Implementing an EHR is a complex project that requires extensive planning and involvement from all stakeholders. Key steps include defining goals and metrics, analyzing workflows, selecting an appropriate vendor, and providing comprehensive training for end users. A successful implementation follows best practices such as establishing executive support, implementing in increments, thoroughly testing the system, and providing ongoing support and feedback after going live. Shadowing providers during training and post go-live periods is critical to ensure adoption and maximize benefits of the new EHR system.

1. Implementing EHR
A best practices guide to implementing EHR
A Lecture to U LV School of Public Health
For Tip Ghosh
4/6/2006
By James Muir

2. EHRs are Big Projects
“A group can’t just go out and buy
an EHR – the acquisition of an EHR
is not the same as buying software
from the local computer store and
implementing it out of the box.
Adopting EHR functionality involves
many steps and much planning.”
– Margret K. Amatayakul

3. Before Starting Your Project
• You MUST have buy-in from all key
stakeholders
– Executive Management
– Physicians & Care-givers

4. Creating Your EHR Project Team
• Who needs to be on the team?
– All key stakeholders
– Physician Champion(s)
– Executive Champion
– Project Manager*
– Content expert/developer*
– IS team
• Plan to hire talent for your project

5. Executive Leadership
• For practices larger than 10 providers executive leadership
support is the single biggest success factor.
• “Most organizations with exemplary implementations of
EHRs indicate that wheras lack of physician support is the
single point of failure, executive management support is the
most critical success factor.”
– Margret K. Amatayakul
• Executive Leadership Responsibilities
– Assure goals are defined and communicated in advance of the project
– Create alignment amongst all stakeholders
– Communicate consistently with all stakeholders
– Gain commitment from all stakeholders
– Maintain commitment to the project
– Advertise project successes

6. Goals
• Why they are critical
– Focus – project is potentially overwhelming
• What to do first
• Scope creep
– Metrics for measuring success
• Did we succeed?
• How much success did we receive?
• Balancing goals from different parties
• Budgeting goals
• Used for assessing solutions
– Ideally goals should be defined before assessing EHR solutions

7. How to define your EHR goals
• Collect issues & goals from all parties
– Both personal and professional
– Issues are move-away motivation
– Goals are move-toward motivation
• Group issues together
• Measure the impact of each issue or the upside of each goal
– Some thing can be measured easily some are less so
• Hard measurements (time, money, counts)
• Soft measurements (quality, satisfaction, risk)
• Do Workflow & Process Analysis
• SWOT Analysis
– Strengths, Weaknesses, Opportunities, Threats
• Be Practical & Realistic
• Prioritize
– Focus on what will have the greatest impact on the organization
• Determine the scope
– How much can you do?
– Chunking
• Target dates
• Communicate your goals to everyone
– Create a goals (scope) document

8. Workflow Analysis
• Define existing workflow & processes
“Workflow analysis is becoming one of the most critical
steps in integrating information systems and moving toward
the EHR. … E&M coding support through the EHR should
yield significant benefits in cash flow, time savings,
collection fees and revenue optimization. These benefits are
achieved, however, only if steps are taken to ensure that the
work flows and processes to support them are in place.”
– Margret K. Amatayakul
• Involve all stakeholders in workflow development
• Re-engineer new workflows with EHR in mind
– SIDEBAR - Why tasking and workflow in EHRs is critical
• Reassess goals based on Workflow analysis

9. Walker’s Fourth Law of Informatics
FOURTH LAW: “Everyone want to use the
EHR to make someone else do something.”

10. Evaluating & Selecting a Vendor
• Create a scorecard based on your goals
• Focus –
– features are interesting, and you will get to
them, but first things first

