Healthcare IT implementation activities are typically grouped into two timeframes divided by the ‘switch’: the 1) Pre-implementation Phase and 2) Implementation Phase
During the Pre-implementation Phase, you:
- Establish a governance process and a project plan
- Analyze and Redesign workflows
- Provide education and training
During the Implementation Phase, you:
- Configure the system to meet your requirements
- Establish a change-management process
- Load existing patient data
- Account for the time your staff needs to make the switch
- Provide support for the new system
- Lead and Encourage Staff
NOTE Common Practice: Vendors will have resources to guide implementation and change management. Documentation and guides are often free, while services such as project managers and trainers are also available for a fee.
Leadership for Change Management
Getting people to change is hard. A number of change management frameworks have been used over the years, but none has endured the test of time as well as John Kotter’s principles for change management.
Th following is a summary of steps and principles adapted from Kotter International and the Office of the National Coordinator for Health IT Change Management Playbook
Create a Climate for Change
- Create a vision for the future state
- How awesome will it be for our staff and patients after the change?
- Build a guiding coalition
- Identify the natural leaders
- build correct teams for the new state
- Establish a sense of urgency
- Do we all know what is wrong with current state?
- Do we know what is better about the future state?
- This is why we need change now
Engage and Enable the Organization
- Empower staff to take action towards future state
- Ensure authority chain is appropriate
- Keep communicating the future state vision
- Vendor demonstrations
- Q/A at meetings
- Site visits
- Plan for and create short term wins along the way
- Recognize change and achievement levels
- Promote and disseminate good ideas
Implement and Sustain the Changes
- Continue to focus on problem areas
- Promote solutions
- Update system based on feedback
- Continue to help change individual behaviors
- Celebrate Successes
- Prepare to train and Retrain
The Implementation Team
Typically Implementation teams include many of the same roles on the selection committee, with the frequent addition of vendor support. The team will include physicians, nurses, receptionists, medical assistants, compliance office staff , administrative staff, IT, Security, and Compliance staff. Clinical members play dual roles by teaching EHR skills to colleagues and also bringing clinical challenges back to the implementation team.
Identify Champions. Decision-makers should identify a champion and an implementation team to begin creating the project and implementation plan. Even in a small practice, a physician or nurse champion can be instrumental in getting the other providers in the practice to use health IT to facilitate practice transformation, and to develop relationships between providers and new implementation team members.
Establish (and disseminate) realistic expectations. Leadership should prepare to manage expectations and fears. Make sure goals are realistic, measurable, and achievable. Developing a realistic timeline is imperative because staff will need protected time to learn and adapt to the new workflows.
Software Configuration and Hardware
IT, Compliance and others will work with users to configure the software to the new workflows and the unique needs of the organization. Interfaces with other systems are established through the network. Hardware and clinic space is the next consideration. Will there be fixed terminals in every room? Is there the space and networking to do so? Establish the specific hardware needs and make the purchases and changes.
Changing a room’s layout is sometimes a major undertaking, but may be necessary. If the provider must look over their shoulder to see the patient while using the computer(e.g. facing away from the patient), patient communication and engagement suffer. If computers are fixed, ensure they can face in the direction of the patient exam chair or bed. If you use mobile devices or laptops, ensure a desk surface that achieves the same communication dynamic.
Migrate (some) of the old data to the new system
Determine how you will migrate data from the former system to the new system (if applicable). This can be a significantly manual and time intensive process. Keep in mind that not all records need to be migrated. Perhaps there are date constraints or patient factors that do not need to be migrated.
Workflow Redesign and Optimization
The introduction of a new system necessary changes the workflow. It is up to you to ensure that this change is for the better, not for the worse. Problems resulting from inefficient workflows or insufficient support staff will be exacerbated during the implementation of an EHR.
Document each clinical administrative and patient process that potentially touches the new system. Review the workflows and make changes to ensure the process is necessary, is done by the right person, and is done in the most efficient manner.
Decide on how you will make the switch
Depending on factors such as workflows, technical dependencies, and implementation resources, you may decide to switch all users over to the new system at the same time. This is often called the “big bang” approach. This method has the advantage of minimizing the time and resources spent during implementation. It can also be highly disruptive and small glitches can become major problems.
Another approach is to implement your changes incrementally. For example you could turning on certain features of the new software first, and others later. Another incremental approach is to implement the change in certain sites, departments, or service areas. This step-by-step approach allows learning and tweaking the process along the way.
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Develop Your Downtime Procedures
You know the workflows, you know the technology. Before you can go live you need to establish the activities that you take when the new system goes down.
Staff need clear instructions about workflows when the EHR is unavailable. Key components of downtime procedures include
- How the downtime will be communicated to staff and patients
- How the patient care flow will continue
- Where downtime supplies are available
- How care/documentation made during the downtime gets into the system when it is back up
You training plan may be the single most influential component of the implementation. If you are implementing a complex technology, -or even a simple technology that requires complex workflow changes, many hours of in-depth training may be required. Training can also be very expensive: either in contracted fees from vendor trainers, or in zero-productivity compensation for your staff.
Training must be carefully planned, because 1) it is especially difficult for users to learn and retain information about a system that they do not yet have access to and use; However 2) it may be impossible to do all of the necessary training in the short period of time between system installation and go live.
Workforce training typically consists of three different modalities, each with unique costs and effectiveness.
Computer-based modules – These are asynchronous in that they can be completed in the staff’s own time and location. Good computer based training is interactive, and builds skills using simulation methods. Computer based training is not the most effective, but it is extremely cost-effective.
Classroom training – Classroom training is best done using a computer lab where learners can get their hands on the technology , -or a simulated version of it. Classroom training is somewhat interactive, and learners can ask questions relevant to their jobs. Classroom training is considered effective, but is somewhat inefficient for the large blocks of tie required. The operational impact and salary costs of having a room full of providers for 4 hours or more can be prohibitive.
At-the-elbow training – At the elbow training happens when a trainer is embedded with the providers in the clinical environment, while they are doing their work. At-the-elbow training is extremely effective and tailored to the providers specific role. However, it requires a specialized trainer to cover only a few learners, and will (slightly) impact operations during training,
Effective training plans may incorporate each of these modalities at different times, for different purposes. For example, users may be required to complete computer based training before they are allowed to be onboarded to the new system and receive at-the-elbow training.
It is also critical to recognize that although there is a surge of training prior to implementation, training is an ongoing need. Ideally, newly hired staff should receive the same training as their colleagues.
New systems will need lots of support. Some if this with be routine (such as password recovery) some will be technical change requests (such as a new documentation template), and some will remedial training.
Identify the platform and process for submitting and tracking support. Encourage users who are constantly interacting with the system to actively engage in improving the system.
User Training (above) is a good time to disseminate support procedures, and contact information for support.