CASE 17: WATSON’S AMBULATORY EHR TRANSITION
Major theme: System acquisition
Primary care physicians play a key role in the U.S. health care delivery system. These providers integrate internal and external information with their clinical knowledge to determine the patient’s treatment options. An effective ambulatory electronic health record (EHR) is critical to supply physicians with the information they need to provide quality care and maximize their efficiency. This case involves the decision-making process to replace an inadequate EHR system in a primary care network owned by a community hospital. The IT challenge reviewed in this case will be the decision-making process that optimizes provider support for the new EHR while addressing the strategic plan requirements of data integration, clinical application, and practice management functionality.
Watson Community Association is a private, not-for-profit corporation that operates Watson Community Hospital (WCH), a 200-bed acute care facility located in Arizona. WCH has pursued a strategy of employing primary care physicians in their primary service area to provide convenient points of access for patients and to secure a primary care base for the specialists who utilize the hospital. WCH employs thirty-six physicians and seven midlevel providers in eight clinics, specializing in internal medicine, family practice, infectious disease, and gynecology.
In 2011, the WCH board of directors adopted a plan to implement a systemwide EHR to, among other things, improve patient safety, integrate information from ancillary systems, and provide access to patient information for all WCH caregivers. In addition, the plan calls for an evaluation of the effectiveness of the WCH physician clinic organization’s EHR.
The WCH clinics currently use the XYZ Data Systems Integrated EHR and Practice Management System. This system has been operational for four years. The XYZ system was chosen because of its compatibility with the hospital’s Meditech platform. Physician needs and application functionality were secondary considerations. As a result, physician system adoption and support has been poor. Under prior leadership, the hospital information technology (IT) department provided limited support for the XYZ EHR. The clinic organization was left to develop its own internal IT capabilities to manage the XYZ system and, as a result, the system has not been routinely updated.
The hospital has decided to stay with the Meditech platform to address the IT strategic plan for an integrated EHR. The clinic organization must now evaluate whether it is in their best interest to stay with the XYZ system, with strong Meditech compatibility, or move to a different EHR platform. The path of least resistance from the IT perspective would be to upgrade the XYZ system. This option offers the greatest integration and could be implemented much sooner. A new platform would require an evaluation and selection process and a significant conversion. With either scenario, physician support will be critical to a successful transition.
EHR PROJECT PLAN
Next is a description of the planning process developed by the leadership team to transition to a replacement EHR. Read and critique the plan by answering the questions that follow it.
The organizational phase of the project will involve establishing a project steering committee and identifying the leadership members who will ensure the project’s success. WCH operates eight separate clinics, each with their unique teams and EHR experience. By necessity, the steering committee will need representation from each of these clinics. The project steering committee will likely have twenty to twenty-five members. In addition to provider representatives, the steering committee will also include nurses, medical assistants, and office managers from each clinic. IT representation is critical to the success of the project, and since the department provided poor IT support in the past, the chief information officer (CIO) will play an active role on the steering committee. A representative from finance should also participate on the committee, given the importance of billing and collections and other practice management issues.
The leadership of the steering committee will ensure the committee addresses key steps in the process and does so in a timely fashion. Ideally, the committee would be chaired by a provider who is respected within the group, is objective, and is a supporter of EHR technology. Although the clinic organization does not have a provider who meets all of these criteria, a physician with strong peer support and credibility will be selected to cochair the steering committee. To complement the clinical leadership, the CIO will serve as a cochair for the committee, providing technical expertise. This individual has implemented other EHR systems and will bring a structured process to the committee to ensure a thorough evaluation process.
Organizations often overlook the importance of understanding the emotional climate of a medical practice when implementing an EHR. Therefore, although the first task of the steering committee will be to define the project objectives, the existing concerns about an EHR transition require that a fair amount of time be devoted to addressing the emotional needs of the participants. Listening to practitioners and empathizing with their concerns will be critical to establish trust and overcome resistance during the EHR conversion.
To address this important issue, a series of discussion exercises will be used to encourage open dialogue and participant engagement. The first exercise will break the large group into teams of four to five members, and each team will discuss the lessons learned from the XYZ implementation that took place four years earlier. Team leaders will be handpicked for their facilitation skills and ability to listen. The group discussions will address the “change readiness” and will surface the major issues associated with the implementation. It will also allow the group members to get to know each other in a less formal setting than the large group. The larger committee will reconvene to discuss their findings and prepare a master list of implementation lessons learned.
While this exercise may raise a number of issues related to implementation, it is also important to openly discuss the current issues with the existing EHR. Once again, small groups will be asked to discuss these issues to ensure participation by all members of the steering committee. Small groups will report out to the large group, and a summary of issues will be developed. This list, as well as the list of implementation issues, will set the stage for a later discussion regarding the scope of the project.
