The implementation of an electronic health record (EHR) is one of the most significant cultural changes a health system can experience because it fundamentally alters the work processes and habits of nearly every individual in the organization. Historically, health systems have focused their efforts and resources on the technical aspects of the implementation, giving minimal attention to strategically managing the cultural transformation. Oftentimes, this leads to dissatisfied end users and organizations failing to realize the full benefits of their EHR.
A successful EHR implementation can no longer be defined as the installation of the technology on time and on budget. Organizations are increasingly recognizing that adoption is a better initial measure of implementation success, as it is a foundational requirement for long-term success in EHR value realization. It is only when the technology is embraced by end users, embedded into the culture and integrated with streamlined operational processes that the groundwork is laid for organizations to leverage their EHRs to achieve the next level of efficiency, cost management, quality and experience. And, the best way to secure adoption is by approaching it with the same rigor applied to other aspects of the EHR implementation - through an effective change management plan that engages clinicians and wins their support.
For PeaceHealth, a large not-for-profit healthcare system, the implementation of a single enterprise-wide EHR was the catalyst for transforming organizational culture and laying the foundation to transition to a clinically integrated network. To ensure success, PeaceHealth employed a structured and deliberate approach to lead and manage the system’s transition based on proven change management principles and methodologies.
PeaceHealth: A Case Study
PeaceHealth is a not-for-profit healthcare system comprised of medical centers, critical access hospitals, medical clinics and laboratories in Alaska, Oregon and Washington. PeaceHealth Medical Group is comprised of more than 900 physicians and healthcare providers caring for patients in PeaceHealth’s clinics and hospitals. Like many not-for-profit healthcare systems, during its initial formation, the system’s facilities were loosely affiliated with PeaceHealth as the holding company. In 2014, the organization began transitioning to an integrated network, strengthening the relationships between its facilities and standardizing medication formularies, care processes and policies. Administrative operations were centralized in Vancouver, WA, and the decision was made to transition all ambulatory, inpatient and business office functions to a single EHR.
PeaceHealth’s clinical operations are organized into three geographic networks: Columbia, Oregon and Northwest. The EHR implementation plan called for a three-phase rollout for the hospitals and critical access hospitals, starting with the Columbia network, which went live on August 1, 2015. In parallel, PeaceHealth Medical Group’s clinics were placed on a rolling implementation schedule between May 2013 and March 2014.
PeaceHealth’s Columbia network is comprised of PeaceHealth Southwest Medical Center, a 450-bed community hospital located in Vancouver, Wash. and PeaceHealth St. John Medical Center, a 346-bed community hospital located in Longview, Wash. Both facilities provide a full range of acute care services, including emergency services, surgical and medical specialties and subspecialties, and women’s and children’s services. PeaceHealth Southwest Medical Center also serves as the region’s trauma center. Combined, there are over 1000 physicians, nurse practitioners and physician assistants on staff. Thirty-four percent are employees of PeaceHealth Medical Group, with the remainder in private practice.
PeaceHealth Southwest Medical Center had an existing EHR, and its physicians were accustomed to electronic ordering and documentation. Over the years, there was extensive customization of the legacy product; physicians were concerned that functionality would be lost with the new system and that it would not be as easy to use. In contrast, PeaceHealth St. John Medical Center did not have an electronic clinical record, so for their physicians, it meant transitioning from paper to electronic ordering and documentation.
To effectively navigate change, PeaceHealth invested in the development of a new Change and Adoption Team. The 10-member team is dispersed across all locations, and its members are seasoned, experienced change management practitioners. The Change and Adoption Team is part of the operation and system service group, which also includes the Project Management Office, Process Improvement and Enterprise Intelligence. The team’s focus is to develop change leadership capabilities and help the organization achieve measurable value from large, strategic initiatives that impact culture such as the implementation of the new EHR.
Principles and Key Components of a Proactive Change Management Strategy
Change management is the discipline that guides how individuals are prepared, equipped and supported to successfully adopt change in order to drive organizational success and outcomes. For more than 60 years, change management practitioners have designed strategies, plans, tools and activities to support stakeholders through the change process and minimize the adverse effects of changing behavior to a business (e.g., attrition, productivity loss, shareholder doubt, etc.).
Change management methodologies vary moderately between experts and across industries, but all contain the same core fundamentals for communication and leadership engagement. Communication fundamentals include tailored messaging for the audience, clearly articulating the change and why it is important. Leadership engagement fundamentals include helping leaders demonstrate their knowledge, support and confidence in the change to drive momentum for adoption within their teams.
Key success factors for PeaceHealth’s change management strategy included:
- Branding the change effort “Change and Adoption” to promote the desired end state of adoption
- Simplifying planning and tool documentation to make certain all leaders, program team members and employees understood the methods and tools used to support adoption;
- Creating Readiness Teams for inpatient, outpatient, lab, revenue cycle and providers. Members of each team were leaders in their areas and became decision makers for the EHR design and implementation; and
- Measuring leader and employee readiness for adoption at regular intervals. These measurements were shared broadly to help identify units requiring additional support.
