The implementation of a new piece of information technology-no matter how thorough the planning-can mean serious disruption across a healthcare organization, from patient care to day-to-day operations to cash flow. Tiny oversights can turn a previously well-oiled machine into a rusty junker. By the same token, interventions that seem minor can avert disaster and bolster morale.
Keys to success include making sure the right project team is in place, the right individuals are assigned the right tasks, ready-and-willing end user support is available and new systems are thoroughly tested.
"It's not really about the technology," says Keith Figlioli, senior vice president of healthcare informatics for Premier, which includes IT implementation advice on the roster of services it offers its 3,400 hospital members. "It's all about process redesign and getting everyone aligned."
And that takes an organization-wide commitment. Figlioli spots trouble whenever providers get too enchanted by technology or if the impetus for adoption is coming from a single sponsor. "Someone's got a pet project and no one else is on board," he says.
Building an effective team
CHE Trinity Health in Livonia, Mich., could write the textbook on developing organizational commitment. It has a steadily expanding number of hospitals-86 at last count, across 20 states-to wrap into its corporate computing platform. Formed in 2013 by a merger of Trinity Health and Catholic Healthcare East, the organization continues to grow both through acquisition and by building new hospitals. Sometimes it takes over an entire health system, and can plan in a somewhat leisurely fashion whether and how to incorporate the new hospitals into its Cerner-based system-wide EHR. Other times, it acquires only a few hospitals out of a group, and has to switch them over quickly to avoid contractual complications with the previous owner's IT vendors. CHE gets the job done with a two-pronged approach: a local team supplemented by a system team that pulls experienced implementers from all its hospitals.
"Each hospital comes with its own internal culture," says clinical director Teresa Sannes of CHE Trinity's program management office.
A key step is to identify who's going to be accountable for the success of the overall project, from the president to the service line leaders, and train those individuals in how to manage the change process. Trinity also has a role called "DOER"-department operational expert resource-who understands both the technology and how it fits into the needs of a given department.
Once the host site has established its go-live schedule, the call goes out system-wide for super-user volunteers who can provide at-the-elbow support. The corporate office covers the cost of their travel and lodging, as well as fill-in staff to cover at their home institution, and maintains a central website where they can coordinate their schedules and travel plans.
The system also provides "revenue buddies" from the corporate office who work with each department to make sure everyone is capturing charges for all items and services correctly and consistently. The revenue buddies track and audit all charges daily and keep a list of charge-capture issues to be managed by the command center.
Discipline and chocolate
Dana Moore, CIO of 15-hospital Centura Health in Denver, is experienced in developing organizational buy-in. He's getting ready to spend the next two years on his second enterprise EHR implementation, and he's thinking of digging out the gaudy shirt he wore several years ago for the first implementation, which marked him as part of the "Hawaiian surf brigade."
Moore and similarly attired support staff appeared at each successive hospital during go-live to give at-the-elbow support, and chocolate, to anyone struggling with any aspect of the new system. "We were very visible," he says. Some of the hospitals enhanced the festive tropical atmosphere with blow-up palm trees and leis for everyone. The surf brigade budgeted a month for each hospital, though many users quickly acquired confidence in their skills and were ready to dismiss them after a couple of weeks.
Underlying the tension-busting attire and the hand-holding was a tough-minded commitment to 100 percent computerized physician order entry. Hospital and health system leaders were evaluated on the success of that goal, and physicians were held accountable as well. Failure to show up for CPOE training was considered a voluntary resignation from the medical staff. "Then people know you're serious," Moore says. Executives were warned not to make side deals with resistant physicians, no matter how many admissions they accounted for. "If you tell one physician, 'You don't have to worry about this,' then you crater the whole system because word will spread."
Centura carefully monitored system usage during go-live, identifying areas of slow CPOE uptake and fixing them as they appeared. Some physicians needed extra training or custom order sets. Most of the hospitals were at 80 percent CPOE by the second day after go-live, and up in the 90s within a week.
Because Centura hospitals were often the first in their markets to require CPOE, Moore worried that physicians might avoid the requirement by fleeing to other hospitals where they had admitting privileges. He was pleasantly surprised that most chose to stick around during go-live and take advantage of the surf brigade's availability, and that some actually boasted about it. "Other hospitals would tell us, 'We're sick of hearing about how you did CPOE,'" Moore says.
Determining who does what, up front, can save a world of trouble later, says Indranil Ganguly, CIO of JFK Health System in Edison, N.J., who's currently embarking on an EHR replacement project .
