Signature Leadership Series

Health Care Leader

Action Guide on
Implementation
of Electronic
Health Records
July 2010
Copyright © 2010 Health Research & Educational Trust and College of Healthcare Information
Management Executives

About HRET
Founded in 1944, the Health Research and Educational Trust (HRET) is a private, not-for-profit
organization involved in research, education and demonstration programs addressing health
management and policy issues. HRET, an American Hospital Association affiliate, collaborates with health
care, government, academic, business and community organizations across the United States to conduct
research and disseminate findings that shape the future of health care. Visit HRET's Web site at
www.hret.org.

About CHIME
The College of Healthcare Information Management Executives (CHIME) is an executive organization
dedicated to serving chief information officers and other senior health care IT leaders. With more than
1,400 CIO members and over 70 healthcare IT vendors and professional services firms, CHIME provides
a highly interactive, trusted environment enabling senior professional and industry leaders to
collaborate; exchange best practices; address professional development needs; and advocate the
effective use of information management to improve the health and health care in the communities they
serve. For more information, please visit www.cio-chime.org.

Disclaimer: This guide is intended for educational purposes only. Consult a qualified expert when
implementing an electronic health record.
 EXECUTIVE SUMMARY

The purpose of this guide is to provide hospital chief executive officers and other members of the
executive team with a basic understanding of the challenges of implementing an electronic health record.
The guide is organized into high-level categories that executive teams should consider in planning and
implementing an EHR.

This guide does not fully address the EHR selection process or meaningful use certification. When the
meaningful use final rule is announced and fully understood, CHIME and the AHA will provide more
specific guidance that will complement the information in this guide. For specific questions, please
contact [email protected] or [email protected].

The high-level categories that CEOs should consider include:

Gather the Executive Team

The success of any EHR implementation hinges on an inclusive executive team, including a CIO, CMO,
CNO, CFO and COO. Many organizations are creating new positions of chief medical/nursing
information officers to gain clinician acceptance.

Develop a Strategic Plan

Information technology should be considered as a tool to achieve organizational goals. Leaders need to
look at their overall strategic plan and include technology as a way to achieve objectives.

Perform Gap Analysis

To plan for implementing an EHR, the organization should measure where it currently stands in
implementing technology and where it needs to go.

Develop a High-Level Project Plan

Committee members can drill down and establish timelines for implementation.

Initiate Culture Change

Culture change can make or break an EHR implementation. Having individuals own a piece of the plan
can enlist their support of an electronic health record system implementation project.

Redesign Workflow Processes

An EHR should not automate already broken processes. This is an opportunity to establish new
processes to improve overall patient care.

Implementation
Training and ongoing support will smooth the transition from paper to electronic health records.
Upfront planning is crucial for successful implementation.

3 Health Care Leader Action Guide on Implementation of Electronic Health Records

 Implementation Roadmap — EHR Implementation

Gather executive
team

Develop strategic
plan integrating IT

Perform gap
analysis

Develop high-
level project plan

Initiate culture Redesign

change workflow
processes

Implementation

Source: Adapted from Rules of Engagement: Proven paths for instilling, then installing a CPOE
approach that works. © 2006 NAHIT publication
TIPS
Tips on Gathering a Team
While the CIO is the point person to achieve meaningful use objectives, HIT initiatives
will affect all aspects of hospital operations. Thus, there is an obvious need for visible
backing from the CEO and other senior executive team members to assure success.
The CIO and CFO should form a close working relationship. The IT needed to achieve
meaningful use will require large capital outlays and involve ongoing support expenses.
Encourage CIOs to participate in educational activities that increase their understanding
of HITECH/ARRA provisions. In addition to federal initiatives, state plans are also
expected to vary, so CIOs should be urged to get involved in initiatives that help them
stay abreast of specific rules for their state.
The senior IT executive should play a lead role in authoring and updating an IT strategic
plan that supports overall organization strategic operating plans, including necessary
components for meaningful use.
The CIO also should be involved in efforts to keep the entire organization informed
about the progress of a new system and progress toward achieving meaningful use. For
example, the CIO can develop a task force charged with attaining meaningful use and
grants, and have them report directly to the board.

4 Health Care Leader Action Guide on Implementation of Electronic Health Records

 TIPS (continued)
Planning Tips
The IT plan is part of the foundation for the organization‘s pillars—quality, service,
finance, people, growth, community.
Use existing committees, such as an EHR steering committee, in assessing the current
state and creating a desired future state. Or form a cross-functional committee, such as a
meaningful use subcommittee, to address achievement of these objectives. One hospital
organization has gone so far as to create a meaningful use czar and team dedicated only
to this task.
Task senior executives to get involved in aspects of the assessment where appropriate –
for example, the chief medical officer can help assess current clinical systems and what
needs to be done to improve them.
Conducting gap analysis is not merely determining what technology is or isn‘t in place. It
also involves assessment of corporate readiness for change, and requires a game plan to
assess people and processes.
Measure progress, gaps and work to be done on a scorecard or ―readiness matrix‖ that
visually presents the work that lies ahead.

Culture Tips
Communication from the CEO sets the tone of the project, lays out the projected steps,
and links it to the overall vision of the hospital.
Project champions should be tasked with communicating progress to their departments.
Physician communication requires special attention and effort. For familiarization and
information briefings, use staff newsletters, focused e-mail, handouts, meetings with
medical staff and office managers, and office visits.
Absolute transparency and honesty are critical to maintaining credibility.
Organizations need to provide a non-threatening way of providing feedback after
implementation.
Milestone events, such as go-lives and achieved targets, merit celebrations.

