Clinical Access to Computer Workstations

There must be ample access to computers for clinical care distributed in a way that supports efficient clinical workflow. This requires a structured walk-through of the nursing units and areas where physicians normally congregate to discuss patient care. This analysis will definitely mean adding additional computer workstations and telephones (if required) to ensure appropriate workflow. Using dual screens have been demonstrated to enhance workflow efficiency during the process of both order entry and electronic documentation, allowing the user to simultaneously review available clinical information on one screen while executing input on the other. Portable device solutions have demonstrated more utility in gathering patient data in the direct patient encounter setting. The adequacy of computer access points must be carefully assessed prior to a live roll out through careful inspections of the demand for computer terminals during peak rounding hours. Demand for computers will not decrease with any implementation. These observations should be followed by augmentation of those areas in the system that may become deficient with go-live. Observations should also be conducted to identify any areas that may need renovation to accommodate the required number of devices. Many hospitals and clinics were constructed well before the introduction of computer technology and as such there are often critical limitations in space for the deployment of computer technology and workstations. New devices and renovations should be budgeted, acquired, and deployed, with follow-up analysis to confirm the sufficiency of the remedy. It is critical to observe how physicians make rounds. If part of the patient chart is on paper, physicians will want a place to sit and enter information, where mobile access devices may not be first choice.

Downtime Procedures

There must be carefully designed downtime procedures, including appropriate backup software and workflow processes in place. All downtime solutions should be tested by regularly scheduled drills to ensure familiarity with downtime procedures and to identify potential gaps in the process. Having paper forms readily available, either printed or printable from the workstation, but secured during normal up time, will expedite continuing patient care by all providers during downtime occurrences.

Computer Authentication Login and Performance

Computer login efficiency and performance should be assessed and optimized with appropriate network, hardware, and software installations that will facilitate rapid screen-to-screen times. Computer processor utilization on the back end as well as user screen-to-screen timings on the front end should be monitored and reported at regular intervals. We learned no matter how fast the back end processing might be, the ease and quickness of screen response on the front end, in fact, defined the physicians’ perception of satisfactory computer performance. Newer technologies are now available, such as mobile desktop platforms and badge login, that allow more rapid access to multiple applications to improve workflow efficiency.

Deployment of Departmental Clinical Support Applications in Advance of CPOE

Prior to any EMR transition, clinical department-based applications that will support the deployment of orders and documentation downstream from the physician input should be implemented, fully tested, and functional. This includes laboratory, radiology, nursing documentation, rehabilitation services, respiratory care, nutrition services, and so on. Most importantly, medication process applications that will support pharmacy filling and verification functions, medication dispensing functions, and the electronic medication administration record should be live and functioning smoothly prior to CPOE to ensure a complete, safe, and effective medication delivery process. Finally, applications supporting surgery, emergency department services, scheduling, registration, and patient management are additional IT building blocks that are best implemented prior to moving to CPOE or to electronic documentation by providers. This will facilitate transition to a paper-free process that is necessary to capture critical efficiencies in workflows.

Preliminary Steps: Getting Physicians on the Computer in Advance of CPOE and Documentation

Part of preparing the medical staff for the EMR should focus on leading physicians to engage the computer in their daily clinical workflow. We facilitated this transition in two ways:

1. Making the post-discharge chart available only via the computer. This was accomplished by first implementing a robust document imaging product. We then transformed the processing of all medical records by our Health Information Management Department such that all paper documents from the inpatient record were scanned into the electronic medical record within 24 hours of discharge. This had the effect of requiring physicians to go to the computer to retrieve any patient’s old record, whether accessing a chart for a patient returning for subsequent care or completing medical record post-discharge deficiencies. This change in workflow proved to be an extraordinary asset to physicians. First, physicians found that they could access the old chart in seconds instead of 20 to 40 minutes when evaluating return patients, thereby greatly improving their workflow. Second, physicians discovered that they could review and complete charts at any time from any location. The dividend from this transition was that all physicians not only became rapidly adept at using the computer, including keyboard and mouse point and click activities, but also became familiar with navigation of the electronic patient record. A final and perhaps the most important dividend was that physicians for the first time experienced concrete benefits in their daily workflow directly attributable to the electronic patient record. This represented a first critical step in the pathway to adoption of the EMR.