Strategies for Engaging Physicians
To truly be effective, a change and adoption strategy must be tailored to the audience. For example, physicians have many priorities competing for their time and attention. It’s particularly important to share critical information and resources appropriately.
The graphic below illustrates the structure PeaceHealth employed to engage the medical staff. Over the course of six stages, PeaceHealth physicians became active participants, acquiring the knowledge and skills to work confidently in the new environment. Anchoring the approach is strong physician leadership and governance, and effective communication.
- Physician Leadership and Governance
Early on, physician readiness teams were established to provide guidance and oversight of all activities pertinent to physicians. Members included the following stakeholders:
- Chief Medical Information Officer for the system
- Chief Information Officer for the Columbia network
- Chief Medical Officer
- Chief of Staff
- Nursing Leadership
- Director, Medical Staff Services
- Medical staff leaders from key specialty areas, such as the ED and hospitalists
The team was an important conduit for obtaining medical staff input, providing guidance on adoption strategies and communicating the value and benefits of the program through members’ daily encounters with their peers.
In addition to one hour monthly meetings, physician readiness teams championed the program by engaging colleagues in meaningful dialogue, seeking input on key issues and playing a leadership role in resolving concerns. Several team members went on to become part-time super users, which well-positioned them to discuss and respond to concerns from their peers. They had the ability to effectively work with the technical team to resolve workflow issues that required a build modification, and assist with order set socialization and personalization sessions.
The physician readiness teams ensured medical staff leaders were visible throughout the initiative, pursuing input and participation from their peers, helping to resolve concerns and promoting the benefits of the new system.
Initial communication efforts focused on creating a compelling and meaningful vision that articulated the reason for transitioning to a single EHR and the value for both patients and caregivers. A brand name “CareConnect” was created, symbolizing the vision and the reality of “one patient, one record.” This branding was used on all EHR communication that was distributed.
A series of roadshows launched the program at each of the PeaceHealth locations. The roadshows were a fun, engaging way for caregivers and providers to preview the new EHR. These customized, 30-minute sessions were held with each service line (e.g., Cardiac, Clinics, ED, Lab, Periop, Pharmacy, etc.) and repeated so employees from all shifts could attend. A handout was also provided with information about key changes for each service line, a list of points-of-contact, an explanation of what to expect and a readiness survey. Importantly, caregiver attitude and value was measured at each session. Responses were overwhelmingly positive and reported back to all levels in the organization.
The communications team oversaw all communications and coordinated messages in adherence to standards. Throughout the program a wide variety of communication channels were used, including a CareConnect website, monthly newsletter, posters and emails to share program updates and information about upcoming events. Above all, the most effective communication tool for engaging providers and gaining support was one-on-one or small group conversations. Order set socialization, personalization sessions, coaching sessions delivered by physician champions, leadership rounding at go-live, presentations at medical staff meetings and hallway conversations — these all provided opportunities for questions to be answered and concerns to be discussed. This surfaced and resolved any causes of potential resistance prior to go-live.
- Order Set Development and Socialization
PeaceHealth leveraged the transition to a single EHR to consolidate many of the order sets used at their 10 hospitals. Over 1400 order sets were reviewed to identify opportunities for consolidation and then prioritized based on which were essential for go-live. Medical staff representatives from across the system met to reach agreement on the content of the order sets, using evidence-based standards and best practice as their guide. Physicians impacted by the changes were then invited to small group sessions to discuss and review the new order sets. These sessions provided the opportunity to discuss the clinical rationale, prepare stakeholders for the changes, and share information about the overall program and events important to physicians.
- Future State Workflow Design
Designing the future state workflow can be a tedious and time-consuming process. Thus, judicious use of physicians’ time in design sessions is essential to maintaining their interest. Workflow changes involve more than the appearance and content of screens; frequently, the responsibility for key process steps changes. It is imperative that the new owners of the process step understand what has changed and how it impacts others. This is particularly important for workflows known to be complex or challenging, such as those in the perioperative and perinatal areas. PeaceHealth leveraged physician champions with support from clinical informaticists to help in the design of the workflows and support their colleagues in successfully navigating these changes during and after go-live.
- Online and Classroom Training
PeaceHealth designed a customized training program led by educators with clinical and vendor-specific experience. The training consisted of online and classroom courses, which were tailored to the unique PeaceHealth workflows and the needs of particular medical and surgical specialties.
While job aides were created, distribution of hard copies was kept to a minimum and online assistance was encouraged so end users had the most current information and the cultural change to a “paper-lite” environment was underscored. One technique that proved effective in encouraging end users to access online assistance was for a super user to demonstrate the Help feature.
PeaceHealth required all physicians to attend training and demonstrate proficiency through an exam. Both registration and attendance were tracked, and deficiencies were reported to medical staff leadership for follow-up.