5 Health Care Leader Action Guide on Implementation of Electronic Health Records

 INTRODUCTION
For more than a decade, hospitals and health systems have been working to realize the promise of
health information technology (HIT) to provide safer, more effective and less expensive care. While
there have been numerous success stories, many organizations are still in the early stages of
implementing HIT to improve care and lower costs. Realizing the true promise of HIT, especially
electronic health records (EHRs), is harder than it looks.

The Health Information Technology for Economic and Clinical Health (HITECH) Act under the
American Recovery and Reinvestment Act (ARRA) of 2009 established a set of incentives and penalties
for adoption and use of certified EHR systems. The ultimate vision is to improve the quality and value of
American health care. In essence, however, HITECH has created a 2015 deadline for hospitals and
physician offices to implement a certified EHR system and meet a set of ―meaningful use‖ requirements
to avoid Medicare payment penalties. Before 2015, HITECH provides Medicare incentive payments for
those hospitals that can demonstrate meaningful use of a certified EHR system. Some hospitals and
physicians may also be eligible for Medicaid incentive payments that will be administered by the states.
CMS has estimated that between $14 and $27 billion in incentive payments will be distributed over ten
years. The actual spending, however, will depend on the number of hospitals and physicians that qualify.

Even before HITECH, hospitals were building EHR systems and recognizing their potential to improve
patient safety and efficiencies in care delivery. Implementing these systems is a time- and resource-
intensive process. Thus, the timelines established by HITECH and the regulatory requirements for
implementation may prove challenging for hospitals.

In addition, most of the incentive payments will be made retrospectively. Because of this, many health IT
leaders are warning hospital CEOs that federal funding should not the primary goal of implementing an
EHR.

―We developed a seven-year strategic What is an Electronic Health Record?

IT plan back in 2007,‖ says Kimberly The Electronic Health Record is a longitudinal electronic
Kalajainen, vice president and chief record of patient health information generated by one or
information officer, Lawrence & more encounters in any care delivery setting. Included in
Memorial Hospital, New London, this information are patient demographics, progress
Conn. ―After careful analysis, we plan notes, problems, medications, vital signs, past medical
to stay the course and not attempt to history, immunizations, laboratory data and radiology
rush our implementations in a hasty reports. The EHR automates and streamlines the
attempt to receive incentive payments. clinician's workflow. The EHR has the ability to generate
The total cost of our project (clinical a complete record of a clinical patient encounter—as
and business IT solutions) is $32 well as supporting other care-related activities directly
million. The ARRA reimbursement is or indirectly via interface—including evidence-based
estimated at $6 million. The ROI is decision support, quality management and outcomes
about $3 million. Hence, we are staying reporting.
the course and not looking to
accelerate.‖ Healthcare Information and Management Systems
Society‘s EHR definition
Separate incentive payments are
available for hospitals and physicians.

6 Health Care Leader Action Guide on Implementation of Electronic Health Records

After the original legislation was passed, Congress approved additional legislation that extends the
incentives to hospital-based ambulatory-care physicians. Other hospital-based physicians that provide
primarily inpatient services, such as radiologists, pathologists and anesthesiologists, are still excluded.

As with any government program that promises federal funds, a number of conditions must be met to
qualify for payments:

Payments can be made only to eligible hospitals and eligible providers, as defined by legislation.
Expanding eligibility to cover other providers will take additional legislation.
Providers must use certified technology to qualify for payments. Separately, the federal
government has issued rules that establish a temporary certification program. This temporary
program will be replaced by a permanent certification program. Only EHRs certified through
this new federal process, which will begin in the fall of 2010, will qualify.
Providers will be required to demonstrate ―meaningful use‖ of electronic health records. CMS
has proposed requirements in each of five areas:
o To improve quality, safety and efficiency, and reduce health disparities;
o Engage patients and families in their health care;
o Improve care coordination;
o Improve population and public health; and
o Ensure adequate privacy and security of health information.

The proposed version of the rule establishes a standard of what constitutes meaningful use of electronic
health records, involving 23 objectives for hospitals and 25 objectives for physicians. The proposed rule
also included new quality measures that must be calculated using EHR systems. Among the proposed
objectives are:

use of computerized physician order entry;

maintaining up-to-date problem and medication lists;
providing patients with an electronic copy of their health information upon request
having the capability to exchange clinical information with other providers of care; and
having the capability to provide electronic syndromic surveillance data to public health agencies.

The objectives are expected to increase in difficulty over time, with additional requirements added in
2013 and 2015. The final rule on meaningful use was not available at the time of publication of this guide,
but is expected by August.

As noted above, payments made through the Medicare program will be made retrospectively, after a
provider has already borne costs in purchasing and installing the EHR system and supporting
infrastructure. For some hospitals and physicians, funds will also be available through state Medicaid
programs, including funds in the first year to support adoption, installation, and upgrading of certified
EHRs without having to meet the meaningful use requirements. The Medicaid program, however, is
optional for states and is limited to hospitals and physicians that meet specific thresholds of Medicaid
patient volume.1

1
The Medicaid patient volume thresholds are generally 30 percent for physicians (less for pediatricians) and 10
percent for hospitals (less for children‘s hospitals). Be sure to consult the final rule to verify the thresholds that
apply to you.

7 Health Care Leader Action Guide on Implementation of Electronic Health Records

HITECH also approved a number of grant programs to facilitate adoption of health IT and health
information exchange (HIEs). Two of those programs will be implemented primarily at the local level.
Regional Extension Centers (RECs) will provide technical assistance to primary care physicians and some
small, rural hospitals on how to select and implement an EHR. The state-level HIEs will promote and
guide development of exchange models within individual states.

