Electronic Health Records 2.0: Focus on Patient Data, Meaningful Use and Training

Much has changed since healthcare organizations first began implementing electronic health and medical records systems two decades ago. Advances in technology, better software options and a deeper understanding of how to gather, store, share and use data, as well as government incentive programs, are all part of the shifting electronic health record (EHR) and electronic medical record (EMR) landscape for organizations looking to implement or optimize systems.

But providers also have the benefit of the strategies and best practices the industry has collectively developed over the years, from choosing and working with a vendor, to optimizing infrastructure, design and workflows, to training users and getting physician buy-in.

For Calif.-based UC Irvine Health, these new dynamics came into play in November when the organization partnered with UC San Diego Health to share a single EMR, moving from Allscripts’ locally-hosted platform to Epic’s cloud-based system. It was the first such technology collaboration within UC Health and was also the first time Epic was extended from one academic medical center to another in the U.S.

After looking at some of the other UC campuses, San Diego stood out, says Adam Gold, chief technology officer at UC Irvine Health and UC San Diego Health. They’d been running a locally-hosted version of Epic for more than 10 years, so they had the expertise and the infrastructure. “We were already working closely with them and they have a highly-competent, high-functioning team,” he adds.

The implementation took 17 months, significantly shorter than the average 24-month timeline at other academic health systems. It also shaved about 30 percent off the price tag, in part by eliminating some of the startup costs of implementing a new EMR.

“There’s so much that has been learned over a few decades of pain,” says Kenneth Kleinberg, vice president of research at Boston-based Chilmark Research. “A lot of the hard work has been done [and organizations] have the advantage of [learning from] those who’ve come before them.”

Whether an organization is implementing a new system from scratch, upgrading an existing system, switching vendors or moving to the cloud, the foundational steps in the process are more or less the same. It’s the way health IT leaders tackle them that’s evolved.

Customization and Your EMR/EHR Vendor

When looking to ensure EHR or EMR success, setting out a firm roadmap is important, says Kleinberg. Before launching into an EHR project — whether installing a new system, switching vendors or upgrading an existing system — IT and organization leaders should consider what’s new in EHR implementation and decide what they want to accomplish before taking any other steps.

But it’s also important not to get bogged down with too much customization.

“If you give people a blank piece of paper and say, ‘Tell me what you want this system to do for you,’ the process would take forever,” Kleinberg says. “We’re very much in an enterprise market now.”

Vendors are increasingly offering a choice of starter configurations and adding them on to proven enterprise models that hundreds or even thousands of organizations have successfully implemented. Even ancillary services such as emergency departments are coming into the fold as vendors introduce new modules.

There are some holdouts, including oncology and ophthalmology. But you have to draw the line somewhere: The Association of American Medical Colleges lists 120 specialties, but no vendor has developed 120 specialty models, Kleinberg notes. “And new ones keep coming.”

For most organizations, a turnkey the solution is the best bet.

Epic, for example, didn’t become a successful EMR and EHR provider because it went after the most advanced organizations waving that blank piece of paper. “They stuck to their guns and said, ‘Install it this way,’” Kleinberg says.

Vendors such as Cerner, Allscripts and McKesson were so eager to give the provider more customized, configurable systems that their implementations were expensive, drawn out, bogged down and not always successful.

The Meaningful Use Incentive Program and Your EMR/EHR Vendor

The launch of the Medicare and Medicaid EHR Incentive Programs — more commonly known as meaningful use — also led some hospitals and their vendors down the wrong path at times. Organizations rushed to put systems in place to capture those bonus dollars, Kleinberg says.

Capturing, sharing and using the massive amounts of data the systems generate to improve care and create efficiencies was for some a secondary goal — and the industry is still struggling with it.

Today, organizations are working with their vendors to take a data-first approach, designing their systems to take advantage of the promise of data analytics, including planning for data that’s not yet mainstream, such as information on social determinants of health.

One more consideration before launching a project: It’s important that your vendor be a true partner, Gold says.

“The [vendor] needs to understand your shop, your culture, how things work and how you’re unique,” he says. “If you’re not partnered with a company ... that truly understands your business [and] your culture and workflow, things can go sideways pretty quickly.”

Identify IT Needs for EMR/EHR Implementation Success

The configuration that makes up the infrastructure of your implementation includes everything from desktop workstations to mobile devices to printers and monitors.

For the UC project, “the back-end requirements were really driven by user load and capacity,” Gold says. “We had to take a hard look at the existing environment and factor in the additional users that were going to be coming on board [from] Irvine.”

Moving from an on-premises solution to an off-premises one has a big impact on the end users, specifically on those using desktop computers — in this case, 10,000 of them.

“Keep in mind we were bringing two organizations from a desktop user experience,” Gold says. “We had to deliver that same experience without disruption.”

Decide on an EMR/EHR Implementation Plan

Should organizations choose a “big bang” rollout or take an incremental approach?

One dramatic go-live day with IT staff running from workstation to workstation to resolve problems was once thought to minimize disruption, akin to ripping off a Band-Aid. But at UC Irvine, a methodical, incremental rollout was the better choice, Gold says.

“We rolled it out across smaller groups in stages and then tracked tickets and incident responses and really watched what was happening in a conscious way, knowing this could impact patient safety and workflow.”

The UC Irvine and UC San Diego project had a pretty successful technical rollout with no major snags, Gold says. But after all that back-end capacity planning, IT administrators were watching the numbers closely.

The agility of a cloud-based system worked in the organization’s favor, Gold says. “If we needed to scale out five more servers … they could spin those servers up in a couple of hours. If this was locally hosted, we wouldn’t have had the resources.”

The final go-live day was, as is typical, “pretty crazy.” But taking the right steps in the correct order and course-correcting through smaller, more incremental phases, meant the IT team was prepared and ready for a major issue that never arose.

Offer EHR and EMR Training to End Users

EHR and EMR training is about more than showing end users how to navigate new screens and workflow — it’s also about showing them the value of the system. There will be folks — both IT department staff and clinical and business clients — who resist. The hard truth is that many people just don’t like change. “You need to show those folks the value,” Gold says. He calls it “communicate and commiserate.”

The more support you get from the organization, obviously, the better the transition is going to be. The key is to show the value, including the benefits to patient care, safety and privacy. Those points, in particular, should resonate with everyone in a healthcare organization, regardless of their role.

“I can’t really think of another career where the stakes are higher,” Gold says.