Project Scope and Objectives
Once the group has had the opportunity to express personal concerns and key issues have been identified, the group can turn their attention to defining the project objectives. Anxious committee members are often tempted to begin discussing whether the steering committee should upgrade this system or consider alternatives. When this occurs, discussions and conclusions are usually based on the emotional attachment to or disappointment with the current system. A more systematic review process will help frame this discussion to ensure the conclusion is based on facts and the needs of the clinic organization.
The leadership must guide the committee in developing project objectives that are based on the needs of the organization, not individuals. Returning to the list of implementation and current issues, the group will be asked to prioritize the concerns that were raised. This prioritization will focus the committee on the most pressing issues that must be addressed. With this background work, the committee will be positioned to articulate the goals of the committee. It will also define the scope of the project by determining what the project is and isn’t intended to address. Invariably, users will raise issues that may not be solved by an EHR application. It is important that the end users review all issues, even though some of those issues may not prove to be within the scope of the project. Users with unrealistic expectations can end up frustrated and disengaged as the process unfolds. Defining the scope and the objectives clarifies expectations before options are considered.
The steering committee will need to establish plans to communicate with the larger audience of clinic users and stakeholders. A plan will be developed that provides this audience with regular updates. The plan must also address how the committee can solicit feedback from stakeholders during the evaluation and selection process. Regular minutes establish the record of the committee’s work and provide a means for communicating with stakeholders. Special meetings with individual clinic groups will also be necessary to address rumors or provide more detailed information regarding the process. The steering committee must communicate regularly to ensure information is flowing to individuals.
Plan of Work
Once project objectives are established, the committee will prepare a plan of work. This plan will outline the specific action steps required to achieve the project objectives and the timeline for their completion. The plan of work focuses on the decision to upgrade the existing XYZ application and remain with a Meditech platform or move to a different software solution. The plan of work provides the steering committee with the road map to achieve their goals.
The key steps in the plan of work are identifying possible vendors, establishing system requirements, and completing a request for proposal (RFP) process. Vendor identification can occur simultaneously with establishing the project goals. This is a reasonable assertion as it will save time and will engage the clinic representatives in the process. The steering committee will select individuals to attend trade shows to maximize exposure to EHR products. IT staff will also participate in this review process to address technical requirements and issues.
Establishing system requirements is a critical step in the EHR decision-making process. The system requirements identify the needs of the organization and are the basis for the vendor evaluation process. The implementation and current issues list developed by the committee will be used to develop the system requirements. Each clinic employee will receive a summary of these lists, and staff will be asked to provide additional input to steering committee representatives. In addition, the IT department will conduct a thorough evaluation of new advancements in EHRs and regulatory requirements that may impact the EMR choice. The first draft of the system requirements will be preliminary. As the steering committee begins to interact with vendors and complete site visits, additional functionality may be added to the requirements. It would not be prudent to submit RFPs to all vendors who claim to have a functional EHR. The steering committee will need to determine the top five to seven vendors, judging by the initial survey of qualified vendors, trade shows, and market information.
Well-defined system requirements will need to be established and included in the request for proposals. Packaging the system requirements in a format that provides structure for vendor responses and steering committee evaluations of vendor responses will be important, as will establishing a record of documentation throughout the acquisition process. The RFP document will provide the following:
1. Instructions for vendors
2. Organizational objectives
3. Organization background information
4. System goals and requirements
The vendors will be required to submit the following:
1. Vendor qualifications
2. Proposed solutions
3. Criteria for evaluating proposals
4. Contractual requirements
5. Pricing and support
The vendor review process will also encompass technical calls, vendor fairs, reference checks, site visits, and vendor presentations. These elements of the review process are designed to ensure that sufficient information is gathered to augment the proposals submitted by the vendors. It will not be feasible for all steering committee members to participate in these activities; therefore, individuals will be appointed to participate on their behalf.
Prior to reviewing the vendor proposals, the steering committee will develop vendor criteria that can be used to evaluate the proposals. Each member of the steering committee will be asked to score the proposals based on the criteria, and a summary score report will be developed. The Watson Community Hospital CEO will give the final approval to proceed with the conversion based on the report and recommendation from the steering committee. However, the final recommendation of the committee will not be based solely on the score report. Ideally, the final deliberations will involve a robust dialogue based on the mutual trust that has developed over time. Ultimately, the committee will balance their objective assessment of options with their intuition and their considerable knowledge of the clinic organization.
The WCH clinic organization will undergo a significant EHR transition if they upgrade the XYZ system or purchase another product. The process that is outlined in this plan provides the organization the best opportunity to make the right decision for the organization and establish support with key stakeholders for an EHR conversion. A good IT decision-making process requires discipline and objectivity. The structural elements of the process involve leadership, committee structure, system requirements, and a thorough RFP and evaluation process
1. What are the strengths of this plan? What aspects do you think are particularly important?
2. How could the plan be improved? What, if anything, might you do differently if you were leading the effort? Explain your rationale.
3. What factors should the leadership team consider when deciding whether to stay with a single vendor for supporting both the hospital and primary care settings?