It is very clear that the implementation of electronic health record systems and the fulfillment of federal
requirements to receive stimulus funds will be complicated. CEOs and other senior executives will need
to work together to successfully adopt the technology and manage the changes that these systems bring
to an organization.
―We do not focus on the ‗meaningful use‘ requirements
Where to Begin
as a separate initiative. We have merged those
Implementing an EHR may seem like a
requirements into our larger advanced clinical systems
daunting task. After all, such systems are
strategy and simply highlighted those areas that address
expensive. Also, HITECH payments will
meaningful use. The meaningful use requirements are the
be made retrospectively, so providers
‗low water mark‘ for advanced clinical systems.‖
cannot count on these funds for such
upfront costs as purchase,
Mary Carroll Ford
implementation and training.
Vice President and Chief Information Officer
Lakeland Regional Medical Center, Lakeland, Fla.
Furthermore, the EHR affects nearly all
aspects of care delivery. EHRs should be
viewed as a tool to revolutionize care systems though workflow redesign and optimization. Workflow
redesign will require change, which requires a clear vision linked with strong leadership and a shared
commitment to action by all users—nurses, physicians, pharmacists, lab, radiologists, and even patients.

To successfully implement EHRs, hospital

leaders, especially those in the C-suite,
should focus on the strategic direction of ―The creation of the HITECH Programs will ‗build the
the hospital and incorporate EHRs foundation for every American to benefit from an
where and how they provide the most electronic health record, as part of a modernized,
benefit. They need to ―rally the troops‖ interconnected and vastly improved system of care
to gain buy-in and user engagement. And delivery.‘‖
they need to secure proper funding.
Successful implementation of EHRs must U.S. Department of Health and Human Services HIT
be built on a solid foundation of planning Website
and execution, along with discipline
across the entire organization for several
years.

This guide outlines an implementation roadmap that can assist hospital leaders in taking a disciplined
approach to EHR planning.

8 Health Care Leader Action Guide on Implementation of Electronic Health Records

 Implementation Roadmap — EHR Implementation

Gather executive
team

Develop strategic
plan integrating IT

Perform gap
analysis

Develop high-level
project plan

Initiate culture Redesign workflow

change processes

Implementation

Source: Adapted from Rules of Engagement: Proven paths for instilling, then installing a CPOE approach
that works. © 2006 NAHIT publication

GATHER THE EXECUTIVE TEAM

Because the electronic health record is a massive investment and changes the way care is delivered in
hospitals, the CEO needs to start with two important steps at the very beginning of the EHR journey:

1. Educate the board to gain necessary support.

2. Create an executive team to formulate and communicate the EHR vision.

Board support is essential because an EHR implementation requires a tremendous amount of capital,
time and culture change. In addition to understanding the general provisions of the federal meaningful
use and certification requirements, trustees need to be regularly updated on implementation progress.
They also should understand that the EHR investment is not a typical IT investment. The CEO needs to
communicate how this investment will improve quality of care, create efficiencies and help the
organization meet its overarching vision.

9 Health Care Leader Action Guide on Implementation of Electronic Health Records

In implementing an EHR system that achieves meaningful use objectives, the biggest risk to organizations
is that leaders will rush to implement systems. In their haste, many essential aspects of planning and
strategizing may be overlooked. Shifting an organization to a new mode for capturing, sharing and
maintaining patient information requires extensive involvement of the entire senior executive team from
the very beginning. Gathering this group—including the chief operating, financial, medical, nursing,
information and human resources officers—to define the EHR vision is essential because this team will
be responsible for communicating with and engaging employees and physicians.

An EHR will affect most workflows in an organization and, therefore, all entities must have input at the
very beginning of planning. Each of the executive officers must have a role in connecting the electronic
health record‘s value to the organization‘s overall vision. Planning should focus on improving the quality
of care; technology should be viewed as a tool to achieve this goal.

The National Center for Healthcare Leadership offers some examples of value statements that can be
used in communicating the value of EHRs across the organization:

Enhanced access to and improved continuity of care

Physician connectivity and support to physicians in maintaining a work/life balance
Reductions in malpractice liability exposure
Protection of patients from harm
Improvements in operational efficiency
Support of facility and service expansion

It is crucial that the full executive staff has an overall view of the organization‘s IT strategic direction and
knowledge of EHR implementation so that they can provide support to the CIO, coordinate efforts
effectively across the organization, interface with the board and other constituencies within the hospital,
be an advocate with the medical staff, and be able to discuss the organization‘s vision and tactics
involving EHRs intelligently in public.

Role of the CIO

The CIO will be at the apex of your organization‘s drive to achieve meaningful use. ―Senior management
is counting on meeting meaningful use [objectives] in the first year,‖ noted a CIO at a New Jersey
hospital. ―It is my responsibility to make that happen.‖

CIOs play a key role in analyzing an organization‘s readiness to meet meaningful use objectives,
determining a game plan and claiming as much of the HITECH stimulus reimbursement as possible. With
meaningful use objectives coming into focus, CIOs have a better idea of what they specifically have to do
to achieve these targets for using electronic health records. Planning has become clearer as a result and
has grown both more complicated and crucial.

For example, the linkage of meaningful use to reimbursement will involve financial considerations, and
CIOs will need to interact with the financial office to understand cost report timing and to minimize the
impact of EHR purchases on cash flow, which could hamper many organizations because of the large
expenditures involved.

