1 1 LESSONS LEARNED: AVOIDING SOME OF THE COMMON PITFALLS OF EHR ACTIVATION By: Shane Danaher; Philip Felt, MBA, PMP; and, Mary Lawrence Siris, MBA, PT Healthcare rganizatins acrss the U.S. are mving twards the adptin and meaningful use f electrnic health recrds (EHR) t imprve care, reduce csts, and imprve rganizatinal efficiency. This is due in large part t the HITECH incentives; hwever, upcming changes in the standards fr electrnic health care transactins, such as the ICD-10 cding requirements n all HIPAA transactins, are als increasingly prving significant drivers fr adptin. The implementatin f these new technlgies and wrkflws must ccur n tp f ther rganizatinal initiatives and csts can be enrmus. Even after taking n the tremendus staff and financial cmmitments necessary t implement an EHR, the Department f Health and Human Services estimates a failure rate f 30 t 50 percent; sme healthcare prviders estimate it t be as high as 70 percent. 1 In light f these statistics, many rganizatins find themselves asking themselves questins such as: What are sme f the factrs that have cntributed t success at ther rganizatins? Are there lessns learned that might make it mre likely that ur rganizatin will be ne f the 50 t 70 percent wh succeed? The Cngressinal Budget Office estimates a cst f $25,000 - $40,000 per prvider fr EHR implementatin in a physician s ffice and an average cst f $14,500 per bed fr the implementatin f CPOE in a hspital setting. Evidence n the Csts and Benefits f Health Infrmatin Technlgy. Cngressinal Budget Office. Ultimately, success depends n a variety f factrs including peple, prcess, and technlgy, as well as the unique character f the rganizatin. Hwever, fr thse rganizatins that have gne thrugh the EHR activatin prcess, there are cmmn successes. This paper identifies sme f the mst essential lessns learned gleaned frm recent activatin experience in multiple EHR systems in health care systems bth large and small. Many f the mst critical successes ccurred during the fllwing five activatin stages: preactivatin planning, activatin supprt staff management, activatin supprt training, activatin management (AM), and metrics and reprting. These successes, while nt a cmprehensive list, represent sme f the cnsistent factrs that have prven repeatedly t be just as critical t activatin success as the technlgy and functinality itself. 1 Charette, Rbert. Bush s Prpsal fr Electrnic Medical Recrds Pses Privacy Risks? CIO April 1, Retrieved n December 8, 2010,
2 2 Pre-Activatin Planning When pre-activatin planning begins depends n the unique characteristics f the rganizatin and activatin; hwever, mst f these activities begin n less than fur mnths prir t g-live. During this phase f activatin, strategic decisins are defined, impacted cre business functins are identified, activatin supprt tls and plans are created, and the activatin timeline is finalized. Prper planning and preparatin will imprve the quality f the prject, psitin the activatin fr success, and ultimately reduce csts. A few f the critical success factrs indentified during pre-activatin planning include: Develpment f a Change Management Plan: Create a carefully crafted Change Management Plan that is in accrdance with the rganizatin s cmmunicatin standards and prcesses. Messaging shuld address bth the benefits f the new system s functinality and the changes that users shuld expect t everyday wrkflws. Develpment f Supprt Requirements: An rganizatin cannt depend slely n their existing staff t supprt a large-scale activatin. Experience shws that large enterprise implementatins shuld plan fr a three (r fur) t ne rati f additinal supprt staff t internal supprt. This level f additinal staffing makes this ne f the mst expensive parts f any EHR activatin. Develpment f an Activatin Plan: The rganizatin shuld thrughly evaluate the activatin and cutver steps fr each prcess and area and include these in a clear and cncise Activatin Plan. A critical element t any successful Activatin Plan is defining a prtcl fr infrmatin updates. Develpment f Activatin Metrics: Activatin metrics are thse data pints that will determine thrughut the activatin if the activatin is ging well. Prir t activatin and in cnjunctin with the leadership team, a baseline shuld be established and key metrics defined and then clearly cmmunicated t all activatin stakehlders. Define Dwntime Plicies, Prcedures, and Tls: This step ensures that all areas are aware f hw t address issues that arise during activatin dwntime and have the ptential t affect prductivity and/r patient care. Fr instance, team members shuld knw hw t cmmunicate rders and results in the event that a system, r