Migration to an Electronic Health Record System, Part 1

Introduction

An important topic when we are beginning the process of preparing to select and implement an Electronic Health Record (EHR) is to determine the process that your organization will take to migrate to an EHR, based on the systems that are already being implemented.

Migration to an Electronic Health Record System

Electronic Health Record Life Cycle:

  • User Needs Assessment*
  • Prototype Development*
  • System selection*
  • System implementation
  • Maintenance

* Covered in this unit

In this unit, we will be discussing the Electronic Health Record Life Cycle.

The components that are covered in this unit are user needs assessment, prototype development and system selection.

The remainder of the components will be covered in future units.

How To Begin Migration to an EHR

  • Develop a Strategic Plan Including the Migration to an EHR
    • Review the Mission and Vision of the Organization
    • Make modifications if necessary that will move the organization towards a quality EHR to improve patient care
    • Develop goals that are reasonable, measurable and tactical
      • Describing the planned migration to the electronic health record including
        • An effective needs assessment phase,
        • A strong migration steering committee that is inclusive of user needs
        • An understanding that this is an ongoing process
      • Developing a timeline for choosing and implementing an electronic health record
      • Assuring the financial and human resources to plan, select, implement , and maintain an EHR

When beginning migration to an EHR, it is important to develop a strategic plan that outlines the process you will take.  Strategic planning will establish the overall purpose and the goals you wish to achieve. In order to have a successful EHR implementation, you will need to understand where you want to go and how you will get there.

There are three basic steps in the development of a strategic plan.

  1. First, it is important to review the mission and vision of your organization and ensure that it is current. The mission will describe who you serve and the vision will provide a view of the future that can be communicated throughout the organization.

  2. Second, if it is not current, this is the time to make modification that will help move the organization towards a quality EHR that will improve patient care.

  3. Third, develop goals that are reasonable, measureable and tactical. We will discuss this in more detail in the next section.

User Needs Assessment

  • Each organization will need to determine what the needs are for an EHR
  • Some organizations will have components of an EHR while others will be starting at ground zero
  • To receive federal funding, though, certain components will be mandatory to each system (see meaningful use unit)
  • In this unit, we will focus on the basic principles guiding migration to an electronic health record

Developing realistic goals is an important step. These goals should be reasonable, measureable and tactical.

  1. The first step when developing goals is to describe the planned migration to the electronic health record. This includes describing a needs assessment phase, developing a strong migration steering committee that is inclusive of user needs, and ensuring that there is an understanding that this is an ongoing process.

  2. The second step is to develop a timeline for choosing and implementing an electronic health record.

  3. The third step is to verify that the financial and human resources are available that will be required to plan, select, implement, and maintain an EHR.

User Needs Assessment Tools  

  • A needs assessment is part of a basic management tool set which will be effective in the decision-making process of migration to an EHR

  • Many tools are available from the state quality improvement organizations, regional extension centers, consultants, and vendors. An example of a toolkit which includes needs assessment is from Stratis Health the QIO for Minnesota.

  • http://www.stratishealth.org/expertise/healthit/clinics/clinictoolkit.html

It is the intention of this unit to acknowledge that there are assessment tools available from many sources. An individual organization will need to find a tool that best suits their facility.

One item we mentioned earlier was the importance of an effective needs assessment phase. One portion of this is to complete a user needs assessment.

This refers to the process of identifying the system technology and software that is needed to advance to an EHR.

Each constituent unit in an organization will need to determine what the needs are for an EHR.

The needs for each organization will vary because some organizations will already have components of an EHR while others will be starting at ground zero.

To receive federal funding, though, certain components will be mandatory to each system. When studying meaningful use, you will learn more about this requirement.

In this unit, we will focus on the basic principles guiding migration to an electronic health record.

Prototype development

  • Each organization will need to evaluate their specific needs to migrate to an EHR.

  • Remember, each organization is unique.

    • Some organizations have basic electronic functions such as billing and coding, scheduling and no clinical documentation ( patient progress notes, lab results) In other words it is a “paper medical record.”

    • Some organizations will have hybrid EHRs with some scanned documents and some electronic systems, e.g. pharmacy, lab results, radiology results

    • Some organizations will be completing electronic with online documentation systems for all providers, online order entry systems, and integrated lab, radiology, etc, systems. These are referred to as “paperless.”