Other areas of concern for CIOs in the meaningful use era include:
HITECH and HIPAA security regulations, which will raise the ante on protecting sensitive
patient information.
10 Health Care Leader Action Guide on Implementation of Electronic Health Records
 IT strategic planning updating, as needed, to achieve meaningful use.
Vendor communication to ascertain where IT suppliers are in providing products that will meet
meaningful use objectives.

Many CIOs also are their organization‘s experts on meaningful use requirements, not only understanding
their implications for the organization, but also being able to frame any discussions and facilitate plans to
achieve objectives. Shifting responsibilities make this an exciting time for CIOs, who find they have new
expectations in reporting to other senior executives and the CEO. Growth in responsibilities also is
moving some CIOs out of their comfort zones, particularly those who are more task-oriented. The
current environment requires top information executives to embrace new responsibilities, many of
which will require additional training, and tighter integration with and support from the CEO.

New Roles—CMIO and CNIO

The enormity of the challenges involved in implementing electronic health records— particularly the
need to gain clinician participation and support—is prompting some organizations to create positions for
specialized executives who can work in both the caregiver and IT realms.

Many organizations are turning to a chief medical information officer (CMIO). In addition, some are
looking to add a chief nursing information officer (CNIO). Estimates suggest that about 2,000 hospitals
or health care organizations have CMIOs; similar data are not available for CNIOs.

Key job responsibilities for CMIO and CNIO roles include:

Serving as a liaison between IT and clinicians to communicate issues and challenges
Involving clinicians with the IT process, including vendor selection, gaining their support
Acting as a change catalyst, motivating and reinforcing clinician behavior change
Assisting in education
Designing and testing information systems
Improving workflow by developing order sets, standardizing care plans and designing clinical
decision support
Facilitating and managing design validation and implementation support
Reporting (outcomes and quality) based on digital records
Documenting and broadcasting realized clinical benefits

CMIO and CNIO roles can help organizations implement EHRs under the tight timelines hospitals will
face in meeting meaningful use objectives. However, organizations can successfully implement EHRs if
they have a CMO or CNO who is open to taking on some informatics responsibilities or if an
organization has several physician champions, sponsors or partially funded roles in IT to provide critical
insight, feedback and leadership.

Organizations with one or both of these positions say they meet different needs. CMIOs assist
organizations with physician adoption and leadership, while CNIOs help organizations achieve success in
outcomes reporting, quality reporting, workflow improvements and data assessment, and generally
allowing the nurses‘ voice to be heard in the implementation process. The CMIO role, in particular, has
evolved over the years, away from merely serving as a liaison between medical and IT staffs. Now,
CMIOs are getting more involved in technology decisions and helping use data derived from clinical
records to develop improvements in care delivery.

Whether these executives hold formal CMIO/CNIO titles or not may not be important if an
organization has talented, credible clinicians who happen to have significant IT knowledge. In any event,
11 Health Care Leader Action Guide on Implementation of Electronic Health Records
hospitals will need to have a plan in place for bringing clinician involvement and support to its EHR
implementation.

Some hospitals have decided not to create CMIO or CNIO positions. Yet where CMIOs or CNIOs
have not been added, organizations generally agree that a key to success is having physician and nursing
leadership, typically provided by named individuals regardless of title. Many hospital executives say that
CMIO or CNIO roles are invaluable because they provide additional leadership that increases clinicians‘
willingness to use EHRs. CMIOs and CNIOs bring the most value to an organization when they partner
with the information systems
department to enable the transition
from paper to digital records. ―Our executive team has been very supportive of my
efforts to make this IT project the number one priority
Strong proponents of the CMIO for the entire health system. That decision was the
position say it is crucial in defining moment for this organization‘s ability to meet
implementing an EHR, and that small the developing requirements for national health care
hospitals should try to fill the role, reform. I work closely with the CEO and the rest of the
even if only on a part-time basis. These executive team on all of the communications to the
proponents say the CMIO is a key medical staff and employees. Being part of the executive
leader and officer for the entire team is necessary to enable this type of success.‖
organization and plays a key role in
workflow design and optimization, Dave Roach
which provide the bulk of return on an Vice President and Chief Information Officer
EHR investment. Kadlec Health System, Richland, Wash.

Team Tips
While the CIO is the point person to achieve meaningful use objectives, HIT initiatives
will affect all aspects of hospital operations. Thus, there is an obvious need for visible
backing from the CEO and other senior executive team members to assure success.
The CIO and CFO should form a close working relationship. The IT needed to achieve
meaningful use will require large capital outlays and involve ongoing support expenses.
Encourage CIOs to participate in educational activities that increase their understanding
of HITECH/ARRA provisions. In addition to federal initiatives, state plans are also
expected to vary, so CIOs should be urged to get involved in initiatives that help them
stay abreast of specific rules for their state.
The senior IT executive should play a lead role in authoring and updating an IT strategic
plan that supports overall organization strategic operating plans, including necessary
components for meaningful use.
The CIO also should be involved in efforts to keep the entire organization informed
about the progress of a new system and progress toward achieving meaningful use. For
example, the CIO can develop a task force charged with attaining meaningful use and
grants, and have them report directly to the board.

12 Health Care Leader Action Guide on Implementation of Electronic Health Records

 DEVELOP A STRATEGIC PLAN
Strategizing about EHRs includes examining current organizational strategic plans. The implementation of
EHRs cannot be viewed as simply a project or the work of the information technology department.
Rather, it needs to be the foundation of an organization‘s pillars—quality, service, finance, people,
growth, community. The strategic role of EHRs in the organization needs to be explicitly spelled out so
that everyone in the organization is aware of the connection. Concrete metrics need to be attached.
Further, the executive team needs to understand the connection so they can communicate and engage
staff and physicians.

