EMR and EHR System Implementation Best Practices - Part 5 - Case Studies

This is the fifth article in a series dedicated toimplemented. The velocity of the changes being
uncovering the best practices for an EMRthrown at the medical staff made it difficult to be
implementation. The information presented hassuccessful (Collins, 2006). Other implementations
been developed by the author as part of arelated to the same program have also been
research project.plagued with issues. The system dubbed "Choose
EMR Implementationsand Book" provides electronic patient records and
As EMR systems become more prevalent, moreappointment booking services as indicated above.
information is being made regarding the successThe system is
or failure of the final integrated system. According17.3 billion British Pounds over its original budget of
to Hoffman (2007), systems implemented at the2.7 billion pounds (Wilkinson, 2006). Causes of
Harbin Clinic based in Rome, Georgia had beenfailures identified in the article include lack of
delayed due to cultural issues including resistancestakeholder involvement, the sheer scale of the
by the physician staff to adopt the new system.project (country wide implementation) and
Due to the issues, the implementation hasturnover in program management.
increased from two and a half years to over fourA case study analyzing two Danish installations of
years. Harbin Clinic is the largest privately ownedthe same EMR system at two different locations
multispecialty clinic, has 20 locations and employsillustrates the approach and subsequent successful
135 physicians. This large implementation hadimplementations of the case study locations. The
significant support from the executive team,case study covers a cardiothoracic surgery ward
however, they found that a number of specialistsand an orthopedic surgery ward at two different
within the organization did not like the aggravationDanish hospitals. Both sites adopted the same
of keying information into the system because itEMR system. The system is a standard system
was not tailored to them. Implementationproviding a shared electronic patient record. The
obstacles identified were the lack of processimplementation of EMR system was organized by
mapping due to the large number of specialties,a project manager who created several diverse
lack of a change management strategy regardingworkgroups to develop integration plans. Super
adaptation of specialty processes to the newusers were identified and leveraged to help with
system. The effect of the obstacles led to thethe design of new work processes to support the
extension of the implementation window whileEMR system. Additionally, the super users
increasing the cost of the overall project by a halfprovided localized support and answers to
a million dollars.questions. User training consisted of 6 to 8 hours
Bellevue Family Medicine Association (BFMA) inin general IT and EMR prior to implementation.
Bellevue, Washington is a healthcare provider withSuper users were provided with more detailed
over 100 patients in daily care. Additionally, theytraining to assist in supporting the EMR.
had over 10,000 active patient charts. BFMAManagement led meetings were leveraged to
implemented a new charting system that tookensure users were informed about the project. All
two years. BFMA's implementation succeeded dueof techniques identified above contributed to the
to the flexibility they gave their physicians onsuccessful implementation of the EMR system
entering data into the system. The use of tabletwithin the two surgery centers (Jensen &
PCs allowed the user to either type or write intoAanestad, 2007).
the system. BFMA paid particular attention to howCayuga Family Medicine in Ithaca, New York, is a
people would utilize the system and accounted forsmall practice consisting of pediatrics and
those aspects in their planning and implementationobstetrics employing two physician partners and a
(Schock, 2007). BFMA also utilized structurednurse practitioner. They implemented an
training on the use of the new charting system.integrated practice management system and
Additionally, BFMA leveraged an outside IT firm toelectronic chart system when they opened in
implement the technology in order to free up their2000. The system served primarily to provide
own resources.electronic versions of the patient chart until one
Dominican Hospital located in Santa Cruz, California,of the partners realized that the software could
implemented an electronic charting system calleddo more through the use of date entry
CareConnect. Dominican is part of Catholictemplates. Once he gained understanding, the
Healthcare West. Dominican utilized formal trainingphysician created a number of electronic forms to
as well as CareConnect provided technical support.facilitate data entry and coding. The effect of this
Dominican also leveraged "super user" groups toactivity provided immediate benefits to improved
help with subject matter expertise. Despite theworkflow and data entry. Additional gains in billing
training and super users, the rollout impacted thewere achieved due to the more accurate data
nursing staff significantly. There appeared to be a(Loehr, 2006). The ultimate improvement in the
lack of process analysis to understand how thesystem utilization came from a small scale version
nursing staff utilized the paper charts toof process engineering and showed that it can
administer medication and care. The end resultwork even on a smaller level.
caused significantly more work for nurses toHerb Smaltz of the Ohio State University Medical
review and validate patient history. Additionally,Center (OSUMC) uses a support "S.W.A.T" team
system issues such as missing or duplicated datato help with EMR implementations. When moving
undermined trust in the system by the usersto a new EMR system, OSUMC leveraged
(Everitt & Hwang, 2007). The systemsteering committees designed to address the
implemented was not analyzed properly toprocess and procedure changes necessary to
understand whether it was user capable or not.implement the new system. Leveraging support
Lack of user involvement, data integrity andteams pre and post implementation helped
usability were significant factors in this failedsupport those users that needed help. OSUMC
implementation.leveraged staff in the selection process to
Thomas Jefferson University Hospital (TJUH) inencourage buy-in for the new system
2001 implemented a computerized provider order(Havenstein, 2007). Also covered in the article
entry (CPOE) system. A byproduct goal of thewas Citizens Memorial Healthcare (CMS) in Bolivar,
project was the building of lifetime electronicMissouri. CMS leveraged the support of the
health records (EHR). Over 950 physicians entercompany's executives along with the IT group
information into their CPOE and related systems.working directly with staff and physicians through
TJUH took an overarching approach to addressingall phases of the implementation. CMS spent 8
the realignment and standardization of processesmillion dollars on their EMR project and have over
and procedures across the hospital. TJUH involved95 percent of patients on electronic charts
users at every level of the organization to help(Havenstein, 2007). The JKL Healthcare system
redesign workflows and tailoring the system tooperates three acute care hospitals and five
the appropriate audiences. Strong backing fromambulatory locations. JKL also operates a research
hospital executives provided credibility that lead toinstitute and a 450 employee physician group with
significant buy-in from hospital staff. TJUH50 local offices and a home care services
implemented an Interdisciplinary Workflow Groupcompany. The article focuses on one of the acute
to assess departmental processes and makecare hospitals recently aquired.
