The EMR Implementation: Thorough Preparation Foils Failure
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The EMR Implementation: Thorough Preparation Foils Failure

Written by John Morissey

Midland Memorial Hospital is readying for a date with disruption, on purpose. And with purpose. The mid-size, county-owned facility in the West Texas city of Midland will replace its collection of older clinical IT systems with a comprehensive suite of electronic medical record applications next March.

By then it will have researched and ingrained the best ways to implement that new system, including observing and aiding a similar implementation at nearby Odessa Regional Medical Center set for next month (Sept. 2017). Odessa will return the favor, mobilizing its staff for Midland’s spring implementation.

By the time an EMR goes live, its odds of either success or catastrophe are preordained by the planning that precedes it. That means managing the change as well as the technology, including setting the right expectations up front about what the EMR will and won’t do, and a realistic timeline of when certain things can be accomplished, said Cathy Menkiena, a managing director with Houston-based Encore, which was recently acquired by emids, which consults on health information technology.

Cathy Menkiena
Menkiena

“This is definitely not an IT project,” Menkiena emphasized. “It’s an organizational transformation project, and if an organization has not approached it that way and included the right constituents whose workflow is going to be impacted on a daily basis, the end result is that there are a lot of change requests after go-live and poor adoption of the workflow.”

CEOs and their leadership teams have to “be visible . . . to all tiers of the organization, and be committed and communicate the ‘why,’ ” she added. Their essential role includes setting up a governance structure that includes operational leaders who really understand their departments, and marshalling “subject matter experts that are the frontline, day-to-day folks that can help visualize and design what the future-state workflow is going to look like.”

Anticipating Trouble

Primary users of the EMR system, if given enough time to become familiar with how it will look, run and perform its duties, are likely to weather the initial disruption. But that’s a big ‘if,’ and it depends on getting physician leaders involved in every material decision as to how IT pros set up functions that can either facilitate or confound use of the system. If clinicians see problems to fix, the response has to be quick to either revise the clunky workflow generally or train docs on tools to customize the way it works for them.

Odessa Regional has been working with physicians for 18 months on the transition from its current McKesson EMR system to the Cerner replacement next month, including demonstrations of how it will work, said CEO Stacey Gerig. With its chief operating officer, Levi Stone, as project manager, the key has been to engage the entire facility, including impact testing to make sure that actions will work as intended.

Stephen Bowerman
Bowerman

Gerig also consults a medical informatics board, comprised of a lead physician in every specialty, plus a physician champion with overall responsibility for the project. The board has been meeting every two weeks, talking about concerns that arise. Meanwhile, education and reinforcement have been the most important tactics of Midland’s efforts, said Stephen Bowerman, senior vice president and chief financial officer. Staff and physicians need to have easy ways to look up and learn how to do things in the new system, both before and during go-live, and that’s especially important for physicians who work a full day, usually using an EMR in their offices, and then do rounds at the hospital on a quite different system, he said.

IT staff have to know the technology of the new system, of course, but just as importantly must know its ins and outs from the perspective of the providers using it and be able to anticipate their needs and concerns, often translating how something done in the current system will be handled in the new one, Bowerman said.

Midland is preparing for a Cerner implementation that will replace an open-source version of the Vista EMR invented by the U.S. Department of Veterans Affairs, plus other specialty IT applications that will account for service lines not part of a veterans hospital.

All About that Workflow

EMR workflow that works for all clinicians usually isn’t baked into the enabling software, nor should it be. Every specialty has nuances, and docs differ on the most important data and features to gain access to without delay or difficulty.

The point at which disconnects about workflow become evident should not be the day or week that the new system becomes operative, said Menkiena. If potential functions and workflows of the new EMR aren’t sufficiently demonstrated and explained months beforehand, clinicians can’t anticipate change and react in time for IT staff and a vendor implementation team to fix things that users can’t easily grasp, or that are wrong for the professionals affected by them, she said.

