We have all heard the question, "Are we there yet?" while on a long car ride or journey. Behind the message is someone who is becoming a bit frustrated. In the context of an electronic health record rollout, senior leadership often hears this from physicians and other users. Setting the expectation that there are additional activities after go-live is important. Go-live brings a basic system online. Optimization turns on the bells and whistles that providers and users enjoy.
During an EHR rollout, everything is planned around the go-live date. The date is the focus; it drives deadlines, planning, testing and training. One large healthcare organization went so far as to mark the go-live date with countdown clocks placed strategically throughout the facility. Go-live dates translate to the users an end point; the switch is flipped, the workflows are implemented and, in a few short weeks, the EHR support staff in bright-colored shirts will be transitioning on to their next go-live.
However, the reality is that go-live is really just the beginning of the organization's EHR journey — if it wants to get its return on investment and improve satisfaction. Numerous reports have shown that the increasing use of EHRs has been accompanied by equally enormous challenges in EHR usability. If your organization is like most, these usability challenges may lead to low ROI and decreased productivity, provider and staff discontent and inefficiency and decreased patient satisfaction. Your clinical leadership is going to look to IT and the EMR team to fix these issues.
Therefore, users should know that there will be an optimization phase after the system is live and stabilized. This is good expectation management. Success lies in having the steps in place ahead of time to assure that optimization is planned early on with resources, budget, governance and communication plans.
The five steps outlined below will provide your organization with a template to successfully begin optimization of your EHR. It is never too early to begin the planning and resourcing of this work, even though the actual work should be done when the system is stabilized and users are somewhat familiar with the basics.
1. Look for signs that the end users are ready for optimization. Following an EHR implementation, users are often in survival mode. They are caring for the patient while trying to use a new system to document and coordinate this care. Soon, however, they begin to get used to the new EHR. It is at this point that the EHR team will begin to see a spike in optimization requests for the system. The user is able to articulate their needs and the value of the optimization requested. Look for the increase in these requests.
Other signs that users are ready for optimization are the discussions and requests in department and leadership meetings. Meeting agenda items often address new safety or government mandates. Users will soon realize the power of the EHR in either reporting data or driving users toward best practices through decision-support tools. Take this opportunity to embed your analyst or clinical support staff within service line meetings or councils. The presence of an expert from your EHR team will help navigate the conversation and capture the requests. It is also a great opportunity to provide a "reality check" of the system. The users may want something the system cannot perform. The request may be able to be fulfilled in an alternative manner, however. This member will work with the group to identify the issues and find resolutions.
2. Realign your resources to support both optimization and production support. During go-live, it is "all hands on deck." The concept of thinking past the go-live is challenging. Optimization planning ideally starts prior to the go live. The plan should include moving the implementation into support and optimization. Part of this plan is to assess your team and identify the analysts who will best support the project after stabilization and into optimization. This is the time in the process that the organization will usually shift from external resources to an in-house team that will manage production support and optimization efforts.
Leadership resources are also critical. As operational leadership sets up the optimization team, setting clear expectations and defining scope are key. The leaders will define roles, responsibilities, communication and documentation tools that will move the optimization effort forward. The optimization team must work closely with the production support team to assure that changes and new build are aligned with the current build. Be sure there is representation from your optimization team in change control and team meetings.
3. Establish a strong governance and project management structure. A strong governance structure for the optimization program will ensure that leadership involvement will be used effectively. This step is often forgotten when beginning an optimization initiative, but in many ways it is the most important step of all. A good governance structure is the foundation for your clinical optimization project. For example, if part of your mission is to increase clinical quality, the governance committee should include leadership from quality management in addition to physician and IT leaders. A solid governance structure will help your optimization work by ensuring that optimization projects are aligned with your organization's overall mission, providing a fair and balanced reviewer/validator for your tough decisions, such as saying "no" to user requests. Having a solid governance structure in place will make establishing priorities easier, help to determine whether the resources and timelines are compatible with other ongoing EHR and IT initiatives and ensure that you and your optimization team are receiving regular feedback from physicians, senior leadership and other key stakeholders. This feedback is especially important, since it is all too easy for optimization projects to get bogged down in details (fix this item, add that record) and stray from the big picture for improving the EHR experience. A good governance structure will ensure that the optimization team gets feedback and direction on the overall EHR environment, including its effects on the organization, the rest of the IT departments and on the end-user community.
