Selecting the appropriate activation approach is a critical decision that any organization implementing an electronic medical record (EMR) will have to grapple with. And although there is no one right way to activate computerized physician order entry (CPOE) and clinical documentation, there are many factors that can and should be analyzed in order to develop the best strategy for your organization. At Lucile Packard Children's Hospital (LPCH) at Stanford University, Stanford, Calif., the leadership of our EMR implementation took a rigorous, evidence-based approach to determining our activation approach.
LPCH, in 2003, signed a contract with a commercial EMR vendor (Cerner Corp., Kansas City, Mo.) and in the fall of 2005 replaced its legacy system functionality as part of a phase 1 implementation. Following this like-for-like functionality replacement, we began planning for our phase 2 implementation, which was to include the advanced clinical EMR functionality of CPOE and clinical documentation across all in-patient nursing units and ancillary departments within the hospital. One of the first and most critical decisions we encountered in our planning efforts was the best approach to activating the scope of our phase 2 implementation.
THE TWO PRIMARY DIMENSIONS TO CONSIDER WHEN DETERMINING THE APPROPRIATE ACTIVATION APPROACH IS THE FUNCTIONALITY WHICH YOU ARE PLANNING TO BRING LIVE, ALONG WITH THE GEOGRAPHIC LOCATIONS YOU WILL ACTIVATE AND THE SEQUENCE IN WHICH YOU WILL ACTIVATE THEM.
The two primary dimensions to consider when determining the appropriate activation approach is the functionality which you are planning to bring live, along with the geographic locations you will activate and the sequence in which you will activate them. In addition to these two dimensions there are organization specific factors such as risk tolerance, leadership engagement, physician and patient populations, and project management considerations around design, build, testing, training, activation support, resource type, and amount available along with technology deployment that should be factored into the decision.
Geographic: Within the geographic dimension there are three primary types of approaches. The first is a big-bang approach that is all units at once. A big-bang approach can achieve early benefits and cost saving along with allowing the organization to focus on one major effort. Yet this approach can also increase risk to the organization and be difficult to support in addition to requiring a huge training and change management effort.
The second approach is a pilot, with one area activated first followed by the rest of the house. A pilot method allows you to work out the kinks in the system prior to going house-wide and provides a controlled environment that is easier to support. And if the pilot goes well, adoption may be more easily obtained on subsequent units. However if the pilot does not go well, this could impact the success of the continued roll-out. The pilot unit also might not be representative of issues that may be encountered in other areas of the hospital and floating staff to this unit could be difficult.
A phased approach, which would be a unit-by-unit roll-out, is the last type to consider. When assessing a phased approach, it is likely that this will be easier to support than a big-bang. The change can be introduced slowly over time, which allows more time to gain adoption, and issue management can be handled more easily. Conversely you may get hung up on issue resolution, which could delay the rollout to the remaining units. Dual processes created by some units being automated and some units being on paper can also cause complexities for transferring of patients and increase patient safety risks. Benefits achievement will also be delayed.
Functionality: There are two main approaches when considering the functionality dimension. A big-bang approach brings all functionality live-CPOE and clinical documentation-all at one time. Some of the pluses with this approach are the ability to maximize the benefits of system integration, limit fragmentation of workflows, and enable closed loop processes. The major drawbacks are there may be more system issues to work through; it can be difficult to support requiring a large pool of resources and will be a huge training and change management effort.
A phased or subset functionality approach is where one piece of functionality is activated first followed by the next piece. For example, CPOE first followed by clinical documentation or vice versa. This approach will allow clinicians to become comfortable and proficient with one piece of functionality prior to implementing another. The magnitude of change is also lessened and the training effort is smaller and more focused. However issues encountered during the first phase can hinder the ability to implement the second phase of functionality. Fragmentation of clinician workflow can also lead to omissions or increased errors due to some information being online while some is on paper. And a multi-phase implementation with a prolonged rollout can also lead to staff burn-out.
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