EHR Implementation: One Organization’s Road to Success

Abstract

This paper describes Ontario Shores Centre for Mental Health Sciences’ successful journey in the implementation of a fully integrated single proprietary solution health care information system over approximately 22 months. The paper describes the various phases involved, the approach for implementation, lessons learned throughout the process and the organization’s future plans for optimization.

Introduction

The era of the electronic health record (EHR) is upon us in the North American health care landscape. Nationally and provincially, there is a shared vision to transition to an EHR by Canada Health Infoway and in many of the regional health districts in Ontario including our Central East Local Health Integrated Network (CELHIN)1. Despite this vision, many health care organizations in Canada have been slow to adopt and implement fully integrated EHR systems. There have been criteria identified that predict the effectiveness of an organization in EHR implementation, including management support, financial resource availability, implementation climate and implementation policies and practices 2.

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is a 325 bed Tertiary Care Mental Health Centre located in Whitby Ontario, Canada. The organization provides a range of specialized tertiary care mental health programs for both inpatients and outpatients, serving a total regional population of approximately 2.8 million. Ontario Shores has approximately 1,200 employees, 16 inpatient units and many specialized outpatient/outreach services. In late 2007, Ontario Shores began its successful journey to the implementation of a fully integrated EHR system. The implementation of this fully electronic single proprietary solution was accomplished through the financial and visioning support of the senior leadership team. Successful implementation was completed over the course of 22 months between October 2009 to August 2011.

Ontario Shores’ goals for implementing a fully integrated EHR system were to:

1. enhance patient safety and quality,

2. enhance interprofessional practice structure, and

3. streamline care delivery process and workflow based on evidence-based practices and standards.

In addition, the implementation of the EHR system would provide an opportunity to enable a new culture of care, increase accountability and transparency in practice, create the ability to collect more accurate data to support decision making, and improve and enhance interprofessional communication and practices.

Background

In September 2008, Ontario Shores began readiness work for the implementation of Meditech 6.0. The process required many steps in order to ensure incorporation of best practices in the roll out of all EHR modules. This readiness work involved process mapping of the current and future state, clearly defining the organization’s interprofessional standards of practice and care delivery, reviewing policies and procedures, and reviewing documentation practices and process which were organized in various phases.

Setting the foundation for the project included a focus on the organization’s readiness and began with process mapping and revision of clinical documentations and incorporation of a documentation methodology. The project was then divided into 3 phases to ensure for smoother transition. Phase 1 included the implementation of the financial, human resources, staffing/scheduling, admissions and pharmacy modules. Phase 2 included the implementation of electronic documentation and order entry for all clinicians including physicians in the inpatient setting and Phase 3 was implementation of the clinical modules in the outpatient setting.

Phase 1 of Meditech 6.0 went live in October 2009, the implementation of the pharmacy module required clinical process changes in relation to medication management and resulted in a new paper Medication Administration Record (MAR) and order process which was to mimic the future state of Meditech 6.0. Prior to the implementation of Phase 1 all paper clinical documentation was reviewed and revised by a clinical documentation working group. This group was committed to ensuring standardization and adherence to best practices in the development of new paper forms that would ease the transition to and electronic documentation system in Phase 2 of the EHR implementation. In March 2010, the roll out of all the new clinical documentation forms occurred and was supported by members of clinical informatics and professional practice.

In October 2010, Phase 2 encompassing the Meditech 6.0 advanced clinical applications including Computerized Physician Order Entry, Electronic Medication Administration Record/Bedside Medication Verification, Patient Care System, Imaging & Therapeutic Services, Laboratory, and Physician Care Manager were implemented in the inpatient setting. This required intense training of all disciplines, including physicians, as well as, significant support during go-live to ensure smooth transition from paper to EHR. During each phase approximately 800 clinicians were trained to support the 16 inpatient care units within the organization. Subsequently, in January 2011 pre-work began for Phase 3, the outpatient implementation and all applicable clinical modules were implemented in these areas by August 15^th, 2011. This phased involved training approximately 200 outpatient clinicians supporting various outpatient/outreach services.

