Chapter 3: Preparing for Implementation
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Chapter 3
Preparing for Implementation
Getting ready
Contents
At a Glance ... 36 3.1 Identify your IT project lead(s) ... 37 3.2 Develop a plan & assign responsibility for tasks... 37 3.3 Build & maintain the “team” ... 39 3.4 How will the EMR change the practice’s workflow? ... 40 3.5 Staff training ... 41 3.6 What new policies & procedures do you need to consider? ... 43 Tools & Resources ... 45 3.7 Tools... 46 3.8 Further reading... 51 3.9 Chapter 3 checklist ... 51 3.10 User notes ... 53
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Chapter 3: Preparing for Implementation
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At a Glance
Installing a new system may require profound changes to the way the practice operates, so making a smooth transition is dependent on careful planning. Before implementing these changes, you should:
1. Assign clinical and administrative project leads who will be in charge of coordinating the EMR project – including planning, implementation, and training. The planning team should comprise representatives from each clinical and administrative group in the practice (e.g., physicians, multi- disciplinary providers, and administrative and managerial staff).
2. Develop a detailed plan. Decide who in the practice is to be responsible for which tasks, such as project management, timelines, communicating with the vendors, defining and building consensus on priorities for EMR requirements, data entry, report generation, etc.
3. Build the “team”. Foster ownership of the EMR project with all members of the practice setting – each member should “own the change” and understand why and how the EMR initiative will be an improvement.
4. Identify and understand workflow impacts associated with the EMR – how will it change job roles and responsibilities for clinical and administrative staff? For patients? How can the EMR help to streamline workflow? 5. Accommodate the time and
expense of training staff in the use of the EMR system. This may include some staff acquiring basic computer skills.
6. Familiarize yourself with any requirements for policies and procedures related to the EMR implementation. Identify any legal ramifications of using an electronic records system. Discard old policies where appropriate, and develop new ones. Consider privacy, security and system management implications (e.g., software and hardware maintenance, disaster recovery planning, and record archiving requirements).
Training on the EMR software was
scheduled to occur in small groups (3
physicians per group), over a 3 day period
for each group. Day 1: morning training,
afternoon office visits using the software
for each physician; Day 2/3: IT/training
support on site, physicians using the
software while seeing patients. Most “Day
3” on site IT support was not required. -
Group Health Centre
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3.1 Identify your IT project lead(s)
Before the actual implementation of a new system begins, make sure you designate both a clinical and an administrative lead, or “champion”, in the practice. A champion can be defined as a peer with special interest in, or skills related to the EMR implementation. Ideally, champions are opinion leaders within the practice, who have the respect of their peers and who can communicate with and influence the practice staff and clinicians to reach consensus on decisions related to the EMR rollout.
The champions will be instrumental in coordinating and ensuring ongoing progress through all the EMR project’s phases. In small clinics, they may also have the role of “project manager” to coordinate the details of the EMR implementation project. In larger clinics, or for larger EMR projects, a dedicated project manager should be designated who will work closely with the champions to communicate with the rest of the practice team.
Whether a champion or a professional project manager is identified as the “project lead”, the lead’s key role is to ensure that the necessary project tasks and activities are identified, assigned, and completed
in a timely manner. A large component of this role is communication with other members of the practice team, to ensure that the goals for the EMR project, and the practice’s specific EMR requirements are well documented, communicated, and that the team has
reached consensus on priorities, objectives and expectations for the EMR implementation project.
3.2 Develop a plan & assign responsibility for tasks
The plan (also known as a project plan, or workplan) is a key tool in managing team expectations about the project. It is designed to document all project steps (tasks), their order, timelines, any dependencies between tasks, and the key
individual who will be responsible for ensuring the task is completed, i.e., who will do what and when. Writing up the plan, with the help of the whole team, will help ensure no implementation details are missed.
Along with the practice’s clinical and administrative staff, the EMR vendor is a core member of the planning team. In most cases the vendor will be responsible for the majority of the implementation and training, and can offer recommendations
Dr. Tom Bailey is the IT lead for his
four-physician practice – in 2001, he
helped lobby the group and several
other physicians in the same medical
building, to cost-share in the adoption
of an EMR. – Dr. Tom Bailey
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about approaches to “going-live”, chart conversion, data coding and quality standards and policies, and numerous other topics.
The plan also serves as a useful communication tool to ensure all members of the team are informed about project steps and timelines, and have common
expectations about the results and implications of each project stage. For instance, be sure that all members of the team are aware of the implications to their day-to- day workflow at each project stage – renovations, for instance, may be very disruptive, and may require the clinic to close or reduce hours for a limited time. The following are examples of methods and resources to assist with developing the detailed plan:
• Alberta’s POSP uses a “Kick-off Meeting” template1 in their discussions with
practices to develop the initial plan for a project. The template provides an overview of project tasks/components, and identifies the group responsible for their completion (clinic, vendor, or POSP change management support team). This high level template can be used as a starting point for more detailed workplan development.
