Thinking holistically about EHR selection and implementation

Despite the effort and energy involved a careful selection process, some EHR implementations still fail. But why?

There are a number of reasons, many of which center on a common theme: a failure to anticipate issues and prepare thoroughly at the outset of the implementation project. Failures may happen in a variety of ways:

• Running out of funding for the project
• Not being able to go-live due to unforeseen problems or complications
• Underestimating the level of sustained effort needed to implement and go-live

Rarely does a single problem doom an EHR implementation to failure. More often, it is a number of factors that come together that put your implementation effort “at risk.” As with any major project, each phase of the implementation project poses risks to on-time, on-budget completion. Throughout, if you take a holistic approach - anticipating and outlining the likely risks and then taking steps to mitigate them along the way - you can increase your opportunities for success.

Risks during EHR selection and contracting

Selecting an EHR and contracting with the EHR’s vendor is the first phase of a successful implementation project. During this phase there are a number of important risk factors to consider, each of which is ranked according to its estimated risk to successful implementation. Let’s consider each in detail:

A. Organizational Awareness and Readiness

An organization must be prepared to embark on an EHR journey by thoroughly assessing its current operations, strategy, and future plans. Simply saying, “we need an EHR” is not sufficient. Understanding what role the EHR will play and how it will facilitate improved care and performance is a critical component of organizational readiness. Knowing where your organization is going is very helpful in choosing an EHR with the right mix of functionality. Among the key awareness and readiness concerns to consider are these:

1.  Overall Organizational Planning: While your Strategic Plan may seem like an unusual factor to consider in EHR selection, it is not. With the help of a current Strategic Plan, you will be able to assess likely service line expansions or reductions, the potential for mergers or acquisitions, and future interactions with physical health care through primary care integration, development of a health home, or participation in an Accountable Care organization. Your organization’s ability to collect business intelligence, perform analytics, and measure its own performance relative to benchmarks is vital to demonstrating its effectiveness and driving its improvement.  Understanding these internal, business, and growth goals are essential for ensuring that you get the best Return On Investment (ROI) for the EHR.

2.  Change management and readiness will be challenged in new ways throughout the process of selecting and implementing an EHR. For example: staff will be asked to perform their job duties in very different ways from what they have known. Some will resist or struggle with learning new processes, a new EHR, and even the basic computer literacy skills that they need. I have seen the training phase of implementations disrupted due to computer literacy problems like these. It is wise to assess staff computer literacy and provide remedial training if needed. This step may be vital to preserving your implementation timeline and will improve the quality of learning during the EHR training process.  

3.  Building and standardizing forms and encounter documentation required for an EHR system implementation is often a grossly underestimated, yet time-consuming and costly decision-making process in many organizations. Faced with the need for complete standardization, work groups often find small, but important discrepancies in processes and forms and end up building or configuring far more specialized forms than they expected. While this effort is necessary, it can unexpectedly slow down an implementation if the scope of the needed changes are not considered and resourced ahead of time.

4.  Underestimating the implementation budget is a sure-fire way to derail success. From the moment you execute the vendor contract, your organization is paying for a system that must produce a predictable return. Any delays in project completion will be costly and will ultimately put the project at risk. Thus, it is essential to comprehensively understand, prior to EHR selection, all of the elements and associated costs needed to make it fully functional.

This category poses the highest risk for EHR failure for those organizations who are not critically thinking through industry forces, trends, and their market position in the industry. Being aware of the tasks, chores, and items that are necessary to make the EHR a value-added asset in your organization will provide the end-goal for selecting and implementing an EHR.

B. Functional and business needs assessment 

After assessing organizational readiness for an EHR, the next step is to assess what the new system must do upon implementation and into the future: a Functional and Business Systems analysis.

While the majority of EHRs in the behavioral health industry claim similar functionality, vendors differ substantially in their approaches to ongoing product development and products may have different strengths. At this stage, your goal should be to identify a “top 5” group of vendors who have the development process and functionality you desire – and whose products successfully serve similar organizations in your state. This will substantially reduce your risk of picking the functionally “wrong” EHR. After narrowing the field in this way, you’ll then find that biggest differences between your “top 5” will be in areas like user-friendliness and customer service, issues that are separate from the essential functionality you need.

While almost any EHR is going to look pretty slick compared to using paper, it is important to assess all areas of needed functionality to prevent the risk of “coming up short” on an essential feature after implementation is already underway. And, while there are hundreds of itemized functional specifications, most fall into about 15 broad categories that include:

• accounting and billing,
• clinical information,
• family and children’s issues,
• psychiatry, and
• compliance.

Among the more unusual functional specifications I’ve seen are agency car tracking and assignments, ability to link to external educational systems, and GPS-based directions and mapping capabilities for community-based workers.

An absolute essential at this stage is to carefully detail how your organization’s current IT systems -- human resources, general ledger, customer relationship management, revenue cycle -- will interface or be integrated with the new EHR. Certainly, having a consultant or someone knowledgeable in this process can be a great asset. It is essential to ask the right questions to mitigate the risk of IT surprises after purchasing the EHR.

C. Contracting

Contracting is rated as a moderate risk to organizations because the financial ramifications can be significant. To help mitigate the risk to your EHR Implementation and keep it on track, there are two very specific things you should look for in the contract:

1.      Hidden Costs: There are a number of ancillary cost items that you will have to consider before you sign a purchase or implementation contract – necessary but sometimes surprising “extras” that escape mention during typical EHR demonstrations, yet are capable of causing very real project delays. Often, these involve infrastructure problems (hardware, network, software versions) that require upgrade or replacement – at your expense – before an EHR system can be implemented properly. Remember, when you sign the contract, you begin paying for the EHR and running the clock toward its anticipated ROI, whether or not your infrastructure will support implementation.

