EHR Implementation — Big Bang or Staged? What You Should Know.

Big Bang describes an implementation where a practice begins using all of the functions at the same time. A staged implementation refers to a practice that gradually starts using a defined subset of EHR functionality before implementing more functionality; this process is then repeated until all of the functions of the EHR system are implemented. The advantages of each approach have been endlessly debated amongst health IT wonks. My view is that the best approach falls somewhere in the middle and may differ for each practice. Before going into the pros and cons of each approach, it is important to elaborate on some of factors that may limit the options your practice considers.

Unfortunately, many EHR vendors are currently suffering from severe resource constraints and may not be able to facilitate staged implementations, especially in smaller practices.  If they are able to support staged implementations, the cost for this type of implementation may be higher, as their on-site training staff may be less efficiently deployed. Many EHR vendors are increasingly relying on interactive online training models that allow practices to train on their own schedule. This approach requires less one-on-one interaction, reducing the demand on trainers and how much vendors charge for training. Practices can also reduce the need for vendor training by utilizing a super-user model where a few clinicians and staff receive extensive training on the use of the system and then help train the rest of the practice.

Big Bang:


  • Theoretically faster as all of the functionality is available at go live.
  • Onsite training can be completed in a single block of time, reducing the costs of training.
  • The drop in productivity experienced after all EHR implementations can be shorter, even though it may be more substantial. This is because staff are not continually trying to learn new technologies.
  • Disruptions caused by the unnatural segmentation of tasks, e.g. the documentation of a patient encounter on paper and then electronically prescribing a medication, are avoided.


  • The scale of change can be overwhelming.
  • There may be incomplete or failed adoption caused by the inability of the practice to adjust to the new system.
  • Productivity loss is frequently larger than with staged implementations as everyone struggles to learn the system simultaneously.
  • Errors or glitches can cascade through the system affecting all of the operations of the practice.  Some practices have reported a loss of all revenue for over three months due to glitches in the interface between the EHR and PMS system that were not effectively tested during go live.

If you decide to go with a big bang approach, I recommend a thorough testing all of the systems to be implemented before go-live. In addition, complete the bulk of the training before the system rolls out.



  • More manageable amounts of change.
  • Productivity drop experienced during implementation can be less severe.
  • More time to test the system. Glitches and errors can be reduced, as they tend to be limited to the modules that are being actively implemented.


  • Theoretically can take longer.
  • Change fatigue can lead to incomplete implementations.
  • The productivity drop can last for longer periods of time.
  • Systems designed to work when implemented as a whole may not function without substantial workarounds.
  • Workflows developed when using isolated components of the system in isolation of each other may not be applicable when using the system as a whole.

Given the complexity of current EHR systems it is unlikely that even the most motivated individuals will be able to start using all features simultaneously. Thus, regardless of whether your practice makes a conscious decision to implement only a portion of the available features, your implementation plan should include benchmarks that can be used to assess the level of adoption at an individual level. You should also anticipate the need for additional training, once your practice achieves a basic level of proficiency using the system. This is necessary, as many of the advanced and nuanced features will likely have been forgotten and/or neglected in order to accomplish the tasks essential to the daily operation of the practice. Regardless of the implementation model you choose, the optimization process is critical if you want to maximize the efficiency of your practice and the quality of your care.

For all of those who have been through an implementation, please take a few minutes to share your experiences. Would you recommend a staged approach or opt for the Big Bang?


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