With the executive team assembled, leaders need to develop the plan of how the EHR will help an
organization achieve its goals. An EHR won‘t improve patient safety on its own, but it will help improve
communication, which then can be linked to improved safety. A clear connection needs to be developed
to achieve a successful implementation.

EHRs also are expected to affect many health care business relationships in communities, as physicians
increasingly look to hospitals for help in adopting EHR systems and as organizations face increased
demands to share health care information with other providers and with patients. How these goals fit
into the organizational plan needs to be examined.

Further, meaningful use objectives can provide a general guide for hospitals that want to determine
where they need to be to qualify for stimulus funds under the HITECH Act. However, organizations
must consider different routes before arriving at that final destination – many are using different
approaches in implementing IT, depending on their individual strategies, cultures, markets and
structures. For example, an academic medical center in a competitive metropolitan market is likely to
have different applications, infrastructure, vendor-supporting and technology management practices than
a freestanding suburban hospital with different mission-centric objectives, community and medical staff
dynamics, and abilities to fund IT.

With the convergence of HITECH planning as well as health care reform, many hospitals are aware of
the increased stakes involved in health care IT. They are dedicating more resources to support
assessments of the current IT state, what the organization wants to achieve in the coming years, and the
IT resources that are needed to get there.

In sum, the push to implement electronic health records will cause significant change in many aspects of
care delivery, and the cost of implementation and degree of coordination required to achieve success
will involve regular attention and participation from an organization‘s CEO and senior executives.
Provider success in achieving meaningful use will serve as a foundation for upcoming payment reform.

PERFORM GAP ANALYSIS

Hospitals typically have a wide variety of applications in place, and leaders need to assess what they have
and what meaningful use will require of them. It is essential for an organization to determine where it is
in the journey to implement electronic health records and how much further it needs to go.

Conducting a gap analysis – assessing the difference between the current state of readiness and the
future ideal state – is sometimes viewed as purely a function of IT, with top information systems

13 Health Care Leader Action Guide on Implementation of Electronic Health Records

personnel leading the analysis and then quantifying current and future technology needs that will be
required to meet organizational goals.

For many organizations, it is natural for the chief information officer to take the lead role in conducting
an assessment of current technology. In many cases, an organization‘s top IT executives interact with or
lead steering committees that provide broader guidance for EHR direction in an organization.

However, CEOs are playing a variety of roles in this assessment phase. At the very least, IT executives
should report their findings to the CEO and the board on a regular basis. In other organizations, CEOs
are aligning themselves as key partners in the process, and other members of the senior executive team
are brought in to provide feedback and increase buy-in. Having responsibility for IT discussions reside
with an oversight committee, defining meaningful use as part of a larger initiative, or blending it into a
strategic plan helps to place meaningful use discussions into a larger context.

Oversight committees may take on various forms, and there may be several active groups in which
dialogue occurs with the intent to form consensus among different EHR stakeholders. HITECH may be
viewed as its own program for progress tracking, or it may be seen as tactical requirements that are
handed off to EHR-related project managers. Clinical adoption through meaningful use, in its broadest
sense, is the key success factor of all EHR-related initiatives, and organizational change efforts to support
it should be pervasive.

DEVELOP A HIGH-LEVEL PROJECT PLAN

It is not just a simple matter of determining what technology needs to be in place to meet objectives and
qualify for stimulus fund payments. Increasingly, the term ―governance‖ is being linked to overall IT
implementation, maintenance and management. IT planning is attempting to answer the following
questions:

What is the governance model?

What is the capacity for change?
What are the idiosyncrasies that are unique to our organization?
What are our particular needs and political landscape?
How do these needs align or compete with other needs?
Does our portfolio align to our mission and current business and clinical objectives?
What can we do to manage risk with such a ―busy‖ portfolio?

The perception and history of successes, accomplishments and failures; the relationships that are in
place or not in place; and the skills within IT are all important components of any planning that occurs in
getting EHRs to a particular future state.

This is also the time to identify project champions representing each population that will be affected by
an EHR implementation—nursing, pharmacy, radiology, clinical services. These individuals will spend a
significant portion of their time on the project, identifying roadblocks and keeping executive
management updated. Getting these individuals engaged at this point gives them the ownership
necessary to implement upcoming changes.

Selecting an EHR
The first step in selecting an EHR vendor is to examine current IT capabilities and infrastructure in the
organization and then develop a list of needs. Again, involving physicians and other clinicians early in the
14 Health Care Leader Action Guide on Implementation of Electronic Health Records
selection process is essential to ―My current senior team expects a game plan and review
prevent user resistance. Further, being of where we are today and what we still need to do to
transparent with updates and decisions make meaningful use a reality in 2011. The most
with other employees will go a long important role I currently have is to maintain the IS
way toward easing anxiety and strategic plan, provide leadership, change as needed, be
frustration. cost-effective and stay focused so the plan is executed in
a successful manner.‖
There are numerous factors to
consider when selecting a system, so Richard Mohnk
doing the proper preparation is Chief Information Officer
necessary. User demonstrations are HealthAlliance Hospitals
necessary and will highlight any clinical Fitchburg and Leominster, Mass.
assumptions built into the product. A
thorough examination of current
hardware and what will be required to make the system functional with clinicians will need to be
examined. Items such as handhelds, tablets or desktops should be included.

