Seven Challenges and Seven Solutions for Large-Scale EHR Implementations

Article · October 12, 2018

Here are seven challenges and seven potential solutions to managing large-scale (greater than $1 billion) electronic health record (EHR) implementations. These are not meant to be comprehensive, nor are they in any rank order, but they try to capture the most salient lessons learned over multiple implementations.

Seven EHR Implementation Challenges

  • It’s a culture problem.

    EHR implementation has its technical challenges, but the most vexing problems in an implementation are cultural. The governing bodies must recognize that the implementation is a clinical one, not a technical one, and most of the effort should focus on preparing the clinical culture for a successful implementation. There will be technical challenges, but those will be relatively straightforward compared with the cultural and change management aspects of the implementation.

  • Focus on the front line.

    There must be a relentless focus on the workflow. In the end, the real change you are bringing about is on the front line. The workflow must be understood, standardized, and tested multiple times. EHR implementations founder on failed workflows more than on failed technology.

  • Be respectful of scale.

    Scale is a function of (scope x size x complexity), and managing scale is possible only through adjustments of these three factors. For example, limiting scope can be achieved by implementing parts of the record at different times; controlling size can be accomplished through a phased rollout across sites; and decreasing complexity can be accomplished by avoiding customization in favor of a more “vanilla” product. Managing those three levers and the inherent trade-offs with each is essential.

  • Interoperability won’t come easily.

    Exchanging information remains challenging and everyone must be prepared to make it work. It is likely that the real work on interoperability will not begin until after the implementation is complete. Entropy is a law of nature and has a powerful impact on EHRs. An enterprise record requires continuous maintenance and energy to maintain its integrity and avoid breaking down into disordered silos. This work never ends and is essential to ensuring interoperability.

  • Beware the homegrown system. 

    Replacing a homegrown IT system, which has become highly customized and evolved with local workflow, is more difficult than swapping vendors or moving from paper to an EHR. Machiavelli summed this up well: “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new.”

  • Implementation will test your local leadership.

    In the end, the EHR implementation will serve as the ultimate barometer of the leadership quality. A strong central leadership team is necessary but far from sufficient — the real challenge will come at the local level, and the engagement there must be unwavering and focused.

  • Be attentive to team fatigue.

    Your implementation team will be working under pressure, doing what is often a thankless job, and will move on to the next challenge before they can take a pause and appreciate what they have accomplished (i.e., they will never have a “mission accomplished” moment). They can easily be burned out and suffer from change fatigue if you are not attentive.

Seven EHR Implementation Solutions

  • Treat the EHR implementation as a military operation.

    It requires a detailed plan, explicit roles and responsibilities, a recognition of mutual dependence, and contingency plans. The process of cutting over to the new record requires a command center with the ability for rapid response and clear decision rights. Those decision rights will be particularly important when well-intentioned forces push for custom solutions at the expense of the integrity of the enterprise record.

  • Take full advantage of opportunities for learning from others and cross-fertilization between sites.

    Site visits to those who have gone before you, and embedding teams who will do future implementations in teams that are currently implementing, is of enormous value. Do not let any leaders have their first experience with a command center be the one for their own site.

  • What the patients want is primary.

    There will be innumerable decisions to make concerning things large and small during the implementation. In making those decisions, always start with how the decision will impact patients and what they will want. Providers and administrators are important, but their needs should come secondary to patients (who in the end will be the largest single user group of your system). Having “What will the patients want?” as a mantra can help shorten what could become a lengthy discussion of what is best among competing interests.

  • Respect and leverage the hegemony of the time line.

    It is convenient to let time lines slip to avoid facing difficult decisions, but the temptation must be resisted. One mechanism to help enforce that discipline is to know, down to the dollar, what a single day of delay will cost, and let everyone entrusted with the implementation know it as well. There is no right answer between the extremes of “implement rapidly and optimize later” and “optimize first and then implement later,” but the time line your organization has set incorporates an inherent trade-off between the two — stick with it.

  • Treat consultants on the implementation as partners.

    It is easy to break down into an “us versus them” mentality but, recognizing that everyone is in it together and has a common goal (getting the system in safely, on budget, on time, and with good usability), goes a long way to combating that phenomenon. Every discussion should reflect that the team, which will include staff, consultants, and vendor personnel, is a “we.”

  • Take advantage of the wisdom of the Board.

    It is likely that your Executive Board has several members who have done >$1 billion-plus IT system implementations in other sectors of the economy (finance, telecommunications, manufacturing, defense, etc.). Leverage this expertise by creating a Board subcommittee consisting of those individuals who can provide broad strategic oversight and advice to the implementation team. This should not pull the project out of the usual accountability channels (the full Board and/or Finance Committee), but instead it should provide a non-fiduciary source of support to the leadership and implementation teams.

  • Take care of the team.

    Small investments in wellness, modest celebrations of reaching small milestones, and doubling down on employee assistance efforts for the team during implementation are prudent investments. In the end, the most talented team members always have external options if you do not make an effort to keep them. Replacing them will be far costlier, in both financial and operational terms, than a small effort to keep them engaged.

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