How will this module help me successfully implement an EHR?
Strategies and tactics to simplify the process
Nine steps to begin implementation, train staff and finalize rollout
Answers to common questions and concerns
Implementation tools, such as an activation checklist
What is EHR implementation?
Activating the EHR involves a multi-disciplinary approach to prepare the new system, ensure privacy and security compliance, design practice workflows, train the care team and manage the adoption process. A thoughtful EHR implementation can help the practice adapt more easily to the new system, which will benefit patients, physicians and staff.
Nine steps to a successful EHR implementation
Create an implementation team
Configure the software
Identify hardware needs
Transfer data
Optimize pre-launch workflows
Consider the room layout
Decide on the launch approach: “big bang” vs. incremental
Develop procedures for when your EHR is down
Initiate a training plan
Step 1 Create an implementation team
Typically this team will include physicians, nurses, receptionists, medical assistants, compliance office staff and administrative staff. Clinical members play dual roles by teaching EHR skills to colleagues and also bringing clinical challenges back to the implementation team. Quiz Ref IDThree important roles to consider include: lead physician, project manager and lead super user.
Lead physician: The lead physician guides the organization throughout implementation, serving as a link between the front-line users and the technical and administrative staff. It is best if the lead physician is also in practice.
Project manager: The project manager works closely with the vendor and all staff in the practice to keep stakeholders focused on their timelines, track the progress of projects and manage day-to-day issues.
Lead super user: The lead super user will function as the in-house expert in the new EHR. The lead super user configures the EHR software, creates templates and order sets, and also develops revised workflows or standard operating procedures to address issues raised by front-line users.
Step 2 Configure the software
First, work with your health IT vendor to configure your EHR to meet appropriate security measures. This may require that you conduct a HIPAA risk assessment. For other tips on protecting practice computers and your network systems, go to: https://www.ama-assn.org/delivering-care/cybersecurity.
Practices can also consider customizing software to optimize workflow.
Develop a list of build elements external to the EHR such as: demographics imported from the practice management software (PMS), computerized order entry (COE), treatment regimens/protocols, medication management settings, standing orders, default patient history settings and billing/charge master updated with new codes and consents.
EHR software can be modified to create specialty- or physician-specific templates, which are used to support documentation. Discuss customization options and cost with your EHR vendor.
Step 3 Identify hardware needs
Quiz Ref IDThe right hardware can save an organization time and money. Some clinics find that a printer in every room saves 30 minutes of physician time per day and a large monitor saves 20 minutes of physician time per day. Furthermore, some practices reduce the time spent logging into the system multiple times each day by providing every worker with their own laptop or tablet to carry from room to room. System hardware (i.e., server and network) needs depend on the type of EHR purchased (see Table 1).
Physician practices may hire an IT service company to help them with their system hardware needs. Typically, IT service companies are independent from the EHR vendor and may not even specialize in the health care industry. Both the IT service company and EHR vendor can be helpful in finding the right equipment at the best possible price. The IT service company may also supply, install and troubleshoot all devices, including the local area network and routers.
Table 1.
Hardware needs for different server hosts
PRACTICES THAT CHOOSE: | WILL NEED TO: |
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Self-hosting, i.e., EHR data resides in the practice. or Outsourced hosting, i.e., EHR data resides with the application service provider. | Acquire and install vendor-specific hardware. |
Software-as-a-service or cloud-based EHR, i.e., EHR data resides on the internet. | Have excellent internet connectivity for all devices. This may require a network upgrade or secure wireless routers for internet connectivity. |
Determine the approach for migrating data from the former recordkeeping system or other PMS modules to the new EHR. A practice can assign existing staff to assist with this process. Alternatively, the practice can hire additional or temporary staff who can upload demographics and past medical, social, family and medication histories prior to the patient’s next visit.
Prepare a checklist of items to be entered into the EHR. This will ensure that no critical information is missed during the transfer.
Establish the amount of time required to transfer information for the average patient. This can help the practice properly distribute workload and set realistic dates of completion among staff transferring data.
Step 5 Optimize pre-launch workflows
It is best to optimize workflows before EHR implementation. Some organizations postpone workflow optimization because they think, “This will all get better when we get our new EHR.” Problems resulting from inefficient workflows or insufficient support staff will be exacerbated during the implementation of an EHR.
For each step, ask:
Is it necessary?
Does it add value for the patient?
Is it being done in the right order?
Is it being done by the right person?
For any step currently being done by the physician, ask:
See the Expanded Rooming and Discharge Protocols and Team Documentation modules for more ideas about task-sharing with the clinical team.
Step 6 Consider the room layout
Placement of the computer in the exam room impacts patient care. If the staff and physician must look over their shoulder to see the patient while using the computer, patient communication and engagement suffer. Many organizations have found that a “triangle of trust” with the patient, physician and computer at points of a virtual triangle facilitates effective communication. One way to create this triangular configuration is to use a semicircular desk, which allows the patient and physician to face each other and, as needed, to each turn slightly and include the electronic information source in their discussion. Another option is to place the computer on a cart that can be wheeled into a position anywhere in the exam room to accommodate patient and physician communication.
Step 7 Decide on the launch approach: “big bang” vs. incremental
Some practices convert all users over to the EHR for all functions and all patients on the same day—the “big bang” approach. This has the advantage of minimizing the time spent managing both a paper record and the new electronic system simultaneously. It can also be highly disruptive and small glitches can be amplified.