multiple systems g dwn such as: The rder entry system is up, but lab system is dwn. The rder entry and lab system are bth dwn. Order entry system is dwn, but the lab system is up. Each f these scenaris may have similar, but different, prcesses and tls, s it becmes critically imprtant that leadership and peratins agree n hw rders and results that ccur during dwntime make it int the EHR. Activatin Supprt Staff Management Large-scale activatins require prper activatin leadership teams t ensure that prductivity levels and patient care standards remain cnsistently high during activatin. These resurces help gauge the pulse f the activatin, practively identify and address issues, and are able t make quick decisins t keep the
3 3 activatin mving in a psitive directin. Activatin supprt staff team members cver a wide variety f respnsibilities including, but nt limited t: Crdinating the Cmmand Center Leading debrief meetings Tracking activatin metrics Tracking ht issues and escalatins Ensuring prper activatin staffing Prviding additinal nursing supprt n the units Having a team f seasned EHR implementatin veterans is an imprtant success factr. Just as imprtant is finding the right Activatin Manager t lead this difficult and challenging functin. An Activatin Manager: Defines Staffing Needs: When defining staff needs fr a large-scale activatin, rganizatins must identify: Number f additinal staff members necessary (in additin t current staffing) Type f staff members needed Specific skill types necessary Cst fr the defined staff member/skill set Cnducts External Staff Recruiting, Hiring, and Training: It can be difficult t identify, hire, and train the significant number f necessary external skilled supprt resurces necessary t supprt activatin. This staffing challenge becmes especially difficult in an abbreviated perid and in a jb market where there is fierce cmpetitin fr skilled IT prfessinals. Identifies Internal Barriers: Internal barriers can include difficulty in securing spnsrship frm senir leaders and finding clinicians willing t serve as champins fr the activatin. Mre than 60% f CIOs respnding t a recent CHIME survey reprted that IT staffing deficiencies will pssibly (51%), r definitely, (10%) negatively affect their chances t implement an EHR and receive stimulus funding. Healthcare CIOs Fear IT Staffing Shrtages Will Affect EHR Implementatins and Other Prjects, Cllege f Healthcare Infrmatin Management Executives, September Activatin Supprt Training The accuracy, effectiveness, and efficiency f end-user and supprt staff training can mean the difference in activatin success and failure. Withut adequate and cncise end-user training, prductivity levels can fall, patient care can suffer, and even the best activatin can fail. Training prgrams shuld be designed carefully, begin early, train fr every step in the prcess, and address change in wrkflws, nt just functinality. Training shuld address nt nly the hspital s staff and physicians, but als the needs f the activatin management (AM) team members. These grups have many similar training needs, but each als has its wn distinct training needs. A few f the imprtant activities that shuld be included during activatin supprt training include: Prvide Sandbx Time: If pssible, prvide AM team members, staff, and physicians with hands-n time with the new system t familiarize themselves with the new technlgy and facility-specific wrkflws prir
4 4 t g-live. Fr AM team members, understanding the chsen technlgy is nt enugh. They must als understand the wrkflws that the rganizatin s clinicians and physicians trained n in rder t effectively manage and supprt the activatin prcess. Smene wh knws the basic wrkflw f the rganizatin and is knwledgeable in the details f the selected technlgy can mean the difference in success r failure. Fr staff and physician members, this advance expsure allws hands-n experience t the new envirnment and significantly reduces end-user stress and anxiety during g-live. Prvide Training Specific t AM Team Members: Lgistics: This training addresses all the infrmatin that AM team members will need t knw abut hw t get t the facility and much abut hw they will perate when they get there. Getting t Knw the Organizatin: This training addresses infrmatin such as hurs, culture, rganizatinal structure, current vlumes and staffing by department, and hw well trained the rganizatin s clinicians and physicians are. Activatin Supprt Gals: This prtin f training ensures that all AM team members understand activatin supprt gals and hw t measure success against these gals. Escalatin Prcess: This prcess shuld be dcumented and each AM team member shuld