The planning phase is perhaps the most critical element in a successful EHR implementation. Because of the complexity and criticality of this phase, a trusted and knowledgeable consultant might be able to provide invaluable guidance to your organization and your EHR project management team. Investing in time and resources up front can often mean spending less time and resources later on, hence increasing your return on investment. This module will help guide your organization through questions like: How does your practice form an EHR project management team? How does your practice determine its EHR goals? How does your practice document and track an EHR project? What is the purpose and steps involved in defining workflow and process redesign? How does your practice set a reasonable timeline for an EHR implementation? How does your practice establish a comprehensive project plan? How does your practice convert paper data into electronic health records (EHR)? And, How does your practice evaluate and hire consulting help? RESOURCES

 How does your practice form an EHR project management team?

After your practice has decided to make an investment in an EHR, you need to start planning how to engage key stakeholder groups and consider how best to form and operate a group of people who should be involved in HIT planning. The table below describes the composition of the project management team including a brief description of some of their roles and responsibilities:

EHR Project Management Team Members

Role and Responsibility

Project Manager

The project manager is the person who coordinates all the EHR project activities, and, if possible, should be dedicated full time to the EHR implementation project. He/She should also be given the appropriate authority to allocate other staffing resources as needed.

Physician and nurse

Since physicians and nurses will be the primary users of your new EHR, it is extremely important that they are represented on the project management team. All clinical staff will be expected to use the system, and therefore should be part of understanding the system and validating that it meets various functional requirements.

Representative(s) from non-clinical departments (select a person in a leadership position)

Even though an EHR is mainly a clinical system, they also support various other operations of your organization, and you need their input to make the appropriate non-clinical decisions.

EHR consultant

An EHR consultant may help navigate the many vendor choices and steps in preparedness, selection, and implementation. Sometimes a consultant can also assist in negotiating your contract

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 How does your practice determine its EHR goals?

An important step in any EHR planning is to establish specific, measurable goals which you then communicate to all your stakeholders. Each practice needs to evaluate what it wants out of an EHR and define their goals accordingly. Having specific and realistic goals play an important part in and leads to thoughtful decision in the planning, selection, and implementation phases. The purpose of these goals is not to measure your progress with the implementation (did we select a vendor, did we launch on time), but rather the goals should state systems and clinical care improvements your practice would like to make. For example do you want to:

    • Decrease the number of pharmacy phone calls regarding prescriptions?
    • Decrease the number of calls to the lab for results/follow up?
    • Increase transcription turnaround time and reduce transcription cost?
    • Decrease the time patients wait for prescription refills?
    • Increase the number of patients who receive preventative health reminders?

In working to identify all your EHR goals, list the major functions your practice performs and understand how your practice captures information about those functions. Consider how a new EHR system could support collection as well as sharing of that data. Use the table below to describe the key functional processes in your practice, how they may be impacted by an EHR, the benefits you want to achieve, as well as keeping track of your expectations and goals. Examples of other clinical functions that might be helpful to consider in planning your goals, and not included in the table below, are:

    • Alerts
      • Health maintenance/ Preventative services reminders
      • Chronic care registry
      • Call back
    • Consent management
    • Examination (Physical and verbal)
    • Referring physician information
    • Medication reconciliation/history
    • Clinical practice guidelines
    • Patient documentation at point of care and level of service
    • Provider order entry (internal office tasks, diagnostic studies, referrals, surgery admissions, prescription writing etc.)
    • Diagnostic studies results management
    • Medical devices information
    • Care communication
    • Charge capture
    • Quality measure and reporting
    • Revenue cycle management
    • Productivity
    • Accounting
    • Supplies management
    • Human resources
    • Patient follow-up
    • Prescriptions re-fills
    • Health information management and archiving
    • Release of information
    • Privacy and security

EHR Goals and Functions

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 How does your practice document and track an EHR project?

It is important to document all aspects of an EHR project, from your initial vision to post go-live. Documentation gets you accustomed to the complexity of the process that you are undertaking and ensures you do not take shortcuts or miss important steps along the way. It is beneficial to have a centralized internal web page to keep your files and documents for the project, in reach and readily accessible for all stakeholders.

Below are some suggestions on ways you can make your meetings effective and efficient as well as sample agenda and minutes, which are important elements to ensure the project run smoothly and should be posted in a timely manner to your centralized web page:

Your initial meeting of the project team should be to set clear expectations to whoever will be involved in the project. Talk about how meetings, communication, documentation etc. will be conducted for this project – establish clear ground rules. Establish roles and responsibilities for all the team members right from the start. Make sure each team member agrees to his/her roles and responsibilities before assigning them roles.