There are many tools available on the Internet and in a variety of books that can provide guidance on the development of a user needs assessment.

A needs assessment is part of a basic management tool set which will be effective in the decision-making process of migration to an EHR.

Many tools are available from state quality improvement organizations, regional extension centers, consultants, and vendors. An example of a toolkit which includes a needs assessment is from Stratis Health, the Quality Improvement Organization for Minnesota.
 
It is the intention of this unit to acknowledge that there are assessment tools available from many sources. An individual organization will need to find a tool that best suits its goals.

Prototypes: Start Where You Are  

  • No electronic systems: at ground zero

  • Legacy Systems: computerized systems that were developed by the organization’s staff

  • Legacy Systems with some vendor solutions: systems that have added on components with the legacy systems with no/some interoperability

  • Vendor systems: vendors systems used to develop computerized and/or electronic systems
When planning for prototype development, each organization will need to evaluate their specific needs to migrate to an EHR. Remember that each organization is unique.

Some organizations have basic electronic functions such as billing, coding and scheduling, but no clinical documentation.  Clinical documentation refers to patient progress notes and lab results. In other words this is a “paper medical record.”

Other organizations will have hybrid EHRs with some scanned documents and some electronic systems. These electronic systems are likely to include pharmacy, lab results, and radiology results.

While some organizations will be completely electronic with online documentation systems for all providers, online order entry systems, and integrated lab, radiology, and other systems. These are referred to as “paperless” environments.

System Selection  

  • The development of ongoing systems towards the migration to an EHR includes decision making about potential new systems

  • Developing a project team to make decisions for the organization
    • Critical to success
    • Involves careful selection of team members
    • Needs leadership

The development of ongoing systems towards the migration to an EHR includes decsion making about potential new systems.

Developing a project team to make decisions for the organization is critical to success, involved careful selection of team members, and needs leadership.

In order to plan for a prototype development, start where you are in your organization. Organizations will vary with the type of technology and software. 

There are organizations with no electronic systems and they will be starting at ground zero in migration to an EHR.

Others may have legacy systems. These are computerized systems that were developed by the organization’s staff over a period of years or they may have been vendor-purchased.

Then, there are organizations that have legacy systems with some vendor solutions. These are systems that have added components to the legacy systems without or with some interoperability.

Other organizations have one vendor with many integrated systems. In this case, a primary vendor system was used to develop computerized or electronic systems.

Migration Project Team  

  • Migrating to an EHR needs leadership.

    • Adler said “Study after study on EHR implementation reports the same thing: People are key, and leadership is one of the biggest issues.

    • An EHR project needs three kinds of leaders: a physician champion (or two or three), a CEO and a skilled project manager.”

The project needs someone with information management skills. This may be the champion of the project, and information technology professional in the organization, a vendor or consultant or a combination of team members who are interested in migration.

System selection is the third step of the electronic health record life cycle that we will discuss in this lecture.
 
The development of ongoing systems towards the migration to an EHR includes decision making about potential new systems.
 
Developing a project team to make decisions for the organization is critical to the success of these systems. This involves careful selection of team members and requires strong leadership.

Choosing the Migration Team  

  • Champions
  • All clinical areas affected
  • All ancillary areas affected
  • Non-clinical areas that use data collected
  • Change agents
  • Technology specialist
  • Work flow analysts

The selection of the migration project team is very important, as is the leadership of that team.   
 
Adler said that "Study after study on EHR implementation reports the same thing: People are key and leadership is one of the biggest issues. An EHR project needs three kinds of leaders. These are a physician champion, a CEO, and a skilled project manager."
 
The project needs someone with information management skills. This may be the champion of the project, an information technology professional in the organization, a vendor or consultant or a combination of team members who are interested in migration.

Responsibilities of the Team  

  • Conduct needs assessment
  • Develop/ support efforts for the Request for Information/Request for Proposals
  • Develop criteria for selection of system
    • Only include vendors that meet ONC criteria for a certified EHR
    • Develop additional criteria that will support the needs of your organization
  • Recommend through discussion/decision-making (or delegation)
    • Big bang or not (with work-flow analysis)
    • Vendor selection (seeing presentations of systems, making visits to other facilities that have them)
    • Ongoing training prior to, during, and after implementation (this includes addressing change management concerns as well as system training)

Developing a team for the migration project includes finding both clinical and non-clinical champions. These are the people that will encourage others in the organization to move towards an electronic environment.

