January 31, 2011

Navigate the EHR Maze — Vendor Selection and Other EHR Adoption Strategies
By Maura Keller
For The Record
Vol. 23 No. 2 P. 10

Industry experts dole out advice on how best to prepare for a major system overhaul.

Paperless offices. Instant access. Electronic records. Not too long ago, these were little more than amusing catchphrases bandied about at conferences by medical technology professionals claiming to have seen the future. Few believed they would become a reality or that electronic health information management would be seen as a competitive advantage.

Today, healthcare organizations of every size are reordering their priorities and reexamining their health record processes with a key goal in mind: to embrace the best EHR adoption strategies in order to streamline their HIM systems.

In the Know
Here’s one thing we know: HIT is in a constant state of limbo. This reality, coupled with the ever-changing nature of the EHR within hospital environments, is changing the face of patient record documentation as we know it.

The complexity of EHRs and the speed at which the technology changes is perhaps the biggest factor driving the need for evaluating EHR adoption. Hospital administrators now realize that researching, testing, and observing other facilities that have adopted EHRs is the key to getting the most out of their potential investment.

“It is of paramount importance to evaluate the vendors in the marketplace thoroughly before selecting the system for a hospital,” says David Vreeland, partner at Cumberland Consulting Group, a national technology implementation and project management firm serving healthcare providers. “In our experience, some organizations do a better job of this than others.”

Vreeland typically recommends that hospitals or healthcare systems use a structured approach that removes as much subjectivity from the process as possible. “Our approach when working with clients is to build a process that is requirements based and involves as many areas of the hospital as possible to ensure that there is significant buy-in to the ultimate vendor decision,” he says.

It should come as no surprise that an EHR implementation may have a significant impact on a healthcare organization’s workflow and processes.

“It will likely impact each staff member in some way,” says Tim Herbert, vice president of research at CompTIA, a nonprofit trade association advancing the global interests of IT professionals and companies, including manufacturers, distributors, resellers, and educational institutions. “Testing the system and training staff prior to implementation improves the odds of a smooth transition. Additionally, it ensures the EHR’s features and capabilities are fully utilized.”

CompTIA’s Second Annual Healthcare IT Market: Insights and Opportunities study found that among practices with EHRs, many were underutilizing features. Additionally, the research confirmed that many healthcare professionals seek additional training in the usage of their EHR system. Of course, testing and training options vary. The EHR vendor or the IT solution provider involved in the implementation may provide it. If it’s a large hospital or health system, testing and training may be handled internally.

By working with clinicians, managers, and staff to document functional and nonfunctional requirements and then structuring an evaluation process that involves a number of representatives from the organization, Cumberland Consulting Group has found that a hospital can make an informed decision about the vendor that is best for that hospital’s particular situation.

To help in the EHR adoption process, HIMSS has compiled a variety of materials that cover EHR adoption strategies. Most recently, the organization released its Electronic Health Records Workflow and Implementation Challenges Checklist for HIMSS members to utilize during their EHR journey.

Likewise, the National Institute of Standards and Technology recently published new publications that offer technical strategies and tactics for improving EHR usability and accessibility.

Narrowing the Options
Discussions with colleagues or organizations that have already implemented an EHR are often a good place to start when narrowing EHR options. “These insights will help start the process of understanding the range of EHR features and capabilities as well as the trade-offs between systems,” Herbert says. “An EHR vendor may be the perfect fit for a particular type of organization but a poor fit for another.”

Other sources of information to help shorten the list of possibilities include industry trade shows or conferences. Experienced IT solution providers who work with a number of EHR vendors also can discuss the range of options.

Some EHR systems that are software-as-a-service based offer free trials, which is a good way to test the waters and find a suitable vendor that fits organizational goals. Only an Internet connection is needed to try these applications.

It is also helpful to have a person in-house who has a solid view of the vendor marketplace so that the intial “long list” can be constructed. In many cases, this kind of experience can be found through working with a consulting group.

Once a healthcare organization decides what resources it will use to narrow the field of contenders, what attributes will factor into the final decision? Vreeland says it is highly dependent on the current situation and the organization requirements. For example, he worked with a client that had been operating a custom-coded patient accounting system for many years.

“This custom system was not prepared to handle the new ICD-10 code set and thus replacing it with a compliant system was top of mind for this client, even in a time in which significant focus is being placed on clinical systems,” Vreeland says. “Each hospital is a little different, [which is] yet another argument in favor of documenting requirements.”

Establishing Requirements
There are numerous best practices surrounding EHR adoption. Vreeland believes it’s important to understand an organization’s goals and objectives and to gather requirements from a broad group of departments to properly select a new information system.

“While this will go a long way toward making adoption of the system go more smoothly, adoption of clinical information systems—such as physician documentation, CPOE [computerized physician order entry], standardized order sets, standardized medication reconciliation, etc—particularly by physicians, is a challenge because it represents such a significant change,” Vreeland says. “In our experience, this is eased by communication, involvement, and support.”

