Navigating EHR implementations: Important considerations for title X clinics to ensure success

Read this if your organization is considering replacing or implementing a new EHR system. 

Have you ever been on a vacation with a group of friends or relatives, whether it was a camp outing at the nearest lake, a trip to an amusement park, or a visit to another country? There's one thing that can make or break a trip: communication. If you had good sound communication with your travel companions, it probably enhanced the enjoyment of the vacation. Nonexistent, poor communication more than likely contributed to an experience you won't want to repeat. The same dynamic is present in any workplace project involving other humans.  

According to research by Salesforce, which included employees, corporate executives, and educators, 86% felt that ineffective communication was the underlying reason for workplace failure. A study performed by the Economist Intelligence Unit identified that poor communication results in 25% of missed goals and 44% of failure to complete projects. By contrast a poll by Expert Market showed that when employees are offered better communication, productivity can increase by up to 30%.  

If your organization is in the process of a large-scale project, such as replacing or implementing an electronic health record (EHR) system in the near future, success will depend on having a sound communication plan in effect before, during, and after the implementation. Fortunately, effective communication is not a difficult task to achieve. Based on our experience helping organizations implement EHR systems nationwide, our team has developed five simple communication steps for successful implementations. 

 1. Reach the right audience 

Determine who will be affected by an EHR system. Remember, it is not just providers and caregivers. Make certain that all affected staff (e.g., IT, schedulers, administrative) and providers are discovered, and determine how the daily workflow will be changed.  

2. Develop a thoughtful communication plan

A communication plan is essentially a well-thought-out guidebook for the implementation team to follow, to spread the message of change. A proper communication plan sets forth the process of updating and educating on the coming changes, requests for needs, reporting of issues, training, and delivering the right messages to the masses that change is happening. (e.g., A provider would not need to know the billing and accounts receivable data, nor would a scheduler need to know the nursing data). 

3. Have a dedicated resource for communication

It is essential to know who will be communicating the change and how that communication should be spread throughout your organization. An organization may have a dedicated change manager who orchestrates the progression of all communications, or this task could be dedicated to a group with shared duties. Regardless, the task remains the same: effectively communicate the changes coming.  

4. Frequently re-evaluate and restructure the communications 

Not all communications work the same. Know your staff and their preferences for receiving their communications. Providers may need a messaging system of notification, nurses may prefer an email, but finance may need a memo. It is also important to re-evaluate frequently how well the communications are getting to the target audience. What may have worked before may not be working now, and the organization needs to consistently re-invent their communications to make sure the message of change is being heard and understood.  

5. Hold periodic implementation discussions 

The dedicated change manager(s) should be given an opportunity to briefly discuss changes coming with members of the organization who may be impacted by the change. This may mean one-on-one discussions, group meetings, or during an operations or full staff meeting. A two-way approach to communication will help to disseminate important information and ensure transparency by inviting feedback and questions.  

BerryDunn’s team of consultants is happy to assist you with creating a Request for Proposal, selecting the right EHR vendor for your organization, and developing communication, change management, and project management for system implementation projects. Learn more about our team and services.  

“Tell me and I forget. Teach me and I remember. Involve me and I learn.” — Benjamin Franklin

Investing in your staff is key to any successful organization. Having the wherewithal to be able to train a group of people, some willing and some unwilling, can be a daunting task. Yet, no matter how difficult to manage or how time-involving training is, it is an essential part of both a successful EHR go-live and maintenance of a system. No matter how technologically advanced the new EHR system may be, if an organization slacks on the training, it will never see the full return on investment of the cost of the system.

From years of implementation experience, I have compiled the five best practice methods to enable an organization to reach its maximal return on investment and user satisfaction with an EHR system.

EHR superuser training

A superuser doesn’t need to be the most technically savvy user, but they need to be able to be teachable and to transfer that learned knowledge to the other staff. These users should be the first to experience a new system. Oftentimes, some of these staff members would have been involved in the selection process. They are the organization’s first-line users and defenders of the new EHR functionality, and the ones that others turn to when they need help. Therefore, they are called super. For best results, there should be, at minimum, one superuser per specialty per every 15 users. At the time of go-live, these superusers need to be relieved of all their routine duties and focus on assisting the staff with the EHR adoption during the go-live dates.

EHR User Acceptance Testing (UAT)

It may say testing, but this is also a training method, and it should involve those already trained as superusers. UAT is time utilized as a field training exercise for your newly trained and specialty experienced superusers to test the system for proper process workflow in all fields of expertise. A testing script should be utilized for each process workflow and there should be room on that script for comments from the testers on improvements that need to be made prior to staff training. Each moment the superusers work on the testing scripts is a training exercise in navigating the system and making them comfortable with teaching their peers at the next venture.

EHR End User Training (EUT): The see, touch, and repeat approach

Training can be performed in many forms. As an organization, a decision on which format of training works best must be decided upon and then kept consistent. Methods of training could be in person, virtual, or online. The key to successful training, no matter which plan an organization chooses, is to involve the "see, touch, and repeat" approach to learning. Trainees should see the system in action, touch the keyboards or tablets and follow along with the instructor or through a written scenario, and repeat the processes multiple times at their own leisure in a testing environment. Implementing this method allows all generations of users in the organization to be properly trained on the new EHR.