2. Making test results and patient data available online. This step was accompanied by a simultaneous implementation to make all or nearly all results and documents immediately available in the electronic inpatient record in real time through direct feeds and interfaces with dictation/transcription, lab, electrodiagnostics, radiology, picture archiving and communication system (PACS), electronic medication record, home and in-hospital medication lists, vital signs, intensive care unit (ICU) flow sheet data, family contact information, active provider lists, and nursing documentation. Because of some remaining paper documents and lack of working interfaces among disparate vendor applications, it may not be possible to enter all information directly into the computer record. Nevertheless, these documents may be made available in the computer through the process of concurrent scanning. Clinical results on paper should be scanned in real time. Nonurgent documents may be scanned in twice per day to keep the computer information current. Once physicians became familiar with accessing patient information electronically, their ability to access comprehensive, fully up-to-date patient data through a single process from any location provides a second revolutionary improvement in their workflow. As a result, physicians quickly transitioned voluntarily from a paper to an electronic process for chart review in their inpatient rounds every day, no longer depending on the time it takes to search for and review the paper chart. This provided a second giant step in the movement toward adoption of a fully electronic medical record.

Development of Patient Care Pathways for Orders

CPOE enables the execution of discreet, legible, and robust orders, including preformatted order sentences and rapid deployment to downstream support services. The process of combining multiple orders into order sets with specifically tailored formats, based on the requirements of specific disease processes and workflows, allows for the introduction of standardization in the ordering process that incorporates best practice standards. The flexibility of the electronic system leveraged in this way also makes possible the ability of the system to rapidly evolve in the inclusion of the latest evidence-based recommendations. Order sets may be designed to support specific processes, such as admission and discharge, as well as complex transitions in care. Such order sets may be termed Patient Care Pathways or Plans of Care. Each organization should establish a department that is responsible for the development and updated maintenance of these plans. The process for creating them should be multidisciplinary and preferably physician led. Lean/Six Sigma processes are recommended for the development and maintenance of these plans, including value stream mapping and supporting data analytics.

This important transition may be expected to result in:

• Improved, highly refined, and streamlined order sets throughout the system, using a common style guide format familiar to all providers

• A comprehensive array of paper order sets, supporting admissions, consultations, titrations, and perioperative/procedure processes

• Improved efficiency in the day-to-day entry of orders

• Improved compliance in general use by all physicians

• Better compliance with best practice and evidence-based standards

• Improved patient outcomes with fewer complications, read-missions, and harm

• Improved financial performance

• Improved compliance with growing regulatory requirements in clinical practice

Physician Transformation

Physician Resistance Understanding how to approach transformation successfully begins with an appreciation of the reasons physicians often resist the transition to the EMR. Some of the most commonly expressed concerns include the following:

• “It will take me too long to enter my orders and create my notes electronically.”

• “I will be spending more time in front of a computer than in front of my patients.”

• “We are just trading one system of errors for another.”

• “There is conflicting literature on the efficacy and safety of computers in healthcare.”

• “You’re asking me to do the work of a secretary.”

A review of the 2008 KLAS data shows how serious this issue of physician adoption has become. KLAS reported in 2008 that only 17.4% of hospitals greater than 200 beds had implemented CPOE at some level. At these sites, only about 60% of orders on average were entered using CPOE and, tellingly, only 3% of physician users reported increased satisfaction with the use of CPOE. Since that time, largely because of the requirements of Meaningful Use, adoption of EMRs to support patient care has exploded. Significant challenges to adoption and utility remain. However, this is related largely to hurried implementations with poorly designed systems associated with multiple vendors, poor options for interoperability, and failure to analyze current and future state workflows sufficiently. Success in creating a seamless, efficient, and effective EMR requires careful planning, workflow analysis, education, and implementation go-live support.

A Physician-Driven Project EMR implementation failure may occur for several key reasons, but at the top of the list is failure to engage physicians in the process. Hospital administrators, often pushing an IT-driven initiative from a business proforma, decide to implement EMR systems with insufficient involvement and collaborative cooperation on the part of the medical staff. It is unwise to succumb to the notion that adequate physician engagement cannot be practically achieved. Physician involvement may be facilitated by the inclusion of physician champions very early in the formative process of decision making. In fact, engaging primarily physician champions to initiate and drive the process toward the electronic record for reasons of improved patient care is by far the best approach to achieving medical staff adoption.

Recommended Steps to Achieve a Successful Transformation

The Transformation of the medical staff may be broken down into a number of components, ranging from the development of an initial, basic understanding of the EMR process to the formulation of implementation strategies. These are discussed in the following paragraphs.

