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Foundation Members:
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CHIME Presents:
The CIO’s Guide to Implementing EHRs in the HITECH Era
CHIME Member Comments on
Chapter 5: Managing Expectations a Key for Project Support
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Question posed to members:
Misconceptions can surround the work involved in implementing EHRs, and the benefits that will eventually be derived.
How have you been managing expectations surrounding the implementation and use of EHRs? How do you prepare everyone, from the CEO to clinical staff, for what the experience will actually be like?
Comments:
“Expectations management is a role shared by the clinical executive sponsor and CIO. In our case the clinical sponsor is very much involved in setting expectations regarding benefits – i.e., patient safety and quality improvement, improvements in documentation capture, opportunities for better throughput and delivery, richer data for research and clinical uses, etc. The CIO should also be versant and supportive of those opportunities, appreciating the diversity of clinical opinion as may prevail on such discussions. Further, the CIO should be key in messaging expectations regarding vendor product efficacy and implementation support delivery, required investment, timelines/scope management, and alternative approaches to infrastructure and end-use delivery. The CIO should also be able to articulate how the EHR elements fit together to strategically position the organization.”
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“All of our hospitals already have a base level of EHR to HIMSS Level 3. Two are at HIMSS Level 4. In general, there has been strong CEO support for the implementations to date. We do have the opportunity to better motivate some of the user community. We have shared with users that the initial implementation of new functionality will typically slow the process until they become more facile at using the applications directly. The actual degree of training varies with the complexity of the task and the audience. For complex implementations, we find that at-the-elbow support is the most effective approach. The biggest challenge is to focus users on process changes as well as the details of how to use the specific application.”
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“During our initial big bang EHR implementation, our CEO kicked off the project with a town hall meeting for all employees and medical staff to attend. At that meeting, the project phases were outlined and it was clearly stated that we were going to follow suggested best practices by our vendor unless we came across a patient safety, cost efficiency, ore revenue issue. During the implementation, we posted progress thermometers on our intranet and throughout the facility showing our progress. Each affected department had an assigned project team member and those team members were also chartered with updating their individual departments at department meetings. We also had at that time, a board IT Oversight Committee that monthly to review progress.
Post go live, we conducted weekly town hall meetings lead by the CIO to address issues and concerns from the staff. Additionally, we launched an EHR change management committee that met every two weeks (now monthly) to prioritize fixes and change requests based upon the new system.
Post CPOE go live, we have been posting usage statistics and CPOE stats in the physicians lounge and this gets reported at our board quality committee meeting.”
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“My facility is fortunate in that much of the EHR is currently in place. We have been doing bedside nursing documentation for over 12 years and have been doing bedside medication verification for almost 6 years. We are now moving more of our OP and surgical areas to electronic documentation. Therefore, expectations and what the experience is like is not an issue at the facility.
Our biggest issue is CPOE and the implementation and acceptance by the physicians. Management and Quality Council have been advised and are ready to work toward this goal.”
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“The implementation of an EHR is never done. Unlike a financial system the goes live and runs relatively smoothly until there is a regulatory change. We are constantly tweaking our workflows to provide better quality and hopefully low cost care. We’ve had a basic EHR for a number of years and we are continuously implementing new functionality. We’ve actually gotten to the point where we feel we’ve outgrown our current product and need to replace it with something more robust.”
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“We have been routinely warning all levels of staff that the most difficult parts of the install are still ahead of us (we are about halfway thru our EHR install). We have regular twice monthly meetings with key users who are building the files for the new system, and review the current version of the timeline in each meeting. We also review the timeline and budget in a twice monthly project steering committee in which we sometimes discuss needed changes to the project. We also have monthly meetings between our install staff and the vendor's install staff to air out any concerns about miscalculated expectations on either side of that equation. We also review the project highlights and concerns in monthly Information Council meeting, in which all IT projects get reviewed and prioritized.”
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“OK, this could be a book chapter, but I will attempt to answer here.
CEO/Board: My first statement to them is this: “don’t think of an EHR as an ROI project but rather an ROQ – return on quality – project”. I then go on to explain that when we first implement an EHR we tend to implement the “plain vanilla” version and then “optimize” over time to squeeze out the quality gains – and “oh by the way” – along with quality gains we should see decreased cost of care (decreased LOS, fewer complications, fewer duplicate/unnecessary tests etc.). So I finish with “although not directly measurable, EHRs, thru improved quality of care over time, should drive down the cost of care – and thus the ROI, but it will take time.
