Strategies for the Successful

Implementation of Clinical
Information Systems (CIS)
like EMR/EHR
Dr Pramod D. Jacob
(MBBS, MS Medical Informatics)
Strategies to implement EMR
Introduction

Background:
 EMR/EHR not many stories of success
 Not a question of if but when

My background and experience in EMR/CIS

Strategies to implement EMR
Secret of success-1

The Clinicians (doctors , nurses, OT, PT etc)

should perceive that the EMR/CIS system is
designed, modified and used by them, for
them and of them.
Buy in and ownership.
Strategies to implement EMR
Secret of success-1

The Clinicians (doctors , nurses, OT, PT

etc) should perceive that the EMR/CIS
system is chosen, designed, modified,
used and souped up by them, for them and
of them.
Strategies to implement EMR
Concept of the EMR/EHR:-

Functions
 Order Entry and Transmittal
 Clinical Decision Support
 Clinical documentation – history , progress notes.
- Messaging system- abnormal results, refer
 Can export/import healthcare data
Strategies to implement EMR
Truisms of the EMR

 Every patient is affected by the EMR

(unlike CT scans, MRI etc).

-The EMR is not a magic bullet - will

amplify inefficiency, incorrect processes and
incomplete data input.
Strategies to implement EMR
The EMR is not a magic bullet

 Will bring in efficiency and better outcomes

if
( proper process redesign, workflow streamlining,
design and functioning of the system done.
and
buy in and ownership by clinicians. )
Strategies to implement EMR
Truisms of the EMR

EMR is intensive in capital cost, labor and

time
Don’t be cheap when going for it
Anticipate stress , effort and cost over several
months (maybe even years)
No short cut
Strategies to implement EMR
Legacy of the EMR

 Devices for input/output (tablets, laptops, and smart phones)

will become obsolete

 Legacy of the EMR system is the database and the health

care information e.g. iPod

 Concentrate on the quality of healthcare information being

collected and exchanged
Dynamics of interaction in EMR
implementation
Clinicians
Management/
(doctors/nurses)
Policy makers

Information
Technology
Interactions in EMR implementation

 Needs absolute top management support

 Many different levels , departments and

stakeholders need to work together

- Policies by policy makers/management

 Prevent us V/S them feeling , should be we

Strategies to implement EMR
 Secret of success- 2

 People management

 Change management

 Technology management
Strategies to implement EMR
Secret of success- 3

Communication in the EMR project:-

 Keep clinicians and healthcare organization in the

know- show and tell presentations, email updates,
EMR newsletters
 Major opinion and buy in is through word of mouth
among clinicians
 Best advocate – clinician who was difficult at first
Strategies to implement EMR
Secret of success- 4

Make the EMR a prestigious project

 Welcome to 21st century healthcare
 Reduction in patient visit time
 Get reports of provider statistics , disease
pattern etc
 e.g. courthouse
Sequence of a Healthcare Organization going
in for a Clinical Information System like the
EHR

Health organization researching

Clinical Information Systems (CIS) like EHR

Learn and get educated about CIS

 Are they ready
for CIS ?

Yes

Product and vendor

Selection

CIS Implementation project planning

 Design, Build and Validate the CIS

Implement in the test pilot site

Roll out CIS to rest of the organization

Stage of optimization and feedback

“Souping” up the CIS

Value addition services

Strategies to implement EMR
Core Clinical Team

 Lead doctor (doctor champion)

 Experienced clinic/ floor nurse
 Clinic Manager/ Ward Manager
Core Clinical Team
Lead doctor desired characteristics

- Experienced, Respected, Influential, Hard working

 Tolerant- way with people
 Savvy with new technology- power end user
 Logical – able to think out algorithms
 Enthusiastic – truly believe in EMR
 Should devote time to EMR implementation
Core Clinical Team
 Experienced nurse- clinic/ward nursing care
processes , tolerant, tech savvy.

 Clinic Manager, Ward Manager- clinic/ward

policies, management procedures and
resources deployment, tolerant , tech savvy.
Strategies to implement EMR
EMR Vendor and product selection:-
 EMR long term investment
 Vendor for the long haul ( marriage -Epic
wedding march tune )
 Comprehensive EMR product (order entry, clinical
documenting, decision support, messaging, data to/fro)
 Involve core clinical team
 Extensive research and evaluation
Strategies to implement EMR
Healthcare Information Flow in the EMR:-

 EMR patient centric

 Design the processes and workflows following the

patient through the clinic visit/ hospital episode

 The other perspectives such as doctor’s , nurse’s

and other health worker’s will fall in place
Strategies to implement EMR
Healthcare Information Flow in the EMR:-

- Start from most “vanilla” to more specialized

e.g. Family Practice then Medicine then
Cardiology ( like a patient’s experience )
Fa Inte Ca
mily rnal
Pra
rdi
Me
ctic dici olo
e ne gy
Healthcare Information Flow EMR:-
Width rather than depth
Start - many patients with some information rather
than few patients with all information . Over time
most patients will get most of their healthcare
information in the EMR system
 Basic Patient Data
. Name : Test Naik
Patient’s Age: 58 yrs ID : 27456343
Address : B5, Palm Grove, Miramar , Panjim, Goa. Tel : 0832-2943344