Other practices implement their EHR incrementally, turning on certain functions in a step-wise approach (i.e., starting with e-prescribing, and a few months later adding visit note documentation functionality). Another incremental approach is to implement the EHR in certain sites or departments and slowly roll out to the rest of the organization, learning and tweaking the process along the way (see Table 2).
Once physicians and staff decide on the launch approach, they can begin to acclimate to the new system in the practice. Different implementation strategies can be used depending on the approach (see Table 3).
Table 2.
Comparison of the immediate and incremental approaches to EHR implementation
APPROACH | ADVANTAGES | CHALLENGES |
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Immediate approach (also referred to as the “big bang”) | Eliminates confusion among physicians and staff since all administrative and clinical tasks will be completed electronically. | Requires significant resources and staff support. |
| Potential benefits of EHR are realized more quickly. | |
Incremental approach | Reduces productivity loss due to operational and workflow changes from EHR adoption. | Requires strictly following a work plan to keep implementation phases on track. |
| Issues are easier to resolve because they are isolated from other EHR modules or functions. | Requires close attention to hybrid processes because not all tasks are completed electronically. |
| Allows physicians and staff to gradually learn and master the capabilities of the system. | Requires awareness of the different functions that are being launched on different dates. |
Table 3.
Strategies for immediate and incremental EHR implementation
STAKEHOLDERS | IMMEDIATE APPROACH | INCREMENTAL APPROACH |
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Physicians and staff | Mobilize all physicians and staff to use the EHR on the first day of launch. This allows all users to access implementation resources and enables all users to gain proficiency in the EHR at the same time. | Train physicians and staff with basic EHR functions and focus on optimization after the launch is complete. This allows physicians and staff to acclimate to their new system before bringing trainers back to provide additional/supplemental education. |
| | Establish a mentorship program that enables staff with similar roles to share their knowledge and experience with the system, rapidly increasing the level of EHR proficiency in the practice (e.g., physician super user teaches other physicians, experienced LPN shadows a medical assistant). |
| | Start with an enthusiastic and prepared physician and/or staff member using the EHR the first week and gradually increase the number of physicians and staff using the system. |
Patients | Use the EHR for all patients in the practice. This approach can minimize variation of protocols used for different patients and appointment types. | Use the EHR according to visit type (e.g., new patients only and patients that made appointments). |
| | Use the EHR according to number of patient visits per day (e.g., a few patients on the first day of implementation and increase the number of patient visits documented in the EHR per day over time). |
Step 8 Develop procedures for when your EHR is down
What will you do in the event of a power outage or severe system malfunction? It is wise to develop procedures for periods when the EHR is down so that physicians and staff have clear instructions about workflows when the EHR is unavailable. Some key components of downtime procedures include how the downtime will be communicated to physicians, staff and patients and how the patient care flow will continue (e.g., check-in and visit documentation). Downtime procedures and supplies should be available electronically and on paper for greater accessibility. Some practices compile the procedures in a three-ring binder and store additional copies offsite.
Access Develop procedures for when your EHR is down.
Training staff and physicians is critical to ensuring EHR implementation success. Quiz Ref IDCreate a training plan to make sure everyone has the necessary knowledge and skills to use the EHR at the time of launch. A few guiding principles can help:
It is best to provide users with basic skills in preparation for launch. It is difficult for users to absorb more than this without having used the software in practice. Later, after the users have had a chance to “drive” the EHR for a week or so, conduct additional training to help users refine their skills and learn more time-saving tricks, such as developing smart sets and other preferences. This is a good opportunity to develop smart sets and discuss downtime procedures.
Step B Arrange for colleagues to teach each other
Whenever possible, train super users in each specialty and for each type of role. Pediatricians learn best from pediatricians; surgeons learn best from surgeons; nurses learn best from nurses. As proficiency with the EHR grows, these super users can then be an ongoing resource to their colleagues.
Step C Plan for ongoing training needs
In addition to pre-implementation training, practices should have a plan for ongoing learning and improvement. After several months, many users will develop shortcuts or find new functionalities that they can share with colleagues. Over time, there will also be EHR updates with new and/or improved functionality, which will require additional training. Some opportunities to effectively handle these situations include:
Develop a platform for submitting and tracking EHR enhancement recommendations so that the change team can actively set improvement priorities. Encourage users who are constantly interacting with the system to actively engage in improving the EHR. They can openly share their input and offer solutions for enhancing usability. This could be a formal tracking system or in an online discussion forum that allows for the sharing of useful tips and tricks.
Establish a mechanism for continuous EHR customization. After physicians and staff have acclimated to the new EHR, they may find that minor modifications to the system can improve their workflow.
Maintain a relationship with the EHR vendor and engage ongoing IT support to:
Develop new or further customize templates for data entry
Revise or reformat forms and letters that are generated by the EHR
Enable new clinical decision support rules if available
Modify order sets as medical knowledge advances or other health care entities change their service offerings
Identify opportunities for integration with other systems that are commonly used in the practice or by other providers
Plan ahead for any necessary group training related to system updates and new functionality. It is likely that practices will have to take time away from seeing patients to attend training. Preparing ahead of time creates less disruption for the practice and its patients.
The strategies and tactics presented in this module will aid you in thoroughly understanding your practice’s specific needs—from the team who will lead the rollout to the software and hardware options to the layout of your office—to successfully implement an EHR.