• BC’s Primary Health Care Branch supplies an EMR implementation workplan2
template to practices and health regions looking at EMR implementation. It identifies the tasks associated with the project in enough detail to be able to establish project timelines and assign work areas to specific individuals. The template can be tailored to meet a practice’s specific requirements.
• OntarioMD’s Project Planning and Implementation Guide3 provides an
overview of critical project areas to document in the plan, and a sample layout for the project plan. The project planning overview section4 of the
OntarioMD website links to their full suite of planning tools and guides. The planning process will help to identify and schedule any site and staff preparations necessary for the project’s success. For example:
• Are renovations necessary? – Is there space in each patient exam room for a computer and monitor? Do you need to lay network cable or are different hardware and network options desirable (e.g., wireless tablets).
• What staff training is required? – Basic computer skills, or just specific training in the selected EMR system?
• What “go live” implementation approach will you use? – How will you install, test, and begin using the EMR? For instance, does a phased or “Big Bang” implementation approach make sense for the practice? Visit the DOQ-IT website to view their summary of EMR implementation options “Incremental vs. Big Bang: Comparing Approaches”5. This slide encapsulates the pros and
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option chosen. For instance, larger practices, without complete consensus about the EMR project, or with complex politics, may consider an incremental approach. Small practices with strong leadership (champions) and good buy- in from the whole team may have success with the Big Bang approach. The CMA’s manual, A Physician’s Guide to Implementing Electronic Medical Records6, also describes implementation approach options.
• What special training or
implementation requirements are there for each different provider type in the practice? Does your project planning process include representatives from all clinical groups? For instance, if your practice team is growing or introducing new multi-disciplinary providers, have you worked with all provider groups to be sure their training and implementation requirements are addressed? How will you maintain communications
among multi-disciplinary practice members throughout the planning and implementation process? Weekly project meetings for all team members are effective for keeping communication open and current, and ensuring any issues are identified early in the process.
3.3 Build & maintain the “team”
Establishing an environment of mutual trust and respect is the foundational principle for building and maintaining a successful team.
This relies on effective communication among all team members, including clinicians, administrators, practice support staff, vendors, and regional support staff. It requires a mutual understanding that everyone’s opinions and ideas are valued.
Each team member must “own the change” and understand why the change will be an improvement. All affected stakeholders must feel part of the project and agree to the project process and goals. Establishing “ground rules” for team meetings and communication is a technique to build mutual respect and trust. Some key resources and tips are:
• The National Health Service (NHS) Working with groups7 document.
Change management for the initial
EMR implementation was through a
“shotgun approach”. That is, “as of
day one of the implementation
(Sep10/2000) we’re using the EMR.”
Software and process workflows
training and orientation were
completed in advance of the “go live”
date, but the clinic physicians and
staff did not know how it would impact
patient flow until they were “living
it”. - Taber Associate Medical Centre
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• Team building exercises. The Introduction to Team Building8 site contains
many tools and techniques for identifying personality types, strengthening group relationships, and team building exercises.
• The NHS “Improvement Leaders’ Guides9” offer practical advice and tools for
implementing and sustaining improvements in health care settings. The Guides’ home page9 and the specific guides on human aspects of change10
and working with groups11 may also be useful.
3.4 How will the EMR change the practice’s workflow?
Implementing an EMR may have significant effects on how the practice functions, and on the roles and responsibilities of individual staff members. Considerations include:
• Anticipating and accommodating workflow changes in the practice. • Using “process mapping” and building on your “Needs Assessment”
(completed in the Getting Started phase) to determine how the EMR will change the practice and how different functional areas might be streamlined. OntarioMD’s template for “Practice Workflow Redesign”12 is a tool to help
identify areas of improvement in each of the main functional areas of a practice. The NHS provides an overview of process mapping13.
• Assessing the potential impact of a process on patients and patient outcomes. Consider how the “patient experience” may change as a result of the EMR – once the anticipated impact is understood, consider implementing a
communications strategy to update patients on how the practice will change as a result of the EMR, and how their care will benefit (e.g., faster prescription renewals, automated recall for required tests and preventive screening, better tracking of chronic disease data such as trends in blood pressure and A1C for diabetes patients, etc.).
• Determining how implementing an EMR will affect clinical and patient flow, how information and data move within, into, and out of the practice, and how workload flows.
• Considering how staff roles and responsibilities may be impacted as a result of the EMR, and how staff may need to assume, stop, or change roles or job functions. Note that all staff may not be prepared to change! There may be attrition if staff do not feel that they have input to the planning process or if they do not have access to (or interest in) the training to upgrade skills to support their new roles.
The initial output of a process mapping exercise is an overview of “how things are done today”. When a process map is accurately completed, with all members of
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the practice team contributing their understanding of the process, the actual process often differs significantly from the way individuals on the team assume or understand it to occur. The resulting map of the actual current state is ideal for identifying potential areas for improvement – where current processes are complex, requiring many steps or interactions among different individuals, there are often opportunities to streamline the “what” and the “how” of each process step.
