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Five steps to electronic health record success: no electronic health record will fulfill its promises if implementation fails. And for a successful implementation, the process must begin internally

Joseph T. Wood, III

"This change is afoot. We're all locked on, and we're not going to let go until it gets done."--David Brailer, MD, PhD, national coordinator for health information technology

Because of the high cost and potential financial benefit to the organization, hospital and health system CFOs are increasingly involved in electronic health record systems selection. Unfortunately, many organizations make the mistake of distilling this process down to a simple comparison of features and costs among vendors. The result is often implementation failures. These can be very costly, but worse, they can disrupt the organization and affect patient care quality and safety.

In its July 21 report, The Decade of Health Information Technology: Delivering Consumer-Centric and Information Rich Health Care, HHS addressed the consequences of electronic health record implementation failures: "Implementation failure and partial use of EHRs are commonplace. Even if EHRs are implemented, there is no guarantee that they will be used and therefore lead to value for clinicians, consumers, or payers. Failed EHR implementation dissipates investment capital and leads to cynicism and fear among those who may want to bring their practices into a more modern era."

Electronic health records have the potential to improve financial performance of a hospital in a number of ways. These include reducing head count and eliminating unnecessary retests and duplicated procedures caused by misplaced paperwork. Electronic records can also improve physician productivity by streamlining record-related procedures. They can automate time and human intensive chart distribution processes. They can decrease the "discharged, not final billed" component of A/R significantly and improve coding turnaround time.

Moreover, they can minimize legal and financial risks by improving patient safety. Studies have shown that paper documentation is not available 30 percent of the time during a physician-patient encounter. Having an electronic health record system that supports clinical decision making through data mining improves overall pattern care quality and safety. Timely and accurate patient health information is the basis for improving patient safety. However, no electronic record will fulfill these promises if it is underused or if implementation fails. The key to successful implementation is to proceed from a logical plan that involves all stakeholders in the organization and takes a realistic look at the challenges and expected benefits.

When healthcare leaders look at an electronic record, they must resist the temptation to view it as an entity unto itself. Instead, it is important to take a more organic view and consider how the record will integrate with existing business processes. Likewise, vendor products need to be seen as a means, not an end. Vendors make many promises regarding ease of implementation, long-term costs, and financial benefits of their products. However, to achieve a successful implementation and benefits to the organization, the process must begin internally, not with the vendor.

The following five steps create a path for electronic health record implementation success:

* Define "electronic health record" throughout your organization.

* Set appropriate expectations.

* Choose the technology and your technology partner--wisely.

* Accept and promote process changes.

* Carefully plan the transition from paper-based processes to the final deployment of the record, and implement in phases.

Define "Electronic Health Record"

Many vendors offer some sort of electronic method for storing and disseminating patient health information. Although all may call their products "electronic health records," there can be wide-ranging differences in what various vendors offer. It is therefore important to define what your organization calls an electronic health record. rather than allow vendors to define and impose their own concept based on what they can offer.

An electronic health record can be a different animal to different organizations and to stakeholders with in the same organization, depending on their vision of the ideal use of patient information. Individual views of the electronic record are based on individual responsibilities to the patient and the organization. With the goal of smooth implementation and, thus, improved financial performance, CFOs and other executives must recognize that an electronic record must meet at least a consensus of needs and expectations.

Set Appropriate Expectations

There is a wide range of expectations of how an electronic health record should perform. The issues it is expected to address range from finance to privacy to patient care. CFOs want to know how the record will improve revenue cycle management, affect head count and salary, reduce retests and duplicated procedures, and improve the efficiency of caregivers and other workers in the organization. Coders want to know how it will facilitate the swift completion of their work. Physicians want to know how it will improve patient care, and whether it will make them more productive or simply add complexity to their already overburdened days. Nurses want to know if it will help prevent errors, and whether it will relieve their paperwork burden or simply make things more difficult. And, if they've never used a computer before, they worry about how long it will take to learn.

In all these various needs, there are common points for consensus. Usability is an excellent example, if an electronic health record is not user-friendly, physicians will be less likely to take advantage of its work saving features. For instance, if an electronic record has Web access and "e-signature" functionality built in, physicians might be spared the three hours a week they once spent walking down to medical records to sign patient records, hours they could then spend on patient care.

Although user friendliness might not be considered a direct need for CFOs, it most certainly relates to their expectations of improved efficiency and financial performance. These types of issues can bring the organization toward consensus regarding what an electronic record is and how it should perform.

Everyone in the organization whose job requires interaction with a patient record should be involved at some level in meetings devoted to "designing" the record. The organization needs to look at its current nonelectronic patient record processes and then determine how those processes could be improved, streamlined, and even eliminated by introducing of a digital patient folder or electronic health record. From this organizationwide assessment, a list of features and performance expectations can be developed.

One productive exercise in these meetings with stakeholders is to have them each make a list of the ideal features they would like to see in an electronic record (see sidebar). Start with the question, "Imagine a world where this electronic health record exists and what our life would be like when we have it." The stakeholders must understand up front that no record will provide all the items on their wish lists: however, this exercise can highlight commonalities for consensus.

