September 4 , 2007

Gone to Pieces
By Elizabeth S. Roop
For The Record
Vol. 19 No. 18 P. 16

By examining failed EHR implementations, healthcare organizations can get a clearer view of how to construct an effective project.

Most presentations about electronic health record (EHR) implementations focus on success stories designed to demonstrate the right way to manage projects. But there are just as many valuable lessons that can be learned from failed—or at least less-than-perfect—implementations.

That is why John C. Joe, MD, assistant professor of family medicine at Baylor College of Medicine in Houston and chief medical officer of Prognosis Health Information Systems, and Larry Ozeran, MD, a practicing surgeon and president of Clinical Informatics, Inc., have spent the past eight years sharing with Toward the Electronic Patient Record (TEPR) conference attendees examples of the process failures that resulted in poorly executed EHR implementations.

“The thing we focus on is that process is key,” says Ozeran. “Most failures are process failures. They are not people failures. They are not vendor failures. Laying blame does not really help.”

After years of examining what did not work, Ozeran and Joe have compiled five lessons that can help others avoid repeating the mistakes made by healthcare organizations that have already traveled down the implementation path.

Lesson One: Leadership
A lack of physician or organizational leadership can quickly lead to delays or failures of EHR projects. For example, take what happened with one multifacility system where the physician leadership took charge of a systemwide implementation.

At about the same time as the EHR project got underway, the executive team was released, leaving the initiative without organizational leadership and subsequently stalling the physician process until new leadership was appointed.

“Even though the physicians continued to meet, in reality, it could be argued that much of their time was wasted,” says Ozeran. “Plus, the organization was a year behind where they could have been if a C-level person had been involved.”

In this situation, the organization could have taken one of two steps to salvage the project: appoint another executive-level individual who had an interest in the project to serve as the organizational champion, or acknowledge the lack of executive leadership and put the project on hold until someone was in place who could take on that role.
Organizational and physician leadership are equally critical to the success of an implementation project because they address two distinct issues: physician and organizational inertia.

“You can’t have one without the other and expect to be successful,” says Joe. “You must have someone who leads the physicians and shepherds them through a long and challenging process. But at the organizational level, the chief executive sponsor … is a spokesperson who can say, ‘One of my top five priorities for our organization in the next 24 months is to get an EHR implemented and used well to improve the quality of care.’”

That kind of consistent support from the top down sends a message throughout the organization. It tells the chief financial officer to allocate the funding when the request is made by the chief information officer or chief medical information officer. It tells the chief nursing officer to allocate personnel to work on the multidisciplinary teams charged with developing workflows for the new EHR.

“The CEO, just by making a simple statement on a regular basis, is going to catalyze a culture change in the organization that will enable resources, both financial and human, to be mobilized in support of the EHR project,” says Joe.

Lesson Two: Funding
Adequate funding for hardware, software, networking, education, and training is absolutely critical to the success or failure of any EHR implementation. If the funding is not sufficient or improperly allocated, it will lead to problems.

Ozeran and Joe cite numerous examples where funding, or improper use of funding, was the root cause of failure. In one case, no budget was set, and the organization wound up spending $38 million with, effectively, nothing to show for it. In another case, funding was set aside, but there were no timelines or milestones put in place to ensure the budget was being properly allocated throughout the project.

“If they don’t have people who monitor utilization of the funds, they may find that they have spent 50% of the implementation and training dollars, but they have only 30% of their clinics up and running. I’ve seen that happen,” says Joe.

Bringing in outside experts with experience in similar implementations is a good option for organizations that either do not have or cannot hire knowledgeable full-time staff.

However, bringing in consultants won’t work if the recommendations they make are ignored, which is what one organization did after the consultant it commissioned to set the EHR budget recommended spending nine figures.

The organization “said they couldn’t afford it and decided to spend approximately a sixth of what was recommended. Of course, that significantly delayed when they got anything accomplished because the budget was too small,” says Ozeran, adding that “you can bring in somebody or hire your own, but there is no doubt that having experienced people gets better results.”

