Jul 24, 2020, By: Heather Ead
- Include staff in the change to reduce unforeseen usability failures and delays in accepting a change.
- Be mindful of the grieving process; it could create opportunities for managing the emotional response to a perceived loss.
- A new health information system can facilitate monitoring of care processes and creating reports, but it will not fix suboptimal practice.
The movement within health care to replace paper charting with an electronic health record (EHR) continues to spread globally. There is a wealth of literature that cites the numerous benefits of an EHR, such as improvements in legibility, communication to health-care providers internally and externally, consistency of care delivery, access to reports, data analysis, and more (Hertzum & Ellingsen, 2019). However, few published articles provide specific guidance on how to support this complex change (Scheck McAlearney, Hefner, Sieck, & Huerta, 2015). This article aims to address this deficiency.
The planning, building, and implementation of an EHR is a highly complex process that affects a wide range of providers, patients, and their families. The move toward computer information systems began in the early 1970s (Safdari, Ghazisaeidi, & Jebraeily, 2015). The central goal at that time was more simplistic: efficiency for the health-care provider. However, over the past 50 years, health care has become more patient-centred and complex. Today’s EHR can address the complexities in health care and optimize the patient’s access to health information (Salameh, Eddy, Batran, Hijaz, & Jaser, 2019). An EHR can create a comprehensive, longitudinal, and complete record over a patient’s lifespan. This helps reduce siloes and delays in accessing vital patient information.
Seven important issues to consider when implementing an EHR:
1. Acknowledge that change isn’t easy
Adopting a new way of accessing and documenting health information can be both an unsettling and overwhelming transition for staff. The learning curve requires providers initially to adjust the amount of time they usually dedicate to locating and documenting patient information. With practice, users become more efficient, but many report that the initial adjustment to EHR functionality is burdensome and time consuming (Scheck McAlearney et al., 2015). An EHR leads to large changes in workflows and routines that staff were previously comfortable with. The organization must apply the principles of change management, and engage end-users in working groups that focus on usability. This allows early identification of challenges related to new workflows (Sennah et al., 2019). For example, providing a demonstration on order entry functionality creates the opportunity for staff to give feedback on what is most appropriate and requires as few “clicks” as possible. Including staff in the change can reduce unforeseen usability failures and delays in accepting a change.
Adopting a new way of accessing and documenting health information can be both an unsettling and overwhelming transition for staff.
2. Be sensitive about the change, allowing time to “grieve”
A review of the literature on the challenges associated with EHR implementation reveals that there is a prominent theme around grief and loss (Scheck McAlearney et al., 2015). This includes the loss of feeling like an expert and the loss of the provider’s work routines. The large learning curve requires many staff to move into the role of novice in regard to using the new EHR. Being mindful of the steps in the grieving process creates opportunities for managing the emotional response to a perceived loss. The Kübler-Ross model of the five stages of grief is well known, and can be a valuable reference for large change projects (Castillo, Fernandez, & Sallan, 2018; Scheck McAlearney et al., 2015). See The five stages of grief and adoption of an EHR and how to manage them below.
An EHR can enable new efficiencies while creating changes in job role descriptions, accountabilities, and even the volume of staff for some areas. For example, with paper charts it may have taken a great deal of manpower for activities such as pulling reports, conducting chart audits, and completing physician order entry activities. However, with an EHR the time and effort to complete such tasks are greatly reduced. For example, a physician no longer needs to ask a clerk to input orders manually. With the EHR, electronic orders flow to the appropriate section of the chart and health-care provider. This allows medication orders to flow automatically to an electronic medication administration record (MAR), to be acted upon by the provider. Such change creates the opportunity to adjust or reduce staff with solely administrative functions. The anxiety related to role changes and job loss requires sensitivity and empathy of the team. The organization’s leaders should keep in mind that fears around job loss can lead to user resistance and negative attitudes toward the change (Safdari et al., 2015). Good communication throughout the project can help alleviate some of these barriers.
3. Design and follow a road map that includes the patient’s perspective
Implementation of an EHR requires strategic project management in all phases. The phases of a large project include pre-implementation, implementation and post-implementation (Ghazisaeidi, Ahmadi, Sadoughi, & Safdari, 2014). A road map that outlines the steps and goals throughout these phases is part of a well-designed strategy.
In the pre-implementation phase, working groups are established, priorities and goals of the EHR are developed, and a health information system (HIS) vendor is chosen. At the implementation stage, current and post-implementation workflows are confirmed, a training program is developed that guides the user to the new workflow, and practice readiness activities take place. Finally, the post-implementation phase includes continued education, updates, and optimization of the system. A project management team and road map that is used in all phases of the project facilitate the success of an EHR implementation (Safdari et al., 2015).
With a large learning curve, staff can become overly focused on the screen of a computer or hand-held device. The functionality of an EHR must not deter from a patient-focused approach to care. From the patient’s perspective, use of an EHR can create an optic of a less-than-personal approach, particularly if staff are looking at a screen instead of the patient. Where possible, the health-care provider can involve the patient in the EHR documentation process, and explain what is being typed or “clicked,” and share the screen view with the patient as appropriate.
The functionality of an EHR must not deter from a patient-focused approach to care.
4. Some assembly is required
After an organization chooses a vendor for their health information system, it is not a simple “plug and play” process. A great deal of build, crossover of prior records, and customization take place before going live with the EHR. This requires a large team, including application analysts and clinical informatics, to work closely with the end-users to ensure the system will work efficiently for the organization’s needs and workflows (Safdari et al., 2015). Being aware of the activities that occur in the pre- and implementation phases can assist managers to backfill their staffing complement to enable their staff (subject matter experts) to attend working group meetings that support the build of an efficient EHR.