11. Organizational
Issues

12. Pre-Kickoff Meeting(s)
• Review project goals (scope document)
• Create responsibilities document
• Review implementation and goals timeline
• Determine who the super-users will be
• Define project team(s)
• Develop implementation plan & project schedule
• Governance
– Include key stakeholders
– Determine how decisions will be made
– Decide who issues will be escalated to
• Develop training schedule
• Develop communications plan
• Create Project Orientation Materials for Kickoff Meeting
– Project Goals (scope document)
– Org chart showing responsibilities
– Description of which person each type of question should be directed to
– Contact information for everyone involved
• Revise policies and procedures manual at this time

13. Kickoff Meeting
• Present the goals (scope document) to all
practice personnel
• Present the responsibilities document to
all practice personnel
• Demonstrate the EHR to all practice
personnel
• Identify any additional issues that are
uncovered by practice personnel

14. EHR Team Meetings
• If warranted by your size meet weekly to
– Identify issues
– Elicit input from the practice
– Plan solutions
– Plan what will be communicated to the clinic

15. Pre Go-live Tasks
• Enter each providers preferences
– SIGs, ICD9s, Chief Complaints, Etc.
• Complete Go-live checklist*
• Dress rehearsals

16. Pre Go-live meeting
• For the target site, pod, provider, etc.
• Reduces anxiety before go-live
• Review progress and successes so far
• Collect and address concerns to the
implementation
• Will prevent postponement

17. Implementation
Issues

18. Work out interfaces
• Practice Management
• Lab
• Diagnostics
• Devices
• Hospital
• ePrescribing

19. Testing of Interfaces
• Some interfaces must be implemented at go-live
– Practice Management
• Desirable (but not required) at go-live
– Lab
• Backloading Lab Data
– Diagnostics
– Devices
– Hospital
– ePrescribing

20. Testing of the Knowledge-base
• Enter 30-40 charts before presenting it
to the doctor
– Learn how the EHR works
• (so you can describe it to the doctor)
– Learn how the doctor does things
– Learn what is missing that the doctor likes
to include
– Learn what is going to slow the doctor down

21. Clinical Content
• Create a Clinical Advisory Team
• Decide how clinical content will be added /
modified
• Dedicate a content expert/developer
• Incorporate the feedback loop

22. Chart Abstraction
•Manual
•Scan
•Electronic EHR
– Import Text
• RTF File Monitor
– Parse

23. The Dynamics of Chart Abstraction
• Scanning
– Lower HR getting in
– Longer time for provider to review
– Some technology can be applied (bar coding)
– Need may diminish over time
• Some Specialists
• Primary Care
• Manual
– Higher initial HR costs
– Shorter time for provider to review
– Need will diminish over time
• Electronic
– Web Portal
– Patient Kiosk
– DocuScan
– Conversion
• Dictation
• Detail

24. What to abstract?
• Allergies
• Problems
• Medications
• Medical history
• Family History
• Social History
• Lab Results

25. Implementation

26. Implementation Approaches
• Big Bang
– Faster payoff
– More challenging to learn
– Smaller group
– Forced to because converting form an existing EMR
– More planning
– More change
– More stress on certain staff
• Incremental
– More gradual payoff
– Easier to learn
– Required by larger organizations
– Differing workflow issues for staff
• Logical Divisions of Focus for Incremental EHR Rollout
– Access
– Workflow, Messaging, Results review
– Order entry & documentation, Decision Support

27. Training
• Use your own trainers with a Train the Trainer approach
• Adults measure their learning by competencies gained, not by seat-time
– Competency-based training is best
• Decreased employee time spent training
• Increases trainer availability
• Self-paced learning
– eLearning
– Help desk
• Question tracking
• Feedback loop
• Combine classroom and self-paced learning
• Determine training needs
– What are the best times for training?
– Should various caregiver types (e.g. physicians, admin, other) be trained
together or separately?
– What are appropriate training scenarios (and other content)?
– Who may need special help with training?
– Should you consider reducing patient load for some providers?

