David Gustafson, MHA
Most healthcare organizations are considering a change to new electronic medical record (EMR) technology. Many focus on the benefits and technical challenges but completely fail to support their people in making what can be enormous change in their daily work life. This often results in a wide range of undesirable conditions, including high turnover, low morale and even failed implementation.
Learn the successful change management strategies that have been proven to ease people through this kind of transition from one of the nation’s leading specialists in EMR change management. Written by consultant David Gustafson from Potential Plus Consulting, this report walks you through the pitfalls and the best practices to help you better understand and successfully manage your EMR implementation.
During the past few decades we’ve seen technology being used by numerous industries to improve operations and data transfer. The healthcare marketplace is no exception. For many years, health care providers and others have been made acutely aware of how outmoded the healthcare records systems are. On the one hand, a patient may have many medical records that document their care available at multiple sites (physician’s office, X-ray, Laboratory, specialist’s office, etc.) but little, if any, of that information is available to the other providers of that patient’s care. On the other hand, and especially in the inpatient setting where coordination is so critical, the patient’s written medical records are available only on the unit where the patient is physically located. If anyone wants to review the record, they have to physically go to the unit and handle the record. In fact, this dilemma creates tremendous liability issues for the providers of care because the concept of “continuity of care” is totally anathema to the concept of a patient’s primary records of clinical care being available only in one location, inaccessible to the other providers of care. For example, a patient on the intensive care unit might have a primary physician, a specialty physician, a respiratory therapist, a wound infection specialist and, of course, several nurses who are monitoring that patient’s care.
For a variety of very good reasons that are apparent to the readers of this article, the introduction of a computerized medical record makes perfect sense. However, the availability of patient records in computer format presents its own set of quandaries, centered on four principal issues:
- Accessibility/availability of records
- Security of patient records (HIPAA requirements)
- Timeliness of record entries
- Integration of records systems for multiple functions
Each of these continue to be the subject of discussion by many notable authors. Please see the references at this end of this article for informed discussions from other authors. Of the four points mentioned above, the first three are challenges for service providers at all levels of the healthcare system. Because I was fortunate to work for Kaiser Permanente, the foremost healthcare provider in Northern California, the issue of integration of patients’ records between different health entities was less problematic than it is in the general de-centralized healthcare systems available to other patients. The fact that Kaiser provides an integrated healthcare system doesn’t necessarily mean that NO integration problems exist. In fact, there were a number of data integration problems that continue to persist among Kaiser’s 300+ proprietary record systems that remain unresolved to this day. The main purpose of mentioning my personal experience with Kaiser is to clarify that working with an integrated system, like Kaiser’s, has given me a perspective that is less complex than that of other healthcare institutions that have to deal with non-integrated systems.
When I was selected to work with Victor Maiki, Director of Change Management for the Kaiser Permanente HealthConnect (KPHC) Project, I was pleasantly surprised. [KP HealthConnect is Kaiser’s name for their electronic medical record system and refers to both ambulatory and inpatient medical records.] I had been on the project as a team leader for an ambulatory implementation team for about two years and, as the ambulatory phase of the project was past the halfway point and was drawing to a close, I was excited to be selected to work on the inpatient implementation team, which had “gone live” at just one of the 21 Northern California hospitals at that time. The experiences and lessons learned in this article are drawn from a period of over three years as first Victor and myself, then later just myself, rolled out the implementation project for the remaining hospitals over a four year period.
As the Change Management Department, we were principally responsible for monitoring and ensuring that Kaiser’s physicians and staff were successful in making the transition from paper to electronic records. This was a huge adjustment for over 18,000 people working in Kaiser’s Northern Hospitals. The thought of converting from documenting all clinical information on hospitalized patients from paper to computer and making that conversion in just a matter of hours was a daunting one for many. The largest segment of the staff, and the ones most deeply impacted, were the nursing staff. Nurses sometimes document dozens of times per hour in their patients’ charts and much of the documentation is repetitive in nature. For a nurse who has been practicing excellent clinical care for what may have been twenty years or more who now has to change her entire documentation process to computerized entry, the task can seem overwhelming.