Clinical Staff: On the question of time, I usually respond with: “In the long run, using an EHR should be time-neutral. Some tasks will take you less time (finding chart, finding results, entering orders), some will take you more time (documentation).” I also point out the improvements we expect to see in quality of care: 1) more info at your fingertips at the time of making decisions makes for better decisions; 2) automated error checking (allergies, interactions, doses etc.) makes for safer orders/care; 3) improved communication (timeliness of, legibility of, completeness of and broader access to documentation) makes for improved care.”
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“We have had a multi-disciplinary, clinically-driven hospital information evaluation team meeting periodically during our vendor selection process, have included the executive team in briefings, and have launched a steering committee for carrying forward the selection through contracting/implementation.”
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“We continue to focus on the reason (s) that we are doing this in the first place: Clinical Excellence and Patient Care. We also consistently communicate the fact that we have to do this right, with proper planning, education & training, as well as careful monitor of the adoption plan. The leadership from the top has been a great plus as the message that “there is no turning back” has been very clear to everyone, especially to the physician community.”
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“Physicians and others have been using portions of an EMR now since early 2005. Physicians have been signing documents electronically and they and others have been looking for clinical results from the lab and radiology (to include images from PACS) increasingly since that time. Physicians and their office staff have the capability to access their patients’ hospital EMR from their remote location when it is requested. Also over this time we have added speech recognition in Pathology and Radiology which further improves the reliance on electronic documentation and direct entry but the provider of care. Our next step is to add nurse documentation.
At each step, familiarization briefings and one-on-one training is provided to our physicians. Familiarization and information briefings are provided in the form of staff news letters, specifically focused email, handouts, medical staff meetings, office manager meetings, and office visits. The one-on-one training is provided at the time of implementation or just after. We endeavor to involve at least one physician who take the lead in the area being most impacted by the electronic enhancement. They become the physician spokes person and champion for the effort at hand. Presentations have also been provided to the board of directors; there are a number of physicians on the board.
This steady rise in reliance and access to electronic patient information has assisted us in taking each next step. There are local providers who have been vocally supportive throughout this process and contributed to further adoption. For those working inside the hospital, each new step has been positive and supported. For some of our independent, community physicians we are not moving fast enough. For others, the entire electronic health record is unproven and has the perception of being a tax on their productivity. For the majority of our independent physicians, they are taking a wait and see approach.”
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“We were early adopters of the Electronic Record. As such, we did involve the entire organization in our “marketing campaign” and used a high touch approach with clinical staff and our medical staff. Our CNO was very involved as the project champion. That helped tremendously.”
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“Having implemented CPOE and clinical decision support functions several years ago on the inpatient side we learned early on that even thought there are benefits there is also additional time required to use these functions resulting in physician dissatisfaction. Early engagement and management of expectations were lessons learned, and even though we thought that we knew this going in one can never underestimate the need to address this. Governance and funding are also big issues that the organization must own as a whole. The cost in effort and time, in addition to capital dollars, is far greater than the sticker price of any system. The organization must have fiscal stamina for these efforts. In addition there needs to be clinical oversight for implementation of order sets and rules. We leveraged existing committees and continue to have a core group of very engaged medical staff members to sort of issues and make decisions.”
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“I speak with them every chance I can about the need to have quantified data elements rather than text blocks if they want me to be able to generate their quality reports. I explain how this adds clerical responsibilities to the clinical staff that didn't exist before and that the trade-off on the reporting comes at the price of additional discreet data capture.”
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“Partnering with our Communications/Marketing department we plan our key topics for the month and hit the organization from executive committees, physician departmental meetings, managers meetings to staff forum. We create the material on our focus point for the month and using hospital executives hit every part of the organization, from every direction. For 30 days they hear nothing but the same message. We listen to what their concerns are and always follow back and respond.”
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“We focused on quality. The most compelling argument we continually made for CPOE was based on a before and after workflow assessment.
