Curbside Consult with Dr. Jayne 12/16/13

The vast majority of ambulatory organizations have either implemented EHRs or in the process. There are different challenges for large organizations and small practices. In talking with a couple of my peers in the physician lounge over the last few weeks, one challenge is the same: determining whether EHR projects should be clinical, operational, or IT initiatives.

When I went live on my first EHR nearly a decade ago, the project was under the IT department. It was run by analysts who knew very little about what happens at a medical practice other than what they had experienced as patients. I was in a solo practice situation at the time, but part of a larger ambulatory group who wanted to use me as a pilot for the EHR system they were planning to roll to everyone else.

The vendor was well known, however, more in the billing space than the EHR space (as was common at the time.) I was busy running my practice and seeing patients, so just went along with what the IT department recommended. At the time, I didn’t know much about project management and lacked the experience to know that things were going very badly.

The vendor sent a trainer who taught us on a different version than what we had installed, and no one caught it before I was in training. There was no training around how to modify office workflow or transform practice. It was merely a parade of templates and how to use them, hour after hour, until our minds were numb.

We struggled with the system for the first six months. It wasn’t just the software, but issues with wireless connectivity, signal interference from the tenant next door, hardware failures, and a lack of a support structure. Eventually we discovered the software had been omitting data during the note-signing process. That was what allowed us to put a nail in its coffin.

I didn’t know at the time how visible the project had been since I was just trying to muddle through while also growing a new practice and seeing patients. When we started the Request for Proposal process for a new vendor, however, it became clear that many eyes had been on the project. Based on the events of the failed pilot, hospital leadership ordered that the next ambulatory EHR initiative would not be IT driven.

The project team that was ultimately assembled had leaders from operational and process excellence disciplines. They quickly hired a physician champion who was in place before the system selection was final. One of the key drivers of the project was clinical transformation rather than just a paperless transition. This required a lot more work than a simple EHR installation. I didn’t understand at the time how important that was, but I certainly do now. By focusing on outcomes from the beginning, we were able to drive adoption in a way that we could not have otherwise.

Our IT resources reported to our project leadership through a charge-back arrangement, but it was clear that they worked for us. They were tasked with supporting the infrastructure and helping us maximize the application and its capabilities. The rest of the team focused on understanding clinical workflow and practice operations. At the same time, they learned the system so that they could pull it all together and identify the best ways to implement various features.

The arrangement served us well and allowed us to deploy the platform to several hundred physicians, but I’m not sure we could make it work in a different organization with different leadership. With that in mind, when people ask me the question about where ownership of EHR projects should sit, my answer has to be, “it depends.” It really does depend on the organization, its goals, its strengths and weaknesses, and the people involved.

Small practices see this acutely, especially those who are trying to implement EHR at this stage of the game. We’re clearly in the realm of the late adopters, and I suspect many of them wouldn’t be doing it at all if not for the Meaningful Use money or the fear of penalties.

I’ve seen a couple of my colleagues fall prey to the idea that these are IT projects and don’t need much operational or clinical involvement. I was recently asked to assist a practice that had signed up for a hosting arrangement which only covered infrastructure. They had a complete lack of understanding of what it takes to maintain a system even if they were using it in a vanilla fashion.

They didn’t understand the difference between an upgrade and a software patch, so needless to say, they hadn’t applied any since going live, yet were baffled when things in the system weren’t up to date. They didn’t attend any of the complimentary training their vendor offered. They have no idea what it takes to attest for Meaningful Use, yet plan to do so in the first quarter of 2014. I hated to break it to them that they didn’t even have all the required components installed, and that based on their continued use of paper telephone messages and dictation of office visits, they are a long way off from being true meaningful users.

I’d like to see EHR vendors perform an “informed consent” process for new EHR clients, especially the late adopters. They should spell out what it takes to be successful and warn clients of the risk if those precepts are not followed. They should explain the need to have involvement from clinical, operational, and technical leaders even if they all happen to be the same people in a small practice.

When clients fail to heed this advice, they should not demand that the vendor move heaven and earth to get them back on track. Although vendors have a vested interest in the success of their clients, practices have to bear a large part of the responsibility for success.

Over time and as our project has gone into maintenance mode, management of our EHR has transitioned to shared ownership between its clinical and operational owners and the IT department. The leadership has matured and learned from its experiences and we’ve all become stronger as a result. It hasn’t been easy, and I have colleagues at different institutions that have had completely different experiences, but I would never trade what we’ve been through together. What do you think of EHR project ownership? Email me.

Email Dr. Jayne.