Ganguly has learned to make sure he has a watertight implementation contract with the vendor. "Is the vendor going to just come in and help with just the first nursing unit, or will they be at your side as you bring on specialty units, like critical care or oncology?" he says. "If you don't get very specific about that, they'll come back later and say they didn't realize you needed that, and there's an extra charge."
JFK will have an internal executive committee decide strategy, but Ganguly says he'll do his best to keep them "out of the weeds." While an executive committee can't decide every little nuance of how a system is implemented, those nuances can snowball into situations that need a strong, decisive arbiter. For example, physicians may want to create order sets that standardize the time of blood draws. Those standing orders may overtax the lab's staff, since they can't be on all units at once, and disrupt their existing routine of visiting each nursing unit at a different time. The lab may demand to add people, and at that point the executive committee needs to get involved. "If the system isn't flexible enough, you have to make operational decisions," Ganguly says.
There is no such thing as too much testing, experts agree. Technology testing within the IT department will catch major problems, but even perfectly functioning hardware and software can mess up users in a thousand ways. "A lot of times what fails is not the system itself, but that the builders didn't think about process," says Kathy Kane, an implementation consultant with CTG Health Solutions, who has grappled with implementations of every major HIT system as both a provider and a consultant. For example, many providers don't plan adequately for handling legacy data: what gets brought across and when, what gets left behind, how to keep everything in sync if there's a period of overlap.
Kane recommends scheduling appointments in both the old system and the new one in the days before go-live, and doing especially rigorous planning and testing at hand-off points. "There aren't many systems that just reside within the walls of one department anymore, and you have to spend time validating anyplace that those systems intersect." ED systems can be a particular pain point, she says; if the ED is used to printing out a piece of paper to send with an admitted patient, that process may need to be converted to an electronic report in the new EHR.
Many providers skip a step that consultant Robert Steele, R.N., of the HCI Group, considers essential: the mock go-live. It comes after classroom training and before the big switch-on day. Steele and his team set up shop during lunch and have each staffer use the system, beginning to end, on a couple of fictional patients. The process tests both system build and workflows, and can expose dozens of hiccups.
For example, a hospital that's adopting a new bar-coding system for lab specimens may uncover confusion about how the bar-coded labels will be printed in cases where departments like the NICU or the ED draw their own blood. If there's only one bar-code printer and it's in the lab, samples drawn elsewhere won't get their bar codes immediately and may ultimately be mislabeled.
A new EHR also can leave an unexpected gap when patients move to a home health provider or rehab center. The paper chart that's normally reviewed by the outside caregiver disappears, but that caregiver doesn't automatically get access to the EHR. In smaller communities, the medical records department may deal with the same few case managers all the time, and it's not a huge security risk to give them their own sign-ons. A hospital in New York or Chicago, with dozens of outside caregivers passing through every day, doesn't have that luxury, and may need to let them review charts in the medical records department, or print partial charts.
"There are multiple answers for each scenario, but you have to think of them before go-live," Steele says.
The HCI Group recently released a free e-book: "EHR Go-Live: The Definitive EHR Go-Live Implementation Guide," available at http://blog.thehcigroup.com/new-ebook-the-definitive-ehr-go-live-guide.
Another tip: Don't skimp on network capacity and hardware. Carolinas HealthCare operates more than 40 hospitals, and in general has chosen to leave each hospital's basic IT systems in place, going for interoperability rather than uniformity, says CIO Craig Richardville. The organization has an ambitious plan to create a "virtual care" environment, where the providers come to the patient via computer networks, and automatically collect their information from home monitoring devices. The unprecedented demand for bandwidth and processing power has created unexpected degradations in system performance.
To combat those degradations, Richardville's goal is to maintain twice the system capacity he needs. His team has built a test environment that duplicates the live system, so it can accurately gauge how new implementation will affect performance. "Many health systems have had to break their platform up, but we've been able to maintain a single network for our patients," he says.
CHE Trinity has learned to expect added network demands in the ED particularly, says clinical director Sannes. "The number of people carrying in laptops and other unplanned devices created a bottleneck in our wireless bandwidth."
Keeping cash flow even
Many institutions dread a spike in accounts receivable days during major IT projects, but it doesn't have to be that way. Debbie Jowers, director of enterprise architecture and integration services at Texas Health Resources in Dallas, has survived four revenue cycle conversions, and has learned to ignore requests to have every detail converted from old system to new. "You don't want to do that," she says. "The systems are never the same, the cycles aren't the same, and when we tried to convert everything, the AR days went through the roof."
Instead, any bills already in the collection cycle are left on the old system for 90 days. The billing staff works through them and pushes the leftovers to outside collection. The new system starts fresh with patients who are currently in the hospital and charges that haven't been billed yet. Using this technique, Jowers avoids any spike in AR days.
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