Configuring Electronic Health Records: Migration to an Electronic Health Record System Lecture 2 Audio Transcript Slide 1 Welcome to Configuring Electronic Health Records: Migration to an Electronic Health Record System. The component, Configuring Electronic Health Records, provides a practical experience with a laboratory component (utilizing the VistA for Education program) that will address approaches to assessing, selecting, and configuring electronic health records (EHRs) to meet the specific needs of customers and end-users. Slide 2 The objectives for Migration to an Electronic Health Record System are to: Describe the process of initial planning for migration to an electronic health record (EHR), including identifying stakeholders, champions, management and implementation teams, and determining appropriate members for a steering committee Develop a timeline for choosing and implementing an electronic health record, including defining the scope of implementation, budget estimates, and additional critical steps to build a basic strategic plan for implementation Develop functional requirements, including a workflow analysis and a gap analysis, and how to recognize when external expertise is needed Develop and apply criteria for selecting an appropriate vendor for the electronic health record including: Generate a request for information (RFI) / request for proposal (RFP) Select an appropriate system, including using an appropriate ranking model Generate interface requirements Compare and contrast EHR solutions (for example, locally hosted versus cloud solutions) Negotiate a contract Develop a training plan Slide 3 This lecture will discuss the process of initial planning and project development in the process of migrating to an EHR. It will describe how to identify stakeholders, determine the most appropriate members for a steering committee, develop a timeline for EHR selection, and implement the plan. Additional critical steps required to build a basic strategic plan to implement the migration of an EHR will also be discussed.
Slide 4 Organizations should develop a strategic plan for migration from paper records to an EHR. A strategic plan is also necessary if the organization is migrating from one EHR to another. A strategic plan will help an organization achieve an optimal EHR implementation. It will also help reduce the cost of implementation, which can be substantial. A clear strategic plan will help the implementation team effectively manage the process of change and efficiently develop goals. To develop an effective strategic plan, an organization begins by reviewing its mission and vision in migrating to an EHR. It then considers the process of change in a deliberate, reasoned fashion and develops a plan for how the change will be managed. Developing a strategic plan helps to generate goals that are realistic, measurable, and tactically appropriate. Slide 5 Successful EHR implementation begins with an examination of several high-level strategies. The organization should begin the process by conducting a needs assessment to determine the best product for the specific needs of the organization, and the best method for its implementation. Personnel from all levels of the organization, from executives to front office staff, will be involved in planning and implementing the EHR. Therefore, achieving multidisciplinary buy-in for the EHR within the organization is essential for the success of the implementation project. An appropriate timeline for implementation should be determined. This will help to define the duration of change and assist in effective cost management. During periods of change, it is especially important for an organization to effectively manage its staff and the logistics of the project. Flexibility and the ability to troubleshoot issues that may arise during periods of change are important characteristics of good management. Slide 6 Identifying stakeholders is a crucial step in planning the migration to an EHR. There are two main types of stakeholders associated with implementation of an EHR, institutional and community. The institutional stakeholders may include the organization's chief executive officer (CEO), chief information officer (CIO), chief medical information officer (CMIO), and chief financial officer (CFO), other senior management figures, and midlevel and site-specific managers and, project leaders (some of whom may have formal project management training). The number of management personnel necessary for EHR implementation depends on the size of the organization and its culture. Project leaders may be selected from within the organization or may be hired from outside the organization.