Only hold meetings to make decisions, take action, or obtain information that cannot be learned independently. Circulate emails in advance of meeting with reports or other pre-meeting information so people can come prepared and able to participate.

Think about how to facilitate meetings, draw people out, communicate effectively, etc. For example, rotate who takes minutes, who types them up, and who distributes or posts them. Rotate the people who lead the meetings. Make sure everyone’s opinion and voice is respected and heard. Set the expectation that all meetings must start on time, which shows respect for everyone’s busy schedule. Meetings should also end on time.

Always develop an agenda. Keep track of all items on the agenda and ensure each one gets accomplished. Identify follow-up activities and assign tasks to individuals and set deadlines for all tasks. The project manager should follow up with these individuals immediately after assignment to ensure they understand the task and have the tools to perform it.

Have fun and celebrate accomplishments! HIT adoption is hard work and may be among the most challenging and largest investments your practice will make. Organizations that recognize the need to “work hard and play hard” and to negotiate compromises are generally the most balanced, effective, and efficient.

Sample Agenda and Minutes

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 What is the purpose and steps involved in defining workflow and process redesign?

EHR adoption is complex and can be very disruptive to current processes. The changes made to current processes needs to be managed to ensure that the change brought about by the EHR is the right change for your practice. But, first you must start by mapping and analyzing your current processes.

Conducting a workflow analysis will help practices identify the ways to streamline, automate, and improve the efficiency of the practice’s clinical workflow. Workflow refers to the series of tasks that make up a process. For example, checking in patients at the front desk might include checking insurance, collecting co-pays, asking the patient to fill out a history, and alerting the clinical staff that the patient has arrived.

Process mapping is diagramming all of these tasks and identifying where they might intersect with another process. An analysis of these concurrent processes let you see where bottlenecks might occur and where there might be inefficient processes.

This will result in making workflow and process changes. Workflow redesign promotes process improvements needed for practice redesign by helping to reduce variation that often leads to inefficiency. Workflow and process changes should take advantage of the benefits offered by EHRs. Workflow and process changes should aid professionals, but they are not substitutes for them.

Mapping Current Workflow and Processes

The following steps should be used to map current workflow and processes:

  1. Start with identifying all the processes that will be impacted by the new EHR.
     
  2. Walk through the process once or twice asking what are the tasks, who completes the tasks, how long does each task take, where are there bottlenecks and inefficiencies, and is there duplication of the tasks anywhere else?
        • Use individuals who actually perform the process to map the current workflow -- they know it the best and by being involved they are more likely to embrace and accept the impending change.
        • Always tell people why it is being done, and how it is done. The more accurate the staff is in identifying problem areas in the current process flow the easier it will be to address them through automation. Make sure everyone will focus on mapping current processes. It is easy to start to identify opportunities for improvement now, but these will discussed later at the redesign process mappings.
  1. Validate the maps to ensure they truly reflect the current processes.
        • Talk with all staff about variations to the process, what leads staff to take short cuts or work-arounds, and what impact that has on patient care.
  1. Collect all forms and reports that are part of processes to be automated through the new EHR.
     
  2. Obtain benchmark data to define expectations for change and for use in benefits realization studies.
     

Workflow and Process Analysis and Redesign

The following steps should be used to map how workflows and processes will be performed with an EHR:

  1. Identify potential problems in current workflows and processes and determine their root cause. Study the following areas:
        • Bottlenecks
        • Sources of delay
        • Rework due to errors
        • Role ambiguity
        • Unnecessary duplications
        • Unnecessary steps
        • Long cycle time
        • Lack of adherence to standards
        • Lack of information
        • Lack of quality controls
  1. Identify quick fixes - changes that may be able to resolve problems today. Implement these and revise maps to reflect the changes 
     
  2. Identify new EHR-enables processes based on desired improvement and document them in new maps 
     
  3. Use maps reflecting new processes to create use case scenarios to identify EHR functional specifications for vendor selection, and later to build out the EHR application during implementation to achieve the desired improvements 
     
  4. Test and re-test all new workflows and processes 
     
  5. Train all staff on new workflows and processes, using the maps as guides 
     
  6. Incorporate changes from the maps into policy and procedure 
     
  7. Celebrate successful new workflow/processes

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 How does your practice set a reasonable timeline for an EHR implementation?

