Pre-Install

Table of Contents

EHR Implementation Checklist / 2
Electronic Health Record Implementation in Physician Offices: Critical Success Factors / 4
EHR Implementation Team / 9
EHR Implementation Team Role and Responsibility Matrix / 10
EHR Goal Setting / 11
Transition Readiness Assessment / 13
Issues Log / 16
Computer Knowledge Evaluation Tool for Physician Staff / 20
Staff Meeting Skills and Agenda Template / 21
Huddles / 23
Scanning and Back loading Tips / 25
Workflow Assessment Guide / 27
Processes / 34
Return on Investment / 36

Task Date Complete___

� Establishment of Project Team ______

  • Physician champion(s)
  • Project manager
  • Additional practice/department champions
  • Subject matter experts

� Development of Project Plan______

  • Scope document
  • Implementation schedule/timeline
  • Roles and responsibilities
  • Change management process
  • Issue tracking and management process

� Communication______

  • Setup regularly scheduled meeting with vendor implementation
  • staff
  • Provide staff regular updates
  • Post implementation timeline in break room and mark overall progress
  • Utilize newsletters, email, etc. to address specific topics or issues

� Mapping of Critical Practice Workflows______

  • Identify problem areas and bottlenecks
  • Re-map practice workflows based on incorporation of EHR into them

� Handling of Existing Data______

  • Identify key information and documents that need to be in system
  • Develop plan for entering them into system
  • Develop plan for handling new, outside documents and information

� Training______

  • Assess PC and keyboarding skills of staff
  • Establish plan for developing staff’s PC and keyboarding skills
  • Have vendor conduct general overview of system for all staff prior to formal training
  • Conduct multi hands-on, task oriented sessions tailored to staff responsibilities
  • Identify “super users” and ensure they receive additional training sessions
  • Allow staff on-the-job learning time to familiarize themselves with system
  • Develop appropriate education material, such as cheat sheets, quick reference
  • cards, diagrams of new workflows

EHR Implementation Checklist continued

Task Date Complete___

� System Testing______

  • Conduct unit testing (i.e., single module)
  • Conduct integration testing (i.e., interaction between two or more modules)
  • Conduct interface testing (i.e., interaction between systems)
  • Conduct system stress or load testing
  • Ensure testing plans cover different scenarios and situations

� Contingency Planning______

  • Develop disaster recovery plan
  • Test ability to restore system from backups prior to go-live
  • Ensure system backup plan in place and running
  • Arrange for regularly scheduled pick up and off-site storage of backups

� Go-Live Planning______

  • Determine amount physicians’ schedules will be reduced (if any)
  • Determine rollout approach:

Incremental vs. ‘big bang’

All physicians vs. physician champions

All practice locations vs. select ones

  • Allow time during day for providers to “catch up”

Mid-morning and mid-afternoon buffers, or

Extra minutes per visit

  • Ensure sufficient resources available to support staff and physicians
  • Make sure staff and physicians know who they can go to for assistance
  • Inform third parties and other vendors, e.g., labs, transcription, etc. of go-live date so they’re prepared to provide additional support
  • Plan for what to do if things go really wrong
  • Identify situations or points where go-live needs to be stopped
  • Decide what to do if that happens, e.g., go back to paper processes
  • Schedule midday “huddle” to evaluate progress
  • Schedule end-of-day debrief to identify and address issues
  • Bring food, patience, and sense of humor
  • Plan to celebrate

Overview

Evidence suggests that implementation and adoption of electronic health records (EHRs) in the physician office has the potential to improve quality of carei, as well as provide a positive return on investment (ROI) for the physician practice.iiAlthough “successful implementation” may be crudely defined as improved quality of care measures and a positive return on investment, a review of the literature on health information technology (IT) project implementation suggests that successful EHR implementation should be understood in a much more complex framework.

Implementation refers to the process of introducing an EHR into a physician office. “[T]he effort of designing, implementing, and using an information system involves numerous considerations and a series of processes that change the organization, the people and the information system involved”iii. “Successful” implementation of an electronic health record in the physician office involves application of technical, project management, and organizational skills, and embodies much more than mere installation of appropriate hardware and software. As Wager et al succinctly states,

Technical success alone does not ensure the EMR will be accepted and used by physicians…[T]he success of EMR implementation and utilization depends on the integration of the system into an often complex organizational setting.iv

Additional research supports this conclusion. In a case study of five community-based practices, all of which implemented the same EHR system, the authors found that the same EHR in comparable settings was viewed very differently. They conclude that within the practices analyzed, “perceived success or failure of the EMR system appeared to be related to organizational factors that were present before or during system implementation”.v

Literature describing implementation of EHRs into physician offices emphasizes the importance of broader organizational context and the effects that EHR introduction has on office workflow and culture. Given the importance of these factors in the implementation process, evaluation of medical informatics projects is increasingly taking into account the “social, organizational, political, and other non-technical factors surrounding an information systems project”.viIn a report titled “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience”, Keshavjee et al state, “[i]nitial success of EMR implementation is largely dependant on managing the stress of the major change in the practice” and depends on a “perception that sufficient value is gained from the change to justify the costs”vii Proper planning, training, and organizational mobilization are critical success factors to EHR implementation.