In addition to management staff, stakeholders from other levels of the organization are also important. Anyone who uses the EHR can be considered a stakeholder in the process of EHR implementation. Among clinicians, medical doctors, nurses, pharmacists, physical therapists, and radiology technicians will be end-users of the EHR. Other personnel will also use the EHR as part of their job, including laboratory staff, schedulers, inventory managers, billers and coders, quality management and utilization review staff, and administrative staff. Of course, not all personnel can be directly involved with system selection and implementation, so it is important to determine the most appropriate stakeholders to represent the wide range of end-users and help guide the organizational change. Community stakeholders are also important to the process of implementing the transition to EHR. These stakeholders can be patients, their families, policymakers, especially at the local and regional level, and the public health community involved in the reporting and population aspects of healthcare delivery. Representatives of community stakeholders are often asked for input during EHR selection and implementation. This allows for a more robust product to be selected, one that best serves the needs of the diverse people who will use it. Slide 7 Once stakeholders have been identified, they can begin building the project team. The project team will be responsible for making decisions for the organization. Therefore, careful selection of team members and leaders is critical to the success of EHR implementation. A project team needs three essential types of members: clinicians, technologists, and administrators. The clinicians who provide patient care are important team members, because they will be the primary end-users of the EHR. Technologists should be included as team members because they will build and maintain the hardware and software for the EHR. A particularly strong role will be that of clinical informaticians, HIM specialists, and other team members with informatics training. Finally, administrators, such as, project managers and organizational leaders will perform the managerial tasks required to successfully complete the process of organizational change and steer the organization into a steady state after implementation of the EHR. Slide 8 Several key people are necessary for a successful EHR implementation. At the top of the organization, the CEO should be a strong leader invested in the process of change. A transformational leader with charisma and vision will be able to steer the organization through the process of EHR selection and implementation. At the next level, CIOs and CMIOs with expertise and training in clinical informatics are also essential to the change process.
Physician champions with an interest in clinical informatics can play key roles. Often, these physicians are early adopters of technology in their practices. Ideally they should also be collaborative and well respected by other physicians. Thus, they are able to persuade colleagues of the benefits and potential advantages of the EHR. Physician champions can act as leaders within the clinical community by disseminating usage techniques. They can also act as liaisons with the technological community that is implementing the EHR. Project managers are responsible for planning and executing the EHR selection and implementation process. Their role is critical to keeping the implementation onschedule. Project managers define and track objectives, and manage the scope of the project. They may also be responsible for managing cost, time, quality, and team members involved in selecting and implementing the EHR. Project managers often have formal training in the field of project management. Information technology or IT professionals with clinical informatics experience are a substantial asset in this process. Their role is to help design and implement the systems that clinicians use. Their clinical experience enables them to understand clinical workflows and how clinicians operate within their environment. As a result, the systems they build optimize the end-user experience and enhance efficiency. A consideration for small organizations is whether they have all the expertise required to implement the EHR. In many cases, it may be necessary to hire consultants who have special technical expertise not found within the organization who can help streamline the process of EHR implementation. Slide 9 Once key people have been identified, a steering committee can be selected. This step is important, because the steering committee has a substantial advisory role, and may oversee the process. Because of its advisory role, the steering committee should be interdisciplinary and include members that have insight into both clinical and technical disciplines. In addition to its breadth of expertise and diversity of professional roles, the steering committee must be representative of the organization's culture, be sensitive to the needs of various elements and personnel within the organization, and have a thorough understanding of the organization's structure and function. They must also understand how the organization fits within the local and regional healthcare delivery infrastructure. Slide 10 A needs assessment is a systematic process of determining the requirements for a project. A needs assessment should address the scope of the project. The project scope will vary by organization, because each organization has different needs. For instance, the project scope for an organization that plans a "clean" or new installation of an EHR will differ substantially from an organization that is upgrading from one EHR system to another. In addition to defining the scope of the project, a needs assessment can help determine if each unit in an organization will determine its own needs, or if a single unit will