Including staff members from all the clinical and ancillary areas affected by the change is essential to understanding everyone’s needs. The medical record has always been communication tool for the health care team, but not all practitioners understand one another’s data needs or roles.

There are also many end users of the collected documentation who need to be a part of the project team.

The team should be made up of change agents. These are individuals who see the need to move forward and are willing to deliver on the goals and objectives of the strategic plan for an EHR. This may also include those who will be developing the organizations change management program.

Initially, in-house information technology specialists should be involved in the team’s work. After a vendor is selected, it is common to include a vendor consultant in the team.

Including work flow analysts on the team will provide the group with insightful information about the processes for changing work environments. Planning for an EHR is not just about the software and hardware. It is about the flow of information, and the needs of those using the systems.

When we refer to “users” of the system this includes both clinicians and non-clinicians. This also includes the work flow of the various users.

Although the project team may delegate some of the work that needs to be done, the team needs to keep very involved in the process so that when a decision needs to be made about the system selection, they will be able to do so with confidence.

This slide lists some common responsibilities of the team.  These responsibilities may be delegated to others in the organization, but the project team orchestrates the process.
 
We will now discuss some of these responsibilities of the team.
 
First, the team should conduct the needs assessment that will determine what type of system is required to fulfill the needs of the users of the EHR.

Next, develop or support efforts for the development of the request for information (RFI) and request for proposals (RFP).  Some organizations may utilize Internet research in place of the request for information.

When writing the RFP, develop criteria for selection of a system. Remember to develop additional criteria that will support the needs of the organization. Include only vendors that meet the national criteria from the Office of the National Coordinator for a certified EHR.

The project team must spend enough time reviewing the needs analysis, discussing the pros and cons of doing a "Big Bang" approach or focusing on one system at a time during implementation. Completing preliminary work flow analysis in a few areas may help to determine the readiness of the users and the environment. Before making a decision about a particular vendor, it is important to have adequate demonstrations of the system with all stakeholders. It is best to visit other sites that have used the system to see it in action.

Ongoing training prior to, during, and after implementation is very important to the success of an implementation. 
 
Although the project team may delegate some of the work that needs to be done, the team needs to remain very involved in the process so that when a decision needs to be made about the system selection, they will be able to do so with confidence.

What is a Request for Information?  

A Request for Information is a tool to ask vendors about their products.

For an EHR it is important to find vendors who are certified by the Office of the National Coordinator.  This will be discussed in more depth in the unit on meaningful use.

The people who manage the electronic systems at an organization use the RFI to keep abreast of current vendors and their products and how they could meet the organization’s needs.

What is a Request for Proposal?

A request for proposal (RFP) is an open request to vendors for specific answers to the needs of an organization.

Remember, each organization is unique. Some organizations have basic electronic functions such as billing and coding, and scheduling. Some organizations will have hybrid EHRs with some scanned documents and some electronic systems which may include pharmacy, lab results, and radiology results. Some organizations will be completely electronic with online documentation systems for all providers, online order entry systems, and integrated lab, radiology, and other systems.

Developing the RFP  

Criteria for an RFP will include many different items. The list included here is not inclusive of all criteria. The project team will develop a list of criteria and a rating scale to help with the process of decision-making. An RFP alone is not the decision-making factor. The project team will want to have vendor demonstrations of products, and in-depth discussions of costs and benefit of the product. The RFP is an important step in the process.

RFPs : Legal Documents towards the Migration Process  

The RFP is a legal document towards the migration process.

An RFP answers the questions of how a vendor will meet the individual organization system needs.

It should include a summary of costs for new or upgraded hardware, software which includes interface and system software, and training during pre-implementation, implementation, and post-implementation.

It should also address support of the project from the beginning to post-implementation.

It needs to state the implementation methodology and post implementation assessment tools that will be required.
 
Since the RFP eventually leads to a legal contract, it is an especially important document to the organization and to the vendor. 

Resources

  • Adler, Kenneth.  How to successfully navigate your EHR implementation. Family  Practice Management, 2007 Feb; 14 (2): 33-39

  • Valerius, Joanne.  The electronic health record: what every information manager should know. The Information Management Journal January/February, 2007, 56-59

  • The RFP Process for EHR Systems. Journal of AHIMA 78, no. 6 (June 2007): 73-76.

Next: Migration to an Electronic Health Record System, Part 2

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