In-person classes should be:

• Separated by specialty or process
• Involve manageable group sizes (one user per computer)
• Include a brief overview of the EHR
• Include a demonstration of the process workflow in action
• Be followed by the user repeating the process on their own device

If there are more than two hours of content to train on, the recommendation is to divide the training into smaller durations to maximize the effects of learning.

Virtual classes involve an instructor performing the same steps as in-person training, but the end user attends from their office or a designated learning area. These can be pre-recorded and the EUT can occur during the optimal time for the user to have complete devotion to the training. In these instances, logins to the testing/training site need to be given out in a separate communication, and these logins should be single-user available, as to avoid complications from locked accounts if many end users are training at the same time. A trainer needs to have availability for questions if this process is utilized.

Online classes involve pre-recorded demonstrations that are included with process workflow scenarios. In these, the end user goes to a training site and watches sections of demonstrations one at a time. At the end of each section, the user may rewatch the online demonstration as many times as they need to, but there must be a self-paced scenario that the user follows along to perform the touch and repeat portion of the learning. Additionally, there needs to be contact information for a trainer should there be issues or questions. Many organizations utilizing this method of training allow the end user access to these training videos for refreshers once the EHR implementation has occurred.

EHR Just In Time (JIT) and At the Elbow (ATE) training

The JIT/ATE training is essential during and post go-live. Once an organization implements the EHR, there is always going to be someone who did not complete the training. That is where the superusers become involved and train these individuals in their time of need. These short, microburst, JIT trainings may involve a superuser hovering nearby the new user as they navigate through a documentation for the very first time. ATE training involves a superuser reaching out to a user who has had training but may have forgotten steps involved to complete the documentation. These are the times that those superusers show how super they are.

Post implementation of the EHR, as the superusers resume their normal duties, there will still be a need for JIT/ATE training, and their expertise will be sought out after by their peers, further assisting in a successful adoption of an EHR. In addition to the superusers, if available, a dedicated informatics employee should be making frequent rounding, looking out for those who may be struggling with the EHR documentation processes and workflows, and performing JIT/ATE training at these discovered instances.

EHR training refreshers and audits

“There are no shortcuts to any place worth going.” – Beverly Sills

This final stage of training is continuous. Once you have an EHR, there will always be a need for training. No matter how successful your training may have been, habits and shortcuts to documenting in an EHR are bound to occur, and then spread throughout the organization. For the most part, these shortcuts result in mis-documentation; audits must be performed to determine how detrimental to proper documentation they are. Once the issues have been identified, the organization must determine how to correct the issue. Sometimes this involves going directly to the end user whose documentation is at subpar levels and performing JIT/ATE training. If it is widespread, a refresher course for all end users may be required to correct the issues. Sometimes a communication of corrective action may work in substitution for JIT/ATE training.

“Don’t decrease the goal. Increase the effort.” — Tom Coleman

Regardless of the effort, all end users should have a contact to reach out to for assistance post EHR go-live and the ability to access a training site as needed. New hire training sessions should continue to be optimizable on documentation.

BerryDunn’s team of consultants is happy to assist you with creating a Request for Proposal, selecting the right EHR vendor for your organization, developing communication, change management, training plans, and project management for the system implementation.

Read this if you are considering a system implementation for Electronic Health Records (EHR) or other systems.

EHR go-lives are often years in the making, from the initial process of vendor selection to system implementation and finally launching the system. Achieving go-live is a significant accomplishment and an essential milestone on the path to success for your healthcare system.

Most successful go-lives have a detailed wave master, project plan, and cutover plan covering everything from who will offer to be “at-the-elbow” support for launch, to parking lot procedures for vendors, to food plans to keep your team nourished. An important area that can sometimes be overlooked during go-live preparations is the front of the house, specifically the patient access area (e.g., registration).

Anyone who has visited a busy restaurant or watched competitive cooking shows such as Top Chef will understand the importance of a well-managed front of the house. No matter how amazing the food is, a long wait, poor customer service, or disorganization can ruin the entire dining experience. Similar to a kitchen, high-quality radiology, laboratory, or surgical departments can be thrown into chaos by inadequate patient access throughput at go-live.

During various go-lives, we have seen 90-minute patient wait times in the patient access area, causing angry patients and downstream problems with clinical care and frustrated departments. This image is not what you want your patients and community to picture when thinking about your new multi-million-dollar EHR system. You spent months communicating that the new system was coming, letting patients know what to expect, and promoting the benefits. Don’t let the first impression they have be one of frustration and problems.

Considerations for EHR system go-live success

To help you create an effective and smooth-running front of house during go-live, here are some items to consider:

Leader at the front
Much like a good front of house manager can make the difference between a successful vs. failing restaurant, assigning a strong leader to serve in a similar role during go-live can make a big difference. Asking someone from your leadership team to park themselves in the patient waiting area to monitor for bottlenecks, resolve problems, exude excellent customer service, answer questions, and perhaps even push around a coffee cart, can be helpful. During go-live, your patient access staff may be fully occupied with their tasks and may not have the capacity to notice any issues arising or the power to gather the necessary resources for resolving problems, so adding a leader solely dedicated to monitoring the front of house can be invaluable.

Training and practice
Operational efficiency is the name of the game at the registration desk. A new EHR has the potential to disrupt the workflows that the staff once had with the old system. The old system may not have been any good, but your registration team knew it inside and out. They knew the buttons and terms, and they knew how to fix and work around its issues. That all gets changed with the new EHR. Registration staff can benefit greatly from education, hands-on training, and access to resources such as standard operating procedures and quick references. Additionally, allowing for extra practice time can help ensure a successful go-live.