Before:
There were 42 steps and 30 opportunities for errors in our manual processes. With 90,000 prescriptions/month this represents 3.78 million steps and 2.7 million opportunities for errors. And when we consider all orders (lab, rad, PT, dietary…) these numbers easily double.
After:
The new process has less than half the steps at 20 with only 2 opportunities for error. So with 90,000 prescriptions/mo we execute 1.8 million steps with only 180,000 opportunities for errors. The two opportunities for errors are with verbal orders: 1) the possible delay in getting the message from the CA to the nurse and 2) the need for the nurse to contact the doctor if an alert arises as she enters the order into the system.
Quite an improvement: from 30 possibilities for errors/trxn to 2.
We never say adopting technology will be easy or faster. However, we do say that the overall process will be better (not necessarily each step).”
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“We have done multiple presentations to our Senior Leadership, Community Physicians and their office managers. Presentations explaining meaningful use criteria along with benefits of EHRs. Of course, we explain that the most important work to be done is documenting existing process workflows and establishing new workflows that best utilize the functions of the EHRs. This is often not a service offered by the EHR vendors and if it is, they usually offer it as a optional cost that most practices will not elect to purchase. Just installing an EHR without change processes will result in an under-utilized EHR or a failed implementation resulting in a desire to replace the system. The other major success factor is the amount of education provided to the office staff and physicians. This is usually where the vendors reduce the dollars in their proposals in order to get their system to an acceptable price point for the physicians.
A combination of good process changes and heavy doses of education will eventually make a practice successful using an EHR. We do however tell the physicians and their staff that they will experience a decrease in productivity for 3 to 6 months. They will only be able to see 50% of the normal patient volume during the first 2 to 4 weeks. They will gradually work their way month by month back to the levels they were use to prior to the EHR implementation.
They can expect to achieve better reporting to decision making. Better coding for more optimal billing. Improved quality of care due to legibility of physician notes. Improved office efficiencies due to the use of ePrescribing…refills becomes easy to process and patient reminders becomes easier to do too!”
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“The implementation of E.H.R.s can easily lead to missed expectations,financially, productivity, etc. We are striving to communicate to a broad group of key stakeholders in many different manners, as often as possible.Some examples are: 1. frequent presentation updates to management teams, 2. quarterly webinars to anyone in the corporate organization, 3. Engagement sessions for physicians, management, and informal leaders every month. The physician meetings are creatively managed to include food, drink, door prizes, and smaller breakout sessions by speciality. This strategy has helped to keep physicians and others engaged.”
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“Expectation management is a key success factor for implementing an EMR/EHR. There are going to be significant changes in the clinical workflow and a shift in who does what work – the most significant being the amount of data entry work the physicians are being asked to do directly. To say to the stakeholders that they are going to work less due to this new tool, is doing them a disservice and putting their confidence in the leadership at risk. The stake holders need to be involved at every step and the expectations clearly defined. It is ideal if they can role-play/test their new workflow utilizing the new system at key milestones. The key is to establish ownership at the lowest level by engaging staff and clearly defining the vision, goals and “a day in the life” of every stakeholder involved.”
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“Our hospital system has a formal project called The Clinical Transformation Project, which began in 2006 with direction from the Board of Trustees and led to a wide variety of information technology projects (and funding) to support the infrastructure and ancillary systems that would be needed for the core EHR system, as well as for the EHR system itself. The Board of Trustees has been updated on the project approximately 3 or 4 times per year. The Board of Trustees also has a sub-committee, called the IT Board Committee, that is updated 6 times a year on the progress of the project. The actual project involves several dozen non-IT employees who are involved in numerous workflow redesign and software configuration activities, and they are liaisons to their home departments. There is an internal intranet site devoted to the project which is updated regularly for all employees and physicians to read. Project Team members also are guest speakers at various department meetings, as well at Medical Staff meetings. The project's status is a topic at the enterprise-wide, Quarterly Managers Meeting, a meeting of some 400 managers throughout the enterprise. There is also a vice-presidential-level "cabinet" meeting that meets monthly, and the EHR project is a regular topic. Lastly, there is an extensive training program for all users of the EHR, which includes classroom-based training, web-based training and one-on-one training---all of which set expectations for use of the system.”