From this list, the organization can develop a list of expected outcomes from electronic record implementation. Expected outcomes should be developed in at least the following areas:

* Improving revenue cycle management

* Lowering costs

* Improving patient care and safety

* Increasing efficiency and improving staff performance

* Decreasing paperwork

* Automating expensive, inefficient chart distribution processes

* Easing compliance reporting and adherence

A careful initial process of defining the electronic health record, designing its features, and developing measurable outcome expectations can result in a wiser choice of vendor, better buy-in from everyone involved, and less chance of a failed implementation.

Choose the Technology--and Your Technology Partner--Wisely

In a given hospital, there may be IT products from a variety of vendors for different functions such as inpatient care, radiology, laboratory, and pharmacy. Consider that an electronic health record uses information from all these sources and more. Therefore, you will be more likely to succeed with a product that uses "open architecture" technology such as extensible markup language to communicate between the various systems.

Simply put, open architecture ensures that, with some modification, the electronic health record will be able to "talk" to other systems and exchange information. If interoperability is left out of the equation, it could mean investing in expensive programming to make the record work as the vendor promised.

Along these same lines, beware of systems that require proprietary hardware, because you will be making purchases based on those costs rather than commodity prices. Open architecture can reduce hardware costs by enabling you to choose from a variety of hardware systems rather than forcing a "shotgun marriage" to a proprietary hardware system. Also, it's a good idea to make sure you don't have to access the application through a proprietary interface. Web-based interfaces are generally the most convenient and economical.

Choose a vendor with a competition-neutral approach to interoperability. To ensure interoperability of the vendor's system within the framework of your existing legacy systems, make sure your vendor is willing and able to work with other vendors' systems even those of its competitors.

Accept and Promote Process Changes

One of the facts of life in any industry is that when systems are automated, some processes may be eliminated. Some in the organization see this as a financial opportunity; others meet this change with resistance, especially in departments in which staff reductions are likely to result. For example, some electronic health record systems make record completion and assembly virtually obsolete, resulting in staff reductions in medical record departments and other areas. At the same time that head counts are being reduced, other functions may need to be added because of electronic record implementation, including quality assurance and ensuring data integrity. Today, with a paper system, several low-wage workers might be assembling patient record information. Tomorrow, their jobs may be eliminated by an electronic health record implementation. However, a single data analyst position--that is, a more skilled worker at a higher wage--might replace those low paying jobs.

As a CFO, you can see that if you replace five low-paid, low-skilled workers with one higher-paid skilled worker and improve your revenue cycle management at the same time, there will be a definite benefit to the bottom line. One of the challenges of senior management in electronic health record implementation is to gain acceptance throughout the organization for these necessary process changes and promote them as the way to make things better for the organization, patients, and physicians.

Healthcare leaders also need to realize that behavioral changes are needed for such implementations to work. Behavioral changes take time, education, and training--something CFOs need to consider in their cost and ROI calculations. Some of these challenges can be overcome by choosing" a system with an intuitive interface, meaning that it can be accessed in a manner that people can easily understand and use. The best choice to lower these costs is an electronic record that can be accessed through a browser-based interface designed to resemble how a true paper patient folder works, thus reducing training requirements and increasing user acceptance.

Carefully Plan the Transition--and Implement the Record in Phases

The "big bang theory" does not work in electronic record implementation. That is, you cannot go from paper records to full electronic health record implementation in days, weeks, or even months. It takes a studied, carefully planned, phased-in approach that supports existing" paper-based processes.

These points are important from the CFO's perspective because of the costs and expected benefits of implementation, and because of the financial repercussions of an implementation failure. It is important that electronic health record implementation be appropriately funded, with all the associated issues considered, including software, hardware, training, and even contingencies such as delays and restarts in certain areas. An underfunded electronic health record initiative is certainly doomed to failure.

Because a phased implementation is necessary, the organization's leaders need to consider which areas of the hospital would stand to benefit most immediately from the implementation. Focusing first on specific areas can have two major positive effects--producing immediate financial and productivity results, and gaining buy in from a group of stakeholders. As healthcare executives know, news--particularly bad news--spreads quickly around a hospital. Piloting the electronic record in strategically selected areas can help ensure that news traveling around the hospital about your new system is upbeat and positive.

One of the common elements in successful electronic record implementation throughout the country is clear and consistent communication about how the new system will coexist with the old. This includes which processes will stay the same, which will be similar, and which will be totally different.

Some organizational leaders make the mistake of starting their record implementations in the most difficult areas first, reasoning perhaps that those will take the greatest amount of time because of issues of scale, training, and user acceptance. However, it is more important to build a solid foundation of support before introducing these new systems into their more challenging implementation environments, because you will already gain a track record of savings and efficiency improvements from those areas.