Over staff
Even in the face of staffing challenges, consider overstaffing for the first week of go-live. Calling in a per diem or part-time patient access person to increase capacity will compensate for any slowness while your staff put their EHR practice into play.

Super-user at the elbow
Having a strong super-user at the patient access teams’ elbow can be immensely helpful. That person can float amongst the team, answer questions, assist them through the new workflows, and communicate build issues to the command center. The super user helps the team feel supported and confident and better able to provide the best patient customer service.

Pre-registration calls
With all the activities leading up to the go-live for the new system, it can be easy to lose sight of your daily operations. If pre-registration calls are a common practice for your organization, you are normally multiple days ahead of the date of the visit. If your implementation has caused you to fall behind, it will only compound the problem during go-live. Maintaining or even exceeding your typical operations before going live will help create a smooth transition.

Laminated cards
During go-live, you may need to ask patients to answer questions, scan their insurance cards, and review documentation. Established and regular patients of your health system may wonder why you're asking for this information again. When patients or family members are not ready for the new registration process, this slows down the whole process. Having laminated cards explaining that a new EHR has gone live, the documents the patient should have ready, and the types of questions you will need to cover will help patients be more prepared and understand what to expect when they arrive at your patient access desk.

No maintenance window
This may sound silly but let your maintenance team know the go-live date and that no work should be done that limits the number of patient access desks available to staff. A smooth process is all about maximizing throughput. If planned maintenance reduces the number of teammates who can see patients, it will create an operational bottleneck on an already challenging week.

Customer appreciation set up
Inevitably there will be some patient or family frustration no matter how well you plan and execute your plan. Having a proactive customer appreciation set up in advance (such as a free coffee) and reactive customer recovery kits (such as gas cards, free lunch cards, etc.) on the ready will help your team manage through the new process and assist in creating a positive customer experience.

Much like the front of the house in a restaurant, the registration area is where patients gather, first impressions are made, and frustrations can build, all before they get to the purpose of why they visited you to begin with: receiving care. Focusing on readiness, providing leadership, communicating clearly, and optimizing the go-live process will help you increase the likelihood of success.

Read this if you are in healthcare information technology.

Professionals that work in healthcare information technology understand that a good superuser is one of the most important parts of implementing a new system or process. However, for many departmental leaders, especially those in smaller organizations, finding superusers can be difficult. Leaders feel they have no other choice but to volunteer their team members that have worked in the department the longest, are good at using the current system, or have schedules that work for project meetings and timelines.

Over many years of implementing electronic health records in all manner and size of healthcare organizations, I have found that, too often, selecting superusers solely based on these criteria leads to superuser disengagement over time—and even resentment. The resentment typically stems from “voluntold” superusers experiencing unexpected levels of intellectual and emotional effort paired with rapidly progressing project timelines, all in addition to their normal work schedules.

The good news? The risk of disengagement and resentment significantly decreases when superusers opt into the opportunity with the right expectations for what success entails.    

Defining and understanding the superuser role

To reframe the superuser role as an opportunity and not a “voluntold” assignment, it is important to understand a superuser’s day-to-day responsibilities. While these responsibilities are central to a superuser’s role, some of them are overlooked or taken for granted by project leadership when looking for help in the superuser role. What are superusers?

• Superusers are change agents
  Superusers will utilize their departmental knowledge and advanced training to guide end-users on how to use the new system or process while focusing on the benefits. They do this by reinforcing training and organizational policies, while highlighting the improvements of the new system or process.
• Superusers are trained experts
  Superusers typically receive early exposure to, and training in, the new system by participating in system design meetings and process testing. When superusers are engaged early in the project, they gain a deeper understanding of the system and can more adequately support their departmental objectives, end-user needs, and organizational goals.
• Superusers are leaders
  Superusers serve as a bridge between end-users and project leadership and are often being asked to attend leadership meetings to help design and implement resolutions to end-user and organizational issues.
• Superusers are effective communicators
  When changes to a system or process happen, superusers are responsible for understanding the impact of those changes on their departmental processes, communicating the changes to end-users, and providing end-user support related to the changes. Superusers also communicate successes and struggles of the changes to project leadership.
• Superusers are advocates for their department
  Superusers will use their departmental knowledge, advanced system training, position, and communication skills to advocate for their department and end-users when decisions or processes may negatively impact productivity and departmental standards, or require more time to adopt than given by leadership.

Best practices to recruit a super superuser

Throughout dozens of implementations over the years, I have found that many organizations and vendors tend to recruit superusers as an afterthought to many other project needs. This means they do not sufficiently prioritize the selection and orientation of superusers. Planning superuser recruitment and clearly defining the role are critical steps in recruiting successful and driven superusers—leading to better project outcomes.