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“Working closely with our CMIO and nursing leadership we try to be realistic that caregivers will be asked to carry more of the responsibility to capture key information (we technically refer to as discrete) as part of provision of care so quantitative data can be capture to support clinical decision making at the point of care but also to greatly improve efficiently for this downstream processes that desperately need data to manage the care of the patient. Preparation:
- Clinician led discovery
- Transparency around impact to time and that tradeoffs are inevitable
- Train hard with expectations that we will support the transformation from paper to digital at every turn”
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“Since we're well along this road, we prepared the organization by stressing this was not an IT project, that it would take considerable effort from the medical departments of the organization. The message was carried by senior staff to their subordinates. We did ease the labor concerns by setting up capitalization rules and allocating considerable expense money to the cost of replacing staff for care duties.”
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“We are fortunate in that we have an EHR/EMR in our clinics. The area we are still implementing is w/in the hospital and we are using the clinic system as the guide to what staff will and will not get.”
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“We do prepare everyone for the experience. One of the variable is sometimes it is difficult to completely define what the experience will exactly like. Also, sometime you find your vendor has perhaps overstated the maturity or capability of their EMR. This could be unintentional as they may have fallen behind in their development cycle. The use of an executive steering committee does help as it provides updates at intervals that continue to set the expectations as things are delivered.”
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“We’ve had an EHR for some time. It was always in our case a physician driven effort. The designs, rollout and support model came from faculty groups (medical staff) that owned the process. It wasn’t an IT project. We tried to be clear in our goals that it was there to impact patient care in a positive way. No ROI, standardization, efficiency goals. Having and employed, academic staff really helped. We now do a CPOE boot camp for new McKesson clients where we do two days of our knowledge and case studies with each organizations leadership to get them ready.”
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“We have been building our EMR since 2003. Our vendor uses an incremental process but all of the integration is automatically included and the user interface is consistent. Users just see additional functionality in the EMR over time. There aren't many totally new users. Expectations for the EMR are conveyed via our IT Steering Committee and prioritized via the budgeting process with review at the Executive Team level. IS communicates the strategic and tactical plans throughout the organization so that users at every level understand what functions are coming when, how they will be utilized, and what the anticipated results of that use are. The biggest issues I face as CIO is in understanding the overall organizational culture and the micro-cultures surrounding each implementation and group of users, and then adapting the implementation approach to meet those specific needs. That is accomplished through a lot of hard work including preparation, education, training, and ongoing support wrapped in constant communication.”
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“The implementation of an EHR is a journey, not a one time event. Trying to determine a financial ROI is difficult at best. The only real benefit to be derived is that of Patient Safety.
You need to include all staff(s) in the design, build and validate process of implementing an EHR. Those staff(s) need to communicate to their peers the progress and the issues surrounding the implementations. The implementation of an EHR is not an Information Systems Department Project, and this message has to be communicated from the CEO and the Chief of the Medical Staff to all employees, including the Medical Staff.”
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“A big part of the process has been bringing physician champions into the process to help assess and communicate realistic benefits…”
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“We have scheduled and attended webcasts that help to educate. There is a standing discussion at our weekly senior management meetings with open discussion on this subject as well.”
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“I find it is important to be realistic in expectations and mange the learning curve to allow people to come out the other side better. It is also important to realize that there will be many benefits that could not be imagined when the process started. We need a vision, we need a stretch goal, we need to hope for more than can be delivered and continue to work towards that "dream". Technology leaders must always be out ahead of the organization, leading the way to next level.
How do you prepare everyone, from the CEO to clinical staff, for what the experience will actually be like?
Total cost of ownership is an important tool, discuss the financial commitment that will be required over multiple years. staff up in areas of implementation, be realistic on when to expect returns and then be relentless on getting that ROI. Stay at the table, one cannot give up the first time someone has "hurt" feelings, or someone struggles with change. This is not a journey for the faint of heart. This is a journey for those willing to walk down a few alleys, get lost, ask for direction and who knows find a new place and become a leader in your own right. Discover new places, new ROI, and new relationships. The vendors get to earn some money and we get to provide better, more reliable, cheaper healthcare in our communities.”
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“Started the education/communication process with the IS Steering Committee.
Medical Staff generally unaware of implications of HITECH. I develop a CME course for the medical staff; gave the presentation on three separate occasions.