The Rationale for EMR Implementation the first step in transformation is to help physicians and clinical support staff understand the rationale behind the decision to proceed with EMR adoption. This argument may be summarized as follows.

• The EMR resolves the chronic problem of deciphering physician handwriting that has plagued healthcare since its inception that can lead to countless errors.

• An appropriately built EMR system provides the opportunity for unmatched clarity and standardization in order entry and documentation format, which in turn removes much of the ambiguity found in handwritten orders and notes, even when they can be easily read.

• The EMR has the advantage of not being confined to one location and one chart, such that the chart can be reviewed, orders can be entered, and documentation can be created from any computer access point.

• The EMR represents not just the simple rote process of effecting the entry of orders and documentation of clinical events, but instead involves the deployment, notification, coordination, completion algorithms, checklists, and safety elements for all departments downstream. The EMR has now been demonstrated to shorten significantly the time of order implementation and clinical documentation in well-designed implementations. CPOE in particular has enabled critical improvements in clarity of order clarity, reliability, and speed of order transmission.

• Perhaps most importantly, the EMR holds the promise of leveraging true clinical decision support to influence clinical decision making. By deploying well-designed, evidence-based clinical order sets; appropriate rules and smart alerts that fire only when an unsafe or undesirable action is invoked; and a series of prompts and reminders, such as prepopulating medication orders with the most commonly used medication order sentences, clinicians are provided with state-of-the-art decision support tools. These tools allow physicians to practice medicine at an enhanced level of performance not otherwise achievable.

• Finally, the EMR is one of the fundamental components that can make up a searchable clinical data repository, permitting analysis of practice patterns and resource utilization tied to clinical and financial outcomes. This process, in turn, creates the opportunity to engineer true continuous quality improvement.

Anticipated Impact of the EMR on Workflow Another early essential step in transformation is the building of a realistic expectation of how the EMR will impact physicians and staff, and a clear explanation of how it may be expected to affect workflow in their daily lives. The physicians should be made aware that they are likely to experience both improvements and difficulties with the new system. Anticipated advantages of the EMR include the following:

• Legibility and clarity of orders and clinical notes are improved, leading to fewer misinterpretations and fewer callbacks for clarification.

• Orders and notes may be entered and reviewed from any location, permitting physicians to provide care without calling the unit or waiting for someone else to finish with the paper chart.

• Well-developed Patient Care Pathways will be immediately available on the computer, obviating the necessity of locating needed order sets in drawers, or requesting staff to find more because the sets needed have been depleted.

• Physicians will have more decision support available to support safer and more effective order entry than is possible with the paper process.

• Physicians can expect more prompt action on orders with CPOE and electronic documentation compared with a paper process.

It is important, however, to be frank with physicians regarding perceived disadvantages of the EMR.

• Some electronic actions may take longer compared with paper processes, such as the login process.

• If the system is not carefully configured notes and orders may be more difficult to implement and locate in the computer. Proper configuration should facilitate intuitive processes for orders search and for locating all results and documentation.

• Orders may be accompanied by alerts and pop-up reminders that physicians may find annoying, impeding, and distracting. If poorly configured and implemented, these instruments will lead to alert fatigue and deterioration in patient outcomes.

• Physicians may find that they are vulnerable to new types of medical errors not present on paper, such as accidentally picking an incorrect, adjacent order from a pick list.

• Physicians will face the difficult task of learning a new and foreign method for completing very familiar tasks.

• Physicians have learned to think about problems and diagnostics through the act of writing. For those with a history of using paper processes, the adoption of the EMR is invariably associated with difficulty in assuring oneself that all considerations and actions have been correctly completed. For newer clinicians who have never encountered paper processes, the adoption seems perfectly normal.

Communicating an Appropriate Expectation The goal of communicating expectations may be accomplished by an initial communication of the intention to move forward with EMR adoption through presentations in meetings, posters, emails, Intranet/Internet postings, mailings, and informal discussions. These efforts should be accompanied by the presentation of a series of scheduled, structured, live demonstrations of the EMR to all practice groups. Live demonstrations of the EMR processes by peers are invaluable in setting the stage for eventual acceptance by the broader medical staff. Many questions and much discussion may be expected along with suggestions for improving processes and, most critically, the creation of engagement.