- Personalization and Coaching
Approximately one month prior to go-live, physicians were encouraged to participate in a personalization session to modify the system to their individual needs. The session topics covered tools and tips for achieving workflow efficiencies including creating rounding and consult lists, customizing default views, and selecting favorite order sets and creating personal versions.
These sessions gave physicians the opportunity to practice using the system prior to go-live, increasing their comfort level and confidence in using it. While classroom instruction can provide an effective overview of the system, the gap in time between classroom training and go-live may result in users forgetting a good portion of what they learned. The personalization sessions refreshed important material covered in the training.
Participation in the personalization sessions was voluntary, but they were heavily promoted via phone calls to physicians, email notifications, posters and presentations at medical staff meetings. As more physicians participated, the value spread via word-of-mouth, and demand increased significantly immediately before and after go-live.
- Physician Champions
A cornerstone of the success of the change management program was having a sufficient cadre of physician champions. This group provided adequate resources for personalization and at the elbow coaching during and after go-live. Champions were respected, approachable physicians knowledgeable of the system, passionate about the program’s success, and able to influence others.
PeaceHealth had a combination of full and part-time champions supporting the EHR initiative. Most of the part-time champions emerged during the course of the program. These were individuals who had interest in gaining expertise in the system and who were well-positioned to represent their colleagues at meetings as well as provide support as a super user.
- Go-Live Support
When end users feel proficient in using an EHR, their confidence and satisfaction increases. It is particularly important that at the elbow support is readily accessible to end users during go-live as they continue to develop their skills while treating patients. Easy access to a super user as well as the visibility of medical staff leaders and hospital administration relieves stress and promotes a positive learning environment.
To determine the number of super users dedicated to physicians, PeaceHealth used a ratio of 4:1 physicians to super users and adjusted it to 3:1 in specialty areas such as the Emergency Department. Physicians had sufficient support to help acclimate them to using the new tool while carrying out their patient care responsibilities.
Many of the super users’ system knowledge was invaluable in percolating important issues to the command center and helping to distinguish those which could be addressed via training and which required a technical build solution.
Measuring the contribution of a well-crafted organizational change management strategy to the success of an EHR implementation is difficult because there are so many variables, both technical and human. While the go-live at PeaceHealth was not without some issues, participants who had experienced other go-lives said it was “one of the best.” Go-live occurred as planned, and the command center was dismantled earlier than expected.
Recognizing that implementation is only a first step towards optimization, physician use of the system was another important metric PeaceHealth tracked. One method, historically used to measure EHR adoption, is the number of physicians using electronic order entry. However, this metric may be inadequate for organizations, such as PeaceHealth, where the expectation is that all orders will be entered electronically. A better indicator of adoption is to measure if individuals are taking advantage of the system’s capabilities beyond those prescribed by policy. At PeaceHealth, of the 654 physicians who entered an order during the first six weeks post go-live, over 80 percent had personalized the system in some way.
- Don’t leave change to chance. An effective change management plan requires planning, perseverance, courage, dedicated resources, funding and the discipline to follow proven methods.
- Broad physician involvement is critical to success. The implementation will eventually impact all members of the medical staff; providing opportunities for involvement and participation early on will create interest and build support. For physicians to become engaged, they need to feel that their time is being used in way that is personally meaningful to them. Employing tactics that offer opportunities for physicians to learn more about the system while making personalization decisions will be viewed as valuable use of their time.
- Small group or one-on-one conversations are the most effective mechanisms for garnering support and swaying opinions. While labor intensive, they provide an opportunity for questions to be answered and concerns to be discussed, thus ensuring causes of potential resistance are surfaced and addressed prior to go-live.
- Implement a plan for physician compensation early in the program. This includes determining the activities for which physicians will be compensated, the number of hours required and how the plan will be operationalized. Implementing an EHR requires additional time from every member of the medical staff, whether that be in learning the tool, participating in content development, acting as a super user or playing a leadership role. Decide how much is reasonable to ask physicians to voluntarily commit from their busy practices and personal lives. PeaceHealth found that compensating those physicians who had a significant role in the program had two benefits; it communicated the value and importance the organization was placing on physician involvement and supported the goal of obtaining broad physician involvement.
PeaceHealth had contracts with over 200 physicians, and contract management was a significant endeavor that had not initially been anticipated. Legal resources and a full time contract coordinator were required for contract development, managing compensation and ensuring regulatory requirements were met.
- Be prepared to make decisions that will not be universally popular, and proactively and aggressively confront and address resistance. Throughout the program, leadership will need to make many difficult decisions. Delaying decision making or not addressing resistance will only cause the program to lose momentum and jeopardize leadership’s credibility.
Increased market competition and economic pressures demand that healthcare organizations realize the benefits of their EHR investments quickly. There is little room for delays or failures. Increasingly, organizations are recognizing that the success of an EHR implementation requires a deliberate and methodical approach to managing the changes to its culture, just as it does to the technical aspects of the project. While leading and orchestrating the cultural transformation may seem daunting, there are proven organizational change management principles and methods that can be employed to establish success and achieve the desired clinical, operational and financial results.