• Clearly define the superuser role
  Before recruiting superusers, it is important to clearly define the role and responsibilities they will have. Outline a clear set of expectations and requirements for the position so that potential superusers can understand what is expected of them.
• Focus on the opportunities
  When defining the superuser role, it is also important to highlight the leadership, advocacy, and support responsibilities the role will have to entice those staff who are interested in not only being strong team players but also enriching their professional development.
• Train soft skills
  Supporting end-users can be a challenging experience, especially when the end-users are resistant to change, chronic nay-sayers, or have become jaded in their work. Providing soft skill training can help superusers to work with these end-users in a positive and emotionally intelligent way.
• Reach out to existing users
  Recruiting staff that have used the system in another organization can have multiple benefits. Among the most valuable is their familiarity with the benefits and challenges their previous organization experienced, leading to advanced mitigation of potential problem areas.
• Promote the program within the company
  Sharing the superuser program publicly reaches a wider audience and can generate excitement about being involved. Social media also gives a platform for spotlighting the efforts of superusers and how they are helping to improve the organization.
• Highlight personal and professional enrichment
  The success of a superuser leads to the success of their peers and overall improved patient care. Focusing on how a superuser can provide long-term benefits to the organization, their peers, and community through their work and dedication can be a powerful recruitment tool.
• Offer incentives
  Offering desirable incentives can help to motivate superusers to continue even when project tasks require more effort than expected. Approved overtime, additional vacation days, and a bonus program with clear achievement goals are just a few examples of ways that project leadership can show investment in the superuser program.

Conclusion

Too often, healthcare organizations that embark on implementing a new system select superusers based on outdated methods. By clearly defining and highlighting the wide variety of responsibilities of the superuser and establishing powerful recruitment tools, an organization can develop their superusers into future leaders and advocates for positive change throughout the organization. If you have questions about the superuser role or a specific question about your situation, please contact our Healthcare IT Consulting team. We’re here to help.
 

Read this if you are considering an EHR system implementation.

Recently, we were working with a client project team on an electronic health record (EHR) system implementation across multiple locations. We were reviewing the results of integrated and unit testing and it was apparent that more testing was needed—but not enough timeline remained before the go-live. The decision was made to delay the go-live. It was the right decision to make as now the team had the time to have a more fully tested and ready system. However, the CIO was concerned that a delay in the go-live would reduce the urgency and effort the project team had been putting in.

We told the client that they needed to go the same speed, and just needed more road. “Same speed, more road” became our battle cry for the remainder of the project, and after a two-month delay, we had a successful go-live.

Organizations are often hesitant to think about changing the schedule or delaying a go-live. It is an understandable hesitation as many things are tied to the schedule including conference room reservations, vendor travel, reduced patient schedules, and even vacation blackouts. However, using the project schedule should be at the forefront of an organization’s project management toolkit. 

The Iron Triangle of project management has three primary variables: scope, schedule, and resources. And in the center of them is the quality of the project. 

In the current healthcare environment, hospitals, nursing homes, and health systems may find it challenging to consider scope or resources as primary tools. 

• Scope
  Whether you are a hospital replacing multiple EHRs with one, or a nursing home replacing paper charts with an integrated EHR, the foundational scope needed is large and expansive and with few items that you can pare back. The required scope limits your ability to use a reduction in scope to improve project outcomes.
• Resources
  Between the significant staffing shortages across healthcare and the financial headwinds health systems are facing, resources are scarce. In the face of these challenges, using resources as a primary tool to keep a project on track presents its own challenge.
• Schedule
  A schedule is the most available tool to use to keep an EHR project on track. While this is a tool not without limits, challenges, or problems, planning for it from the onset of an EHR project is key to successful implementation. 

EHR system implementation schedule flexibility tactics

To have schedule flexibility as a readily available tool for your EHR project, here are tactics to set you up for maximum success:

• Realistic timeline
  EHR vendors often provide you with timelines that may be realistic to achieve under ideal conditions but may fall short when reality sets in. Reviewing and planning an EHR implementation timeline with your preferred vendor in advance of contract signing is beneficial. You should look to incorporate known constraints, known risks, and sufficient contingency time to keep the project on track when issues arise. For example, if a vendor provides you with a six-month implementation time frame that starts in October and concludes in April, it may not account for the disruption the fall and winter holidays could have in shrinking the actual number of project weeks within that six-month window. 
  
  If you anticipate a survey window during a particular point in the project and have no contingency time to redo a project even if the surveyor shows up, that could cause problems. Also, when reviewing the timeline, look at the time between each testing event and the scheduled go-live. If there is not sufficient time between each of these important project milestones, you will not leave yourself enough time for defect resolution or an additional testing event without having to change your go-live date. By setting a realistic timeline with sufficient slack time between major events, you increase your likelihood to address issues and maintain your planned go-live date.  
• Effective contracts
  Negotiate contract provisions with your preferred EHR vendor to give you schedule options that are not overly punitive to your health system. Contract provisions that allow you to delay if the vendor has challenges that warrant the delay without financial penalty are essential. You will need clear acceptance criteria that must be achieved in order to go live and set expectations for how schedule changes would be addressed if you need to delay for your own resources. Without planning the options in advance of the project, schedule changes and delays can become overly contentious with the vendor and costly to your health system.
• Set priorities
  Work with your senior leadership, medical staff, and board to understand how the schedule may be used as a tool for project success. Describe how, why, and when a project delay may be used. Get everyone on the same page with the go-live criteria that will be used, conditions that would warrant a delay, and how the timeline will be used to bring about a successful go-live. 
• Know why
  No EHR go-live is perfect or risk-free. It is all about acceptable levels of risk in order to proceed to go-live. Be clear and differentiate between being nervous and needing to delay. Use your go-live criteria, your risk and issues logs, and the input from senior leadership and staff to establish if you are just nervous or are actually at a risk level that warrants a delay. 
• Be better
  Delaying and doing nothing differently can make you run later and more expensive, but no more successful than had you gone live on the original date. At a minimum, embracing the “same speed, more road” battle cry is warranted with a delay. There is no slowing down, taking a break, or stepping back. If anything, depending on your situation, it may warrant “faster speed, more road” to be successful. This can come in the form of daily project huddles, repeated pulse surveys, dedicated events focused on resolving project issues, additional testing events, and any recurring meetings between your leadership and the EHR vendor’s leadership team. When you delay, have a clear plan of attack for improving the project.
• Try not to kick the can
  If you are facing a project delay, it can be very tempting to want to delay it as little as possible. This is understandable as everyone has been working hard and wants to reach the go-live date. Be cautious and confirm your delay is sufficient to address the risks, issues, and tasks needed to improve the project. Medical staff and colleagues will be tolerant of a delay to achieve a successful EHR go-live but will grow wary if you must delay repeatedly. When you make a delay call, build a plan and schedule with sufficient time, including contingency time, built in. It is better to be ready and confident early than have to face the challenge of a repeated delay.

