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December 17, 2012

Change for the Best
By Julie Knudson
For The Record
Vol. 24 No. 23 P. 14

Strong communication, thoughtful planning, and recruiting a handful of key players can help smooth the transition to an EHR.

Implementing electronic records is no small task. Technologies need to be selected, workflows analyzed, and users trained. But as you dive into the process, it’s always advisable to learn from those who have gone before you.

G. Daniel Martich, MD, chief medical information officer at the University of Pittsburgh Medical Center (UPMC), says the right approach to change management—no matter the type of project or which groups are affected—starts with a wide-scale buy-in. Martich knows a thing or two about EHR implementations: UPMC recently launched electronic records across its system.

“Make sure that the executives or C-suite of the hospital are completely behind it,” he says. It’s not uncommon in some organizations for tacit support to be given only for it to be yanked away when problems crop up. That kind of half-hearted commitment won’t be sufficient to carry an implementation to a successful completion. “There needs to be vocal, visible, and enthusiastic support from the top,” Martich says.

This top-down championing is crucial to gaining buy-in from the rest of the organization. “This, to me, is one area where the leadership of the initiative cannot be delegated,” says Randy Hountz, MBA, director of Purdue University’s regional extension center (PurdueREC) in West Lafayette, Indiana, which has assisted with EHR implementations earlier this year.

Hountz explains that top-level support must be robust enough to overcome resistance and ensure everyone is on board with the project’s objectives. Executive efforts need to include action items such as cheerleading the project to other departments. “If there’s a CEO that tells the IT department to make it happen but doesn’t talk about it in other forums or attend meetings, it’s far less effective,” he says.

Identifying and recruiting the influencers in your organization is another crucial step. That means finding out who holds sway in nursing, pharmacy, and every other department the project will affect. “If those folks aren’t with you, it’s going to be tough,” says Monica Arrowsmith, RN, MSN, JD, PurdueREC’s director of strategy and development, who cautions that the influencers often are not found in the traditional power or leadership positions. “A lot of those individuals are ‘unofficial,’ but make no mistake, these folks have plenty of pull with the others in their respective groups, and they can truly be make-or-break partners in any change management effort.”

A solid communication plan goes beyond telling people about the project’s timeline and final objectives. Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, CIP, principal of Dak Systems Consulting, says providing details such as intended benefits can often help convince staff that interim hurdles will be worth it in the end. “You need to inform all the stakeholders of the reason for the change,” she says. “Explain the whys, what’s in it for us, what’s in it for you, and all other details.”

This approach should be tied to an educational component designed to alleviate users’ concerns about gaining proficiency with the new systems and processes. “You have to devise an effective training program for the skills needed across the organization. If you don’t do that, then you’re in trouble,” Kohn says.

To help increase the chances of a change management plan’s success, Jane Adler, MD, president of NeoVista Health in Rockville, Maryland, recommends starting early. “Begin before the new technology is acquired, if possible,” she says. One advantage to this approach is that it gives staff a greater sense of ownership in the project. “They care more about successful outcomes when they feel they have a say or have been involved from the beginning,” Adler says.

Plugging people into the project early also provides an opportunity to gather valuable information during the planning phase. “That means you’ll have fewer re-dos and fewer mistakes,” Adler says, adding that she’s seen clinical settings that discovered problems with their initial technology setups that might have been spotted earlier had the right resources been involved. “The sooner you can bring people together, the better.”

Once the project is under way, experts advise staying alert for warning signs that may indicate trouble’s ahead. A popular roadblock, Martich says, is when someone who’s expected to participate in the new workflow digs in his or her heels. By itself that scenario isn’t uncommon—it’s when a hospital agrees to make an exception for them that things begin to unravel. “You cannot make day 1 ‘exception day,’” he says.

Caving to the demands of a particularly vociferous individual might look like an easy way out, but the problem could soon snowball. At first there are just a few of them, Martich says, and before you know it the project has detractors all over the place. “Those kinds of revolts can happen to the detriment of any kind of project,” he says.

Every project hits the occasional snag, Kohn says. It’s when people make those glitches out to be more important than they really are that you could find yourself facing an unexpected hurdle. “It’s troublesome when people keep harping on the problems that have occurred,” she says. If those involved in the project are belaboring errors or delays, act quickly before they poison other staff. “I believe in having a change manager who is always monitoring the situation,” Kohn says. “And those are the kinds of things you need to notice so you can deal with any negatives right away.”

Because problems are likely to crop up even in well-planned implementations, Hountz warns of the “valley of despair” that can sometimes give the perception that the project is in trouble when perhaps it’s just going through a difficult patch. “The hard part is understanding if it’s just a normal valley of despair in implementing change or whether you’re really off track,” he says.