Communicating the reasons for change, ensuring involvement in the design of future processes by the individuals most affected, and providing flexible training and support on the new workflows and supporting systems will help significantly.

And while there is a lot that goes into EHR adoption, there are several best practices that can ease the transition. “Facilities must remain committed to EHR adoption since this transition does not happen overnight,” Herbert says. “The staff must buy into the need for EHR adoption and be willing to help make the transition.”

Facilities must also be willing to remain adaptable and work through any hiccups that may occur in the early stages of EHR implementation. Finally, facilities should regularly review and assess what is working and what’s not.

“We typically recommend that a long-term communication and training plan be developed for these kinds of initiatives and that both executive and clinical leadership play a role in executing the plan,” Vreeland says. “Knowing in advance that change is coming helps adoption a great deal. And obviously executing effectively on the implementation project plan is crucial for credibility.”

No One Sits on the Sidelines
Involving users in the adoption process is paramount. Just as Vreeland recommends putting in place an efficient strategy that utilizes significant numbers of individuals from the organization, he believes in the involvement of end users throughout the system implementation life cycle.

“Roles such as design session participant, user acceptance tester, trainee, and superuser are all good ways to get and keep the users involved,” he says. “This is a good thing all around; you don’t want these system implementation projects to be simply IT projects. … We find that for clinical system implementations in particular, because in many cases the project represents the first time that the area is moving to using information systems at all, ie, they are currently on paper, it is really important that the organization views the project as a workflow transformation initiative that is utilizing information systems rather than an IT project.”

With respect to clinicians, many of the same theories apply. However, with busy physicians and other providers, it’s important to fashion ways to involve them that take into consideration their hectic and often erratic schedules.

“Some physicians prefer to learn differently than others. We try to offer multiple venues for training so that we can appeal to different styles, as an example,” Vreeland says. “Of course, having a clear timeline is critical for an EHR adoption project. More specifically, a timeline that is reflected in an easy-to-understand Gantt chart [a bar chart that illustrates a project schedule] allows the project team to communicate broadly the plan for the initiative and build some collective organizational group thinking about where things are headed. These simple tools are critical success factors.”

Challenges Aplenty
According to Vreeland, the biggest challenge in adopting EHRs is typically moving to advanced inpatient clinicals, which requires physicians to enter their own orders and do their own documentation.

“These kinds of projects also typically require significant standardization of the way physicians document,” Vreeland says. “These things represent a significant change in the way many physicians practice medicine and exercise workflows. This is the hard stuff in our business, but the degree of collective inevitability of clinical automation has never been as evident as it is today.”

CompTIA research suggests the greatest pushback comes from the perceived impact on workflow or processes. In the survey, EHR users suggested several ways to improve EHRs, including making the technology faster, easier to use and less complex, and more capable of achieving interoperability with other systems.

Any technology implementation that revolutionizes how an organization operates faces myriad challenges and setbacks. According to the Cumberland Consulting Group, the common mistakes made during EHR transitions are not all that different from large system implementation projects in general. There are many, but a few key ones include the following:

• lack of clear project goals and objectives;

• lack of basic project management techniques applied to the work;

• ineffective or complete absence of governance (eg, a structure of people that enables the operational executives to have insight and impact on the project);

• lack of scope definition or such a broad scope that the project is doomed to fail; and

• limited involvement of the end user community in design, testing, and training.

To that list, Herbert adds the following mistakes:

• failure to do homework up front, not understanding the organization’s needs can lead to a poor fit with an EHR vendor;

• failure to get commitment from senior management and buy-in from staff;

• failure to communicate;

• underestimating the impact on workflow and processes;

• underestimating the learning curve because staff do not become experts in new systems overnight; and

• failure to invest in adequate staff training.

The Government’s Role
Should meaningful use be a driving force or a natural result of EHR adoption? From Vreeland’s perspective, it should ideally be both.

“I think the Centers for Medicare & Medicaid Services has done a pretty good job of focusing on the things that make the use of EHR technologies ‘meaningful,’ he says. “At the end of the day, though, it’s very clear to us that the HITECH Act is having the intended effect of accelerating the adoption of information systems in one of the last areas of the U.S. economy to have yet to reach a tipping point of automation. Is it possible that some organizations will ‘slam in’ these systems in order to get the incentive payments? Sure. But all organizations will be forced to optimize their use of these systems over time, something that is a best practice in the use of EHR technologies.”
Whether meaningful use should drive EHR implementation or vice versa really doesn’t make a difference, Vreeland says. “If it results in the cost reductions and improvements in patient safety that many believe will ultimately result from clinical automation,” he says, “I think it’s a good thing.”

— Maura Keller is a Minneapolis-based writer and editor.