EHR implementations are hard, stressful, and intense endeavors. They overturn nearly every process in your health system. By the time you approach go-live, people are ready to get there and hesitant to make changes. However, you may not be ready to go live successfully. The scope of the project may not be able to be reduced and additional resources may not be available. Using schedule flexibility to your advantage may be your best option for a successful go-live. Know why, how, and when to use this tool—and communicate clearly and broadly to your organization—and success can follow. 

Read this if you are considering an Electronic Health Record (EHR) system implementation.

The go-no-go decision is a pivotal milestone in an EHR implementation. The meeting is years in the making. You’ve evaluated EHR vendors, signed a contract, waited for the implementation to begin—and then spent the better part of a year battling through the hard work of an implementation. Your team will be tired, stressed, and very focused on reaching that goal of the go-live event. The team has very little desire to have the project go on any longer than needed. The EHR is built and tested. You are likely focused on finalizing the training plans for your providers, nurses, and other end users. You may be in the process of lowering patient schedule volume for the go-live window. 

The desire to go live can cause both the vendor and your team to want to downplay the go-no-go decision and just proceed. Whatever you do, avoid that impulse. 

The go-or-no-go discussion: an EHR implementation best practice

Take the time to have the discussion of whether to go live or not. Doing so is an implementation best practice. It allows your team to step back and ask some fundamental questions. Are we ready to go live? Is there an acceptable level of risk, being aware that there will never be no risk? When you decide to conduct a go-no-go meeting, here are some points to consider:

• Acceptable level of risk
  As the reality is that no go-live is risk free, you’ll need to assess if there is an acceptable level of risk with your leadership team. This will vary by the specific risks and issues of your project and the specific conditions at your health system. For example, if the testing results for charge capture and claims testing are less than desirable and the financial health of the hospital cannot tolerate a significant impact on cash flow, it may not be an acceptable risk at this time. Or, if your orthopedic group or surgical team are both influential groups of leaders and high revenue generating departments and their order sets, charges, and documentation templates are not yet built, it could be a reason to delay. Acceptable risk is not clear cut and varies from organization to organization. By focusing on the risks and issues, you can determine as a team if the risk is acceptable.
• Continuation bias
  Continuation bias is the unconscious belief that you should continue with an original plan (such as a go-live date) despite changing conditions. In aviation, this can lead to flight crashes when weather changes. Similarly, it can lead to failed EHR projects if, for example, the testing results were low, the defects were not quite resolved, and the system was not quite ready. To reduce charging forward, discuss the concept of continuation bias in advance with your leadership team. Discuss openly if you believe it may be creeping into your thinking. Use the written risks and issues for the project to guide your decision-making much like a pilot would look at the current weather conditions before deciding to land the plane.
• Contingency plans
  Mitigation plans reduce the risk from occurring and negatively impacting the project. As you get closer to a go-live event, you will want to document contingency plans for what to do if the risk occurs after go-live. By documenting contingency plans, you can identify which, if any, contingency plans are not realistic. For example, if Accounts Receivable is disrupted and cash flow is slowed, your contingency plan might be to use your line of credit. However, if your line of credit is fully used because of the recent construction project, that contingency plan is unrealistic. If you have unrealistic contingency plans and the likelihood of needing that plan is high, you may not be ready to go live. 
• Around the room
  It is important you allow all the voices of your leadership and project team to be heard. It is possible that some people believe you are ready to proceed while others do not. Working through the differing opinions until you have general agreement to either proceed or delay will help your team get behind the decision. Silence is not an option during this session and all leaders and perspectives need to be heard and understood. This better prepares you to lead your health system through the subsequent steps and minimize any Monday-morning quarterbacking. 
• Readiness survey
  Your leadership and project team may not see all the reasons for proceeding to go live—or choosing to delay. The wider group of employees and those involved in the implementation may see important information that should be taken into consideration. An electronic readiness survey prior to your go-no-go meeting is an effective tool for gathering this information. It can be as simple as a readiness Likert scale and some open-ended questions about readiness and top concerns. Survey responses can provide your leadership team with a deeper level of information to inform decisions. 
• Can you name it
  It’s normal for your team to feel anxious heading into a go-no-go decision. Differentiating between generalized worry and an impactful risk is important. Ask your team to name the risk, describe the risk, and define the impact of the risk. If they are able to complete that exercise with specific details, it may be a risk to consider. If they are unable to share that level of detail, it may be an indicator of just plain old worry, and it may be safe to proceed. 
• Missed approach criteria
  Even after you make a go decision, there is a small chance you could have a problem occur that would cause you to not go live when planned. The list of factors that would cause you to not go live should be short and defined in advance. For example, if the vendor has a major technical issue making the system unavailable for go-live, if weather prevents any of the vendor team from arriving on-site for the cutover, or if a critical issue that was planned to be resolved before go-live is not. Having these criteria defined and known in advance allows you to use them if something occurs that needs further clarity and agreement with your leadership team.