Some groups requested follow-up presentations. As these presentations were rolled out, physicians’ preconceived notions of the EMR (almost uniformly negative) were successively replaced by an educated and more realistic understanding of the actual facts of the matter. In this regard, the importance of being brutally honest about the expected impact on the workflow of the providers cannot be overemphasized. Overselling or overmarketing may be perceived as disingenuous, which could result in creating loss of confidence in those putting forward the effort. These initiatives to build understanding and an appropriate expectation will take a significant period of time. This time should be factored into the cost and the timeline. Any plan to minimize this component of the preparatory process is likely to lead to serious problems with adoption later in the course of the project.

Engaging Physicians in the Process A very important step is the process of actively engaging practicing physicians with the EMR design and implementation processes. Often there is perceived reluctance to impose the EMR on physicians and request their time to help with implementation and maintenance. This reluctance must be overcome. With proper support and incentives, physicians are generally willing to step forward and become involved in many aspects of the project. Some of these aspects included participation in leadership roles, site visits, assistance with the design of orders, order sets/Patient Care Pathways, documentation note formats, assistance with the design of specialty-specific folders, and participation in EMR pilots and go-live support. In virtually every case, their participation may be expected to improve the execution of the project and led to improved adoption.

Physician Leadership

Any project of this magnitude and controversy will require strong leadership. The role of the physician leadership in the design and support of the EMR implementation is a critical element in the success of the project. If the implementation is to proceed with high adoption, the project should be led primarily by the physicians themselves. This begins with the need for a lead physician and a CMIO or leader in a similar role who is afforded the necessary time and resources to organize and lead the overall process effectively. The CMIO should enlist a group of interested physicians to form what may be termed an information technology clinical advisory committee to review and make formal recommendations to the hospital and the medical staff on clinical IT initiatives. This group will prove to be critical in both guiding the process and providing the most visible nidus of physicians to lead the initiative.

The chief and vice chief for medical staff must play pivotal roles in the leadership effort. Their clear and articulate understanding of the value of the EMR and their willingness to aggressively support the aim of the project is very important. These individuals, in turn, worked to provide the medical staff service lines and departmental clinical leaders, usually during meetings of the medical executive committee, with presentations and opportunities for input and decision making that directed the implementation.

Four Critical Questions for the Physician Leadership to Address: A Crossroad Decision for the Leaders During this process the chief and vice chief of medical staff must address a number of critical questions to the medical administrative committee.

1. Whether they should endorse the decision to proceed with the EMR, how and whether to stage implementation components, and, if so, over what timeframe.

2. Whether EMR adoption should be mandatory or optional for all providers. In this regard, the leadership must be apprised of a comprehensive list of pros and cons. Careful deliberation of the patient safety risks inherent in a protracted dual process (paper and computer) will be inherent in any optional adoption strategy. A dual process represents an ongoing patient safety risk and workflow efficiency risk, not only for clinical review of orders and documentation, but also for the dual deployment of these modalities to downstream departments should an optional strategy be chosen. In general, a mandatory approach is preferred.

3. Whether the EMR should be implemented by a “big bang” or a sequential go-live process, again with consideration of the potential risk associated with dual ordering methods during a prolonged sequential approach. A big bang implementation is generally felt to be the most effective approach to EMR implementations, but only if the necessary education can be provided proximate in time to the go-live and if the necessary “at-the-elbow” go-live support can be provided.

4. Whether physician education would be a sufficiently important factor in promoting a smooth and safe transition from paper to electronic order entry to justify requiring that EMR education be mandatory, including a requirement that all providers who intend to enter orders spend significant time in class. Again, a mandatory approach is recommended.

These questions may be bitterly debated in leadership meetings and in the hallways. Including physicians in the discussions and approval process is the best avenue to achieve the desired outcomes.

These decisions represent the most important ingredients in the recipe for a successful implementation of EMR components with full adoption by the medical staff. They incorporate the critical role of physician leadership with the necessary mandatory elements to bring along those members of the medical staff who inevitably would resist the transformation. Without these decisions, as has happened in many hospitals where optional participation was permitted, a significant percentage of physicians on staff would almost certainly have persisted indefinitely with paper processes.