EHR Implementation: Phases and Benchmarks of Successful Implementation

As the framework below reflects, a large proportion of the effort associated with implementation should occur before the actual system is installed. Critical to project success is the up-front investment of time and energy.viii To illustrate this, in an eight-phase IT project framework outlined by Worthley in his textbook, Managing Information in Healthcare, “system installation” is the seventh step in the process.ixThe majority of the implementation process precedes installation, and involves problem identification, system design, and testing.

Various implementation and IT project management processes have been put forth in the literature. The outline below highlights dominant themes and factors identified with successful

EHR implementation, but is not intended to serve as a comprehensive “checklist” or sequential timeline to successful implementation. Rather, it is intended as a broad framework to identify many of the key broad and widely cited critical success factors for EHR implementation. It is broken down into three major phases: Pre-Installation, Installation, and Post-Implementation. As the literature suggests, the majority of critical success factors fall into the “preinstallation” phase.

Pre-Installation
Identify Physician Champion
  • In a study of solo/small physician practices in California, the authors state, “identify an EMR Champion- or don’t implement”x. The importance of strong physician leadership is underscored in the literature.
  • The literature broadly emphasizes the importance of a physician champion to drive HER implementation. The following characteristics are associated with this lead:
  • Formal or informal authority to lead change: A well-respected leader who is “powerful enough to make things happen”. xi
  • Commitment to EHR implementation and ability to sell benefits to other physicians and office staff. To be successful, physicians and office staff must “buy-in” to the project.xii
  • This leader must be careful to set realistic expectations.xiii
Prepare Organization for Change
  • Change management is critical to successful EHR implementation. Prior to implementing and installing an EHR, a leader must prepare the organization for change by identifying core values, understating broader organizational context and stakeholder concerns, understanding end-user needs, creating a vision for change, and being sensitive and responsive to organizational stress resulting from change.xiv
Identify Strategic Objectives
  • A critical element in preparing an organization for the change that will result from implementation of an informatics project is “identifying key core values and focusing efforts on those.”xv
  • Clarifying areas for practice improvement in quality and efficiency helps to focus IT solutions on these areas.xvi
  • Strategic alignment of IT investments with the practice’s clinical and business strategies is one important critical success factor for organizations that wish to assess the ROI of IT investments.xvii
Gain Support of Organizational Leadership/Secure Management Commitment
  • The importance of organizational support is one of the most dominant factors associated with successful implementation of EHR. Support from management and/or senior leadership helps ensure adequate resource commitment, critical to successful implementation.xviiiSuch resources are “needed to build an infrastructure to support the system and its users over time” and include not only up-front investment in hardware and software, but also time and staff allocation. xix
  • In one study of EMR implementation in an ambulatory care setting, the authors found an association between perceived usefulness of an EMR and organizational support. The authors explain, “By providing strong support for the redesign effort, management can communicate its commitment to the EMR investment”.xx
Involve Multiple Stakeholders
  • Involve the entire staff including upper management and administrative staff in implementation

and training activities.

  • Being able to meet the needs of conflicting stakeholders, including physicians, nurses, office staff

and administrators, as well as vendors and patients requires a strong project manager who can

ascertain broad needs, build support, and effectively negotiate solutions.xxi

Good Project Management
  • Establish project infrastructure (i.e. project team, including project manager, physician champion)

to support proper planning and ongoing support of the project.xxii

Consider Workflow Redesign

• “To be successful, health informatics systems need to support- or at least not be in conflict with the

organizational structures of the organization in which the systems are implemented.”

• In one case study of EHR implementation in a solo pediatric practice, one critical success factor

identified was the minimal amount of “reengineering” that occurred in re-designing workflow:

automated processes reflected, and sometimes simplified the physician’s manual workflow.xxiii

Conduct Research

• The process of choosing software is “an important time to learn about the strengths and

weaknesses of the EMR, the vendor who is selling it and the type of support that is likely to be

required for the EMR product”xxiv

• Site visits and speaking to experts helps establish realistic expectations for physicians looking to

implement systems.xxv

Offer Hands-On Training and Testing of Software

• Hands-on training, geared at appropriate computer skill levels is critical. “Hands-on training with a

software demonstration program, or a simulated demonstration model should occur early and

often, and be tailored to the needs and work schedules of the physicians.”xxvi

Installation

“Go Live”

