Recently while on a long bike ride, my mind began to wander. I started to think about the successes that we have had when implementing the Allscripts EHR system. While the vast majority of our offices have achieved some remarkable results in reducing paper, streamlining workflows and implementing the full functionality of the EHR, others have been slower to achieve this success. I started to think about why this might be considering that all these offices were using the same software system. How is it that some offices can reap the rewards of an electronic system while other offices struggle and seem to take longer to achieve success?

I did some further investigating and found two case studies that highlight the attitudes and practices that can make or break an EHR implementation. The first case study looks at a typical scenario that leads to a very unsuccessful implementation of an EHR system. The second case study looks at a similar practice that was able to achieve huge success within a very short time frame. These two case studies are about fictitious practices, but these scenarios ring very true for those of us working in this field.

CASE STUDY #1

Setting: Private ambulatory care practice with three physicians, an office manager, a billing person and five ancillary staff

Prior to the arrival, the implementation team coordinated the details of the project plan with Dr. W, the senior physician and decision-maker for the practice. The plan included where to set up the hardware, when to train the staff, and a tentative implementation schedule. Dr. W assured the team that he understood the purpose of the EHR, what the implementation entailed, his role as champion and senior decision-maker and his business goals. The team took him at his word and did not test his comprehension of the plan and design; this proved to be a mistake.

The implementation team arrived at the office after office hours on the first day to install the hardware. The first problem encountered was technical. Although Dr. W agreed to in the initial design, he failed to install an ethernet connection to handle broadband transmission of data. The team installed the hardware and returned the next day for training. However, Dr. W was not present. Instead, the team was greeted by the office manager who was somewhat surprised by the sudden appearance of all the equipment. Dr. W had not apprised any of the staff of his intentions to implement an EHR, with the exception of vague plans he shared only with the office manager.

Dr. W was not easily reached throughout the implementation and seldom came to the office. The office manager, however, was able to assist in planning how the EHR would be integrated. Given that Dr. W had not informed the staff of the change, the office manager assumed the role of the EHR champion and the implementation team assumed the responsibility of introducing the EHR to the staff. They were able to achieve buy-in with two staff members who were excited by the new technology. The majority of the staff, however, was resistant. The billing person, who had the most power in the office after the physicians and office manager, balked at the implementation. She remarked that it would occur "over my dead body" and was obviously concerned that the billing portion of the EHR might supplant her power, or worse, her job. All staff members were concerned that Dr. W did not inform them of the project beforehand.

Dr. W, who had initially champion and coordinated the EHR initiative, was present less than any office staff throughout the implementation. Although the team was able to motivate the office manager and some of the staff to learn and to use the EHR, the team did not have authority in the office and could not compel the staff to fully cooperate. There was a lack of understanding of the technology, skills, training, and work effort required to run this project. Dr. W never took the time to fully understand the project and, thus, underestimated its complexity.

Dr. W decided that he would not learn the EHR system until his staff was adequately trained. He did not create an incentive program to reward staff for the extra time they needed to spend on this project. As a result, the staff was not motivated to use the EHR and viewed senior management (Dr. W) as being non-supportive.

Dr. W continued to be absent from training and did not make time to work with the team to customize the disease management templates and preferred drug, diagnoses and procedures databases. Without Dr. W's leadership, the billing manager continued to refuse to use the program. One of the other physicians declined to learn the system because Dr. W was not making the effort to learn it.

Workflow design was hampered by the staff's inability to answer simple questions about how patients traversed the office during a medical visit. The scheduling component or the EHR was delayed due to the inconsistent work hours for the physicians.

Followup
The implementation team returned several times over the next six months to try to revise the implementation. Training sessions were scheduled via phone, but neither Dr. W nor any office staff kept the appointments. Six months after the installation, the office manager quit and the EHR implementation came to an abrupt ending. One year later, Dr. W had a demonstration of the EHR system that was working smoothly and effectively in another office. He has since contacted the "Dr. Know" implementation team and asked to restart the process.