Diagnosis List Recent

- Hypertension Test
- Diabetes Mellitus Results
- Hepatitis A
Active Medication List
- T. Hydrochlorothiazide
- T. Metformin Hydrochloride

Allergies
- Penicillin
Strategies to implement EMR
Implement from most enthusiastic, tolerant
and positive to less enthusiastic , positive and
tolerant

Most
To Obstructive,
enthusiastic,
negative
positive
Healthcare Information Flow
Ambulatory (OPD) first then Inpatient

 Ambulatory more of a longitudinal record e.g.

trends of Diabetic and Hypertension control

 More important for Inpatient to know what

happened in the OPD (rather than other way)

 Ambulatory 9 to 5 ; Inpatient 24 X 7 and

Healthcare Information Flow
Ambulatory (OPD) first then Inpatient

 Ambulatory input mainly by doctors , Inpatient

input mainly by nurses

 Inpatient EMR main appreciation for features

like clinical decision support, work lists,
eMAR rather than the information recording
Strategies to implement EMR
Opportunity for process re-design and
workflow stream lining healthcare delivery
more efficient , less time consuming , more
comprehensive and holistic. Shake the boat,
bring about change for the better.

Example:- Clinic pharmacy process, workflow

redesign.
 Provider B's Avg Cycle Time

400
350
300
250 Tot A.C.
Minutes

200 E to CO
150 W.R.
100
50
0
05-Sep 05-Oct 05-Dec 06-Feb
Date
Strategies to implement EMR
Opportunity for process re-design and
workflow stream lining
 Objections to change.
 People management skills and negotiations to
get buy in or compromise
 Be Flexible
Is it good enough ?
Can you live with it ?
Strategies to implement EMR
Perceiving benefits of EMR

 After go live- 2 months for benefits of the

EMR perceived
 Need repeat visits to build up database with
patient healthcare information e.g. -trends in
BP, blood glucose test results of a given
patient.
- Will see benefits earlier in “ frequent flier ”
Strategies to implement EMR
Clinician productivity after EMR –
 Productivity comes down
 Initially steep learning curve
 After comfort level in EMR, then about 90 %
 Less in specialties like Geriatrics ( multiple problems)
 May increase specialties like pediatrics- templates for
well child visits.
Strategies to implement EMR
Training
 Computer skills assessment and training

 EMR training-
Lots of screens and icons, many new processes
and workflow methods- some policy driven
and un-intuitive

- Steep learning curve

Strategies to implement EMR
Training
EMR training-

 Spend money , time, effort and loss of productivity

to do proper training. Schedule classroom time
outside office time or give time off for attending
these classes.

 Not more than one week gap between training and

go live.
Strategies to implement EMR
Reduction of schedule during go-live
e.g. 50 % first week then 75 % for next two weeks

 Learning period for the EMR system- steep

learning curve
 Abstraction of basic patient data for every
patient in system ( diagnosis list, active medication
list, allergies )
Strategies to implement EMR
Support and help during go live

 Elbow support very important – one support

for every two doctors.
 Doctors don’t like to be seen unable to
navigate the system by their patients
 Extra healthcare support staff like temporary
clinic nursing staff
Strategies to implement EMR
Correct interval between go lives

 Too slow- implementation can be tedious with

temporary dual systems workflows
 Too fast- clinician users will become frazzled,
not enough support time to reach comfort zone
 Two or three successful go lives - peer pressure
on remaining clinics /departments to do
successful go lives
Strategies to implement EMR
Hard Stops and Alert Fatigue-
 Minimize hard stops to truly important fields
that need to be completed before moving on.

- Have alerts that are clinically very important

like severe drug drug reaction – level 3 .
Otherwise will lead to Alert Fatigue e.g. MS
Windows Vista
Strategies to implement EMR
Review Rounds-
 Review round of users individually one month
after go live
 Sort out issues, offer tips on using EMR better
( short cuts or better navigation), change bad
habits (allow for personalization)
 Allay fears and concerns
 Help them get to the comfort zone
Strategies to implement EMR
Personalization :
- More than one method of doing a task in EMR
- Recognize that individuals will choose what
they are most comfortable with.
- Don’t force them into the most efficient way
e.g. copy and paste.
Strategies to implement EMR
Optimization Rounds:
- After six months round for optimization.
- Input and suggestions from the clinician users,
more efficient work around and short cuts
- Revisit some of the processes and workflows
for improvement
- “Souping up” the system with clinical
decision support features, templates and other
“bells and whistles”
Strategies to implement EMR
Summary

 Secret 1- Clinicians buy in and ownership

 Secret 2- People management, Change
management, Technology Management
 Secret 3- Communication
 Secret 4- Make EMR prestigious project