Since then, I’ve presented a slightly modified version and presented to various departments within the hospital, regional hospitals and their medical staff, and local private practices that have requested it.”
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“My formal forums are sometimes limited but will spend time with most individuals willing to listen.... at our stage of implementation (HISS4.33 missing level 6-do not have POC medication verification) the
questions surround ease of use, training and support, why is this ____(fill in the blank) feature not present, standard formats vs customized functions, purpose of the system... operations, research, clinical decision support, legal record.... why do department based systems data is not included- in part or whole, limitations of data sharing as we move away from our hospital properties....
I try to explain where we are and limitations such as the technology level 3/4 EMR, limitation due to standards, limitation due to silo decisions regarding workflow or technology... the need of business and
clinical leadership and time..... use a lot of simple expression like....crawl, walk and then run..... building a multi story house.... get the foundation and first floor right before moving into the upstairs master
bedroom....In the end business needs drive projects.... therefore ARRA MU created a business model for clinical IT...”
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“This is difficult because the organization has a natural tendency to stress all the possible benefits of implementation to justify the significant expense required. I had a section on Expectations Management in my BOD presentation. For example, I told them that despite the significant capital I was requesting, the successful installation simply brought us a threshold to demonstrate MU and to produce the type of data required to leverage evidenced based medicine.
Another phenomenon that I find is that it seems that the prospect of the EMR is the solution to every issue! I have to speak up at many meetings when everything from bed flow to RAC audit protection and many things in between, will be resolved once the EMR is available.”
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“Expectations are like people, no two of them are the same or they are like the weather, stick around it will change soon. In our particular case, we began with a Board Endorsed commitment to patient safety and satisfaction. We had convinced ourselves that if we produced benefits from the EMR that had a demonstrable impact on those two things we had accomplished the mission, and if other good things came from it, that would be a bonus round. With the first applications we implemented, within a couple of months we were hitting our target of 90% plus compliance, but more impressively, our medication errors reduce by 75% in 90 days (they are now down by over 95% from pre EMR days). When these results got posted, even the nay Sayers, had to take notice. Nursing documentation came at the same time, and in a short while both the nurses and physicians saw benefit. The real struggle was CPOE, everyone except the physicians see benefit, and the best we get from physicians is that it is time neutral, but most say it costs them a bit of time. E Signatures and prescribing are making up a portion of the time loss, but we still have a ways to go.
My CEO and CNO were easy: They lead the safety vision, and focused on those results. Some nurses did not want to change whatsoever. What I learned quickly is that you can lose a lot of enthusiasm if you starve them for equipment. Put Computers everywhere, make them fall over them almost. Do not starve them. Relatively speaking they are cheap, and if you can take the .availability argument away, you are one step closer to winning the nurse or physician. Honesty, communication and trust are huge, Admit issues and problems, do not hide them, and work like heck to resolve them, but above all else, stay the course of your vision, while addressing the issues as they arise. Some will try to derail the process early, but leverage your credibility and stay the course.
I tried to tell them this would be as much fun as a root canal, but if properly anesthetized the root canal was not so bad, nor was the recovery. We prepared for the worst, and worked to relieve it. However, we were completely honest: This was going to be tough and it involved significant change. Sr. Management and the Board, stated that this was where the bus was going and those who wanted to continue to take the trip were going to ride on this new bus. That helped.
As to the CFO, he and I partnered. We set a goal of breakeven. We were facing an HIM system that was sun set, and we had no EMR that worked back in 2004. We had to do something and our five year TCO projections, were tolerable. We did not realistically predict a positive cash return, but focused on the soft returns of Patient Safety and Satisfaction. We set those expectations of best case breakeven for the CEO and the Board, and they supported that. What we actually received was a positive improvement in operating margin, but we managed the financial expectation tightly and in co-operation with the CFO. Fortunately we had a positive margin when we started the journey, along with great reserves. We are actually in better shape today, financially, that we were in 04.”
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“Probably not as well as I should. Difficult to explain what process changes will need to be made to implement EHRs. Have had consultants in to help with gap analysis and some setting of expectations.”