When looking for areas to improve, focus on what each function (each step in the process) is, not on who does it. Then ascertain what the best set of skills is to carry out the function. This may result in significant redistribution of work among members of the team (see Redesigning roles14) in order to
implement the streamlined processes in the day-to-day practice workflow. This process and workflow redesign to support the EMR may result in the identification of new training or staffing needs. Ensure any new training
requirements are added to the training plan developed later in this section.
3.5 Staff training
Assess and include current and ongoing training requirements in the training plan. Use a simple matrix or a User Skills Template15 to assess current skills and to
identify the types of training each user will require. Some users may require training in basic computer skills and desktop software as well as in the specific EMR application. Training in data privacy, security, networking, and Internet use may also be required. The University of Maryland University College provides a free online Basic Computer Skills tutorial16 for Microsoft Windows®.
From the user skills template, develop a detailed training plan. Ensure the contract with your EMR vendor addresses, at a minimum:
• Initial EMR training to familiarize users with the administrative and clinical aspects of the EMR software.
• Additional post-implementation training to ensure all users are comfortable with using the software on a day-to-day basis. Initial training is often overwhelming for users and only a portion of the information shared in the
Prior to the EMR, “runners”
responsible for delivering paper charts
to their destinations were a large
proportion of the administrative staff. It
was expected that the EMR would
significantly reduce the number of
runners required. Although this was
true, the “runners” all upgraded to
become scanners and transcriptionists –
this demonstrates successful role
changes for staff as a result of the EMR
workflow redesign, but also created
increased staff costs for the higher skill
jobs. - Group Health Centre
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training sessions is retained. Followup training should start within one to two weeks after implementation and
continue until all users are fully trained and comfortable with the EMR.
• “Advanced training”, once users are familiar with the software, to allow them to utilize more advanced clinical decision-support features such as custom or rule-based recall and alerts, self-audit for patient populations, reporting features, etc. • Training to help integrate the EMR
with practice workflow, and to change practice workflow where necessary to make the most of the EMR.
• Training for updates and enhancements to the EMR software as they become available.
In addition to specific training in the EMR software, determine if the EMR vendor provides other training. For instance, they may offer basic computer skills training or training in other critical areas such as:
• Data backup and recovery, including validation of backups to ensure they are working correctly.
• Basic hardware and network maintenance and troubleshooting, including protocols for when and whom to call for help.
• Basic computer skills.
If your EMR vendor does not provide these training services you will need to go to other sources.
For the EMR application, focus on building “super users” among your practice team. Clinical and administrative users who have a good basic understanding of computers should be considered as potential “super users” and as candidates to receive additional training in the EMR software so they can provide technical support to other users. It will save time, and potentially money, if problems can be resolved in-house, without needing to call the vendor’s “help desk” for every issue. Plan for each user’s training time. Schedule dedicated training time and light workloads for all members of the practice team during the training period and during system implementation. This will give users the time to familiarize
Software learning opportunities are
part of the weekly “all staff” team
meetings. Ideas for process
improvements, workflow changes,
EMR enhancements, software
tips/tricks and training are often
exchanged. This gives all users the
opportunity to learn from their peers,
as well as reinforcing good data entry
and coding practices. - Central
Interior Native Health Services
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themselves with new concepts and tools without the pressure of a full workload. Adequate, planned training time increases the likelihood that the new tools will be accepted and continue to be used in a sustainable way once workloads are back to normal higher levels.
For larger practices, a longer term training strategy may also be of use. Microsoft provides a series of training articles and templates17 to help with budgeting and
developing a business case for ongoing training.
3.6 What new policies & procedures do you need to consider?
Introducing an EMR forces many changes at many levels of a practice. This provides an excellent opportunity to develop new policies and to review current policies and procedures in various areas of the practice. Incorporate the specific legislative and jurisdictional standards in place for your jurisdiction when developing these policies. Your regional primary health care support resources, local professional associations, or regulatory bodies may have additional templates or recommendations in these areas. Some areas specifically affected by the
introduction of an EMR are:
• Privacy: In the context of an EMR, “privacy” refers to the concept of
“information privacy” – the right of an individual to have knowledge of and control over the information about them. Maintaining adequate privacy of sensitive patient information requires privacy, confidentiality and security measures in a practice.
o To establish privacy policy, review the Canadian Medical Association (CMA) Privacy Wizard18. CMA members can log in and walk through a
step-by-step tool which will assess current privacy practices and recommend areas for improvement. It will also produce a customized “privacy policy” document for physicians to post in their offices. o Vancouver Coastal Health Authority’s “Privacy Toolkit”19 builds on the
CMA “Privacy Wizard”. It provides an overview of the contents of the CMA Privacy Wizard (particularly useful for non-CMA members), and introduces privacy and security concepts and legislative considerations in Canada (particularly BC). It also provides practical tips for implementing a privacy policy in a primary health care practice.
• Security: Security refers to the technical considerations (rather than the policy