understand the prper way issues are handled. This is a key cmpnent t ensure all issues are lgged and accunted fr at the debrief meetings. Cnduct a Dress Rehearsal/Mck G-Live: Cnduct a cmbined mck g-live with all invlved AM team members and peratinal areas. The areas addressed during this activity shuld include, at a minimum: Timeline fr cutver Plans and tls fr data entry (if data is nt being cnverted frm ther systems) Staffing plans fr each area (peratinal cverage and leadership respnsibility) Cntact lists with phne, cell, and pager numbers, fr each peratinal area and the Cmmand Center Define and Train n New Tls and Prcedures: Ensure that bth AM team members and the hspital staff and physicians understand the use f the new tls and assciated prcedures. Utilize departmental perating structures t cnduct dwntime training prir t g-live. Activatin Management Prjects d nt manage themselves. The shift frm siled department-specific implementatins t larger scale, rganizatin-wide activatins has resulted in the need fr larger AM teams. An AM team helps the rganizatin manage and crdinate the entire activatin prject frm pre-activatin planning, t pstactivatin supprt, thrugh activities such as staffing ptimizatin, issue management, Cmmand Center management, and regular stakehlder debrief and status meetings. Sme f the critical factrs that a successful AM teams addresses during activatin include: Utilizatin f a Cmputer-Based Resurce Management Tl t Optimize Staffing Levels: Organizatins can expect t increase staffing fr the first three t fur weeks pst g-live. Fr example, nursing units shuld generally expect t add ne t tw additinal end-user supprt resurces per shift. Other areas in
5 5 the rganizatin can expect similar supprt staff needs during their hurs f peratin. These resurces are in additin t the necessary patient care clinical staff members and, fr that reasn, rganizatins shuld expect the cst fr supprt hurs t make up a significant prtin f their activatin management csts. The exact amunt f time additinal staffing is necessary, as well as the necessary staffing mix, varies by rganizatin. This additinal staffing must be defined, recruited, trained, managed n-site, and ptimized ver the curse f the prject. There is a science and art in the ability t scale up r dwn resurces t effectively ptimize supprt acrss the entire activatin. This ability t ptimize resurces ensures cntinued prductivity and patient care levels while als cntaining activatin staffing csts. Excel spreadsheets are n lnger an effective answer. A cmputer-based resurce management applicatin can take the needs f the rganizatin int accunt and create staffing schedules ptimized t the rganizatin s unique needs. Practively Manages Issues: Issue management is anther significant factr in activatin management. At the rt f successful issue management is effective cmmunicatin. There are endless pprtunities fr cmmunicatin failure between stakehlder grups in the fast-paced, ever changing activatin envirnment. Examples f issues a well thught ut Issue Reslutin Plan might address include: Resurce lad n the fly adaptin during activatin and then cmmunicatin f thse changes t the apprpriate parties Wrkflw adjustments based n n-the-jb wrk Leadership r prject managers caught by surprise when a prblem arises Cnflict between supprt staff r trainers and rganizatin staff and physicians arund hw the EHR changes the wrkflw and hw they d their jb Creates a Centralized Cmmand Center: The activatin management team establishes a Cmmand Center that prvides sufficient space fr team members and then wrks with the rganizatin s leadership t define senir nursing and medical staff leaders t staff the Cmmand Center. These leaders shuld be relieved f their daily duties in rder t fcus cmpletely n supprting the g-live. Successful Cmmand Centers include planned seats fr many different rles and functins including the Cmmand Center crdinatr, help desk, change management, EHR training, EHR build (multiple areas, if apprpriate), and leadership. Cnducts Regular Status and Debrief Meetings: A key part f activatin management, as mentined abve, is cmmunicatin. A cmprehensive and clearly cmmunicated meeting schedule ensures that meetings with the apprpriate participants, n the apprpriate tpics, are happening in a timely manner thrughut the activatin prcess. Tw key meetings that shuld be included in every meeting schedule include: Cmmand Center Daily Debrief Meetings: These meetings with peratinal leaders (nt just the prject team) shuld practively share prject status, current prject team pririty issues, and deliver key daily messages. These meetings are held as lng as the Cmmand Center is pen.
