Electronic Health Record Travel Blog (Part 3)

T-29.?If you don't learn anything from this blog post, know that ?Provider Adoption is a thing for a successful EHR implementation.

Knowing your culture before you deploy an extensive application like an EHR is critical. I arrived at the organization seven months before go-live, and we were behind in a myriad of deliverables. My goal was to focus on the past due deliverables quickly. Still, I also prioritized learning the organizational culture by watching and observing the organization leadership, gauging risk appetite, and the IT Department's relationship with its customers. The knowledge gained was crucial in appealing to the clinical staff for engagement months later. A medical center is busy. A medical center in the middle of a pandemic is crazy busy. A medical center that is a Level 1 trauma center in the 7th largest city in the country is crazy ridiculous busy. Now add a new system that will sunset four major clinical applications of inpatient, outpatient, emergency department, and dental--which means every single clinician (around 9,000) will be affected across over 70 buildings and throughout South Texas.

Once I realized this, I kept wondering how do I not be Alexander and have a Terrible, Horrible, No good, Very Bad Day.

However, you eat an elephant one bite at a time, and that is how I approached this project. A few nuggets of wisdom:

• Assess how comfortable the organization is with new and emerging technology and change. Use survey tools to ascertain your organization's willingness to embrace new technology. Ineffective change management is the most significant barrier to an EHR deployment. Fortunately, the Department of Defense is a leader in change, and BAMC has been recognized as Most Wired multiple times over the years and the leader of emerging technology for years.

Picture below: In 2019, I was the CIO of Carl R Darnall Army Medical Center in which we were recognized and I also accepted the Most Wired award for BAMC in 2019 for LTC Peter Huynh, who was the CIO at the time).

• Recognized if you don't have sufficient clinician buy-in or staff committed to the project, you run the risk of encountering user resistance and potential failure because of inadequate engagement and training. To counteract this belief, you must demonstrate the value of the application either through increased efficiency, improved communication, streamlined workflows, or quality of information.
• The very minimum is to have a robust informatics steering committee where the clinical community can discuss their concerns. If clinicians cannot be a part of the design, which is commonplace with many EHRs providing out-the-box solutions, at the minimum, at least LISTEN to your teammates and ELEVATE their concerns and challenges. As a CIO, I ensure that clinicians have the tools to do their job. If the EHR is a safety concern, I owe them a platform to highlight their concerns. The clinical team and I have the same goals of safe, quality care. If the care providers do not feel they are providing that basic premise, I must ensure that any concerns are given proper due diligence to the vendor.

It is also imperative to recognized how workflows affect different clinical groups.

• Changes in workflows that affect nurses' and physicians' time are challenging for users to accept. A process that may have taken a few seconds and now might take several minutes could be frustrating. Role assignments with a new EHR may not allow as much access as previously, which could delay care.
• Recognize the workflow changes with the EHR and determine who will change the most. This group will likely be your resistant group, which you must target early and often. For us, this was inpatient nursing as they will feel the brunt of the workflow changes, but schedules cannot be reduced to accommodate time with the new application. The key is to have specific nursing informatics colleagues who will be able to engage directly with the team and address the concerns. We had two nursing informatics from inpatient services who were embedded in the IT Department. Informatics involvement is our superpower.

Provide resources to ensure success. As they say, go big or go home. This is not the time to skimp on resources.

• User acceptance comes from confidence in the EHR. To build confidence, allow as much familiarization of the system as possible. Our organization sent 150 staff members to various hospitals using Cerner to see the product in action.
• ?Provide dedicated resources to the EHR deployment. This sounds simple, but who has staff members sitting around. Our medical center may have thousands of doctors and nurses, but we also lead the charge in assisting states overrun with COVID cases. We had teams of nurses, techs, and physicians sent all over the region during our prep. However, it is crucial to fence off a few people who understand the system and work behind the scenes to ensure all the toll gates are met. This will pay off in the long run.
• Ensure you engage in all the activities that allow for familiarization. With Cerner, it is the ability to log in to verify correct role assignments, customize routine medication and order sets, and run through patient scenarios for familiarization with the clinical team in addition to training. Additionally, encourage attendance to change management sessions, design builds, and integration validation. This will allow a peek of the system and the new workflows.
• Do not forget your administrative and IT staff roles and responsibilities. We had to add hundreds of network drops in the hospital -mainly inpatient rooms. It required engagement with our bed manager and cabling team. The team staged as much equipment as possible, but we had to bring additional contract staff to perform services quickly when beds were available.

Implementing an EHR requires a significant amount of planning and preparation. However, provider adoption is the critical area that will deliver success. Ensure you have representation from the various departments as part of your steering committee and clinical informatics leading the charge for engagement. Clinical champions are helpful as well as they can solicit input for areas of concern and provide the implementation team quality feedback. Leaders should understand the EHR value to your facility will be realized over time. It will happen as staff is more familiar with the applications, learn how to optimize the system, and provide input to improve. Value realization will not occur overnight, so allow grace as the staff is hesitant to embrace it fully. Trust is the key.?