changes where necessary to ensure that the newJKL began their implementation in 2001 to install
processes and systems aligned.an EMR system. JKL chose EPIC and had a
TJUH leveraged the use of a pilot to test the newbudget of 35 million dollars. JKL leverage process
system and processes. The pilot allowed them tore-engineering and certification to help facilitate the
evaluate progress and then adopt at a pace theyintegration of the new system. JKL made
could effectively support. As the pilot became thephysician certification required in order to refer
implementation, TJUH leveraged the experiencepatients to the hospital. To help compensate for
pilot participants to assist with integration of thethe training required, they waived their
other users (McGurkin, Hart, & Millinghausen,professional staff dues as an incentive to
2006). TJUH utilized a number of opportunities toparticipate in the training and continue to refer
ensure the success of their rollout by heavilypatients to the hospital. JKL leverage super users
integrating the stakeholders into the entireto facilitate integration of the systems after staff
process. The integration and change managementmembers received training. The day that JKL
strategy contributed to the success of theirwent live, they assigned each physician a personal
implementation.trainer that completed rounds with them.
Yakima Valley Farm Workers Clinic (YVFWC) is aAdditionally, super users were stationed at every
multispecialty community practice. YVFWCpatient unit to assist with questions or procedures.
operates 18 clinics in Washington and Oregon.Ninety percent of the physicians using the system
YVFMC purpose for implementing an EMR systembelieve it is beneficial and made it easier to do
was to improve patient care and portability oftheir work (O'Brien, 2006).
medical information between the various clinics.Healthcare Partners Medical Group (HCP) located in
Patients would commonly visit multiple clinicsCalifornia moved from an older EMR system to a
depending on where they were located at thenewer product offered by Allscript Healthcare
time they needed service. Without access to all ofSolutions, Inc. called Touchworks EHR. HCP
a patient's records, it became difficult to keepoperates 38 sites, and four urgent care centers
them synchronized. YVFWC decided it was timeserving half a million patients. The overall project
to implement an EMR system that could becost 4 million dollars and was scheduled to last 3
accessed by all sites. TVFWC conducted researchyears. HCP leveraged a multifunctional team to
to determine the best way to implement theiridentify requirements for the new system and
EMR system and discovered that "big bang"break them down into "must haves" and "nice to
approaches were to be avoided.haves". The team was also leveraged to evaluate
They leveraged a pilot approach to ease theand select the new software package. Vendor
transition to the EMR by implementing just oneconsiderations were heavily weighted in selecting
module at time. Doing this, they were able tothe new product. HCP focused on ensuring vendor
avoid the frustration that quick change brings onstability and ability to support such a large
along with the unintended consequence of userimplementation. HCP analyzed workflows in order
resistance and distrust. The pilot approach allowedaddress changes to fit the new system and also
them to continually refine the implementationcompleted performance testing to ensure the
tactics and overcome obstacles before the largersystems could handle large amounts of data
organization was affected. TVFWC did run intotransfers. Training was a critical focus for all the
issues related to the lack of standardizedusers of the systems and included e-learning,
processes from site to site. This led to someinstructor led training and individualized training. HCP
resistance at local site. They overcame thisadopted the use of super users to help field
deficiency by leveraging a consistent rollout teamquestions during and post go-live. The rollout of
to help train new and consistent processes in thethe software was accomplished using a pilot
local sites. Training regimens were utilized before,method bringing up each location independently.
during and after implementation (Simmons &Prior to each location go-live event, managers
Tschauner, 2006).conducted dry runs of the implementation to
Dean Health System (DHS) is located in Madison,ensure that systems and personnel were ready
Wisconsin. DHS is a multi-specialty healthcare(Yocum, 2006).
system that provides a network of 60 multi-levelA study conducted by Miller and Sim (Miller &
ownership clinic that provide a wide range of careSim, 2004)analyzed survey data provided by 90
in the southern part of the state. DHS deployedrespondents regarding their use and perceptions
an EMR system from EPIC Systems using a aof their EMR installations. It was noted that
phased approach leveraging a pilot phase to workphysician's attitudes were of utmost importance in
out issues. Their rationale for the pilot was to gaindetermining the success of an implementation.
committed users to help with future expansion.Those practices that had an "EMR champion"
Additionally, DHS leveraged additional tools to helpwere more successful and had higher usage of
with adoption like speech recognition andthe EMR systems. In contrast, those practices
integrated transcription services. The combinationwhere there wasn't a champion of the
encouraged greater adoption of the technologytechnology, the use of the system was minimal.
(Cordio, 2007).Also noteworthy was that larger practices with
The Newhan Primary Care Trust in East Londonmore staff tended to be higher users than smaller
and Nuffield Orthopedic Centre at Oxfordpractices and the authors associated this
implemented a system from Cerner, a U.S. basedphenomenon with the ability of the practice to
company. After the implementation several issuesabsorb implementation costs with regard to
with appointments being mailed out to theadditional personnel needed to integrate the
incorrect people were found resulting in peopleproject.
missing appointments and people showing up forThe next article(s) will delve into additional
appointments that did not exist. People working onreference material and best practices related to
the project associated the many problems withEMR Implementations.
the speed at which the systems were being