HM312

1. © 2017 American Health Information Management Association© 2017 American Health Information Management Association
Health IT and EHRs:
Principles and Practice, Sixth Edition
Chapter 9: Health IT System
Implementation
and Ongoing Maintenance

2. © 2017 American Health Information Management Association
Implementation Planning and Management
• Health IT planning and implementation never end, but:
o Any component on the migration path is a project with a
defined beginning and ending
o The importance of planning for any component
implementation is critical
o Implementation planning follows the SDLC at a granular level
• Stakeholder engagement for any health IT
implementation must include:
o Workflow and process improvement
o Change management
o System configuration (such as building out the software to
reflect the specific needs of the specific organization)

3. © 2017 American Health Information Management Association
Overall Implementation Approach
• Roll Out Strategies
o Phased
o Big bang
o Pilot
• Turnover Strategies
o Straight
o Parallel

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Conversion Strategy
• Chart conversion
o Hospitals often scan records to achieve
a paperless state prior to achieving full
EHR or other health IT
• Hybrid record (part paper/part electronic or
part scanned paper/part structured data)
can be an issue.
o Ambulatory care may have greater need
for previous visit data than hospitals
have for previous admissions – but in
structured form, so conversion includes
a combination of:
• Scanning
• Abstracting (pre-load)
• Continued pulling of paper chart (may
result in “hybrid” record with its issues)
• Data conversion
o Preparation of data, files,
and software to go into
production environment
o Data conversion
between old and new
system is challenging
and should only be
performed when
essential
o Data conversion rarely
results in a one-to-one
match; test data
conversions prior to
deployment

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Installation vs. Implementation
Installation
• Assemble hardware
• Connect devices
• Run hardware setup
• Lay network cable
• Install network devices
• Test network connectivity
• Load application software
Implementation
• Review contract and develop detailed
implementation plan
• Establish issues/risk management
system and (system) documentation
• Prepare infrastructure, such as data
center, user area, other
• Procure hardware, accept delivery,
inventory and asset tag

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Issues and Risk Management
• Prepare to use an issues log
• Manage risks:
– Procurement issues (delivery of software, hardware, or tasks performed by
consultants)
– Communication issues
– Time management
– Task dependencies
– Milestone completion
– Resource leveling
– Budget overruns

7. © 2017 American Health Information Management Association
System Documentation
• System documentation includes hardware and software
specifications, implementation instructions, user manuals
• Changes made during system build must be documented
o Change control processes should link changes made to their requests,
approval, completion, testing, and roll out
o Documentation associated with changes often include process maps,
use cases, and other materials that should be retained
o Changes in data requirements, decision support rules, and other
automated processing must be reflected in the system’s metadata (see
also chapter 10)
• Policies and procedures, forms and reports, job descriptions, and
other applicable documentation should be retained for future
reference – often to be used for training, issues management,
product recalls, and subsequent change management

8. © 2017 American Health Information Management Association
After Installing Hardware & Software
• Configure applications
• Design technical controls, security access controls
• Change control
• Test
• Train
• Document policies and procedures
• Check/rehearse
• Go-live
• Evaluate
• Celebrate or correct course
• Transition to full adoption
• Acceptance testing

9. © 2017 American Health Information Management Association
Infrastructure Preparedness
• When the project plan has been established, there are many preparatory
tasks. Some of these address the equipment and physical plant of the
organization; others address people and processes.
o Hardware infrastructure
• Prepare the organization’s infrastructure for the EHR system
• Perform hardware purchasing and delivery tasks
o Workflow and process infrastructure
• Complete process analysis and design
• Identify and obtain agreement on standards
• Map from the vendor’s vocabulary, or even standard vocabulary, to
standard data sets
o Stakeholder preparation
• Prepare people for the level of change
• Develop communication plan
• Reassure staff
• Plan and execute training activities

10. © 2017 American Health Information Management Association
Sample Communication Plan

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System Configuration (System Build)
• Process in which:
– The software is configured to the organization’s unique needs
– The extent to which an EHR can be configured depends on product,
with products offered through a straight license being more
customizable than ASP and SaaS products
• Includes:
– Data dictionaries (What structured data will be captured?)
– Master files and tables are compiled (May include physician names and
DEA numbers, nurses and their credentials, list of medications stocked
in the clinical pharmacy)
– Rules logic for decision support (Will every rule in the standard
implementation fire, or only certain rules turned on?)
– Screen layouts (Are there enough or too many comment fields? Are
personal preferences accommodated?)
– Data quality edit checks (May include values for lab results, medication
doses)
– Report designs (Will a standard report need modification for state data
reporting? Is creation of a new report needed?)
– Technical controls (May include security access controls, error
correction routines)

12. © 2017 American Health Information Management Association
Data Dictionary Change Control Log
Copyright © 2012, MargretA Consulting, LLC. Reprinted with permission.

13. © 2017 American Health Information Management Association
Testing
• Testing is a critical step that is sometimes overlooked
or shortchanged, especially in smaller organizations.
• Testing involves:
o Establishing a test environment.
o Developing a test plan and schedule.
o Developing test scenarios or use cases to ensure testing
accommodates the organization’s specific needs.
• Acceptance testing (as used in healthcare) refers to
the time at which the organization accepts the system
as working properly, often some time after go-live, to
assure the majority of users have adopted the system

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Types of Testing
Copyright © 2016, MargretA Consulting, LLC. Reprinted with permission.

15. © 2017 American Health Information Management Association
Training
• Training of varying intensity, methodology, and purpose
should occur periodically and strategically throughout
implementation process
• Types of training
o Introduction
o Education
o Briefings
o Skills building
o Instruction
o Support
o Retraining, refresher, or
coaching
• Human resource or labor relations issues are associated
with training that should be planned for in advance
• Training modalities
– Posters, newsletters, email blasts,
sound bites at meetings,
dashboards, progress-o-meters
– Classroom or online courses
– Hands-on self-training
– “At the elbow” support
– Online, context-sensitive help

16. © 2017 American Health Information Management Association
Pre-Live Activities
• Plan to lighten the case load, move (some) patients to
another unit, reduce number of patients scheduled, select a
day usually lighter than others.
• Go-live rehearsal
o If actors rehearse before every play or concert, what makes
health care organizations spending millions of dollars on an
EHR think they don’t need to rehearse before their live
performance?
• Support: if anything can go wrong, it will. Swarm users with
support “at the elbow.”

17. © 2017 American Health Information Management Association
EHR Adoption and Optimization
• Although applicable to all health IT, gaining EHR
adoption (basic use) and optimization (use that
improves productivity and contributes to quality
improvement)
o Monitor system usage to identify any non-users.
o Audit data to check for proper usage.
o Conduct satisfaction surveys.
o Celebrate: not just at the end but for each milestone reached;
EHR implementation is stressful.
o Conduct a benefits realization study.
o Create a customer service attitude.
o Conduct walk-throughs or perform rounding periodically
throughout the life of a project.

18. © 2017 American Health Information Management Association
Celebration
• Celebration may be considered a form of
communication, change management, or other
element associated with EHR leadership.
• Regardless of its categorization, the value of
celebration cannot be overemphasized.
• Celebrate tastefully, but have some fun; touch
everyone as part of the celebration.
• Round food represents the
circle of EHR life!

19. © 2017 American Health Information Management Association
Ongoing Strategies
• Benefits realization
o To correct course and celebrate ongoing success
o For continual quality improvement
• Lessons learned
o For the next phase, for others
• Migration path
o What’s the next step?
o EHR implementations never end, there is always
some new application, utility, technology, feature or
function, or idea.