determine the needs of the entire organization. The needs assessment should not only focus on the internal needs of the organization but also on external factors that may be identified. These factors are outside the organization, such as government or insurance company mandates. One critical external factor is the meaningful use program of the HITECH [high-tek] Act. The needs assessment can also identify the critical aspects of implementation that may drive implementation. For example, meeting the meaningful use criteria might be identified as the primary reason for an organization to migrate to an EHR. Slide 11 When conducting a needs assessment, an organization should determine the desired level of EHR functionality. For instance, the functionality will be different if the implementation is a "tabula rasa" [ta-boo-laa raa-sah], that is, a migration from paper to electronic records compared with a migration from a pre-existing EHR to an updated system. The organization should determine what existing elements need to be integrated into the new EHR. For example, if an organization wishes to keep its practice management software, it must ensure that the software seamlessly interacts with the EHR. Additionally, an organization may want to ensure that data stored within its legacy clinical information system can be transferred to its new system in an efficient and adaptable fashion. Because some existing systems may be rendered obsolete by implementation of the new EHR, an inventory of current hardware and software should be conducted early in the implementation process. Slide 12 Determining the timeline of the implementation is a necessary, but sometimes challenging process. There are two general types of EHR implementations. The first type is known as a "Big Bang" implementation. With this method, all EHR functions are enabled at the onset of implementation. From that point forward, clinicians will only use the EHR when delivering healthcare services; paper records will no longer be available. It may also involve concurrently implementing multiple modules and features of the EHR, or implementing the EHR simultaneously at multiple sites. The second type of implementation is called a staged implementation. This implementation model enables predefined elements of the EHR in stages until the entire suite of functionality has been implemented. For example, some elements of the EHR, such as, drug to drug interaction, e-prescribing, and problem lists may be implemented ahead of other elements, such as computerized physician order entry (CPEO) and clinical decision support. A staged implementation may also require specific elements of the EHR to be implemented sequentially at different sites. Each type of implementation has advantages and disadvantages. The Big Bang approach usually has a shorter implementation time, but it has a higher risk of failure.
The staged implementation allows clinicians to gradually acclimatize to the electronic health record, thus it is more amenable to physicians who are resistant to change. Staged implementations are associated with lower initial productivity losses and higher total implementation costs compared with the Big Bang approach. The culture of the organization may favor one type of implementation over another. Considerations of cost and the availability of essential personnel may also influence the type of implementation selected. The type of EHR to be implemented is an important decision. The EHR may be a single product or suite of products from a single vendor, or it may be a clinical information system comprising different modules supplied by more than one vendor. The latter is known as a best-of-breed approach. Purchasing an entire suite of EHR services from a single vendor has some advantages. The primary advantage is that the organization deals with only one vendor who is responsible for the entire spectrum of EHR functionality, and for supplying, upgrading, and maintaining the EHR. Additionally, a single vendor approach eliminates concerns about interoperability between modules, and contract negotiations are often less complicated. A single vendor approach also ensures seamless data sharing across the organization. However, a single product may lack some functionality required by the organization, or some of its modules may be inferior to a best-of-breed solution. Additionally, some organizations may require niche systems not available from mainstream EHR vendors. Cost is also a consideration. Large, integrated products offered by single vendors may not be financially feasible for some organizations. The choice of a single vendor versus best-of-breed solution should be carefully undertaken. The characteristics, expertise, and culture of the organization, as well as the practices and workflows of the end-users of the EHR should be deliberated along with financial and strategic considerations. The type of EHR chosen may significantly affect the timeline for the implementation process. The timeline will also depend on whether hardware and software prerequisites have been met for EHR implementation. For example, the organization must ensure that it has sufficient workstations, and that they meet the requirements to operate the EHR. Ultimately, the timeline will depend on the availability of key personnel to lead and assist with the implementation. The organization should assess whether it needs to hire and train personnel before the implementation and factor these activities into the timeline. Determining the appropriate timeline can be a complex process, but it is critical for a successful EHR implementation. Slide 13 The organization needs to generate a document listing the functional requirements of the EHR. This document will define the parameters that the system must meet. Certain functional requirements may be considered critical to the organization and may limit the selection of the EHR. For example, an organization may require its EHR to be