28. Training (continued)
• Timing
– To be effective training needs to be JIT (just in time)
• Week or two before go-live
• Justification
– Try and include “why” things are done instead of just “how”
• Content
– Create modular training content
– Scaled repetition
– Physician Training Example
•
Phase I – 6 scaled repetition encounters
•
Phase II – Practice more comprehensive test notes
•
Phase III – Document their own notes (the 30-40 used for testing the KB)
•
Phase IV – Document their own notes (that have not been tested)
• Go-Live Shadowing (see separate slide)
• Follow-up training
– Communications
– Shadowing
– Classroom
– Self-paced

29. The Dynamics of Shadowing
• Why Shadowing is the best training practice
– Confidence – real-time support
– Immediate feedback
– Beginning of the improvement cycle
• How it works
– Help physicians remember where everything is
– Documenting provider use of safety-nets
• Appropriate use
• Forgotten from training
• Shortcoming of the knowledge-base
– Feedback loop*
• Logistics
– 1 on 1 shadowing or 3 support personnel for one pod
– 1 on 1 shadowing in the exam room for 20-60 encounters for Physicians
– 1 on 1 shadowing in the exam room for 10-15 encounters for MAs
– Super-user provides on-site support for 1-2 weeks after go-live
• Bodies – the limiting constraint
• Follow-up shadowing
– Observe
– Retrain
– Feedback loop

30. Training Approach Effectiveness
On-Site Group Training On-Site Personal Training
On-Site
Sweet Spot
Off-Site Group Training
Off-Site
Computer-based Training Off-Site Personal Training
Manual-based Training
Group Training Personal Training

31. Go-live – What to expect
• From the first patient the physician knows the
system
• The physician does little or no typing
• Will gain efficiency after 20-60 patients
• After 4-12 weeks (900 encounters) point &
click method of documentation becomes very
fast

32. Strategies for Retiring the Chart
• Give the provider the chart for
two visits
–Sticker method
–Marker method
–Note method

33. Post Go-live Support
• Shadowing
• Make EHR a standing agenda item at meetings
• Have regularly scheduled post EHR training
– Start about 3 months after go-live
– For Providers
– For Clinical support
– Have attendees prepare questions and suggest changes
• Keep communicating milestones and successes to
everyone

34. Is it possible to go-live without
seeing less patients?
• Yes, if that is your goal
– Time takes precedence over EHR
– Multiple Strategies
• Scaling

35. Top 10 EHR Implementation Mistakes
1. Proceeding without executive support
2. Skipping the goals process or setting unrealistic goals
3. Trying to do too much at once (or too soon)
4. Underestimating the total cost / opportunity cost
5. Simply piling EHR project management responsibilities onto
existing staff responsibilities
– ot having an internal project manger
– ot having a content expert / developer
6. Skimping on training & implementation
7. Expecting the vendor to do everything
8. ot communicating
9. ot testing the knowledgebase
10. Implementing EHR at the same time as Practice Management

36. Top EHR Implementation
Best Practices
You just heard many of them

37. Tips
• Use Incremental training process
• Shadow providers, observer, create feedback loop
• Test the vendors knowledge base by entering 30-40 actual charts (for each provider) before you present it to the
doctor.
• Define preference lists for providers before go-live
– Medications
– SIGs
– ICD9s
– Chief Complaints
– Etc.
• Let patients know you are transitioning to computerized patient records
– Letters
– Posters
– Brochures
– News Media
– Face to face
• Publish your practical EHR tips in a document or on your internal web site and send them out every two weeks or so
• Attend your vendors user group meetings
• Complete all training and self-paced learning
• Keep go-live groups modular [reword]
• Don’t schedule go-live during peak season
• Get computer training before training for those not as computer literate [reword]
• Have as many super-users as possible
• Celebrate small victories
• Create three EMR environments – Demo, Test & Production
• Be 100% committed
• Provide your project manager all the resources they need to succeed
• Don’t under-resource your technology
• The IT staff cannot do everything. IT is just one of the skill sets required for successful implementation