Planning Tips
The IT plan is part of the foundation for the organization‘s pillars—quality, service,
finance, people, growth, community.
Use existing committees, such as an EHR steering committee, in assessing the current
state and creating a desired future state. Or form a cross-functional committee, such as a
meaningful use subcommittee, to address achievement of these objectives. One hospital
organization has gone so far as to create a meaningful use czar and team dedicated only
to this task.
Task senior executives to get involved in aspects of the assessment where appropriate –
for example, the chief medical officer can help assess current clinical systems and what
needs to be done to improve them.
Conducting gap analysis is not merely determining what technology is or isn‘t in place. It
also involves assessment of corporate readiness for change, and requires a game plan to
assess people and processes.
Measure progress, gaps and work to be done on a scorecard or ―readiness matrix‖ that
visually presents the work that lies ahead.

INITIATE CULTURE CHANGE

After the technology goals are aligned with the strategic plan and the executive team is assembled, it is
time to work on culture and workflow processes, two essential steps that will determine the success of
an EHR implementation.

Organizational culture embodies everything in an organization — assumptions and beliefs, values, models
of behavior, rituals, practices, symbols, heroes, artifacts and technology. With IT implementation,
especially an effort as all-encompassing as an EHR, hospital CEOs and other members of the C-suite will
need to spend a significant amount of their time on culture change. Their job will be to help employees
and physicians connect the dots between the EHR and the actual goals it will achieve. This is why it is
15 Health Care Leader Action Guide on Implementation of Electronic Health Records
essential that the C-suite team have input in the change management activities that will take place. If they
are invested in the change process, then they will be much more effective in convincing other staff of the
possibilities.

Before embarking on any change management plan, CEOs need to conduct a readiness assessment to
identify a starting point. Questions should address the following issues:

Staff knowledge and understanding of patient safety and clinical effectiveness issues
Current levels of automation in existing workflows
Current levels of users‘ computer skills
Other organizational initiatives under way that could compete for time and resources2

Change is facilitated by trust and concern for other people, flexibility and innovation, policies,
procedures and information management. If a group believes the specific technology effectively supports
values that are significant to it, the group is more likely to support that technology. Conversely, if the
group believes the technology will have a negative effect on its goals, the group will oppose the change.
A general approach that emphasizes goals, guiding principles, fundamental concepts and principles of
design process may make it easier to adopt the technology and tweak it as necessary.

At first, C-suite members need

Eight Steps to Transforming an Organization
to focus on communicating the
message and creating the sense
of urgency for change, two of Create urgency
Kotter‘s eight steps in the change Form powerful coalition
process (see box). Create vision for change
Communicate the vision
Employees and physicians need Remove obstacles
to be convinced of the benefits of Create short-term wins
the EHR system and its impact Build on change
on efficiency and goal Anchor the changes in the corporate climate
achievement. Similar to any
implementation that has the Source: Kotter, John P., (1996) Leading Change, Harvard
potential for creating a great deal Business Press
of change in an organization, the
key to success is having every
user believe that they own the
technology. ―The technology champion is a manager who lobbies for
project acceptance and who lobbies for resources needed for
Board members and the CEO implementation. The activities of a successful technology
should be broadcasting the champion reduce employee resistance to the innovation and
importance of the EHR in obtain access to resources.‖
achieving the organization‘s
vision. Other members of the C- Linton, J., Implementation Research State of the Art and Future
suite team are responsible for Directions, Technovation, Vol. 22, Issue 2, Feb. 2002, p64-79.
communicating the message to
their division/department leaders and gathering their input about how to achieve EHR goals. If the

2
Adapted from Rules of Engagement: Proven paths for instilling, then installing a CPOE approach that works. (2006)
NAHIT publication

16 Health Care Leader Action Guide on Implementation of Electronic Health Records

board, CEO and C-suite team are successful, they should have created an army of managers who are
excited about EHR possibilities. Out of this group, project champions should be identified in each
division/department.

Clinician Buy-in
Many EHR capabilities will change the way nurses, pharmacists and technicians currently perform their
work. Therefore, success depends on their acceptance of the EHR into their daily work lives. Most
people have established preferences for the ways they do their work, and variation from these preferred
practice patterns will take more time, at least in the beginning.

Leaders need to be completely honest about the upcoming learning curve. Executive leaders need to
communicate to staff that new processes take time to learn, but also make the connection between the
new processes and the benefits, such as improved care, more time with patients, and better work/life
balance. As with any work, satisfaction comes with knowing that the work has purpose and meaning.

Any type of change runs into roadblocks at some point. This is why clinical champions need to be
identified. These individuals will play a key role in conveying the benefits of change. At the beginning of
project planning, they should provide input into designing new workflow processes and providing
support to other employees. Senior management needs to communicate with this group through emails,
newsletter and face-to-face meetings. Communication efforts need to be ongoing and their concerns
need to be taken seriously. Failure to engage and keep champions engaged will almost certainly spell
disaster. Each champion from every division should own the EHR.

Physician Buy-in
Because of the unique relationship between hospitals and its physicians, getting physicians to accept and
utilize new technology is often a challenge. Yet, their cooperation is essential to success.
Communication and transparency will go a long way in making the case for new technology, as does
trust. Electronic health records will change the way in which all physicians practice, so leaders must
involve them from the beginning, obtain their ongoing input and feedback, and incorporate their views
and preferences into new
workflow processes.
―We use regularly recurring ‗town hall‘ meetings with proper time allotted
The physician champion for questions and answers. We also try to be absolutely transparent to all
must be a trusted medical employees who are curious or anxious about the changes. On the hospital
staff colleague. He or she and clinical side, we try to listen more to their concerns and needs and
‗back in‘ those inputs into our ongoing planning sessions.‖
must remain a ―practical
zealot‖ throughout the most Curt Kwak
challenging of times during Chief Information Officer
the EHR implementation Providence Health & Services, 26 hospitals located in Alaska, California,
lifecycle. At the same time, Montana, Oregon and Washington
he or she needs to be a key
change agent, knowing how
to demonstrate empathy while motivating physician behavior change in ways that are in tune with the
organizational culture, and have the authority to act.