The go-no-go decision is a crucial step in implementing an EHR system and often can be the difference between success and failure. Planning this step from the start of the project will set you up to have the discipline to complete it when the pressure of the implementation and your timeline is bearing down on you.

Read this if you are considering implementing an EHR system.

As the era of multiple Electronic Health Record (EHR) systems wanes, the focus is on a single integrated EHR across the health system. This shift is both an opportunity and a challenge for most hospitals and health systems. On one hand, it brings the opportunity of a single view of the patient for a provider, population health at a system level, and greater efficiencies across departments. On the other hand, it requires implementing an enterprise system, changing processes across every department and location, and going live in a “big bang” manner. Historically, hospitals implemented solutions piece by piece over years of time and didn't implement everything within a year. Moving to a single enterprise-wide system represents a tremendous amount of change in a very short time frame. The risk of resistance to change by your people is significant. 

How you address that risk may make the difference in your project’s success. Prosci^® has a risk assessment tool that looks at two primary dimensions: 

• The scope of the change. Is the change small, incremental, or large and disruptive? 
• The culture of the organization (organizational attributes). Is your organization ready for change or is it change resistant?

Based on the assessment of these two factors you can plot from a change management perspective whether the change is high, medium, or low risk. 

Three components of a high-risk EHR implementation environment

1. Large disruptive change
   It is a fair assumption that if you implement a new EHR system across your entire health system (that impacts every clinical, financial, and operational workflow), it would be a large, disruptive change. And certainly a high risk from a scope of change perspective.
2. Change resistant culture
   The next question is what is the culture of your organization? Are your people generally accepting of or resistant to change? How do employees remember past changes? How adept is your management team at leading through change? While the scope of the project is often front of mind, leaders may overlook these very important aspects of your culture. In our experience, many organizations have a culture that is at least slightly change resistant, if not more so, particularly if your workforce has been in place for a long time and has not replaced any systems recently. Many people in your organization may only know the way they have always done things and may not have even had exposure to another EHR system. This sets people up to be inherently nervous and even fearful of what a new system may mean for their day-to-day work and even job security.
3. Change saturation
   Lastly, you add the change saturation to the mix. Prosci ® defines that as when disruptive changes exceed your capacity to adopt them. For healthcare, the last three years have been a lesson in extreme change saturation. People are tired, burned out, and ready for more stability and less change.

When you combine a significant scope, a change resistant culture, and a high level of change saturation, you have created a high-risk environment for implementing a new EHR. So, if you are a senior leader about to embark on an EHR project, what should you do?

• Start change management as soon as possible—early recognition that an upcoming change will be challenging gives leaders an opportunity to learn early, engage early, and adopt early. Organizations who engage a wide audience early in a complex change have greater opportunity to communicate answers to “why,” “what does this mean to me,” and “how do I have to prepare “questions.
• Select the right project sponsor—the single most determinate factor in project success is having an engaged and effective sponsor. The sponsor needs to bring credibility to the change, provide energy to the organization for change, and be visible and transparent as to why this change is needed now.
• Establish an effective leadership team—for an EHR implementation, the sponsor cannot “go it alone.” An effective change leadership team provides consistent messaging and in-depth knowledge of the change and engages in conversations throughout the organization explaining the need for change.
• Be active and visible leaders—once the leadership team is established, getting out the word is crucial. Leaders should engage in division and departmental meetings, educating teams on the change and the need for change. Repeat appearances and follow-up communications begin to establish a collective understanding across an organization. Rotating leaders through these communication opportunities also brings different organizational perspectives as to why the change is important. Hearing from different clinical, financial, and operational leaders helps people understand the common themes and current ideas on the necessity of the change. Leaders must engage and empower management to understand and support the change. 
• Identify and engage supervisors and influencers—most organizations have team members who are very influential within teams and may not hold management positions. Prosci ® says that a direct supervisor is the best communicator to effect change. In addition, influencers may not have the title but the whole team will look to them for indications that the change is good or not. Training these team members on the importance of the change helps them educate their team members and improves their team’s opinions and support for the change.
• Use vendor backlog to your advantage—vendors are having a challenging time staffing projects that can lead to delays. Use the months you have leading up to project start to focus on change management. Build excitement with your people. Train your leaders to be effective change managers.
• Rinse and repeat—monitor your change management activities carefully and repeat the processes that prove most effective. Change the content of the messages being delivered, but not the approach on how they are delivered. 
• Celebrate early and often—take the time to thank your teams. Change can be difficult. Rewarding and recognizing accomplishments, big and small, during the project life cycle builds momentum and desire for the upcoming change. Thanking your people with food is always a crowd pleaser. Be sure to make these celebrations public to share the good news.

Most organizations experience challenges when implementing change and an enterprise-wide EHR implementation is the definition of a high-risk change. Starting change management activities early in a project provides the highest likelihood of reducing change resistance and improving adoption. The goal is to have most team members understand the change, the need for change, the impact of the change, and how the organization is going to support the change. An early start provides the smoothest entry ramp into a new world. 