2.      Project Management: The selected EHR vendor outlines their approach to EHR implementation in the contract, assigning your organization a project manager, billing expert, and others to support your team through the process. In many cases, these contracts will specify the hours allotted per person on the implementation team, noting that any hours in excess of the allotted time will be billed at a vendor-specified hourly rate. It is important for your organization to have a good idea how many vendor support hours you will need and to negotiate these hours before completing the contract. Vendor contracts often assign a relatively high level of implementation-support hours and can end up costing you extra in up-front costs. Consider carefully what types of support you need and negotiate accordingly.

D. Selection Burn-Out

EHR “selection fatigue” can result as members of the product selection team spend months reviewing and analyzing organizational preparedness, internal system needs, writing and releasing a RFP or RFI, reviewing the vendor responses, and attending product demonstrations. Ensuring that the team is available for the many needed demonstrations and reviews is challenging in itself, over and above the tedious process of sifting through requirements during hours of initial and final product demonstrations.

Those who contribute most may be most susceptible to selection fatigue, so it can be tempting, given the weeks or perhaps months of implementation time ahead, to make personnel changes on the EHR team following the completion of system selection and vendor contracting. But this is a major mistake, because not even the best documented projects can ever replace the loss of hundreds of items of context, detail, knowledge, relationships, and expectations formed during the selection process.

It is imperative that the EHR Team has realistic expectations about the length of the project, as well as the consistent support of the organization’s leadership team, who must recognize that team members are carrying a heavy load. Actively limiting the additional workload assigned to team members, as well as budgeting for occasional “team fun,” are two ways to mitigate the damaging impact of selection fatigue as the project moves ahead.

Risks during EHR implementation

Anticipating and preparing for known and foreseeable risks, including three important risk categories shown below, is important to successfully seeing an EHR implementation project through to conclusion. Key concerns and risks during the implementation phase (installation-go live-validation) of an EHR system include:

A. Budget Risk

Purchasing the right EHR system for your organization is certainly a costly concern, but the system’s cost is just the first of your budgetary concerns. Your project budget must allow for all of the ancillary items needed to make the EHR fully functional in the way you have envisioned. Whether the items are related to hardware, software, network equipment, or staff capabilities, if you fail to anticipate, budget for, and complete these items before you contract for an EHR implementation, you’ve put the cart before the horse.

I know of organizations that have stuck themselves with paying for new EHR systems, due to issues like these, long before implementation could actually begin and years before the first possible “go-live” date. Here is a short list of additional items or upgrades that you will need to budget for prior to contract signing:

• Hardware, infrastructure, internet connectivity, computers, tablets, mobile devices, signature pads, and portable scanners.
• ePrescribing, Meaningful Use functionality, and licenses to other software programs needed for full EHR functionality.
• Interface development or integration tasks, including:
• Data conversion or exchange with multiple laboratories and key business or care partners.
• Development of Meaningful Use functionality and dashboards for data recording and reporting
• Fees and interface development costs for participation in local or regional health information exchanges
• Customized forms and treatment planning tools
• Creation, equipping, and upkeep of user training lab (floor space, hardware, office furniture, access)  
• Need for additional IT consulting expertise or IT vendor support
• Input, analysis, and reporting tools to support business intelligence, organizational analysis or benchmarking, or outcomes tracking and reporting.

B. Complex Implementation Tasks

Complex implementation tasks include configuring the new EHR to meet organizational requirements, since few EHRs can be used “right out of the box.” During hours of EHR product demonstrations prior to selection, your selection team will see a range of almost seamless EHR capabilities. What will become clear later is that a multitude of options in virtually every EHR system must be carefully evaluated, then configured to deliver key capabilities in ways that meet work process, treatment process, compliance and business requirements. Work like this constitutes the bulk of EHR implementation work, and typically falls into these buckets:

Configuration involves setting up the many options and variables in an EHR system’s functionality to match your organization’s workflows and needs. Here are a few examples:

• Treatment planning: What tool will be used? Does it need to be purchased? How will it be supported?
• System forms: Configure the forms library provided by the vendor, or develop your own set of forms? Has the team reliably estimated the time needed for forms configuration, review, and testing?
• Access: How will access to patient records and system features differ according to provider and staff responsibilities?
• Clinical decision supports: Which clinical decision supports are needed/preferred by which providers?
• Meds: How will medication lists be organized, presented, and maintained? Should they be customized to meet state, plan, or physician requirements?

In the world of EHRs, the need to customize – literally, to rewrite base software to change its functions – increasingly is something to avoid. Vendors have invested a lot in making their EHRs more configurable because they hate to change any features in a proven (and often certified) product for fear that something will “break” and result in a maintenance headache.

If you purchase EHR software and run it on your own servers, you may have the option to customize it yourself. However, if you do so, your organization is going to bear the cost of maintaining that one-of-a-kind version for the rest of its operating life. If a change to internal work processes or the choice of a different EHR system could eliminate the need for a costly, one-off customization, consider it.  

C. Billing

Implementing and testing the billing-related functionality of an EHR takes extensive time, testing, and effort. It demands that all inputs – patient, provider, treatment, and pricing information – are correct on your claims submittals. And it demands that you identify, test, and manage your interactions with payers, because their data links, forms, and rules are complex and changeable.

Perhaps one of the worst EHR implementation scenarios is to “go live” without the benefit of a working revenue cycle. Because a steady revenue stream is critical to the predicted ROI for the EHR system, continuous testing is imperative in the months prior to go-live. Avoid going live unless thorough testing and proven redundancy assure you that your revenue cycle is working correctly.

Lisette Wright, M.A. is a consultant on IT projects in the health and human services industry and executive director of Behavioral Health Solutions, P.A. in Minneapolis.