Over the years I have spoken with many physicians, practice managers, and change management consultants about the process of EHR implementation. What makes for a successful implementation? How can a practice improve their chances of success?
One of the most important requirements for success is to establish realistic personal expectations. Certain system functionality needs to be present, e.g. the EHR allows the physician to generate prescriptions electronically or record notes using free text fields, drop down menus, and templates; however, usability requirements are not always immediately apparent. Expectations often relate to data input and recording clinical notes in the EHR. Some clinicians prefer to record information graphically with liberal use of diagrams. Others prefer free text entered in a narrative format. Few clinicians would choose rigid structured note taking over a system that allows for greater flexibility.
And herein lies the natural tension. For data to be extractable for reporting, quality improvement metrics, etc., it must be entered in a standardized format. As a simple example, if blood pressure was entered in different ways, e.g. 120/70 versus one hundred and twenty over seventy, the EHR would not know that they meant exactly the same thing. Finding the balance between structured and non-structured data is difficult, as a system that is too structured can be felt to impact the ability to accurately present the nuances of an individual’s clinical condition. Similarly, an EHR that allows too much flexibility may not be able to produce the reports necessary to report on Meaningful Use measures or demonstrate improvements in quality of care.
If a clinician expects not to have to change some of his/her practices regarding note taking, the result for the practice can be extremely negative. I am aware of instances in which a physician has refused to use the EHR post-implementation to record clinical notes because it does not match their style of practice.
A number of other discussions also frequently come up. Some of these requirements relate to deficiencies and readiness to adopt the EHR, e.g. ensuring that all members of the practice have foundational computer skills, can type and use the Internet, email, and a word processor. Other requirements are operational in nature, such as ensuring there is an individual who has been designated to be the practice champion or lead and understands the level of commitment that will be required through the implementation. It is not difficult to see that if unresolved, expectations can create a significant problem for the practice.
When setting expectations, think very carefully about what you expect to remain the same post-EHR implementation, and what you would like to change. Then make sure you discuss and validate these expectations with all members of the practice and your EHR vendor before proceeding. In this case, an ounce of prevention may be worth a pound of cure!
Have you been disappointed with your EHR’s ability to document clinical notes? How did you overcome expectations and reach consensus in your practice when you implemented your EHR? Add your comments.