Communication is Key
An essential tool for gaining staff buy-in is communication. Hospital leaders should use every vehicle at
their disposal—newsletters, emails, intranets, and town-hall and smaller meetings. Open lines of
communication will promote the transparency necessary to gain staff EHR ownership. Leaders need to
be honest upfront and address issues, such as increased staff time to learn the new system. An effective
17 Health Care Leader Action Guide on Implementation of Electronic Health Records
communication plan should be aimed at various audiences over the entire span of a project—from initial
communication with the board, to ongoing publicity throughout the organization, from implementation
announcements to reports of follow-up enhancements and additional training.

Initial messaging from the CEO, board and others in the C-suite sets the tone for the importance of an
EHR project, and they should continue to emphasize that message throughout the duration of the
project. IT leaders can also participate in the larger effort of communicating with the staff, physicians and
community. Marketing and communication staff can augment EHR communication efforts.

Frontline users crave communication that reinforces the perception that IT staff or project team
members will be available when the switch is turned on for a new system. Communication needs to
continue after implementation so that concerns and issues can be addressed.

Culture Tips
Communication from the CEO sets the tone of the project, lays out the projected steps,
and links it to the overall vision of the hospital.
Project champions should be tasked with communicating progress to their departments.
Physician communication requires special attention and effort. For familiarization and
information briefings, use staff newsletters, focused e-mail, handouts, meetings with
medical staff and office managers, and office visits.
Absolute transparency and honesty are critical to maintaining credibility.
Organizations need to provide a non-threatening way of providing feedback after
implementation.
Milestone events, such as go-lives and achieved targets, merit celebrations.

REDESIGN WORKFLOW PROCESSES

Much focus needs to be placed on workflow redesign as IT will create the impetus to improve current
processes. An EHR should not just automate paper charts. Rather, improved processes should be
created and then automated. The processes will reflect the IT results; sub-optimal processes will create
sub-optimal results.

A key element in workflow redesign involves understanding the steps in each process and how they
connect with one another and relating that back to the organization‘s goals. It starts with process
mapping to determine the actual workflow; don‘t assume that just because a process is written out on
paper that it is actually performed that way by the caregivers. Unseen barriers may have created
workarounds that are the new ―standard‖ workflow. Observing the actual processes will help to
implement changes that make sense to the frontline worker.

After the steps in the actual workflow are identified, it is time to redesign the processes, keeping in
mind how IT can be used as a tool to automate certain steps. At this point, the Plan-Do-Check-Act

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cycle can be effective because it uses data to understand the problem, evaluates and refines the solution
over time, and standardizes the new processes.

When redesigning the steps in the workflow, it is imperative to get input from frontline workers. Ideally,
clinicians, employees and physicians should design the new processes, with the IT team giving input on
what the technology can automate and what needs to be included in the EHR to qualify for meaningful
use. The team should try to develop a new system of doing things through the use of HIT.

Examine each major process—medication refills, appointment requests, lab reviewing, prescription
writing, patient demographics and so on—and write its current steps out on a flow diagram. Then,
examine the capabilities of the EHR system and how it can improve the process. Teams should challenge
all assumptions and limitations. Some existing workflows will not be needed, and some others may be
added. The front-line user needs to understand why processes are added or removed and how it will
help them achieve the organization‘s goals.

Not all EHR processes will be quicker and more efficient. Don‘t insist that people switch from an
efficient paper process to a less-efficient HER-based process just for the sake of automation. Sometimes,
however, a slower EHR process can pay off in other ways. For example, progress note documentation
with an EHR is slower than using dictation. However, by documenting directly in an EHR, notes are
readily available to be shared with patients or consultants, or the notes can be used for immediate
review of those patient-care questions that arise before a dictation would normally be ready.
Additionally, while some processes may take longer, the time can be recouped in terms of quality of
care. Physicians may be able to access data from their homes in the middle of the night, enabling them to
make better, timely decisions.

Finally, all processes need to be redesigned with the customer in mind—the patient. Don‘t design for
efficiency because the unintended consequence will be that you are removing steps that add value to the
patient. In hospitals, patient value comes from having the right information at the right time to assist the
clinicians in making the best decision regarding the patient. Implemented correctly, an EHR can
dramatically improve communication among providers.

IMPLEMENTATION
After workflow analysis is done and a change management plan is started, it is time to start training and
then implement the actual IT component. The communication plan needs to stress that while some new
work processes might take longer or are more cumbersome with the EHR system, patient care will be
improved. Training and support must be provided in order to overcome resistance and problems.

Training
Different people have different levels of comfort with IT. From early adopters to laggards, training needs
to accommodate for the differences. There will be a lot of anxiety when a hospital or physician practice
begins to use an electronic health records system. Tasks that were once done intuitively now become a
labor of mouse clicks and keystrokes that seem to involve a secret code. Data easily found in a paper
chart seems hidden somewhere on a computer screen.

In any health care setting, training in advance of using a new EHR system and tangible support for the
implementation in its first days and weeks of use are critical success factors for facilitating the
deployment.