Approach

Building the team

The key theme throughout the design and implementation of the clinical modules was to focus on people, process and workflow; there was strong belief that technology should not drive practice 3. Also, literature relates the poor adoption of information technology within healthcare to factors such as lack of attention to the effects of workflow by the electronic documentation, inability to capture all the processes involved in the clinical work being done, and lack of training and support for end users 4,5,1. Taking into consideration the factors limiting EHR adoption and the key focus for the design and implementation, Ontario Shores chose to assign the Clinical Informatics portfolio under the Professional Practice umbrella. The strategic alignment ensured that clinical practice was the focus of all functionality design and development in the EHR and this in turn supported adoption within the organization. The recruitment of the team included the identification of clinical informatics staff that would balance both knowledge of mental health practice along with understanding the complexity of decisions needed in building the content of an EHR.

Throughout the process engagement of key clinical stakeholders was a primary focus. A governance model (Figure 1) that include a Clinical Systems Steering Committee, Physician Advisory Group, Safe Medication Practice Committee and Application Design Team/Working groups fed key pieces of information and decision to the already existing governing committees in the organization. The design team working groups included front line nursing, allied health staff, physicians and members of the Professional Practice Department. Involvement by all these stakeholders ensured that the build of the system reflected current best practice standards and met the expected documentation requirements by all regulatory bodies. This engagement ensured that the design of the system was led by clinicians and not IT professionals who focused on the devices and operationalization of the system.

Figure 1:

Project Committee Structure

Process Mapping

A focus of the design team from the pre-work to implementation phase of the project was to document using a consistent process mapping framework. Few organizations are able to recruit staff with the skills and expertise necessary to effectively and accurately map out clinical processes 5. Early in the process the organization partnered with a local university to receive process mapping training and utilized a new innovative mapping model. Also Lean/Kaizen Methodology was utilized during the preparation work for the outpatient implementation to support streamlining of processes within practice. Ontario Shores has adopted the utilization of Lean methodology for evaluation of many processes and activities, including outpatient services, within the organization, as it focuses on providing value to clients through lower financial cost by eliminating wasteful activities. The methodology supports improvement in patient satisfaction, financial resources, and greater throughput 6.

Training

Training development was led by a Clinical Practice Leader in the Professional Practice Department. The curriculum development mainly focused on the adult learning principle of practicality to ensure the education on the system was meaningful for staff and relative to their daily clinical work. The curriculum content was based on “a day in the life of” concept that would walk the clinician through documentation on the EHR from the beginning to end of their shift. An e-learning online module which provided a high overview of the Meditech 6.0 functionality was utilized for staff as an introduction to the system during training classes, as well as, post training it was available for review by user. The training also allowed each clinician to practice in real-time what was being taught with a “test patient” to allow for greater opportunity for knowledge translation. The length of face to face training varied amongst disciplines based on what they would be using within the system. Nursing received 24 hours of training over three 8-hour days; allied health received 12 hours of training over 1.5 days; and physicians received 8 hours of training divided into two 4-hour blocks. All training was completed in a group setting on site using temporary computer lab stations set up across the hospital. A few months prior to the commencement of training, the organization also offered basic computer skills training classes to support users who lacked this skill.

There were approximately five concurrent training sessions for 6 weeks. In anticipation of training support and go live, super users were recruited from each unit/program across the facility. These individuals were provided with additional education and were integral in providing support during training and on the units during and post the go live period. A similar methodology for the outpatient training was utilized over a short period of time due to a significantly lower number of staff who required training. Overall, the training methodology was extremely successful as every clinical staff attended and participated in training.

Device Selection

The devices selection process was led by IT with collaboration with Clinical Informatics and Professional Practice. An evaluation of various medication delivery carts and point of care devices were conducted by frontline staff and Clinical Managers by participating in a variety of demonstrations by multiple vendors and completing an evaluation form. The selections were made based on evaluations provided.