In any major organizational change, there is usually a bell-shaped curve plotting willingness to adopt new technology against the number of providers. The curve typically ranges from a relatively small number of ready adopters to a much larger number of individuals who are less opinionated and assume a wait-and-see attitude, to the deeply entrenched, highly resistant, and, regrettably, highly vocal naysayers. The challenge is how to bring along even the most resistant elements without allowing the naysayers to convince the much larger group of “undecideds” also to become resistant to the proposed change. One element can prove critical in disabling an effective resistance to the EMR implementation: ensuring that the process is driven by and voted on by the elected medical staff leadership. Following the decisions of the medical staff leadership, rules and regulations may be amended to incorporate the mandatory components, including clauses that would specify accountability and accompanying consequences for noncompliance. A letter jointly signed by the administrative leadership (usually the CEO) and the medical chief of staff may be especially helpful in both setting expectations and ensuring compliance with education and adoption. In the final analysis, however, it will be the quality of the product, as defined by the software and hardware configuration as woven into workflow, coupled with effective education and go-live support, that will determine the success of the project.

Project Organization, Management, and Budget

In coordination with physician leadership, the hospital administration and board of directors must also be fully informed, engaged, and uniformly aligned in their commitment to the success of the EMR project. Their roles include ensuring the development of an appropriate organizational structure for project design and implementation, a credible scope of project, an implementation plan with milestones and oversight, an appropriate budget, and a large bully pulpit from which to engage and support the effort across the organization.

In terms of organizational structure, a number of teams, all utilizing formal project management methodology, should be created to address each of the core elements necessary for the design and implementation of the EMR. These include teams for:

• Computer access downtime

• Functionality (the design of build of the Product) performance

• Completion of all processes necessary for online viewing of results and documentation, whether directly entered into the computer software system, interfaced across to the system, or scanned into the system

• Completion of clinical process mapping for current and future state

• Transformation, including communications, education, policies, rules, bylaws, pilot strategy, education, and go-live support

Each team should be assigned an appropriate team leader and stakeholders. A scope document and plans should be developed and physician and administrative sponsors should be assigned for each team. The teams should be coordinated by an overall project plan, requiring sign off by identified executive and physician leadership sponsors. Team leaders should meet regularly to report on progress against the plan; to coordinate with other teams; and to raise, escalate, and track issues. The teams should in turn report to an EMR executive oversight committee consisting at a minimum of the CIO, the CMIO, the CMO, the COO, and the informatics project manager. This committee is responsible for general oversight, review of milestones, and issues resolution.

The EMR project must be supported by a solid budget. Because of the cost and complexity of the design and implementation, specific funding should be allocated to the project, based on the defined scope as determined by formal project management, including all software, hardware, and anticipated staffing.

CPOE

The CPOE Product consists primarily of all of the orders, order sets, rules, alerts, and formats forming the basis of the computerized order entry tool. The Documentation Product consists of those elements that support fast and complete clinical notes, including required document templates, supporting autotext and macros, and robust voice recognition software with voice command capabilities that enable preformatted documentation. The final product should be fast, elegant, and easy to use. In IT terminology, one could say the system must possess speed, intuitive usability, interoperability, and breadth of functionality. As stated earlier, if the Product does not work well, no amount of transforming will lead to adoption.

The most basic element of the build is the individual orderable. Each orderable contains within it a set of detail options and values, also known as order entry formats, that allow each order to be easily modified to suit individual patient needs. The rules for the construction of orderables are fairly simple, but clearly the design, build, and testing of this massive compendium of orderables demand a considerable effort to complete, depending on the amount of work preformatted from the vendor. Several key features that should guide a correct approach to orderable build are listed below.

Synonyms

First, orderables must be easy to look up, as they are generally not entered as free text, but rather are matched to the terms within a search catalogue. Stated differently, ease of look up means that as the provider begins typing in the name of an order, the search engine successfully matches and converts the provider’s idea into a standard prebuilt order. This requires that each orderable name be listed under a variety of commonly used aliases or synonyms, mandating careful attention to completeness in the catalogue build. Consider, for example, an order for a CT of the Chest. This orderable can be listed variably with synonyms as “CT Chest,” “Chest CT,” “CT Thorax,” and “Thorax CT.” Thus, the orderable catalogue must be comprehensive to include nearly any order that may be imagined. In this approach, as the physician thinks of the name of the test, he or she may expect to get a positive match with a prebuilt orderable from any reasonable search.

Modification of Order Details

Modification of orders should be easy for physicians to complete and should have the fewest possible required fields for order completion. Some required fields are necessary to capture all relevant information to construct a clear and complete order. The number of required fields may be minimized using several techniques. One of the most important fields is a listing of prepopulated order sentences attached to each medication orderable. The most common sentences for all formulary and many nonformulary medications should be prebuilt so the provider may easily select the closest one to the desired order sentence required for the order, thereby avoiding the completion of additional required fields specifying dose, dose unit, route, and frequency. These prepopulated order sentences also serve another important function. They provide real time decision support at the point of order entry by prompting the provider to choose from the most commonly used and safest order sentences, thereby preventing errors by providers who may inaccurately recall a medication order sentence.