19 Health Care Leader Action Guide on Implementation of Electronic Health Records

There is wide diversity of opinion about how to gain the greatest benefit from training and make
education efforts effective. In an informal survey of CHIME members, several overarching themes on
training emerge:

At some point during training, learners must break away to participate in training sessions
outside of their normal work environment and away from their day-to-day duties.

Effective training uses several approaches that attempt to cover the variety of learning styles and
preferences of a diverse hospital staff.

In addition to being offered in classroom settings, training programs need to take advantage of
other avenues for getting knowledge to people – workbooks/user guides, quick reference
guides, Web-based instruction, one-on-one trainers and ―super-user‖ assistance.

When well-designed, computer-based training modules offer the ability to train both inside and
outside of the classroom. Further, questionnaires and EHR-based ―practice sessions‖ enable
closed-loop measurement of trainees‘ comprehension and retention. Further, the information
garnered from closed-loop tests may help identify those who could serve as super-users and
support their co-workers, and they also can show those who may need additional support
before and during go-live efforts.

Workforce members are likely to retain only a percentage of what they learn in training in
advance of actually using a new system. Thus, training and support is critical the day of go-live,
and in the days and weeks that follow.

As users‘ knowledge base grows, they can be further trained to incorporate systems‘ advanced
functionality and to take a fresh look at how workflows and processes can be improved.

Going Live
Choosing between a rapid or a staged implementation depends on how much upfront planning has been
completed. Rapid deployment requires significant planning and change management. Organizations must
have the resources available to deal with problems as they emerge and provide support to staff. A
staged implementation allows organizations to discover and solve problems before system-wide
implementation. However, it requires organizations to maintain an electronic and paper-based system
until full implementation can occur.

Either implementation style requires clear communication about timelines, training and support.
Clinician and physician champions can provide support and encourage laggards and slow adopters.
Additionally, ongoing support must be provided during the first few months after the go-live date.

CONCLUSION
An EHR system has the potential to transform the ways in which care is delivered. It should not be
viewed as an IT application, but rather an asset or tools that can assist in achieving organizational goals.
However, EHR implementation is not an easy feat. Strategizing and upfront planning take strong
leadership and commitment. Additionally, it requires ongoing support and training. Large-scale changes,
such as an EHR system, present big challenges, but also significant opportunity to achieve safe, effective,
efficient, patient-centered care.

20 Health Care Leader Action Guide on Implementation of Electronic Health Records

 TERMS AND DEFINITIONS

ARRA
American Recovery and Reinvestment Act of 2009
http://www.recovery.gov/About/Pages/The_Act.aspx
A response to the economic crisis, the Recovery Act has three immediate goals:
Create new jobs and save existing ones
Spur economic activity and invest in long-term growth
Foster accountability and transparency in government spending

HITECH
Health Information Technology for Economic and Clinical Health Act
http://www.cms.gov/EHRIncentivePrograms
The HITECH Act established programs under Medicare and Medicaid to provide incentive payments for
the meaningful use of certified EHR technology. The Medicare and Medicaid EHR incentive programs will
provide incentive payments to eligible professionals and hospitals as they adopt, implement, upgrade or
demonstrate meaningful use of certified EHR technology. The programs begin in federal FY 2011. These
incentive programs are designed to support providers in this period of HIT transition and instill the use
of EHRs in meaningful ways to help our nation to improve the quality, safety and efficiency of patient
health care.

RECs
Regional Extension Centers
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1495&mode=2
This federal extension program consists of Health Information Technology Regional Extension Centers
(RECs) and a national Health Information Technology Research Center (HITRC). The HITRC will gather
information on effective practices and help the RECs work with one another and with relevant
stakeholders to identify and share best practices in EHR adoption, effective use, and provider support.
RECs are designed to make sure that primary care clinicians get the help they need to use EHRs. A list
of websites and emails for each REC is featured on the REC web site. RECs will:
Provide training and support services to assist doctors and other providers in adopting EHRs
Offer information and guidance to help with EHR implementation
Give technical assistance as needed
Provide outreach and support services to at least 100,000 priority primary care providers within
two years.
ONC has funded 60 RECs throughout the United States to ensure plenty of support to health care
providers in communities across the country.

ONC
http://healthit.hhs.gov/portal/server.pt
The Office of the National Coordinator for Health Information Technology (ONC) is the principal
federal entity charged with coordination of nationwide efforts to implement and use the most advanced
health information technology and the electronic exchange of health information. The position of
national coordinator was created in 2004 through an executive order and legislatively mandated in the
HITECH Act of 2009.

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 EHR RESOURCES

AHA Health Information Technology Advocacy – Meaningful Use

http://www.aha.org/aha/issues/HIT/100226-hit-meaningful.html
This web page features advocacy updates, bulletins, issue papers and a calculator for measuring incentive
payments (for AHA members only).

American Academy of Family Physicians

www.centerforhit.org
The Center for Health Information Technology at the AAFP features a variety of tools and resources.

American Medical Association

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/health-
information-technology/hit-resources-activities.shtml
AMA comments and updates are featured on this web page.

Association of Medical Directors of Information Systems

http://www.meaningfuluse.org/
This website features link to the latest news, information and blogs on meaningful use.

Centers for Medicare & Medicaid Services

http://www.cms.gov/EHRIncentivePrograms
The official web site for the Medicare and Medicaid EHR Incentive Programs.

CHIME ARRA/HITECH
http://www.cio-chime.org/advocacy/stimulus/index.asp
This web page features white papers, advocacy statements and summaries of regulations.

HIMSS
http://www.himss.org/EconomicStimulus/
The Healthcare Information and Management Systems Society (HIMSS) provides a variety of resources
on meaningful use, certification criteria and standards, and the HHS certification process.

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