Hand-in-hand with a strong governance structure is a strong project manager. The optimization project manager acts as the day-to-day agent of the governing body and therefore needs to be carefully chosen. In fact, this is probably the most important personnel decision you will make for your optimization efforts. The precise characteristics of a successful project manager will depend on the unique needs of your optimization project. However, most successful project managers are good at managing fluid, complex projects, have the ability to engage the project team and are good at explaining decisions and setting clear expectations.
4. Set up a change control process and follow it. A successful strategy for optimization includes an established change control process followed by all teams. It is not uncommon to have several teams co-existing within your EHR team, such as meaningful use, ICD-10, operational support and optimization and upgrades. A change control process provides structure, guidance, rules and overall consistency. Take caution to make sure your change control team is representative but not too large. Solid documentation and communication also enables a high functioning team.
Once membership is established, the team will create the roadmap for rules and structure around change control. Start by defining change control. The team can be charged with setting up the tool to submit change and optimization requests. When designing this tool, keep in mind the people who will be using it. Organizations can opt to have end users, managers, help desk or EHR staff complete the request. The formatting and wording should be understood by all with clear definitions.
Tools such as SharePoint will provide a way to track change control requests and provide priorities, accountability and testing plans for them. The tools used to document, track and assign new build and workflow changes are often underappreciated. Invest in resources that can develop templates to capture these functions. It will save you both time and frustration as more teams utilize the tools. Take the time to identify an owner of your tool with deep knowledge and understanding of its functionality. It is frustrating to have the application lose data or "go down." The owner of the tracking tool can also assist with assigning access, template development and report generation for senior leadership that will, at a high level, outline the volume of work coming in and the status of the new build and change control requests.
5. Communicate, communicate, communicate. Communication can make or break even the simplest projects. Marketing and public relations are valuable members of a successful go live. They assure that messages are clear, consistent and follow a branding style that users can easily identify. Continue to use marketing and PR to help set up communication mechanisms when sending out updates and changes to the system. It is important to capture users' attention. Continue the use of branding and style with all communication; colors and images used in these messages will quickly identify them as EHR-related.
Continuity in timing and delivery of changes and updates to your EHR system will provide huge satisfaction to users. Work with your optimization team and change control to release non-critical changes on the same day of each week. Communication about these changes should be just as predictable. For example, communication regarding upcoming changes can be communicated on the third Monday of each month and via email, staff meetings or on bulletin boards. On the third Wednesday of each month, the changes will be put into production. Users will come to expect the system to have "tweaks" or changes on that set date.
Communicating early and using consistent communication tools helps the optimization team succeed. The methods of communication must meet the needs of your audience and have a multi-pronged approach. Emails are often the easiest form of communication. However, it is also the easiest way for users to ignore and delete the communication. Consider reaching the users via a dedicated communication board within their departments or units. Involve the staff to keep the board updated and hold staff members accountable for reviewing the posted information. Another successful tool is a newsletter that can be sent electronically as well as distributed throughout the organization. Ideally, this is a one-to-two-page publication that incorporates the branding and design of your EHR communication. Users appreciate quick bullets and the "what's in it for me?" approach. When outlining the changes, be sure your team includes the reason for the change. Users do not like change, and unless the benefits are explained to them, they don't understand why their screens, navigators, tools need to have changed within the EHR. Communicating benefits helps improve adoption rates.
Finally, communicate the positive effects that the changes have had on patient care and for the organization. Some gains will be very small and impact a small group of users. Others will have a significant impact on safety, revenue, patient satisfaction and end user satisfaction. Be sure the optimization team has included the ability to report on improvements after the changes have been made. Senior leadership will want to visualize the gains and see a cost-benefit analysis of the optimization team.
Summary
Implementing an EHR has been compared to a marathon or journey, which both have a predictable end. Merriam Webster defines the word "end" as, "the furthermost imaginable place or point." By this definition, the EHR will never have an end, or a point of finality. The planning, preparation and implementation are only the start to the journey, albeit a large one. The optimization team will continue to adjust, modify update and enhance this powerful tool.
Beginning an optimization program is a challenging task, but it can be made less challenging by involving the entire organization, having clarity of purpose and focus, utilizing the right staff and having a strong governance structure. It is well worth the effort when users start to use the tools and find that they can get their work done more efficiently. An effective clinical optimization program will transform your organization, leading to streamlined access to data, increased clinician collaboration, better processes and improved outcomes.
Irene Bonin has more than 25 years of nursing and technology experience, focused on systems management and clinical transformation in multidiscipline clinical setting. As a consultant for Hayes Management Consulting, she serves in many roles, including as project manager for EHR implementations and optimization planning.