5. Communicate effectively
One of the central benefits of an EHR is improved communication across the circle of care. Ironically, it can be challenging to maintain communication with a diverse group of providers during all phases of a project.
EHR implementation requires a wide group of users and departments to synchronize their processes; the complexity of the health-care organization becomes evident early in the project. For example, communication throughout the project must occur among clinics, labs, billing, registration, in-patient units, pharmacy, diagnostic imaging, and many other department representatives (Merhi, 2015). Clear communication and direction by project members, leadership, and staff can facilitate decision-making and success (Merhi, 2015). For example, the staff in the operating room would need to collaborate closely with departments such as booking, transfusion services, and pathology to ensure that functionality meets all regulations and standards. Involving staff that serve as change agents and early adopters helps maintain good communication (Salameh et al., 2019).
6. Manage expectations
A new health information system is not an automatic fix to challenges such as suboptimal practice. While the EHR can facilitate monitoring of care processes and creating reports around compliance to protocols, the accountability remains with the staff to provide quality care. All providers should remember that the purpose of an EHR isn’t to make one’s job easier, but to integrate care processes across the circle of care and improve access to health information (Scheck McAlearney et al., 2015). It is also recommended that the organization have policies in place related to the EHR, and that these are communicated to staff prior to going live. The staff should be aware of policies such as response to automated best practice warnings, dual signature requirements, time requirements to acknowledge new physician orders, and acceptable abbreviations such as “WDL” for “within defined limits” (Gray, Gilbert, Butler-Henderson, Day, & Pritchard, 2019).
Other expectations to consider include ease of use. Staff may be surprised to find that initially, the EHR doesn’t feel as user-friendly as they expected. Providing staff with adequate training, go-live support, tip sheets, and ongoing assistance is key to the implementation and post-implementation phases. In most organizations, computer literacy and comfort with technology varies among the staff. This creates an opportunity to provide a review of computer skills prior to the start of functional training. Such a review can help reduce anxiety and ensure that training sessions on the new system’s applications go smoothly.
7. Remember why you’re implementing an EHR
Adoption of an EHR can be one of the most significant projects for a health-care organization. Staff must keep the rationale for the change at the forefront. This can be done by recapping at staff meetings the specific benefits staff will gain from the EHR. Pausing to reflect on the long-term gains and benefits an EHR provides will help staff navigate large learning curves and change. For example, the time-consuming step of manual entry of diet, lab, and other orders is not required when the physician enters orders directly into the system. Reviewing the many wins for patients and staff can help staff navigate through change-related stress.
Overall, one can see that a great deal of planning and support is required to have a successful transition from paper to e-documentation. Organizations must be ready to manage the emotional response to change and support staff members as they adapt to new routines. Applying the seven tips in this article can help navigate complex changes, while enabling the many benefits provided by an EHR.
The five stages of grief during the adoption of an EHR and how to manage them
- Reinforce goals and benefits of an EHR
- Create excitement and energy around the project
- Establish a sense of urgency — “we need an EHR!”
- Manage the culture and apply the principles of change management
- Encourage staff to vocalize and provide constructive feedback
- Ensure representatives and subject matter experts are involved and engaged with the project
- Acknowledge that change is unsettling and difficult
- Provide staff with a comprehensive training program
- Ensure tip sheets and other resources are readily available to all staff before and after going live
- Allow time to adjust to the new process. For the initial transition period:
- Reduce patient-to-staff ratios
- Reduce the volume of elective procedures and surgeries where possible
- Provide hands-on, at-the-elbow support to staff to enable troubleshooting
- Conduct daily team huddles to support staff
- Celebrate small wins
- Update policies to reflect changes in workflow and accountabilities
Source: Castillo et al., 2018; Scheck McAlearney et al., 2015.
Castillo, C., Fernandez, V., & Sallan, J. (2018). The six emotional stages of organizational change. Journal of Organizational Change, 31(3), 468–493.
Ghazisaeidi, M., Ahmadi, M., Sadoughi, F., & Safdari, R. (2014). A roadmap to pre-implementation of electronic health record: The key step to success. Acta Informatica Medica, 22(2), 133–138.
Gray, K., Gilbert, C., Butler-Henderson, K., Day, K., & Pritchard, S. (2019). Ghosts in the machine: Identifying the digital health information workforce. Studies in Health Technology and Informatics, 257, 146–151.
Hertzum, M., & Ellingsen, G. (2019). The implementation of an electronic health record: Comparing preparations for Epic in Norway with experiences from the UK and Denmark. International Journal of Medical Informatics, 129, 312–317.
Merhi, M. (2015). A process model leading to successful implementation of electronic health record systems. International Journal of Electronic Healthcare, 8, 185–199.
Safdari, R., Ghazisaeidi, M., & Jebraeily, M. (2015). Electronic health records: Critical success factors in implementation. ACTA Informatica Medica, 23(2), 102–104.
Salameh, B., Eddy, L. L, Batran, A., Hijaz, A., & Jaser, S. (2019). Nurses’ attitudes toward the use of an electronic health information system in a developing country. SAGE Open Nursing, 5, 1–8.
Scheck McAlearney, A., Hefner, J. L., Sieck, C. J., & Huerta, T. R. (2015). The journey through grief: Insights from a qualitative study of electronic health record implementation. Health Services Research, 50(2), 462–488.
Sennah, S., Shi, J., Hollenberg, E., Johnson, A., Ferguson, G., Abi-Jaoudé, A., & Wiljer, D. (2019). Thought spot: Embedding usability testing into the development cycle. Studies in Health Technology and Informatics, 257, 375–381.
Heather Ead, RN, MHS is a clinical educator at Trillium Health Partners in Mississauga, Ont. She can be reached by email at: Heather.Ead@thp.ca