In the case of some orderables, many useful order details that would otherwise need to be completed by the physician may be pulled from information already present elsewhere in the system. For example, when ordering a radiology examination, relevant details for mode of travel, monitoring, oxygen support, nurse escort, pregnancy status, and others may be pulled from daily nursing assessments into the order details without querying the physician for this information. A more complete description of the design and build of orderables will depend on the format and software design from each particular vendor. Nevertheless, the point here is that the ease and speed of order entry, facilitated by a smooth search, and the inclusion of all relevant information within the order are critical components in the successful adoption of CPOE.

After successful order entry, efficient and effective order fulfillment must follow. The design and build of the downstream deployment of orders must include the clear and proper communication of the order intent, the provision of all necessary accompanying information, and careful design of processes needed to facilitate order completion and documentation. The design of these elements is best facilitated, as previously stated, by constructing a detailed analysis of current and future state workflow processes for each clinical support department.

Order Sets Design and Construction

Another necessary element in the build of the Product is the creation of a useful array of order sets based upon the Patient Care Pathway model. An order set may be defined as a set of related orders required for the management of a series of integrated clinical tasks. Common uses for order sets include the admission process, transfer, and pre- and postoperative processes, adapted to the needs of each specialty. In addition, diagnosis-specific order sets may be constructed. Others may be used to facilitate safety measures, such as immunizations or venous thromboembolism prophylaxis. Order sets may also be constructed to guide the administration of complex medications, such as titrated drip medications requiring additional orders for monitoring labs or titration algorithms. These may be additionally supported by relevant guidelines, reminders, supporting lab results, nomograms for administration, and dose calculators.

Occasional high-risk medications require the provider to address a list of indications and contraindications prior to use. These may be incorporated into required ordering formats for specific medications. Other order sets may be constructed to support the performance of bedside procedures or the ordering of groups of related tests. Order set utility may be further enhanced by the inclusion of nested order sets and sequenced order sets. Clearly order sets are highly useful, not only for the purpose of saving time for the user, but also for the provision of real-time decision support to guide ordering precision, consistency, and reliability at the proper point along the continuum of care. Physicians from each service line or specialty should be involved in the construction, revision, and approval of all order sets that support CPOE.

Documentation: Provider Notes

Provider notes typically include progress notes, procedure notes, operative notes, history and physical notes, transition in care notes, consultation notes, and discharge summaries. Templates and supporting software must be configured to facilitate the efficient creation of each of these note types. That being stated, the end user should be able to leverage tools to further customize his or her notes to support the individual’s requirements for documentation, down to the level of individualized, preconfigured physical examinations and procedural techniques. Creating global templates in an attempt to support all specialty notes and procedures hampers the ability of the individual user to adapt the notes to his or her workflows, creates cumbersome template searches for the end user, and becomes a long-term management challenge.

Note creation should be supported by state-of-the-art voice recognition software. Such software should include capabilities to support voice tracking with high fidelity, allowing the user to translate voice into text with a minimum of required editing across a broad range of accents. It should support robust range voice commands to format and prepopulate text easily. Appropriate tools that support ease of editing are to be expected.

Refining the Product: Usability Testing

Following design and build, the Product must be refined and polished prior to productive use. This critical phase involves extensive testing. A system as complex as the practice of medicine involves the assembly of many documentation requirements, more than 60,000 orders, each with numerous ordering options, and hundreds of order sets. Therefore, great care must be exercised to avoid errors and ensure the safe application of orders to patient care. In addition to customary unit testing, application testing, and integration testing, an additional category is recommended that is referred to as usability testing.

Usability testing consisted of creating realistic clinical scenarios to which end users are asked to apply configured electronic tools, using the hardware that will be used in production. For example, in the case of CPOE, scanned copies of thousands of handwritten paper orders may be tested by requiring users to translate these orders into electronic formats in a test environment. Testing may be conducted by informatics personnel converting these handwritten orders into electronic orders. Each user records on standard forms any difficulty or impedance he or she may encounter, however minor, to the successful computer entry of these orders. All such order defects are reviewed by a change control committee, charged with evaluating each complaint and recommending appropriate action to amend and improve the order. Usability testing may need to be conducted in waves, such that successive attempts are able to result in a product that performs nearly flawlessly with associated ease of use.

