EHR implementation: one organization's road to success
This article is adapted from MacDonald A and Riahi S(2012)'s article " EHR implementation: one organization's road to success" 
The electronic health record(EHR) is becoming more and more integral to the healthcare.Nationally and provincially, there is a shared vision to transition to an EHR by Canada Health Infoway. Despite this vision, many healthcare organizations in Canada have been slow to adapt and implement fully integrated EHRs. Management support,financial resource availability,and implementation policies and practices are determined to influence the effectiveness of EHR implementation. Ontario Shores centre for mental health services(Ontario Shores) is a 325 bed tertiary care mental health centre in Whitby,Ontario,Canada. In late 2007, Ontario Shores began it's successful journey to the implementation of a fully integrated EHR system. This was accomplished through the financial and visionary support of the senior leadership team.
In September 2008, Ontario Shores began work for the implementation of the Meditech 6.0. This readiness work involved process mapping of the current and future state clearly defining the organization's interprofessional standards of practice and care delivery, reviewing policies and procedures,and reviewing documentation practices and process which were organized in various phases. The project was divided into 3 phases to ensure smoother transition:
- Phase 1(October 2009) included the implementation of the financial,human resources,staffing/scheduling,admissions and pharmacy modules. Prior to implementation, all paper documentation was reviewed and revised by a clinical documentation working group which was committed to ensuring standardization and adherence to best practices in the development of new paper forms that would ease the transition to electronic documentation system in phase 2.This was supported by clinical informaticians and professional practice group.
- Phase 2(October 2010) included the implementation of electronic documentation and order entry for all clinicians including physicians in the in-patient setting. This encompassed the Meditech 6.0 advanced clinical applications in-patient implementation including Computerized Provider Order Entry(CPOE), Electronic Medication Administration Record (eMAR)/bedside medication verification, Patient care system, Imaging and therapeutic services, lab, and Physician Care Manager. This required intensive training of all disciplines plus support to ensure smooth transition from paper to EHR.
- Phase 3 was implementation of the clinical modules in the out-patient setting. Pre-work began in January 2011 and involved training of out-patient physicians.
Building the team
The key theme throughout the design and implementation of clinical modules was to focus on people,process and workflow. Ontario Shores chose to assign the clinical informatics portfolio under the Professional Practice umbrella. The recruitment of the team included the identification of clinical informatics staff that would balance both knowledge of mental health practices along with understanding the complexity of decisions needed to build content of an EHR. Throughout the process, engagement of key clinical stakeholders was a primary focus. A governance model that include a Clinical system steering committee, Physician Advisory Group(PAG), Safe medication practice committee, and Application design team/working groups added key decisions. The decision team working groups include nursing,allied health staff,physicians and members of the Professional Practice department. Involvement of all the key stakeholders ensured that the design of the system was led by clinicians and not IT professionals.
A focus of the design team from the pre-work to implementation phase of the project was to document using a consistent process mapping framework. Few organizations are able to recruit staff with the skills and the expertise necessary to effectively map out clinical processes. Early in the process, the organization partnered with a local university to receive process mapping training and utilized a new innovative mapping model. Ontario Shores has also adopted the Lean/Kaizen methodology for evaluating many processes and activities,including out-patient services. The methodology supports involvement in patient satisfaction, financial resources, and greater throughput.
Training development was lead by a clinical practice leader in the Professional Practice department. The curriculum content was based on "a day in the life of" concept that would walk the clinician through documentation from the beginning to the end of their shift. An e-learning online module, which provided a high overview of the Meditech 6.0 functionality, was utilized for staff as an introduction to the system during training classes,as well as,post-training for review. This training also allowed each clinician to practice in real-time with a "test" patient. The length of face to face training varied amongst disciplines. Nursing received 24 hours of training over three 8-hour sessions. Allied health received 12 hours of training over 1.5 days, and Physicians received 8 hours of training divided into two 4-hour blocks. In anticipation of training support and go-live,Super users were recruited from each unit/program across the facility.
The devices selection process was led by IT with collaboration with clinical informatics and Professional Practice.The selection was based on evaluation provided by frontline staff and clinical managers.
A "big bang" approach was used. The in-patient integration of Meditech consisted of two go-live phases to enable the available resources the ability to complete staff training,chart conversion,and on-unit support. Each phase consisted of two weeks of intense on-unit support with each unit having a minimum of one super user. Chart conversion was done the week before the go-live. The same process was followed for out-patient implementation too.
There are numerous examples of literature that identify critical factors to ensuring successful EHR implementation, one such work is “Best Practices in EMR Implementation: A Systematic Review.”
UTILIZATION AND ADOPTION
100% of clinical documentation and orders are now done through the EHR in both the in-patient and out-patient settings. More specifically:
- 96% of orders are ordered into the system directly by the ordering provider
- 99% of the time, patient identification is confirmed through Barcode medication administration (BCMA)
- 93% of the medication administrations are scanned
- 45% of the time, physicians use order sets.
Leadership support and physician engagement were key enablers in the success of the project. The senior management team showed unwavering commitment to the success of the project. The project team also strategically selected a physician champion which enabled a highly successful P.A.G for the project. Inclusion of frontline clinicians was integral in the evaluation of various processes and documentation within the system. One of the major success factors was the ability of the team to work together and adapt to the various challenges encountered throughout the project. This specifically included a strong project manager and team leaders for each of the modules that were implemented in phases 1-3. Also, the collaboration between clinical informatics, PAG, and Professional Practice was key in ensuring that all appropriate decisions were documented and approved in a timely manner. Use of super users for training and on-unit support was also one of the reasons for the success of the implementation of the EHR.
At this point of EHR evolution, sustainability and optimization are key to ensuring ongoing utilization and adoption by the staff. Informatics personnel need to be active stakeholders in all decisions and committees to ensure seamless integration of new processes to the electronic system. The role of nursing informaticians will continue to evolve to support this. The next phase for the EHR system at Ontario Shores will be the integration of the Resident Assessment Instrument-Mental health into Meditech to continue to support streamlining of documentation and processes.
I totally agree with the authors statements that the future of healthcare resides in EHRs and there is the need for multi-step process of building the team, process mapping, training , device selection and finally go-live in both in-patient and out-patient settings to achieve this. Obviously, leadership support and physician engagement are very essential. Also, the super users offer crucial training and on-unit support and are very crucial in gaining the confidence of the clinicians and gaining the vital "buy-in" to improve the healthcare and patient outcomes.
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