Discussion
The problem encountered with this practice's implementation were largely the result of failure to identify an EHR champion and lack of top management commitment and support. Even if Dr. W had delegated the role of EHR champion to another willing individual, his lack of commitment would still have derailed the process. More detrimental to the implementation is a declared champion who is absent, incapable or disinterested. In addition, he underestimated the complexity of the implementation in the EHR system itself.

Other reasons cited for the problems in Dr. W's office included poor communication, disorganization, and unwillingness on the part of employees to adopt an attitude and behaviors that would allow the EHR to be successfully integrated into the practice.

Also working against a successful implementation were a lack of a clearly defined business goal, a lack of qualified personnel with the skills necessary to run the EHR system, no clearly defined goal with time lines and milestones, and very little understanding of who the stakeholders were and what needs had to be addressed.



CASE STUDY #2

Setting: Private ambulatory care practice with two physicians, an office manager, a billing person, and five ancillary staff

Dr. Z had been interested in EHRs for at least six months before becoming part of the "Dr. Know" Beta project but was unable to purchase one due to budgetary constraints. A stipend from the health plan to help defray the cost of hardware enabled Dr. Z to move forward. He compared numerous EHR systems and then carefully reviewed his office workflow and business practices. He anticipated a short-term reduction in productivity as a result of EHR implementation and had prepared his staff for the changes in workflow that would occur.

Dr. Z was, at the same time, the EHR champion and senior management supporter for the practice. He understood that the implementation process was complex and committed his time to the training. He encouraged his staff to do the same. In contrast to Dr. Z, the staff was ambivalent about implementing an EHR system in the office. The staff possessed some technical skills, however, prior to the implementation. The staff had to use computers to check patient eligibility online. But the EHR, by comparison, was far more complex and they were afraid of the disruption it might bring to the office.

With these concerns in mind, the implementation team took small, calculated steps in training staff. As the staff grew more comfortable navigating simple parts of the EHR they became motivated to further their learning. With Dr. Z's enthusiasm motivating them the staff quickly adapted to the full EHR functionality.

Dr. Z began using the EHR soon as he was trained. Almost immediately, he began crafting his disease management templates. He selected his favorite prescriptions, diagnoses, and procedures and took other actions to customize the EHR to his practice.

Dr. Z's routine use of the EHR helped him retain what he learned during training and helped him elucidate how the functions of the EHR corresponded to his current workflow. He was able to rethink and improve his clinical and business processes. Thus, not only was the EHR aligned with his business processes, it created an environment in which those processes could be observed and improved.

The speed the process of implementation, the team was able to extract patient demographic information from Dr. Z's billing package and important them into the EHR. This saved a significant amount of the staff's time and enabled them to use the EHR to see patients almost immediately. Therefore, the disruption of workflow in the early stages of implementation was negligible.

Followup
Six months after implementation, Dr. Z and the staff continue to successfully use the entire EHR system, including the clinical, scheduling, billing, and prescribing modules. Dr. Z has been able to identify patients who need preventive care, treatment, or follow-up and who might have been missed through the manual system. His patient flow increased by 20 percent and his income by 15 percent. (This difference between volume and income is explained by the number of capitated patients for whom Dr. Z did not receive any additional income.)

Discussion
Dr. Z's success was the result of clearly defined goals and his ability to become both the EHR champion and project leader. He communicated well with his staff and allowed them enough time to train. The initial resistance was greatly diminished by his senior level support and enthusiasm for the project.

Dr. Z had anticipated a slow down in workflow but this was ameliorated by the ability to electronically transfer patient demographics from his billing system into the EHR system. His staff's basic computer skills facilitated EHR training during implementation and enabled them to learn the system quickly.

Dr. Z was cognizant of the needs of the health plan in terms of delivery of quality care and preventive medicine. He gradually initiated a culture of change in the office so that the EHR was accepted.

The implementation was a complete success.


These case studies were adapted and printed with permission from the "Guide to the Electronic Medical Practice: Strategies to Succeed, Pitfalls to Avoid," by Stephen Arnold, M.D., MS, MBA, CPE, Editor, published in 2007 by the Healthcare Information and Management Systems Society (HIMSS).