The following fascinating article appeared a little while ago.
EHR Success All in the Details
APR 30, 2012
There's always something. Whether it's a pasture of COWs (computers on wheels) gathering dust, dead spots in your Wi-Fi coverage, or clinicians who want an unmanageable amount of customization, no EHR effort is without glitches. The eight providers below are doing about as well with EHRs as anyone-they are collecting meaningful use dollars, have reached Stage 7 on the HIMSS Analytics EHR adoption model, or have won a HIMSS Davies award for their implementations.
Health Data Management asked CIOs and other technology leaders to share their experience: what they wish they had known when they began, what they would do differently, what they still struggle with.
While their suggestions ranged across all aspects, there was widespread agreement about one thing: don't skimp on screens. Reliant Medical Group started out with 17-inch and 19-inch screens at its vendor's recommendation. Director of Medical Informatics Lawrence Garber, M.D., wishes they were 23 inches, which is what the vendor is recommending currently. Tom Smith, CIO of NorthShore University HealthSystem, recommends two screens, one for data review and one for charting-and again, the bigger the better. Following are more tips.
Boston Children's Hospital
Daniel Nigrin, M.D., CIO
Vendors: Cerner/Epic
HIMSS Analytics Stage 7
* Focus on nurses. When you hear about EHR implementations, a lot of attention goes to how you make it appeal to doctors, but once all your systems are automated, you realize that the nurses are the ones who interact with it on a daily basis, far more than doctors do. A lot of the success or failure of an implementation revolves around accommodating nurses' needs and their workflow. When we did CPOE and nursing documentation, we got a lot of great feedback from the nurses before the doctors had to interact with the system, and when they did, the system was more stable and responsive and better set up. Also the nurses were able to give a lot of assistance to the doctors.
* Implement point-of-care medication administration early. We implemented it relatively late. We saw a reduction in medication errors when we went live with CPOE, but a much bigger one when we went live with bedside bar-coding. We always expected there would be an improvement but the degree caught us off guard.
* Standardize-but don't overdo it. When we implemented our systems, we looked at our existing processes and recognized that each floor had a different way of doing things. We used the implementation of the EHR to standardize, but I think we went overboard, in a few instances. Sometimes there is a darn good reason why something is the way it is, and if you change it you break something important.
The standard presentation of data works fine for patients on general units, but we got a lot of feedback that intensivists and nurses weren't able to synthesize the patient the way they had been able to do with their tri-fold piece of paper. They couldn't get a broad overview of what was up. We worked with our vendor to take the existing data and give them a better, customizable presentation. Now that capability is available as a commercial product.
Citizen's Memorial Hospital, Bolivar, Mo.
Denni McColm, CIO
Vendor: Meditech
HIMSS Analytics Stage 7
* Consider the environment as well as the device. When we eliminated the paper chart, we needed a place for providers to go. They were used to going to the nurses' station to write orders and do charting. We gave them COWs and tablets at first and they didn't use them. They told us they didn't write orders in the room even when they were using paper. We converted an office into a physician resource room, next to our med-surg unit. It's stocked with computers, phones, microphones, and large screens. That room also ended up as a location for us to support them. We have someone there Monday through Friday for three or four hours. Every time we stopped staffing it, physicians would call.
* Consider the provider-patient relationship. We didn't train much on how to use the EHR in a way that engages the patient. We assumed it would make sense at the time. We've since helped the nurses learn to show patients the screen while they're putting in the data. It's part of an inpatient engagement strategy, but it helps the users because they get the documentation done as they're doing the care and don't have to do it later.
* Pay extra attention to physician communication, even if you don't think you need to. We thought the quiet ones were getting along fine, but we hadn't given them a way to say what they wanted changed. We had to give them a special number to call and a place to send written suggestions, and we asked them how things were going. Some wanted to talk with other docs and have everyone hear them, so we held forums. Also, if something was easy to solve, we would solve it, and we would assume they noticed, but often they didn't try something again. It made a big difference when we followed up to point out that we had solved their issue.
* Watch out for conflicting world views. In the pharmacy they set things up based on the drugs they have in inventory, so you might be able to order 60 mg of a certain drug as either three tablets or two. The EHR was initially set up the same way, but the docs were confused by it and were ordering the wrong quantities. Now the front end just shows the number of milligrams ordered.
The other seven CIO’s points are found here:
This is obviously a great collection of hard earned wisdom and really must be read and thought about by all interested in the field. One of the best articles I have seen in years.
David.