Read this if you are implementing a new Electronic Health Records (EHR) system. 

Electronic Health Record (EHR) implementations are large-scale, high-risk endeavors that can bring wild success or frustrating failure. While there is justifiably a lot of attention paid to clinical workflow, change management, integrated testing, end-user training, and at-the-elbow support, we want to address a far less exciting, but critical component of EHR implementations—unit testing. 

Most EHR implementations use commercial-of-the-shelf software and increasingly cloud-based or vendor-hosted solutions. This software is being configured with little actual custom software development. With this in mind, we define unit testing as the testing of an individual component of configured software. For example, units to test could be a single order, lab test, charge, etc. Integrated testing we define as testing multiple components of configured software through a designed testing scenario to test if the components all work together as expected. 

We’ve seen EHR vendors put an increasingly higher focus on integrated testing and less emphasis on unit testing. With a greater shift towards cloud-based and vendor-hosted solutions, we have seen EHR vendors have a more substantial role in the configuration and build of the EHR software. In this scenario, the client primarily submits data through completed worksheets, documents, and forms to guide the vendors' configuration efforts. 

Expand EHR testing for a more successful outcome

The combination of less focus on unit testing and the higher reliance on vendors doing the configuration puts your health system at risk. Integrated testing is great for testing how the system works together—but is not sufficient for broadly verifying if the vendor has correctly completed the configurations. 

Think about it. How many orders, tests, assessments, medications, charges, and other configured components can you include in a realistic integrated testing scenario? It’s likely that only a fraction of what is likely contained in your order catalog, pharmacy formulary, or charge description master is included. This puts you in a vulnerable situation: the system is configured sufficiently to pass an integrated testing script but not configured at a broad scale. 

An effective treatment for this risk is thorough unit testing. For example, test each medication in the pharmacy formulary, try every order set, drop each charge, try every visit type, or complete each assessment. Unit testing the components will increase your confidence that the system is built and ready to go. Conducting unit testing in the production system can help reduce risk of an error or discrepancy between the build in the non-production and production systems. If you do this, be sure to have a plan with your vendor to address any transactions this may create in the production system. 

Effective unit testing

Here are some tips to help you conduct unit testing effectively:

• Develop a unit testing plan
  A well-documented plan that outlines the scope, timeline, assigned responsibilities, and performance expectations for unit testing will keep the testing process organized and efficient.
• Prioritize unit testing
  The leadership team should establish clear expectations that unit testing is an essential component of the EHR implementation process and allocate adequate resources and time to carry it out effectively.
• Assign responsibility to project leaders
  Ensure that each department head or subject matter expert understands their respective build and the critical components that need to be tested during the unit testing process.
• Establish a system for documenting results and issues
  Implement a clear system to record and track test results, identify failures, and log issues encountered during testing. This will facilitate efficient communication and help the testing team and the vendor resolve issues.
• Adopt a no-idle-hands strategy
  Utilize any idle time during integrated testing or project events to conduct unit testing. This will help maximize testing efficiency and identify issues that may have been missed.

While implementing EHR systems is a complex and multifaceted endeavor, unit testing is a crucial component that should not be overlooked. Properly conducting unit testing can greatly improve the success of an EHR implementation and minimize the risk of problems.

Read this if you are looking at implementing a new Electronic Health Records (EHR) system. 

Not since the early years of the meaningful use incentives have we seen such client activity in implementing new EHR systems. The primary driver for this activity is a strong desire to move away from combinations of multiple different EHR vendors across a health system toward a single, integrated EHR platform from one vendor. Continuity of care, population health, and patient-centric data are trumping a strategy of having niche EHR platforms at the department or care-setting level. Implementing an integrated EHR across an entire health system is a big, ambitious, high-risk project that comes with significant change for your people—even under normal conditions. 

Conditions have been far from normal for most workforces over the past few years. After three years of the COVID-19 pandemic, exhausting work conditions, and the unusual labor market (commonly referred to as the "Great Resignation"), staffing challenges are understandably at an all-time high. 

It is no surprise then, that when we ask clients what some of their top project risks are heading into an implementation, staffing is listed as their number one or two risk. And staffing is not just a risk for clients. EHR vendors are also facing increased employee attrition. 

So, when you combine very large and high-risk projects capable of changing every process for your people with a labor market full of turnover and vacancies, you have a higher risk EHR implementation environment than at any time in recent memory. 

This environment may lead you to think that now isn’t a good time to implement a new system. At times, waiting on the implementation may be the right call for your organization. Maybe you should hang tight for a bit and wait until your team is more stable. 

However, it may not be best to wait. Staying with a combination of legacy EHRs bolted together may not reduce your organizational risk. As viable legacy EHRs are dwindling, the chance that a change in EHR will be forced upon your health system increases. Replacing a system under duress, rather than choosing when to implement a new EHR system, would actually be more stressful and most likely introduce even more risk. 

If you are planning to or are currently implementing a new EHR in these workforce conditions, here are some recommendations to help mitigate staffing and vendor risks and manage, if not strengthen, employee well-being.