- Technology is important but people will determine the success or failure of the implementation. The finest software in the world won’t work unless people embrace it and want to use it. We consistently found that people had three key questions that had to be answered if they were to remain open to accepting the new computer system.
- Will I still have my job if I have struggles with the new system?
- When does training start?
- What kind of support will I have?
- Develop consistent, positive, authentic communications. As with any change management project, communicating why the change is happening and making a point of being positive and open about the opportunities and hardships of the transition are critical. The communication message must start from senior leadership at the local facility and must consistently be strong, clear and positive at every level of the management structure all the way down to the front-line employee’s manager.
- Develop a cadre of local champions. Even before the regional implementation team became highly visible at the facility, the most effective organizations developed local talent and groomed physicians and nurses on staff to learn the new system very well and become champions for the change. Because of the robust KP implementation schedule, the Regional Implementation Team would start showing up at individual facilities about three months before the “Go-live” date and then, after some phasing out, be completely gone about four weeks after implementation. This didn’t mean the implementation process was complete; it just meant that local physicians and staff were left to ensure that the new technology was in the hands of the local facility, a process that continued for months after the regional team left the premises.
- Provide ample support before, during, and after implementation. “You can never have too much support!” That is, you must plan to maximize the support that is needed and then cut back accordingly only if you find the support provided is not being utilized. Kaiser’s model was to bring a broad contingent of front-line support to the hospitals about four weeks before the cutover date and then gradually cut that “hand-holding” support level back progressively over about four weeks after cutover.
- Respect the vulnerability of intelligent learners. No one wants to look foolish or incompetent. We dealt with thousands, of highly competent clinical practitioners, all excellent clinicians. However, when it came time to learn how to use the computer efficiently to document the high quality of care they provided, it was apparent that NO ONE wanted to show their lack of competence in this area publicly. The change management team frequently stressed that, although the new users were highly competent clinicians, they were just beginners in the area of electronic clinical documentation. Individuals had to be coached in a variety of styles befitting the specific needs of each individual. Offering an opportunity to learn in a safe, low-risk environment was one key to Kaiser’s implementation success story.
- Conduct the training sessions as close to implementation as possible. Everyone is familiar with the idiom, “If you don’t use it, you lose it.” This is especially pertinent to learning computer skills. People were given training as close to the implementation date as possible, usually no more than six weeks prior and, in some cases, one day prior to cutover. However, if they didn’t take advantage of opportunities to actually use the system fairly regularly between the time they received formal classroom training and when they had to start using the system to document care on live patients, their chances for success were greatly diminished.
- –Create successes early and build on them. Success breeds success. Kaiser had an aggressive implementation schedule, rolling out the new hardware and software across 20 facilities in less than four years (with a one year lag between the first and third facilities.) As success was achieved at one facility after another, people gained more confidence as time went on that (a) the regional team really DID know what they were doing and (2) if (xxxx) facility can succeed at KPHC implementation, then certainly WE can. Part of the success was the “cross-pollination” effect of scores of people who had earlier implementation dates helping with the cutover process at later facilities and those whose implementation dates that were later attending several days to a week of immersion in the new system at newly-converted hospitals. In fact, later in the sequence, a healthy bit of competition developed between facilities to see which one could cut over from paper to electronic medical records in the shortest possible time. Of course, all facilities are not created equal and some had more patient records to convert than others. Nevertheless, it was encouraging to see a healthy competitive spirit motivate the senior leaders and managers at each facility.
As you can see, the Kaiser model was one that required a huge amount of technical and human resources but their processes led to an overwhelming success story. The lessons learned from the experience of working with the Kaiser team was a tremendous privilege and I trust that the reader has learned several lessons that are transferable to their own EMR implementation process.