certified. This process of certification is very closely tied to the ability of the EHR to have meaningful use functionality, and the process is governed by a number of certifying bodies, such as the Certification Commission for Health Information Technology (CCHIT [see-see-hit]). If a requirement is deemed essential, then it becomes a limiting factor in the EHR selection process. Some organizations may determine require that its EHR infrastructure use an application service provider or ASP model. An ASP vendor hosts the servers, maintains the software, and curates the IT aspect of the service. Using an ASP vendor allows the organization to allocate fewer resources for maintaining, updating, and troubleshooting the EHR. If an organization decides it needs to maintain control over both the client and server environments, an ASP solution would not be acceptable. An organization may decide that its EHR integrates practice management functionality, or be interoperable with legacy practice management software. This is another example of an essential functional requirement that needs to be considered before EHR selection. Compliance with the Health Insurance Portability and Accountability Act or HIPAA, is another common functional requirement for EHR selection. HIPAA compliance poses an interesting situation, since it is not optional. Electronic health records that meet meaningful use criteria are eligible for incentive reimbursements; therefore, many organizations select an EHR that meets these criteria. Considerations for selecting an EHR that meets meaningful use criteria include specific functionality, such as, CPOE, clinical decision support, or the ability to query and report selected health data, as required in the definition of meaningful use. Some organizations need an EHR to function in an interoperable environment and exchange data with other electronic health records of local or regional clinical information systems. Some organizations prefer to maintain a high-level of control over their EHR data. Others want their EHR to integrate with ancillary modules, such as, the laboratory or radiology modules, either offered by the same EHR vendor or as part of a best-of-breed solution. Another consideration when selecting an EHR is whether the vendor offers upgrades and support. The track record of the vendor with respect to previous implementations is also a consideration. A personal health record, or PHR, gives patients the option of entering data and information about their health and healthcare. Some organizations may also consider whether electronic health records offer a personal health record or functionality that approximates a PHR option, which a feature often demanded by patients and their families. Unfortunately, usability of an EHR cannot be determined by just generating a list of functional requirements. Usability is best determined through a demonstration of the EHR so end-users can evaluate how it operates in a clinical environment and determine how its use impacts workflow.
Slide 14 A workflow analysis evaluates how work is done in an organization. There are two main types of workflows in the healthcare delivery environment, clinical and nonclinical. Clinical workflow is the series of steps taken by clinicians to deliver patient care. Examples of non-clinical workflows include the process of billing, coding, and reimbursements. Both types of workflows can be mapped and analyzed. These analyses can help organizations modify workflows to make them more efficient with the new EHR. Workflow analysis also allows organizations to become aware of and prepare for the changes in workflows that will occur as a consequence of implementing a new EHR. Slide 15 Another useful tool for preparing for the migration to an EHR is a gap analysis. This type of analysis compares the conditions that currently exist within an organization with those that will exist after implementation of the EHR. The difference between the two sets of conditions is the "gap". A gap analysis can help determine the steps needed to transition from paper records to an EHR. By listing current characteristics, noting future objectives, and mapping factors required to make this transition, gaps can be identified and help the organization understand and define exactly what is needed to make the change to an electronic health record. Slide 16 Teams of personnel working together are necessary for EHR implementation to be successful. An organization needs to know when to ask for help with the migration and how to determine whether adequate expertise exists within the organization to successfully implement an EHR. Both clinical and technical subject matter experts will be necessary. If an organization does not have the appropriate internal expertise they will need to hire consultants or take active steps to learn from other organizations that have successfully selected and implemented an EHR. Slide 17 There are additional critical steps that foster successful EHR implementation. An organization needs to manage the expectations of personnel, especially clinicians, concerning the capabilities of the EHR. Expectations of return on investment must also be calculated in a realistic fashion. Soliciting opinions from multiple stakeholders at each step in the implementation process allows for a higher level of buy-in from the people who will use the system. Organizations lacking buy-in from staff often find implementation challenging. Buy-in needs to be elicited at all levels of the organization. The support and commitment of the stakeholders is critical to the successful implementation of an EHR.
Slide 18 This concludes Migration to an Electronic Health Record. In summary, this lecture examined the development of a strategic plan, and discussed various guidelines for a successful EHR implementation. Stakeholders were identified, and the process of building a team of key people was described. How to form a steering committee was discussed. The value of conducting various types of assessments, such as, needs assessment, functional requirements, workflow analysis, and gap analysis were described. Finally, methods used to determine the desired level of EHR functionality were discussed. Slide 19 References slide. No audio.