Lesson Three: Planning
If there is ever a time to apply the adage “failing to plan is planning to fail,” an EHR implementation is it. Improper planning leads to improper execution, which leads to failure.

For large organizations in particular, the planning process can take months and should involve the following:

• identification and education of stakeholders;

• gathering stakeholder input;

• evaluating, purchasing, and implementing systems;

• training stakeholders on the system;

• obtaining continuous feedback from stakeholders; and

• making updates and upgrades.

The entire process will fall flat if there is no hierarchy or communication structure in place to keep stakeholders engaged in the long-term planning and execution. It is something Ozeran says he has seen too often.

“You identify your stakeholders and you work with them, but you’re not ensuring frequent communications, so you are just assuming everything is working. It is amazing how little is required to lose your stakeholders,” he says.

Lesson Four: Contracting
Failure to specify every component that the vendor or consultant is expected to deliver and assign appropriate penalties for breaching contractual obligations are the most problematic areas of IT contracting.

“If it’s not in the contract, it’s not in the contract,” Joe says. “If something is important, then it needs to be in writing, or there is no obligation on the part of the vendors or consultants to follow through on it. Unfortunately, these are the times we live in. The current environment mandates that anything important must be in writing.”

Specificity can go so far as to hold vendors to promises made regarding features to be included in future software versions. In fact, because vendors today are doing a better job of delivering core functionality, it is often just a few existing features and the promises of upcoming enhancements that can tip the balance in favor of one vendor over another, he says.

“I’ve seen it happen where the physicians who see a product develop a liking based on a few key features that differentiate it from its competitors. If those are not delivered, if they are not implemented for the physician, there is huge dissatisfaction, and there are issues for the administration if they try to get the vendors to deliver and they don’t have it in writing,” says Joe.

This illustrates why it is so important for every contract provision to have a penalty for failure to satisfy the agreement. Penalties can run from small refunds to removal of entire systems.

“If there is no penalty and the clause has no teeth, then there is no reason that they would necessarily meet the contractual obligation,” says Ozeran. “That does not mean there couldn’t be a penalty adjudicated by the courts, but no one wants to go through mediation or a court if they instead could put the penalty directly in the contract.”

Lesson Five: Incremental Implementation
The debate over incremental vs. “big bang” implementations is one that continues to rage. However, the decision—which should be made during the planning process—needs to take into consideration the fact that implementing EHRs involves more than just deploying a technology.

“It is about changing the culture of an organization,” says Joe. “You can do widespread implementation of something, like results viewing across the entire organization, and it doesn’t require a huge amount of culture change. But if you do a big bang of documentation, order entry, and results viewing, it is too much to learn at once. Most organizations do not have the personnel to train the entire medical and nursing staff on such key functionality. So, for practical purposes, it is quite a challenge to do big bang of key functionality across an organization.”

The overarching issue between big bang and incremental implementations is twofold: workflow and funding. From the funding standpoint, a big bang implementation requires upfront payment for the entire project. Incremental, however, allows payments to be made over time as the project rolls out. For workflow, the reality is that it is simply easier to handle one process change at a time as opposed to dozens.

“It comes down to the fact that we’re only human. We are not computers,” says Ozeran, adding that incremental implementations also allow participants to learn lessons from one project segment and apply them to future segments.

“You can learn some lessons about your culture and how your culture interacts with this change, then take some of the lessons you’ve learned in one area and use them as you roll it out in other areas,” he says.

Communication Is Key
The one commonality that runs throughout all five lessons is communication. From stakeholders to vendors to consultants, communication is the key to avoiding the mistakes others have made that negatively impacted their EHR implementations.

“The organization needs to understand its goals and objectives, and in order to understand those, it must communicate with all the stakeholders so they have a clear and complete picture. Without a clear understanding of goals and objectives, their implementation will be fruitless. The organization can’t rally the people together who are necessary to achieve cultural change and can’t achieve measurable return on its investment,” says Joe.

Adds Ozeran: “If you don’t know where you are going, you can’t get there.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.