EHR Implementation Update at 6 months

Surprisingly, it has already been 6 months since an enterprise EHR was implemented at the hospital where I work. Things should be going smoothly by now, right? I truly wish I could say that were the case. It may be an understatement to say that the EHR project has hit a few speed bumps. I hear that just a few weeks ago the medical executive committee considered a motion to turn off the EHR for 6 months while it is re-engineered to meet the demands of local practice and function in a more user friendly fashion. That must have been a really scary moment for administrators present at the meeting. I never imagined that a recapitulation of what happened at Cedars Sinai years ago would happen in Yuma. Instead of turning the system off, the decision was made to hire more consultants and IT staff to speed the "optimization" of the system. But I assert that the response of medical staff members was totally predictable.

Optimization is the process whereby the EHR is modified after go-live to correct unanticipated user issues. Above, I mentioned that user outcry was predictable. What did I mean? Adoption of an EHR goes through a well-known life cycle that has been validated by years of experience. First, the institution determines its EHR requirements and (often) produces a RFP (request for proposal) to be submitted to a battery of EHR vendors. Then a multidisciplinary committee sifts through the responses, selects a small group of finalists, makes site visits to hospitals where vendor products have been implemented, performs other due diligence activities and makes a final vendor selection. The next step is contracting for the software license and, often, vendor implementation support. Here, the hospital should take legally binding steps to protect its multimillion dollar investment. Once an agreeable contract is reached, the next steps are to refine local user requirements, perform work-flow analysis, set up governance structures to help manage the EHR, and begin implementation of change management strategies. Then the real fun begins.

Design and build of the software is carried out by local and vendor-provided IT staff based on data collected in previous steps. Testing of the software build in a simulated working environment is essential to verify interface function, safety of the build, stability and performance of IT infrastructure, and generally to make sure that everything works as designed. Everyone who will use the EHR must receive general and specialized training before go-live. Go-live is always a high stress time but really should go smoothly if all the preceding steps were done properly. Finally, optimization is really just part of the maintenance that all IT systems require after they are introduced. So where did the processes at my hospital go wrong?

First, I believe that the selection process was as good as it could have been. The selection that was made was the best that was available at the time. I think that many of those involved in the selection process now feel that we did not get the system or design support that we expected, however. I wasn't privy to the specifications and protections for the hospital built into the contract. Certainly, the investment required in post-implementation support is much greater than the administration expected. I hope the hospital was protected by an appropriate service level agreement.

I am disappointed that more user input specific to our local routines and workflow patterns was not incorporated by the design team. My impression has been that the design team did not do their homework. Governance structure for the EHR is still evolving. Even now, it is not designed to efficiently manage user feedback. The CMIO was almost the last IT staff member hired, a year after other major hires. There was little time to build a sense of team membership/ownership. Everything I have ever read has emphasized the importance of physician involvement from the earliest stages of EHR implementation. I think many of the current problems could have been mitigated had a qualified CMIO participated from the start. I made this point to medical staff leaders and administration members during the selection process; the consequences were predictable; and outcome could have been avoided. Communications have been poorly managed. It is hard to know if or when a help desk ticket has been acted upon and what the outcome is. There is no system of publishing institution wide lessons learned with the EHR. A few notes have been posted in physician's lounges and in mini-pamphlets of "tips and tricks." I would have liked to see ticket request information posted on the private intranet of the hospital. I would also have liked to have lessons learned posted to the intranet along with an index to help find information of concern. Finally, I cannot determine if we selected an unsatisfactory system. It does seem to have many inherent deficiencies but some of these may be design and build related. The next few months of EHR IT department work will see optimization steps that will seriously revisit the previous design and build activity, incorporating our nascent governance input. Hopefully, the future EHR will more closely fulfill the needs for functionality and usability our medical staff members demand.