Over the past 35 years, I have overseen and participated in many enterprise EMR/EHR implementations, including the nation’s largest Epic ambulatory big-bang implementation (146 clinics with 1,500 providers). Some of these implementations went according to plan. Others, not so much. Following are a few of the strategies that have proven themselves time and again in turning EMR implementation pain into EMR performance.

1. Adopt a modified big-bang approach

To help mitigate the inevitable go-live operation/workflow issues, I advise clients to bring up hospitals and clinics at different times. For clinics, I recommend bringing up a pilot group first, and then bringing the remaining clinics up in waves of similar types. One client that chose the enterprise-wide big-bang route could not keep up with the call volume even with an 18-person phone bank, greatly impacting overall user satisfaction.

2.  Understand that EMRs must be clinician-led

An IT-driven EMR agenda is a mistake. While the IT department is typically well-qualified to manage the project’s complexities, the reality is that EMRs are 75 percent clinical operations, while only 25 percent technical in nature. Successful EMRs are championed by the end-users (i.e., physicians and nurses). In my experience, the ideal staff ratio is at least 40 percent of the project team having clinical/operational background experience and at least 40 percent having prior project-related experience deploying clinical and/or financial information systems. This mix provides an optimal balance between clinical effectiveness, user adoption, and the strong project management needed to stay on schedule and budget. Training and education should be workflow-based and involve as many clinicians as possible. By incorporating operational changes into technical training, users are able to begin the process of adapting their workday/workflow to the new system.

3. Engage executives and middle management

Executives frequently believe they have rank-and-file support only to learn later they are wrong. Executives who regularly miss weekly steering committee meetings and fail to engage clinical department middle management are not leading by example and put the project at increased risk for end-user resistance. Demonstrating executive commitment and including middle management and end-users in selection, workflow design, and implementation goes a long way to ensuring successful adoption.

4. Establish good governance

Sound governance is the foundation of efficient decision-making and successful implementations. Project charters should clearly define decision-making responsibilities and include a formal process for communicating and documenting decisions. In my opinion, 80-90% of issues should be addressed at the project team level. Only issues affecting project scope, budget, major workflow change, and operational impact should be escalated to the executive team. Task forces must feel empowered to make the best decision based on available information. Inaction or “analysis paralysis” only results in delays and cost overruns.

5. Own the decision-making process

Consulting firms and vendors bring great value in providing advice, options, and recommendations from experienced folks who’ve “been there/done that.” The information they provide is key to informed decision making. However, the organization ultimately owns and must drive all final decisions to end up with an EMR that truly suits its needs. Look at how you can best leverage outside expertise while maintaining overall control.

6. Set realistic budgets

Make no mistake, labor accounts for the largest share of the overall EMR cost, followed by hardware/workstations, software licensing, and third-party software. While there will be some variation within each category, the TCO for major vendor EMRs will be about the same for organizations of like size implementing similar functionality. Institutions get in trouble because they don’t accurately account for the true project cost. Common pitfalls in accurately accounting for true project cost include underestimating the required number of internal and external trainers; backfill; change management costs; unrealistic deadlines; training facilities, third-party software interface and conversion costs; failure to make true apples-to-apples system comparisons; and putting too much emphasis on licensing fees (a comparatively small portion of total costs). 

7. Test the EMR from start to finish

The EMR involves end-to-end integration. Testing functionality of the system - from the initial patient encounter, all the way through the end systems, including departmental, billing, state registries, etc. – is imperative.
 
8.  Expect, identify, and measure benefits

Organizations often approve EMR budgets of $100 million or more without first defining expected benefits. Performance metrics should be defined at the start and then measured and tracked before, during, and after roll out. With your Key Performance Indicators identified, you will be able to monitor and quickly identify changes in data at go-live, and document the many clinical, financial, and operational benefits of EMRs going forward.

I hope sharing my experience can help you on the road to a successful EMR implementation.

Ted Reynolds, vice president of CTG Health Solutions, has more than 35 years of consulting and executive experience in healthcare information, and is responsible for overseeing the consulting firm’s provider and payer services.CTG’s North American headquarters are in Buffalo, New York.