  • Go live date should be “boring” because all staff has had experience testing and using

software.xxvii- Application/installation of hardware/software: Computer hardware should be

selected and ordered well before installation. Staff should already be familiar with the hardware

from training activitiesxxviii

  • Cable high volume work areas and exam rooms
Post-Installation

Ongoing EMR Quality Improvement and Management

  • One EHR Implementation methodology suggests that after the EHR software is installed, the

ongoing management should be “handed over” to an office support team.xxix

  • As software, technology and medicine change, practices will continually have to adapt.
  • Building flexible systems and continuous improvement of management processes are among the

critical issues to consider in analyzing the success of health informatics projectsxxx

Ensure Ongoing IT Support: Vendor and/or In-House

  • Vendor support: The importance of proper technical support cannot be understated. Various

authors cite the importance of vendor supportxxxi

  • On-site technical support: It is important to have on-site support to make adjustments to the

system, and address technical issues that arise.

  • In one literature review, the authors report many successful implementation efforts involve

physician “super-users” who assist in training of others. “Super-users are those physicians who

rapidly become expert users such that other physicians can call upon them for assistance.”xxxii

  • Customizing EMR: Some reports suggest that the ability to customize an EHR to physician and

practice needs is related to the success of EHR implementationxxxiii. However, opinions in the

literature regarding the importance of EHR customization are mixed.

  • In a literature review of best practices in EHR implementation, Keshavjee et al found the ability to

customize software was cited in the literature much less frequently than many other critical

success factors. “Many authors neglected to mention whether their software was customizable,

whether they did any customization work or whether they thought customization of EMR software

was important to achieve success in their implementation”xxxiv

  • “Most implementers mentioned that special problem-solving teams involving technical people,

trainers, nurses and physicians were an important tool to help achieve course corrections when

problems start arising after ‘go-live’. Problems were considered inevitable and having dedicated

staff to help users resolve their problems and achieve productivity goals is an important tool for

implementers as they computerize practices.”xxxv

System Evaluation: Have Objectives Been Met?

  • Evaluation of the EMR implementation provides opportunity to assess adoption and ascertain

whether new problems have arisen.xxxvi

i Miller, R. H. and Sim I. Physicians’ Use Of Electronic Medical Records: Barriers And Solutions. Health Aff, 2004; 23(2): 116-126.

ii MacDonald K, Metzger J. Achieving tangible benefits in small physician practices. First Consulting Group. Oakland, CA: California

Healthcare Foundation. September 2002. Available at:

iii Kaplan B. “Addressing Organizational Issues into the Evaluation of Medical Systems.” J Am Med Inform Assoc 1997; 4(2):94-101.

iv Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348

v Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348

vi Kaplan B. “Addressing Organizational Issues into the Evaluation of Medical Systems.” J Am Med Inform Assoc 1997; 4(2):94-101.

vii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online. Available at:

viii Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

ix Worthley JA. Managing Information in Healthcare: Concepts and Cases. Chicago, IL: Health Administration Press; 2000.

x Miller, R., Sim, I., and Newman, J. (2003). Electronic medical records: Lessons from small physician practices. California HealthCare Foundation. Available at: Accessed on: 6/3/2004.

xi Wager 2000, Disastrous; Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xii Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xiii Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:

; Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xiv Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xv Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xvi Worthley JA. Managing Information in Healthcare: Concepts and Cases. Chicago, IL: Health Administration Press; 2000. ; MacDonald K, Metzger J. Achieving tangible benefits in small physician practices. First Consulting Group. Oakland, CA: California Healthcare Foundation.

xvii Arlotto P. Pam Arlotto, Healthcare IT Strategist, Shares Insight on the ROI Process and IT J Helathc Inf Mgmt Fall 2003 17(4) 18-19.

xviii

xix Wager K et al. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J AM Board Fam Pract 2000; 13(5): 333-348

xx Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999 Nov- Dec;44(6):440-54; discussion 454-5.

xxi Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.

xxii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online. Available at:

xxiii Cooper J “Organization, Management, Implementation and Value of EHR Implementation in a Solo Pediatric Practice”. J Healthc Inf Manag 2004; 18(3), 51-55.

xxiv Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report Online.

xxv Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:

xxvi Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999 Nov- Dec;44(6):440-54; discussion 454-5.

xxvii Casey A, Drazen E, Metzger J, Patrino K. “Eleven Critical Success Factors for Implementing Electronic Medical Records.” Available online at:

xxviii Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001

xxix Keshavjee K, Troyan S, Langton K, et al “Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience” Canada: COMPETE, 2001. Report online.

xxx Lorenzi N, Riley RT. Organizational Aspects of Health Informatics: Managing Technological Change. New York: Springer-Verlag. 1995.