As mentioned previously, look across your entire enterprise and find processes that can benefit from automation from day one. Often, those processes that can benefit most involve several areas of the organization. In your implementation planning, find those areas that are affected by those processes and implement the electronic record there first.

Examples of opportunities for relatively quick success are in areas in which electronic systems can be integrated. For example, a dictation/ transcription system, a computerized physician order entry system, and a picture archive communication system might all be made to "talk" with one another on day one, serving to reduce or eliminate manual data entry into the patient record. Also, users who are already familiar with their own systems thus gain increased functionality without having to learn anything new.

Integrating such systems with an electronic record can quickly result in cost savings, efficiency improvements, and positive image value for the new system in several areas and among many stakeholders.

Finally, ensure that all processes and outcomes are tested and verified so that people at all levels can be satisfied that the electronic health record is meeting organizational objectives on all levels: administratively, financially, culturally, and institutionally.

Incorporating these five key elements into your planning will help promote full use of the electronic health record and go a long way toward avoiding a costly implementation failure.


There's no denying that the electronic health record is on its way. By taking the following five well-planned steps, healthcare CFOs and CJOs can help make electronic record implementation in their hospitals as smooth as possible:

* Define "electronic health record" across the entire organization

* Set appropriate expectations

* Choose the technology carefully

* Accept and promote process changes

* Carefully plan the transition from paper-based to electronic records


CFO Needs

* Head count reduction

* Smooth implementation

* Improved productivity

* Reduced retests/duplication

* Improved revenue cycle management

Physician Needs

* More time for patients

* Improved patient care

* User-friendly interlace

* Chart info printed at bedside

Nurse Needs

* More time for patients

* Less time shuttling charts

* Reduced paperwork burden

Administration Needs

* Elimination of chart copying

* Automated chart completion


Define what you are trying to build.

* Develop a way for the processes to be adapted to the new environment.

* Measure your major processes against the vision you have defined.

Set expectations.

* Don't overpromise or underdeliver.

* Communicate throughout the organization:

** How long the implementation will take

** How much work and sacrifice it will involve

** How the organization, staff, and patients will benefit (financially and otherwise)

Choose technology and partners wisely.

* Choose technology characterized by an open architecture free of proprietary hardware and software.

* Choose technology that is interactive and user-driven.

* Choose a technology partner who is willing to work with other vendors to ensure optimal functionality.

Accept and promote process changes.

* Recognize that although some processes will be eliminated, resulting in reduced head count, other new processes will be created, possibly requiring higher-paid and more skilled personnel.

Carefully plan implementation of the record.

* Develop a solid project plan that accounts for transitioning from a paper-based environment over time.

* Clearly understand and communicate how the new system will co-exist with the old paper-based system.

* Budget for implementation restarts and delays.


A committee of the Institute of Medicine has identified the following eight core care delivery functions that electronic health record systems should be capable of performing to promote greater safety, quality, and efficiency in health care:

* Health information and data

* Results management

* Order management

* Decision support

* Electronic communication and connectivity

* Patient support

* Administrative processes (such as scheduling)

* Reporting (such as disease surveillance, patient safety)

This list of key capabilities is being used by Health Level Seven (HL7), a developer of healthcare standards, |o devise a common industry standard for electronic record functionality that will guide the efforts of software developers.


The Office of the National Coordinator for Health Information Technology has identified four major goals that will be pursued in realizing the vision of an electronic health record for all U.S. citizens within the next 10 years. Each of the four goals has a corresponding set of strategies and related specific actions that will advance and focus future efforts.

Goal 1: Inform clinical practice.

Strategy 1. Incentivize electronic health record adoption.

Strategy 2. Reduce risk of electronic health record investment.

Strategy 3. Promote electronic health record diffusion in rural and underserved areas.

Goal 2: Interconnect clinicians.

Strategy 1. Foster regional collaborations.

Strategy 2. Develop a national health information network.

Strategy 3. Coordinate federal health information systems.

Goal 3: Personalize care.

Strategy 1. Encourage use of personal health records.

Strategy 2. Enhance informed consumer choice.

Strategy 3. Promote use of telehealth systems.

Goal 4: Improve population health.

Strategy 1. Unify public health surveillance architectures.

Strategy 2. Streamline quality and health status monitoring.

Strategy 3. Accelerate research and dissemination of evidence.


On Oct. 21, 2004, David J. Brailer, MD, PhD, national coordinator for health information technology, announced that the Office of Management and Budget has included promotion of health IT in the scorecard for President Bush's management agenda for agencies involved in health care. This support will accelerate industry's adoption of health IT because of the federal government's size and position as a healthcare provider and purchaser, said Brailer. He also said the administration plans to present initial proposals by July 2005 for possible regulatory revisions that could reduce hurdles to wide implementation of health IT.

Joseph T. Wood III is vice president and CIO, Columbus Regional Healthcare System, Columbus, Ga.

Ralph Aceves is COO, Vianeta Communications, Milpitas, Calif.

COPYRIGHT 2005 Healthcare Financial Management Association
COPYRIGHT 2005 Gale Group

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