Implementing the Second Electronic Health Record - Part 1

A lot has been written about why organizations should upgrade from a paper-based system to an electronic health record (EHR). External standards and opportunities such as Meaningful Use (now Merit Based incentive Payments System, or MIPS) have been contributing factors. What hasn’t been explored is why organizations make the decision to switch to a new EHR — not simply upgrade to a newer version, but change software and vendors altogether. Data migration, staff retraining and other challenges make such a move challenging at best. So why do it? There are a lot of reasons but changing EHR vendors generally falls into two general categories:

• The original EHR is inadequate
• Vendor dissatisfaction

The original EHR is inadequate

This is arguably the most common rationale– the EHR simply does not do what the organization needs it to do, and the root causes can be external or internal.

External Factors

As previously noted, MIPS has placed many demands on organizations and, in turn, their EHRs. While some vendors responded well, others were challenged. As a result, some organizations that had to meet the MIPS requirements found it necessary to change vendors and EHRs.

Sometimes a modification in payment models will necessitate a change. A billing system tuned to fee-for-service may not readily adapt to case rates or capitation. However, organizations should thoroughly research their current EHR capabilities before automatically changing platforms. Unused functionality is not the same as absent functionality.

Some organizations learn a lot about themselves through their first EHR implementation – and that’s a good thing. In an ideal world, organizations would use their first EHR implementation to revise workflows, rethink priorities regarding data capture and reprioritize clinical activities.

In other words, they should think about the EHR implementation as a strategic shift in the way the organization works rather than a software implementation.  Many do, but even the best still learn a lot after they go-live with their first EHR.

Despite their best efforts to use the first EHR implementation as a strategic re-engineering of the enterprise, some amount of “muscle memory” can creep in, allowing old paper-based processes to show up in the new EHR. Invariably, the inefficiencies of these old processes become obvious when the EHR is used routinely. Depending on their severity, some of these processes will be fixed immediately but often times they go untouched because they are familiar and they “aren’t that bad.”

When it comes time to upgrade or replace the EHR, these processes come under scrutiny and are targeted for replacement, possibly in the new EHR. It is unusual for problems of this magnitude to trigger a change in EHRs by themselves but, coupled with other elements of dissatisfaction, they could necessitate such a change.

Internal Factors

A bigger problem occurs when the EHR is viewed as incapable of meeting the needs of the organization, but the real problem lies with the organization itself because there was a failure to do the necessary work up front to implement their first EHR.

There are lots of things organizations must do to prepare for EHR implementation. Data mapping, hosting strategies and a myriad of other technical details must be addressed. All are critical but two factors more than any others frequently undermine success implementations:

1. Workflow analysis and redesign
2. Leadership

Rethinking workflows is a critical success factor that virtually every vendor will try to address. However, clients often subvert this process because they are wedded, consciously or unconsciously, to their traditional ways of doing things. This is especially unfortunate since workflow redesign is arguably the biggest benefit of going electronic.

Despite choosing a vendor with extensive experience in implementing EHRs, some organizations will discount or reject outright suggestions and information about best practices because they think they are different from other organizations and cultures. This view is so ubiquitous that it has earned its own descriptor: terminal uniqueness. Vendors that do dozens, if not hundreds, of implementations per year will tell you organizations are not that different.

Organizations can also limit workflow analysis and redesign by requesting the electronic replication of existing processes: “I want that piece of paper on that screen.”

No, you really don’t want that.

Paper-based processes are optimized for a unique data collection device – a piece of paper. But once the paper document is removed from the equation, processes are freed from the constraints of paper.

Organizations intent on replicating paper processes in electronic systems are invariably disappointed in their EHRs. Successful organizations flowchart all their core processes long before implementation. These flowcharts should be accompanied by a critical review of the data elements in the flowcharts.

Challenges such as “why do we need this piece of data?” and “show me the regulation that requires us to ask about ____” should be common. The resulting data flows will help define the new processes that take advantage of one of the biggest benefits electronic systems have over paper-based systems: you only have to ask a question and capture the answer once.

Organizations that neglect this step in EHR implementation invariably end up with an EHR that, at best, underperforms and, at worst, doesn’t function at all.

And who is likely to be blamed for an EHR that doesn’t work? The EHR itself, and by extension, the vendor. If the EHR is believed to be the problem, the next logical step is to get a new one. But without the prerequisite workflow redesign, no vendor will be able to accommodate the organization’s demands.

Join us for Part II of our series where we’ll dive into making the right strategic move toward a new EHR as well as common factors that play a role in whether or not an organization takes the leap. Stay tuned to CareThreads for more!