By stepping back to examine the types of problems—who’s expressing concern, who’s encountering difficulties, where the project stands compared with the original plan, and whether potential solutions are within your power to implement from a cost, schedule, and expertise perspective—you can often get a better idea of the severity of any complaints.

Conquering Fear
It’s a common axiom that people fear change. And while the term “fear” may overstate the prevailing feeling surrounding an EHR implementation, there likely are going to be folks who aren’t exactly thrilled with the notion. Working to alleviate the concerns that often come along with change will help keep the project on the path to success.

“Healthcare cultures change amazingly slowly,” Martich says, adding that the trepidation actually can be an ally. “In healthcare, people respond to data. And there is a glut of medical information in the literature about medication errors and the benefits of [computerized physician order entry], so wherever there are data- or evidence-based medicine, present that and say, ‘This is why we are doing it.’”

Arrowsmith believes strong communication channels are key to winning over those who are skeptical of where the project will take them. “Fear dissipates with understanding,” she explains, adding that it also “dissipates with trust in the project’s vision and the organization’s leadership.” By openly sharing how changes will be implemented and how they’ll ultimately affect workflows, staff will be able to develop a better comfort level in what their jobs will entail when the project reaches fruition.

“If I’ve got a lot of trust in my organization and I know they’re not going to mislead me, I have less fear,” Arrowsmith says. Sharing the organization’s vision for success also can help move the project team beyond its initial concerns.

Management Misconceptions
Change management and project management are sometimes referred to interchangeably, but those who have led EHR implementations say they are different disciplines. Change management, Kohn explains, is a structured approach used to transition people from doing something one way to doing it a different way, all in a manner that encourages them to embrace the new method. “Project management isn’t managing the change, but change management is part of the project,” she says. “For an EHR implementation, I believe you often have to have a project manager and sometimes also a designated change manager because change management is just one part of the project management process.”

A successful EHR implementation requires expertise in managing not just the project but change in a more holistic sense. Adler says project management often is narrowly focused on the technology and its logistics, such as hardware and software, network and security requirements, schedules for the various activities, data migration, and budget management.

On the other hand, change management relates to the people component. “It’s getting people to actually utilize the technology,” Adler says, by moving them beyond going through the motions and “getting them to really adopt it in order to get the best possible outcomes.”

Change management is the “how” of an EHR deployment, Hountz says. “It’s how to get the buy-in, the support, and the compliance,” he notes, adding that it also will help transition staff from the current workflow to effective use of the new EHR platform.

But for all the expectations and goals that rest in change management’s basket, Hountz says the project management piece is where many EHR implementations focus their investment of time and money. “Project management is specifically what we have to do,” he says. In a nutshell, it’s the action task list, the budget, and the schedule, sometimes in painstaking detail. “It’s every specific task that has to be accomplished to get that particular technology live,” Hountz says.

— Julie Knudson is a freelance writer based in Seattle.


Outside Help vs. Internal Resources
“Leading change is an inside job,” says Jane Adler, MD, president of NeoVista Health. In her experience, the organizations that have the most successful EHR implementations are those that recognize the need for internal change leadership.

“It’s about delivering outcomes from the technology. Change leadership involves understanding the inner workings of the organization and influencing physicians and staff,” she explains. Effective change leaders will need to talk about the project as well as support it through his or her actions by attending meetings, talking with staff about their concerns, and attending to the various needs that come up at different stages in the project’s lifecycle.

While Adler says that building the necessary collaboration among physicians and staff is best done by someone in-house, that person doesn’t have to go it alone. “There are tools and strategies and information available for people who are charged with leading change,” she says. For example, outside advisors can be leveraged for planning purposes, to guide leaders through the right steps, and to craft a systematic and structured approach for the impending transition.

But not every hospital system has the in-house resources to successfully shepherd an EHR implementation from beginning to end while also leading change management efforts. What’s safe to outsource and what needs to be done internally?

G. Daniel Martich, MD, chief medical information officer at the University of Pittsburgh Medical Center, says training is probably best accomplished in-house because many providers are adept at focusing on the use of the technology “but don’t understand how the integration of an electronic health record goes with the workflow.” Should an organization choose to go outside its walls, transition teams need to be diligent in determining a vendor’s level of EHR integration expertise, he says.

Martich also is hesitant to outsource support functions. “If it’s third-level support from the vendor and they’re talking with someone who’s already an expert on the second level locally, maybe that’s acceptable,” he says. “But if you’re going to do clinical IT support, you better have boots on the ground. That’s typically not an outsourced effort.”

Project management is a structured discipline of its own, one that Adler says often is a good candidate for outsourcing if the resources don’t exist internally. “The project manager has to be able to manage multiple timelines, coordinate relationships with vendors, keep the technology implementation on track, work with the budget, etc,” she says.

If those skills are sought outside the organization, Adler says the internal change leader must work in close partnership with the external project management team. “They need to make sure that those project management steps work in your particular organization,” she says.

— JK