Vendor turnover

• Negotiate provisions
  During contract negotiations, address turnover and vacancies directly. Contractual terms for notification, transition plans, and timelines for filling vacancies won’t prevent turnover but will make it more manageable when it occurs.
• Meeting summaries
  Direct the vendor to use a consistent meeting summary format and post it to a project portal within a set period of time; this can also help the transition from one vendor teammate to another. 
• Executive sponsor notice
  Require the vendor to provide notice to your executive sponsor as soon as the vendor knows about staff turnover. This allows leadership to be prepared for the news and lead their team through the staffing transition calmly and from an informed position. 
• Transition plan and call
  Have vendors document a written transition plan and hold a transition call between the client and vendor resources. This can’t be accomplished with sudden departures but can be with planned departures. 
• Timeline provisions
  Vendor staffing disruption can be a project risk and can negatively impact implementation timelines. Negotiate timeline change provisions to limit the negative impact on your health system if a vendor encounters staffing turnover. 

Health system turnover

• Change management
  Focus on deliberate, intentional, and proactive change management. Active and visible sponsorship for the change will help your employees embrace the change to the new EHR. By making the new EHR more exciting and less daunting, it will give employees one less reason to seek employment elsewhere.
• Have contingency and management reserves
  From a project management perspective, increasing your contingency funds and management reserves can help you account for a higher likelihood of staff turnover, more recruiting, or staff augmentation, if needed. 
• Establish staff augmentation arrangements in advance
  Identify firms for staff augmentation before you start. Know who you will call to get the talent you need when you need it. Having expectations of contracted rates in advance can help you fill vacancies more quickly.
• Use your senior team as your coaching staff
  Some leaders and managers will find an implementation more stressful than others, decreasing their effectiveness as team leaders. Assigning senior leaders to different department heads to serve as coaches and mentors can give managers the support they need to get through the implementation.
• Address weak leaders before the implementation
  In a tough labor market, you may be reluctant to address your weaker leaders for fear of not being able to replace them. Our experience is that implementations don’t often make weak leaders stronger, and their weaknesses will hinder the project. You’ll need to determine if you can coach them up, make the tough call to replace them, or find a leader within their team to step up for the implementation. 
• Negotiate delay provisions
  While not as easy to negotiate as vendor staff turnover delays, having a defined process for changing the timeline if you need to can be helpful. Provisions of this nature can help you manage the risk and know in advance what will happen if you were to delay the project. 
• Monitor for the non-project turnover
  Often implementations will have a staffing and turnover plan for people on the project. However, a less obvious staffing risk is turnover of people in departments not assigned to the project. Those turnovers tend to put more non-project work on project team members. Having a plan to resolve vacancies quickly will help you reduce this risk.
• Have job descriptions ready
  In order to speed up the process to address turnover and vacancies, have job descriptions ready. This can allow you to go to market faster when (not if) you have turnover during the implementation. 

Employee well-being

Large-scale, complex initiatives can place new strains on employees, leading to greater levels of stress, and in some cases, employee burnout. By taking a proactive approach to supporting well-being (physical, mental, social, financial, and professional), the organization can better manage the performance, retention, and interpersonal dynamics of the project team. This can help reduce the risk of project delays and improve overall project outcomes.

• Prepare people for what to expect
  A large system implementation can be a source of concern and uncertainty. Employees may worry about how the change will affect their jobs and what will be expected of them. There may be fears around how these expectations will impact other personal and professional commitments. Transparency, proactive planning, and an individualized approach can help alleviate fears and reduce stress and uncertainty. 
• Unite project leadership at all levels
  Inconsistent messaging and decision-making can quickly undermine trust and may trigger cynicism, disengagement, and even animosity. It is imperative that executives and team leaders share a common understanding of project goals, guiding principles, and core organizational values around well-being—and communicate that understanding to the team. 
• Be intentional about trust
  Trust is a core element of well-being that is built upon authenticity, empathy, and credibility. Make sure to make trust a part of the project as it is also the foundation for the collaboration necessary among the organization, vendor, and implementation partner. 
• Pulse surveys (Stay in tune with how people are doing)
  Workload demands will shift throughout the implementation. At the same time, personal circumstances of employees will evolve. Maintaining a “pulse” on how the team is doing and being able to quickly respond when teams or individual contributors are struggling can help project leaders and managers stay ahead of disengagement, burnout, and resignation.  
• Celebrate success and show appreciation
  It can be easy to miss opportunities to celebrate milestones and recognize individual contributors when timelines are tight, and workloads are high. We emphasize the importance of appreciation, celebration, and finding moments for fun throughout the project. 
• Support for stress management and resilience
  Often, there are opportunities to help staff improve stress management with practical, research-supported activities, such as five-minute breathing exercises, stretch breaks, and environmental changes (brief walking breaks and outdoor meetings, for example) to support stress regulation. 
• Highlight wellness and well-being resources
  Employees may benefit from existing wellness and well-being resources throughout the project. There may be opportunities to work with human resources or a well-being manager to increase awareness for these resources or design custom programming in support of the project.
• Promote healthy lifestyle choices
  Implementations are often synonymous with long hours sitting in meetings or at a screen, “always-on” mentalities, and team donuts, pizzas, and bowls of candy. While these behaviors (and tasty treats) may offer short-term benefits, they degrade employee resilience and well-being over time. Small behavioral nudges can make a big difference, such as replacing (or at least supplementing) typical “command center treats“ with healthier options, emphasizing breaks (both throughout the day and PTO), and agreeing to off-hours communication expectations and boundaries. 

It takes strong ambition to take on a large EHR project in normal times. Under the current staffing stresses, it is crucial to be prepared. If you plan in advance for vendor and employee turnover, manage your people deliberately, and focus on employee well-being and change management, you can reduce the risk and increase the likelihood of a successful outcome.