Education

Because CPOE and electronic note creation differ substantially from paper processes, and because many elements are not entirely intuitive, the issue of formally educating the medical staff and hospital staff must be carefully planned. Our education process began with the development of interactive computer-based training modules (CBT). CBT modules should be developed as short vignettes that can be used both for initial education and also as reference modules for later refresher tools. They were internally developed by our education staff and several physicians using a CBT software development tool. The CBT should be made broadly available via a direct link in the EMR and also via an Internet link for ease of access from the physician’s home or office.

Education classes should be scheduled months in advance to permit physicians adequate time to adjust their clinical schedules. Classes should be scheduled as closely as possible to the go-live event to minimize memory loss of information acquired during the class. In general, no class should be scheduled more than four weeks in advance of go-live. Classes should be small, generally with no more than three providers per class. This allows a great deal of individual attention and facilitates directing education to the needs of a range of subspecialty requirements. The resulting schedule requires planning for a number of educators and concurrent classrooms at a range of available times throughout the day. Educators are optimally contracted from a national pool of experienced personnel. Available software products may be employed to help configure complex scheduling. Sufficient open classes should be held the final few days prior to go-live to accommodate stragglers and those needing to reschedule.

In general, classes should utilize a working format, wherein the physician is required to actively engage in executing all steps of the processes with coordinated demonstration and proctoring support from the educator. The format of the classes should consist of the following:

• A brief introduction describing the intent and format of the experience to follow.

• A demonstration overview of the skills that the user will be expected to master.

• A working class may be divided into two phases. In the first, the user is expected to execute each individual keystroke, mouse click, and voice recognition command to effect entry of each required order and creation of each required documentation. For this purpose, the physicians should each work from separate computer workstations. The educator should circulate as necessary and maintain close communication with the physicians during the class to offer assistance and answer questions. Completed orders and documentation should be examined to ensure that the information is entered correctly.

• In the second phase, the physician is given time to practice using common orders, order sets, and note configurations that are relevant to his or her practice and specialty. This should include time to prepare individual favorite folder orders and customized note configurations, using both autotext/macros and voice commands.

Although admittedly tedious, by the time physicians had completed this classroom activity, they should be able to execute a broad range of basic EMR functions independently.

Beyond the education classes, it is useful to offer supplemental education in the form of an “open lab” to give providers and selected groups of physicians an opportunity to have additional assistance with order entry and note creation education specific to the needs of their specialty. Practice patients should be in an electronic training domain in order that providers would have the opportunity to work independently on their own for additional order entry practice both in the classroom and after class for additional practice opportunities. Educators were also stationed in the physician lounges who were available to help with questions and assist physicians with useful tips and tricks. By communicating an expectation that the go-live experience would be seriously challenging for those not sufficiently familiar with the order entry application, many physicians, concerned about the impact to their workflow, are likely to take advantage of these additional options.

Certified Medical Education Credit

Physicians are likely to question what offset is being provided to compensate them for lost time in their practice. One option is to apply for and provide a number of required hours or Category I Certified Medical Education (CME) Credit. Hours can be estimated both for time in the classroom and also for time spent learning during the implementation process itself with go-live. CME requirements may vary by state. Because providers are required to maintain a minimum number of CME hours for accreditation and licensing, this will prove to be an appreciated benefit for the trouble of going through the process.

Building Physician Favorite Folders

Because physician specialties tend to select from a limited range of commonly used orders, allowing physicians to build individual favorites folders containing frequently used or complex-to-build orders prior to go-live was expected to be useful. Training for favorites folder build was included in our physician education program. In addition, selected members of the medical staff assisted in the build of folders of orders specific to each of their clinical specialties. These folders were useful for assembling collections of specialty specific orders and also served as templates to assist some physicians in the construction of their personal favorites folders. To accommodate the need for physicians to build orders into their personal favorites folders, a technique was devised allowing physicians access to the Production Domain prior to go-live to build their favorites folders, but without allowing them to sign and implement orders until the scheduled go-live. Having a prebuilt favorites folder available to use on the day of go-live proved helpful and reassuring to many physicians.