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“Managing expectations can be like herding cats when it comes to EHR as many have opinions of what they are, will be, should be, etc. I reality they come in many forms. What we focused on was the vision of being totally electronic and communicated where we are/were often. The electronic record evolves over time in functionality, customer understanding of the capability, people’s capacity to change and use the system, etc. Many demos were presented to users, educational sessions held, direct participation in meetings to present the system and so forth. During each stage of the implementation we started with a demo and discussion of what we should expect with this upgrade, patch, etc.
As CIO, I also hold regular I/S Steering meetings that include many members from across the organization, write monthly board updates, attend medical staff meetings, hold department manager strategy sessions and more. You must get information out there for people to inquire about, see, touch and also see some of the good, bad and ugly.”
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“We began about three years ago through our PHO providing education to our PHO members and our community physicians about EHRs, the models, the costs, the impact on work flow; the advantages etc. With the arrival of ARRA and HITECH we have provided further education on the implications, the needs to determine the capabilities of their vendors etc. From the hospital side we are lucky in that we have had Advanced Clinical applications in place including nursing documentation, medication administration & CPOE for almost ten years. We have been able to demonstrate the advantages of these systems in terms of reduced length of stay, compliance with core measures and the effect of evidence based order sets.”
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“ Involving many of the clinical staff in the configuration - frequent meetings and communication efforts including weekly e-mail updates - not promising everything - being real open about limitations and anticipated issues - extra staff prepared to assist with go-live”
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“Managing expectation is hard and we rely heavily on the project teams and work teams. With our current project we are meeting individually with various medical departments, attending nursing staff meetings and unit secretary meeting. We have formed an Executive Steering Committee made up of VP’s and VP MA so we can keep them informed. Each gets a weekly project report. We also have a Project Steering Team that meets twice a month and they also get updates and help make many of the decisions.”
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“Based on our experience it is a lot of work to implementation and then no relief to “celebrate” after going live. People are used to working hard to reach a “finish line” but the truth is the EHR requires constant work, re-work, and redesign to adjust to the practice’s workflow. It does parallel other major system implementations and the organization needs to manage the support appropriately (especially post live) so that provider and staff satisfaction/dissatisfaction does not affect the patient experience. In other words, manage the PR because this is your brand now to the patient/customer.”
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“Part of expectation management comes from having the rank-and-file on the development teams for the implementation of each module. They know what the system will/won’t do and communicate that to their peers and superiors. We have a Physician Advisory Committee that we also use to communicate expectations to physicians. We also use that forum to get sense of their needs – and we try to meet as many as are feasible. They become part of that process. Prior to a major roll-out, we communicate to the managers at the monthly department managers’ meeting. For my part, I regularly report to the other executive staff members so they know what to expect. We also do a series of electronic communications. So, that covers, workers, managers, physicians, and executives. I don’t want to paint a picture of perfection because in spite of all the communications, many still claim that they don’t know what’s going on. Generally, the process works.”
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“We’ve done a better job prepping our senior leadership team, since we’ve had to make serious budget consideration for our migration to our vendor’s upgraded platform from our current arena. But we’ve been EHR for close to a decade in the hospital, and for three years in our outpatient clinic. Still, there is always much additional preparation for CPOE, EHR to the ED, and other evolution yet to come. Generally, we start with one-on-one discussions with the most affected department leaders; sort of a “divide & conquer” approach, but supplemented by information at the all-department-leader monthly meetings, and supplemented further by group e-mails to the management team. It is difficult to engage the brains of DLs who are not yet affected by upcoming changes. They have too much to think about, and don’t want to really spend time thinking about impact or improvement of the local EHRs. Hence, repetition is key, and giving them small doses (generally high-level) is the best early awareness.”
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“I have explained this through the documents supplied by CMS on their website. Although not 100% formalized, I believe they are going to be very close to the final product and with said, the work and efforts are towards that end.
We have an Executive HER Steering Committee with the CEO and CIO joint chairing it which contains many of the C-level players, 2 board members, 2 physicians and 2 CEO’s from surrounding Critical Access Hospitals. We have, from the beginning, shared our goals and direction in an almost open forum with the intent to be a two way communication. We explain our goals and then solicit each members input. The results of this discussion are then published in both our monthly news letter that is mailed to employees, doctors and board members homes and also in a weekly table tent located on all the tables in the cafeteria.”
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