One question you may have as you start your EHR adoption project might be “How long does an EHR adoption project take in a clinical practice?” There are a lot of variables that needs to be considered in order to answer that question and each situation/clinical practice is different. However, some of the most important variables are:

    • How motivated is your practice to implement an EHR
    • How favorable is your practice staff to implementing an EHR
    • Do you have adequate resources to spend the time and the energy needed to focus on the implementation

Taking into consideration these variables, an implementation in a clinic may take up to two years. Below is an example of an EHR adoption in a clinic with suggested timeframes:

Step 1: Preparation (timeframe: 90 to 150 days)
The first step involves forming your project management team and becoming familiar with the terminology, features, and functions of the EHR. This step also includes evaluating current work flows and looking for opportunities to eliminate operational inefficiencies as well as getting a clear handle on your goals and objectives with respect to the EHR.

Step 2: System Selection (timeframe: 60 to 120 days)
This is where you narrow your EHR vendor selection list down to a few (approximately five) and send out RFPs to these vendors whose products best meet your clinic’s EHR needs.

Step 3: Implementation (timeframe: 45 to 180 days)
The third step is to develop a formal implementation plan. It should enumerate tasks, the parties responsible for seeing them completed, and deadlines. Updates to the plan should be made available to everyone at regular intervals. Your clinic may need to bring on temporary help and/or outsource chart conversions. Training sessions should be supplemented with simulated or "dry runs" of clinic days so physicians and staff become accustomed to using the system and can begin to identify additional workflow changes that may be needed. The implementation plan should include a "go live" date and may actually include many such dates, depending on the complexity and phases of the EHR. The dates may change depending upon the workflow adaptation and system configuration efforts.

Step 4: Post Implementation (timeframe: 6 to 12 months)
After the EHR is up and running, adjustments to practice operations will need to continue. Policies and procedures will also need to be continuously updated especially the changes related to HIPAA Privacy and Security regulations.

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 How does your practice establish a comprehensive project plan?

A comprehensive project plan serves as the critical map for your practice as you map out the preparation, system selection, implementation, and post implementation phases of the EHR project. It will serve as a constant reference point for evaluating progress and detecting potential problems. A project plan details the tasks, sequencing, responsible parties, and timeframes for the vendor and your practice’s project team to effectively implement a new EHR system.

Microsoft Project is a software program that is often used when constructing a project plan. However, if this is not available to use in your organization, you can easily construct a project plan using an Excel spreadsheet or even a word document.

Example of a project plan using Microsoft Excel


The various components of the example project plan are:

Phases
We chose to divide this example project up into four different phases. The anticipated duration of each phase is illustrated in black shaded cells that extend under the week columns.

Tasks
Tasks are the elements you need to perform, such as “Establish clear goals and objectives for the EHR.” Tasks consume time, and can range from a few minutes to months. Each task has a responsible party assigned to ensure the task gets completed. The anticipated duration of each of these tasks are illustrated in yellow shaded cells that extend under the week columns.

Responsible Parties
The responsible parties are teams or individuals you expect to complete the task(s) that are assigned to them. You should enter the team or individual’s name that is assigned to the task in this column.

Complete column
The complete column is where you indicate (yes/no) whether or not a task is complete.

Milestone
Milestone is an event that has no time, such as “Schedule implementation kick-off” in our project plan example. It is a point in time that triggers the rest of the project. We are illustrating our milestones by placing an “X” in the cell corresponding to the time in which the event should occur. It is important to keep track of milestones and make sure they occur on schedule. Delays and extra time spent on tasks will delay your project and often end up being costly as well.

For any given project, the actual phases will be specific to the application and the vendor’s implementation strategy. However, this example should give you a good idea of the level of detail, the nature of the tasks, the need to identify responsible parties, as well as the importance of time management that is needed when developing your own project plan. Once you have developed your own project plan, review and compare it with the one your vendor will supply. Coordinate the necessary changes with your vendor and finalize a project plan that work for both your practice and your EHR vendor.

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 How does your practice convert paper data into electronic health records (EHR)?

Although chart conversion is not performed until immediately prior to going live, careful planning can help in both selecting a product and making the chart conversion process go smoothly. The purpose of planning for chart conversion is to determine what content of your current paper charts will need to be converted and how to best convert it. The process of chart conversion pre-populates the new EHR with select patient information, thus making the EHR adoption easier for all your staff members.

Below are a list of questions and recommendations for you to consider:

    • What data is essential for you to have in your EHR to meet most of your patient’s needs, and which will be processed by the computer in creating lists, graphs, or clinical decision support?
       
    • What part of your patient’s paper medical charts should be saved into your new EHR (e.g., last 12 months of visit notes)? Involve your clinicians in this decision.
       
    • Are there documents in your patient’s charts you will rarely need to reference? If so, you might want to keep these archived in paper form. However, you need to determine if you have the storage space needed, and put together a plan on when to re-examine these documents to see if they are still needed (perhaps 2 to 5 years from now).
       