The Pilot

Ultimately a structured physician pilot for CPOE is recommended to serve several purposes preceding the primary go-live. First, the pilot serves as a final proof of concept for the order entry and/or documentation process. This proof-of-concept will be closely watched by the entire medical staff as they observe their piloting colleagues’ reactions throughout their transition for signs of failure or success. Second, the pilot serves as a final “polishing” of the Product to clear up any final identifiable defects in the build prior to the main go-live. Issues with orders and processes should be carefully recorded by informatics personnel assisting the pilot physicians and sent to the change control team for analysis and remediation. Finally, the pilot serves as a proving ground for workflow effectiveness for providers, nurses, and clinical support departments.

There are many ways to structure the pilot and the transition leading up to the main go-live. Some team members had advocated a more complex, sequential pilot leading up to the main go-live, whereas other members advocated a simplified pilot shortly followed by a “big bang” go-live implementation. Regardless, involving heavy users in the pilot is a sound strategy. It is also helpful to involve several special type workflows groups, such as hospitalists, surgeons, emergency department providers, and critical care. The length of the pilot may vary, but should be long enough to establish a credible proof of concept and allow for time to remediate any issues that arise. This typically requires a number of weeks up to several months, depending on the complexity of the go-live and the range of workflows that will require testing. If the pilot goes well initially, it is not unusual for other provider groups to request to join the pilot. This behavior is typically driven by anxiety over fear of being thrown in with the masses in the main go-live. In some cases, including additional specialist groups may prove helpful. In other cases, it may be prudent to ask them to wait, because of the challenges associated with supporting a very large number of pilot providers. The pilot may be limited not only to the number of providers, but also to specific geographic locations. This containment serves to localize the required support and to simplify the workflow analysis and issues tracking.

The Main Go-Live

The movement toward go-live will be afforded additional momentum as the physician pilots from a number of specialties find the EMR processes reasonably easy to navigate and use. The day of go-live should prove relatively uneventful with careful planning, education, expectation-setting, and robust, competent go-live support. For the go-live, excellent support staff that provides EMR transitional support in many hospitals may be recruited for this event. Interested individuals should be carefully screened and interviewed to ascertain their competency, experience, engagement qualities, and especially their interpersonal and communication skills. Go-live support staff should take positive action to engage providers in their workflow and not wait to be approached with questions. At least one or two individuals should be stationed on every clinical area. In addition, a small staff of “roaming” support personnel can be available to be deployed to any area where the other staff has trouble keeping up with the flow during peak hours. Nights and weekends should also be staffed, but at much lower levels, depending on the number of providers anticipated to be working on site. In general, the first three days should be fully staffed, followed by tapering support over a 10- to 14-day period, depending on the demand for assistance from the providers. An IT staffed command center for five to seven days as dictated by call volume and issues log, utilizing a rotating phone system to take calls requesting assistance. In general, the go-live support staff may be divided into teams. Team leads should be appointed to be responsible for ensuring proper performance of the team members, to triage and allocate staff as appropriate to the busiest locations and manage escalation of issues. Issues raised should be called to the team lead, who would determine if the issue can be managed directly or if a call to the command center is warranted. Typically the largest number of calls to the command center occur in the first 48 hours, followed by a rapid tapering. By the end of five days, the call volume should be very small. Most issues fielded can typically be dealt with through educational reinforcement. A smaller percentage will require more detailed analysis by the change control team, of which only a few percent should be expected to require some type of change in the build or escalation to the vendor for remediation. Within two weeks, in an absence of major issues or adverse events, and with rapid response to identified problems, the EMR implementation should be well on the way to cementing itself into the new culture of the electronic support of clinical patient care.

Change Control and Long-Term User Support: Final Polishing of the Product

Over the first three to four weeks following EMR implementation, a gradual decrease in need for assistance, but an increase in calls for improved computer access in specific locations and for improved functionality in terms of EMR build configuration and advanced decision support may be expected, particularly as the strain of new processes in downstream departments and services surface. The need for adequate ongoing maintenance, support, and education cannot be overemphasized. Postimplementation support by phone should be readily available 24/7 by an on-call team of trained users. Issues and concerns lodged should be registered, assigned to appropriate staff for remediation, and tracked to resolution. Solutions should be routed through a relatively small change control group consisting of IT staff and clinical participation from physician, nursing, and pharmacy representation, with others from specific departments as needed for dealing with problems relevant to their particular areas.

As a final note, decisions should be made up front regarding which data to collect to document the impact from the EMR transition on a variety of processes, including adoption, resistance, issues, safety, clinical outcomes, and financial outcomes. Time motion analysis of new EMR processes should also be evaluated for providers and other staff pre- and post- go-live.