Implementation Process

The inpatient integration of Meditech consisted of two go-live phases to enable the available resources the ability to complete staff training, chart conversion and on-unit support. The organization was strategically divided in half to allow for the intense training and support for a “big bang” approach to implementing all clinical modules at one time in each of the go-live phases. Each phase consisted of two weeks of intense on-unit support with each unit having a minimum of one super user present on each go-live unit to solely support documentation on Meditech. This intense support for front line clinicians enabled reduction in anxiety for the big shift in documentation from paper to electronic, as well as, allowing the support team to have the ability to identify and efficiently resolve issues with the system affecting practice and process. The week before each go live, the clinical units were expected to complete a chart conversion form for each patient registered to a bed. This form included specific risk and clinical indicators that a stakeholder group identified required being documented in the clinical record for the day of go live. Chart conversion also included transcription of all active orders into the EHR. For the Outpatient departments implementation was again completed in 2 waves. The chart conversion for outpatients was completed by the front line staff during the first patient appointment post go live.

Utilization & Adoption

100% of clinical staff are now using the EHR to capture all clinical documentation and orders in the inpatient and outpatient setting. More specifically;

• 96% of orders are entered into the system directly by the ordering provider (Physician or Nurse Practitioner)

• 99% of the time patient identification is confirmed through canning of armband barcodes rpior to medication administration

• 93% of medication administrations are scanned versus manually documented

• 45% of the time physicians use pre-determined Order Sets for new admissions

Lessons Learned

Early in the journey towards implementation of the EHR system it was evident to the project team that this was an opportunity for process improvement and clinical redesign. For this reason we placed great emphasis on the readiness work prior to building the EHR system. Our outpatient pre-work process was accomplished in a shorter amount of time and the team saw a distinct difference in the quality of the EHR design and implementation between outpatients and inpatients that we believe reflected the different approach to pre-work process. Specifically there is a significant amount of re-work required for the outpatient departments as opposed to the inpatient units.

Leadership support and physician engagement were key enablers in the success of the project. The Senior Management Team possessed an unwavering commitment to the success of this project. This included the allocation of appropriate resources to ensure the project met all timeline and budgetary goals. The project team also strategically selected a candidate for the position of physician champion who was a well respected member of the physician team. This enabled a highly successful Physician Advisory Group for the project and ensured that physician adoption and engagement was a prime focus throughout each step of the process. Inclusion of frontline clinicians was integral in the evaluation of various processes and documentations within the system which also increased staff engagement and “buy-in” to the system.

It was fairly evident post go-live that there was a lack of clear understanding of processes when clinicians and clinical leaders were given the task of choosing med carts and point of care devices. The low participation rate by clinical leaders and clinicians during the vendor demonstrations and limited understanding of future state resulted in inaccurate number of devices, such as med carts and barcode readers, to be available on go live date. Frontline clinician involvement and education on processes are vital in the success of appropriate device selection.

One of the major success factors was the ability of the team to work together and adapt to the various challenges they encountered throughout the project. Specifically this included a strong project manager and team leaders for each of the modules that were implemented in Phases 1–3. The teams met biweekly and then more frequently as required. Also the collaboration between clinical informatics, physician advisory group and professional practice were key in ensuring all appropriate decisions were documented and approved through the various committees in a timely manner.

A success for the implementation project was the use of super users for training and on unit support. This allowed the project team to build a group of clinicians who were confident and knowledgeable about the system, which also supported the peer-to-peer help during off-hour shifts where additional supports were limited.

Next Steps

At this point in the organizations EHR evolution, sustainability and optimization are key to ensuring ongoing utilization and adoption by staff. This requires a realignment of informatics and practice and a reexamination of roles to ensure effective collaboration amongst the teams for future initiatives as the fully integrated EHR system will be impacted with changes in practice. Informatics personnel need to be active stakeholders in all decisions and committees that are looking at developing new processes throughout the organization to ensure all decisions are made in a way that ensures their seamless integration with the electronic system. The role of the nurse informaticians will continue to evolve to support to optimization and sustainability of the system. The next phase for the EHR system at Ontario Shores will be the integration of the Resident Assessment Instrument – Mental Health into Meditech to continue to support streamlining of documentation and processes as well as a focus on improving other indicators of adoption and utilization.