With the federal government poised to give $19 billion for meaningful use of electronic health records (EHRs), hospitals and health systems across the country will be either upgrading or implementing these systems over the next 5 years. How well facilities prepare in advance of go-live will determine whether they can sustain high-quality and safe care delivery seamlessly. If the work required is underestimated or left to address until the last minute, nursing workflow and patient care could be adversely affected as well as reimbursement.
Approximately 12% of U.S. hospitals have adopted EHRs, and many technology vendors are on track to release reconfigured versions of those systems to support meaningful use criteria phased over three stages. As hospitals advance from one stage to the next, compliance will become increasingly complex and nursing workflow will be affected by some requirements. To successfully navigate the coming environment and ensure workflow supports quality care and patient safety, it's essential that hospitals develop a road map for installing an EHR.
Develop project plan
The key to ensuring a successful EHR upgrade or deployment is to create a project plan outlining the tasks, timelines, and responsibilities of the vendor and the provider. Ideally, this is a collaborative process between key client stakeholders and the vendor's project management team. However, organizations should be aware that some companies don't offer this service, leaving the plan's development entirely up to hospitals.
Before a plan can be crafted, the first action that hospitals must undertake is asking the vendor a series of questions:
- What's the purpose of the upgrade?
- Who will be impacted and how?
- How significant is this upgrade?
- Will it require training?
- Does it include many end-user changes?
- Will the upgrade require a few hours or a few days to activate?
- How will you perform the upgrade?
- Does our IT department need to be involved? If yes, at what level?
- Should we expect downtime?
The answers to these questions provide the institution information needed to assemble a project team, identify the right people to bring to vendor-hosted planning meetings, figure out logistics, and determine the amount of time and resources to set aside. For an EHR in particular, it's vital to involve and solicit input from nurses as early as possible, as they're typically the heaviest system users.
Scrutinize workflow and documentation practices
The project team must closely examine whether the new EHR functions or changes affect nursing workflow and patient safety. If they do, hospitals should ensure the proposed redesign of the workflow is efficient and in the best interest of nurses and patients. The assessment—and follow-up—should be performed by the hospital's nursing representative on the project team in consultation with nurses who work on the floor.
During this process, providers can assess if the proposed changes comply with their documentation policies and make revisions as appropriate. This review can be used as an opportunity to look more closely at certain troublesome documentation practices and build in the assessment or requirement into the upgrade, making life easier for nurses and all others involved.
Set a go-live date
The vendor will ask the health system for a go-live date at the earliest stage of the process. The provider should set a date that's convenient for them. Once the timing is finalized, both parties will know exactly when to kick off the project. For example, Paradise Valley Hospital scheduled the go-live of its perinatal EHR upgrade for January 11, 2010, which meant that we and our vendor launched the project in late November. Together, we estimated 6 weeks to be scheduled to execute project plan activities, including testing and training, in time to meet deadline.
Based on our experience, institutions can expect implementing a "best-of-breed" system upgrade for a department such as obstetrics to take roughly 6 weeks, whereas hospitals installing inpatient EHR upgrades enterprise-wide would require additional time, as the project involves a number of departments and diverse users. Facilities digitizing records for the first time can expect to spend 6 months or more, partly because they're making a much greater leap than providers already well versed in the use of electronic records. Unlike those familiar with EHRs, new adopters typically undergo a significant cultural change in addition to learning a new way of documenting care.
Schedule weekly calls with the vendor
These "meetings" enable the partners to communicate their respective progress reports, resolve issues, and take steps to ensure deadlines and milestones laid out in the project plan are on track.
Prepare and get word out early
Hospitals should communicate the go-live date as soon as possible. Nurses who are experienced EHR users are recommended to attend a 2- to 3-hour class for a major upgrade, whereas new adopters might need a full 8 hours.
The amount of training is subject to many variables, including the role of the user and the extent of workflow impact resulting from the changes. Organizations can schedule, reserve space, sign up nurses, and prepare training materials early. For minor upgrades, a handout or web-based tutorial covering the changes in software might be sufficient.
To facilitate and optimize learning, facilities must be careful not to schedule training sessions too early in the process. It's best to begin classes a month before go-live to help nurses better retain the new knowledge. Hospitals also can recruit RNs to serve as "super users" while promoting training classes. These individuals will receive one or two extra training sessions to prepare them thoroughly to help colleagues use the EHR upon activation. The in-house trainers should be computer-savvy and good communicators. They also should be selected from the day, night, and weekend shifts.
Schedule software upload
Hospitals using EHRs that run on redundant servers don't have to worry about choosing a good time for the vendor to load the software because their systems never go off-line during an upgrade or scheduled maintenance. When one of these events takes place, the vendor transfers all users to the second server while loading the new software version in the first server. As a result, nurses will continue documenting electronically without having their workflow and patient care disrupted. Organizations whose EHRs run on one server should schedule the upgrade when nurses are least busy, and have paper charts readily available once the system is taken down.
Allocate sufficient hardware resources
Deploying EHRs is such a complex undertaking that it can be easy to overlook hardware needs. It's critical that providers stock sufficient numbers of mobile carts and PCs at go-live to avoid nurses having to wait on others to finish using a cart or computer.
Station super users on the floors
A key to successful implementation and securing nursing buy-in is to address all questions or problems promptly. When upgrading our EHR earlier this year, we put super users on every unit for a 2-week period from the go-live date. Making this support available 24/7 is critical to minimize users' frustration. Although this is an improbable scenario for current EHR users, it's still essential to deploy super users to avoid patient-care disruptions.
Conduct postimplementation analysis
Over the next 5 years, some providers may upgrade systems more than once to meet meaningful use requirements. Consequently, it's a good idea for nursing managers, end users, and the project team to meet with the vendor to discuss lessons learned to apply to the next release. This postimplementation exercise can be conducted 2 weeks after go-live, while the experience is still fresh.
Providers and vendors also are advised to review the EHR after nurses have charted electronically 4 to 6 months. By that time, nurses are more comfortable with the upgrade changes and will have constructive ideas and comments to consider configuring to further improve documentation efficiency.
As important as it is to have a project plan, providers should keep in mind that, in the end, the primary factors influencing a successful EHR upgrade or implementation are open dialogue and collaboration among nursing leadership, staff nurses, hospital IT employees, and the vendor, with frontline clinical staff prominently leading the way. The end results—enhanced care management, patient safety, and nurse job satisfaction—are 99% guaranteed.