6 6 Hspital/Supprt Team Member Status Meetings: The supprt team members and the hspital shuld be meeting n a regular basis. The AM team is respnsible fr the meeting schedule, agenda, and cnducting these meetings. These meetings ensure that meetings with the apprpriate stakehlders are ccurring in a timely manner and addressing apprpriate agenda items. Metrics and Reprting With the pprtunity fr greater federal funding fr the successful implementatin and demnstrated meaningful use f EHR systems in healthcare rganizatins, the need fr frmal evaluatin becmes necessary. In rder t prperly measure prgress, a baseline shuld be taken first t gauge activatin success against. Once a baseline is established, specific activatin-specific criteria and statistical metrics are defined. Regular metric tracking and reprting is critical t determining if the system is meeting gals, bjectives, and expectatins. Examples f EHR activatin metrics that an rganizatin might reprt n include, but are nt limited t: General Metrics: Physician Metrics: Clinical Statistics: ED Statistics: # f service desk incidents pened fr the facility # f service desk incidents reslved fr the facility # f utstanding service desk enhancement requests # f physician issues fr the facility # f physician lgns % f rders entered by physician Utilizatin f physicians using dcumentatin # f verbal rders used % utilizatin f rder sets by physicians # f verdue tasks per persn, per unit % f cancelled rders # f verdue medicatin(s) by unit, by persn per 24 hurs # f dcuments signed electrnically # f unsigned dcuments ED patient vlume Average LOS in hurs % f patients LWOT Patient average time frm ED dr t physician Patient average time frm ED dr t triage
7 7 Summary While activatin success is dependent n a variety f different rganizatinal peple, prcess, and technlgy factrs, experience prves that there are cmmn factrs that cntribute t activatin success. Prper preactivatin planning and preparatin, experienced activatin leadership teams, accurate and effective activatin training, an ptimized AM supprt staff, and the definitin and measurement f key metrics are just a few f the many critical factrs that make the difference in the 70 percent f rganizatins wh are successful in their activatin endeavrs and the 30 percent wh will fail. Abut DIVURGENT: Funded by a team f cnsulting veterans, DIVURGENT is a natinal health care cnsulting firm fcused slely n the business f hspitals and ther healthcare prviders. DIVURGENT prvides advisry, interim management, revenue cycle management, prject management, and mdeling and simulatin services t help imprve patients lives. We are cmmitted t: Prviding Thught Leadership Prviding Exceptinal Value fr ur Services Facilitating Knwledge Transfer Ensuring Client Satisfactin 6119 Greenville Avenue Suite 144 Dallas, TX Crpratin Lane Suite 229 Virginia Beach, VA (877)
8 8 Abut the Authrs Shane Danaher is Client Services Vice President fr DIVURGENT. In this rle, he is respnsible fr develping strategic service fferings, driving client satisfactin, and develping sund marketing strategies. Shane brings ver seven years f experience t the healthcare technlgy field and has a prven histry f establishing successful relatinships with prviders and healthcare rganizatins. Shane's strng technlgy backgrund cmbined with a deep understanding f the healthcare market has helped him create slutins fr clients that maximize their prject successes. Shane has an Ecnmics degree frm Haverfrd Cllege and is currently pursuing an MBA frm Virginia Tech. He is als currently serving as President-Elect fr the Virginia chapter f HIMSS. He has served as a bard member fr this chapter fr ver 2 years. In additin t HIMSS, Shane has been invited t speak regarding industry relevant tpics, such as Meaningful Use, t ther prfessinal rganizatins including MGMA, AAHAM, Wrkshp n Health IT and Ecnmics (WHITE), and reginal physician grups. Philip Felt, MBA, PMP is a Partner with DIVURGENT and leads the Prject Management Practice. He is a healthcare executive with a prven recrd f accmplishment in prgram, prject, and change management in his 11 + years in healthcare technlgy. He has cnsistently demnstrated results in leading healthcare rganizatins thrugh grwth and technlgical change. Philip is a certified prject management prfessinal (PMP), a Certified Prfessinal in Healthcare Infrmatin and Management Systems (CPHIMS) and is a Six Sigma Yellw Belt. He specializes in reengineering peratinal prcesses, creating, and managing prgram/prject management ffices. Mary Lawrence Siris, MBA, PT is the Principal f DIVURGENT s clinical transfrmatin practice, brings nearly 20 years f healthcare peratinal and strategic planning experience acrss a wide spectrum f prvider envirnments. She has wrked with large and small healthcare systems n the necessary planning fr clinical transfrmatin, quality imprvement and patient safety based n best practice and evidence-based prcesses. Mrs. Staley-Siris is respnsible fr leading DIVURGENT s clinical transfrmatin practice in cllabrating with clients t hardwire the prcesses and tls that will allw fr the cllectin, measurement, and applicatin f data tward imprving the safety, timeliness, effectiveness, efficiency, and patient-centeredness f the care they prvide.