Physician engagement can help determine whether the training is covering what it should. At Odessa, doctors looking at a patient record were being trained on how to get test results at a certain point in the EMR, but they weren’t sure “how to get to the point where the training started” on that function, said Gerig. They wanted first to be shown from the initial log-in how to proceed to the results access. It was how they work.

One of the most common examples of problematic workflows is medication reconciliation, Menkiena said. Multiple professionals and the patient are involved in entering, adding to or subtracting from the med list, from intake to transfers with changes in level of service through to patient discharge. The drug formulary is central to the process. If the information can be “presented in a way that the most commonly ordered dosages and frequencies are at the fingertips of who’s doing the data entry, and the nurse does it correctly on intake, it directly impacts how easy it is for the physician to perform the (reconciliation) process.”

Implementations are full of new and unfamiliar features, all intended to improve some processes but are not always necessary at the launch. “There’s only so much change that an organization has the capacity to absorb,” Menkiena cautioned, so decisions have to be “realistic as far as what that change is going to look like, communicating it via multiple communication vehicles, and sufficient training and provision of at-the-elbow support when they go live.”

Ferdinand Velasco
Velasco

When Texas Health Resources, an Arlington-based 24-hospital system, began its implementation of a network-wide EMR in 2006, it engaged physician leadership months before going live at Texas Health Plano to get input into, for example, what features to turn on at the outset and what to steer clear of until clinicians digested the initial operation of the Epic platform, said Ferdinand Velasco, chief medical information officer.

THR had a few advantages going for it. For one, it was able to learn from each implementation and make subsequent hospital EMR approaches even smoother, says Velasco, so that by the fourth go-live, the full lineup of software functionality was activated on the first day instead of phasing it in over time. Another advantage THR had was that it was able to plan and execute implementations more deliberately and methodically in the years before hospitals had to contend with pressures from external forces to accelerate EMR projects.

Fighting Implementation Pressures

Some organizations struggle because they are motivated to meet EMR meaningful-use targets to earn federal reward money, or avoid penalties residing in such reimbursement instruments as the Medicare Incentive Payment System, Velasco notes, adding those are important considerations but shouldn’t be the primary motivation. If so, a lot of the decisions that go into implementation “become largely motivated by the regulatory factors, or the external factors, and that doesn’t go well with the clinicians.” Compressed timelines, sometimes as short as one year, spell disruption. Depending on maturity of software and the organization’s culture, that rushed approach can trigger a backlash, he said.

Texas hospitals can’t shut off the external pressures pushing them into EMR adoption, but they can do it more successfully by learning from one another. Odessa Regional and Midland Memorial are drawing on experience from collaborative efforts of all sorts as they prepare their organizations for the change.

Odessa is part of Iasis Healthcare, which operates 18 hospitals in Texas and five other states. The health system implemented the Cerner EMR at two of its facilities thus far, in April and July. Odessa staff met with those facilities for three days to learn their lessons leading up to go-live, and volunteered staff as resources for the second implementation, said Gerig. Once Midland aids Odessa next month, the battle-tested Odessa staff moves to the Midland effort as the chain of collaboration continues.

In addition to that cross-pollination, Midland and Odessa Regional learned from a third Cerner implementation earlier this year at Medical Center Hospital in Odessa. Some physicians on staff at that hospital also are on staff at one or both of the others and have been using the Medical Center system, and their experiences are entering into decisions on what to make sure gets done in the coming go-lives.

Iasis created a corporate-level board of specialists from each facility to help develop effective workflow, including training in customizing the new EMR in ways that weren’t possible in the past, Gerig said. One big event is a physician favorites fair, where practitioners are walked through the steps of creating their own priority data displays, which then will be in place before they ever sign on to the new system. The docs using the Medical Center EMR have done that already and can add their feedback, she said.

These collaborations can take any number of forms even for standalone or small-scale health systems. Menkiena has seen individual organizations come together as a limited-liability corporation to pool their efforts to select and implement a common EMR. Additionally, she said, non-affiliated organizations have created an umbrella entity supplying shared services for EMR selection, implementation and networking.