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.
Other Key Considerations: The level of risk tolerance of your organization as well as leadership engagement are key organizational factors to consider around whether you chose a big-bang, pilot, or phased geographic approach as well as the amount of functionality you chose to bring live at once. There are some important considerations related to your physician and patient population related to the readiness of the M.D. constituents as well as the acuity level of the patients in various locations of the hospital that also should be explored.
THE LEVEL OF RISK TOLERANCE OF YOUR ORGANIZATION AS WELL AS LEADERSHIP ENGAGEMENT ARE KEY ORGANIZATIONAL FACTORS TO CONSIDER AROUND WHETHER YOU CHOSE A BIG-BANG, PILOT, OR PHASED GEOGRAPHIC APPROACH AS WELL AS THE AMOUNT OF FUNCTIONALITY YOU CHOSE TO BRING LIVE AT ONCE.
The design, build, testing, training, and activation support needs of your implementation will all be impacted by the choices you make related to your activation approach. The more units and the more functionality you bring live together, the greater the implementation effort will be. There are also technology needs to investigate based on the needs of the areas you activate in addition to the functionality you bring live. Specialty areas may require larger monitors and stationary devices versus computers on wheels versus the need for hand-held devices should be weighed.
In the summer of 2008 we conducted a survey related to activation strategies. Twenty hospitals responded to the survey all of whom had activated CPOE and documentation representing four major vendors. Questions were asked about the approach taken to EMR activation within their organization. The results of the survey showed that each organization activated CPOE and clinical documentation using different approaches. However 73 percent said they would use the same activation approach if they were to do it again.
Based on all the information gathered during our intensive due diligence process related to determining our activation strategy, we developed an “acuity-based” strategy which consisted of a phased geographic and a big-bang functionality activation. In our phased geographic approach we activated more than 90 percent of our inpatient beds and then activated our highest acuity pediatric intensive care unit and cardiovascular intensive care unit at a later time. In terms of the functionality that we activated, we decided that due to the integrated nature of our CPOE and clinical documentation build, we would activate them together using a big-bang approach.
From the data collected and evaluated plus our own EMR activation experiences we have determined that there is no one right way to implement CPOE and clinical documentation, however there is a right way to activate it for your organization. Through the application of a thorough and thoughtful decision making process which studies the factors outlined in this article, you can position your organization for a successful EMR implementation. Good luck!
Lisa M. Grisim, R.N., M.S.N., is director of operations, Department of Information Services; and Christopher A. Longhurst, M.D., M.S., is chief medical information officer, Department of Clinical Informatics, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, Calif. Healthcare Informatics 2011 December;28(12):47-50