    • Will paper be destroyed, warehoused, or miniaturized? Are there special state law requirements? Be sure to follow your organization’s record retention schedule and destruction policy. Do not destroy any records where there may be potential litigation.
       
    • Put into place policies and procedures to ensure that hybrid records (i.e., part electronic/part paper) will not be created, to avoid repetitive work or patient safety risk.

Chart conversion generally is done by one of three methods. Often these three processes may be done in combination.

Document imaging/scanning makes paper images available electronically. Scanned documents may be accessed at any time from any location within the organization. Most clinics are now starting to pre-load key data and scan paper chart forms only for special cases. Most clinics find the expense associated with pre-loading pays bigger dividends than scanning, because it improves the learning curve for EHR and reduces productivity loss.

Abstracting/pre-loading of data requires someone to abstract key data from the paper chart and enter it into the electronic system. Such a pre-load process results in structured, or discrete, data that makes the data available for use in clinical decision support. Individuals who perform the pre-load should have mastery of medical terminology and display strong attention to detail (e.g., medical transcriptionists, coders, and nurses). Many physician offices and clinics are finding that document imaging is not the best way to perform chart conversion due to the expense of fully scanning all documents. Often the information is old and asking patients is easier than finding the right document image from the electronic folders.

Data conversion is where certain structured data that exist in a current electronic application are converted to the new application electronically. This process usually requires a special conversion program to be written.

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 How does your practice evaluate and hire consulting help?

When selecting an EHR for your practice, often using a trusted EHR consultant can help save you both time and money if you select a consultant who has experience implementing EHRs and is also a good fit for your practice.

The first step in selecting an EHR consultant is determining what you want a consultant to assist with (e.g., vendor selection, implementation, or post go-live support). This decision will drastically influence the type of consultant you want to use.

The best way to find capable and reliable EHR consultants is to ask colleagues who have had good experiences. Local colleagues are best, since they can recommend consultants who know the local labs, payers, and pharmacies with whom your EHR will interface. Always ask for references from a consultant’s previous clients.

Remember that every EHR has its limitations. Select a consultant who is aware of the challenges associated with EHR implementation and who will openly discuss those challenges and real world solutions for overcoming them. Fit is very important. You will spend considerable time and money working with this consultant, so if you do not feel comfortable around that consultant, keep looking for one who does make you feel at ease and that you will be able to work with for an extended period of time (one to two year timeframe).

Practices interested in finding a good EHR implementation and post go-live support consultant should start by asking their EHR vendor. Vendors are often aware of consultants who are familiar with their software, and that would be a good fit for your specific organization.

Below are some of the benefits of hiring an EHR consultant

Contract negotiation
A well-trained EHR consultant should be well versed in EHR contracts and be able to assist with negotiation, point out problem areas, and suggest missing details. EHR consultants can even help small clinics negotiate things like long-term pricing arrangements, concessions for time spent hosting site visits for vendor prospects, and upfront costs.

Outside perspective
A consultant can provide a perspective that is not influenced by organizational norms. Fresh eyes are often able to see problems that daily users of a system have learned to overlook.

Vendor relationships
When selecting an EHR, this could be a problem. However, once an EHR is implemented, an EHR consultant’s relationship with a vendor could be the key in obtaining needed changes or fixes to the software.

Educated configuration decisions
Most EHR systems require extensive configuration. Bad configuration decisions can have a long-lasting impact on the end users. Experienced EHR consultants know what has worked before in similar settings for a particular EHR and what hasn’t and can assist you in determining which configuration options best meet your clinical needs.

Knowledge of available technology
An EHR consultant should understand the capabilities and limitations of available technologies (fax servers, voice recognition software, microphones, biometric authentication, scanners, card readers, digital cameras, printers, tablets, desktops, wireless, shared drives, OCR, IM, etc.) and be able to advise which are suitable for your practice.

Converting paper charts
A number of options exist for handling old paper charts. Selecting the option that fits the needs of your practice is best done by someone who has experienced the transition firsthand.

Improved clinical buy-in
Consultants with a proven track record of successful EHR implementations can instill more end-user confidence. They can also share firsthand experience related to the benefits of an EHR implementation.

Targeted training
EHR vendor training is usually generic training that covers every feature of their EHR software. This training can be confusing, overwhelming, and a waste of time because no clinic uses every feature of an EHR. A good consultant can train end users on only the features likely to be used by the practice.

Please note: It is unrealistic and unlikely to expect that any EHR consultant can provide all these benefits listed above. Instead, your practice should decide which are most important for your practice, and then use those criteria when researching and vetting EHR consultant candidates.

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