vendor is crucial as EHR implementation is not a one-time activity but a continuous process. So, monitor how well your vendor reacts to your concerns and feedback. As for the internal communication among the medical staff, they can leverage a Social Knowledge Networking (SKN) system to report and discuss problems with EHR more efficiently, or share best practices about its use.