Expanded Implementation Of The Existing Electronic Health Records (Ehr) System To Non-Medical Areas: Barriers And Options Case Studies Examples

Introduction

Despite the risks and limitations, interoperable Electronic Health Record (HER) system continues to attract organizational interests due to its promise of process efficiency, permanence of health records, patient privacy, and secure operational environment (McGinn, et al., 2011). These characteristics had positive impact to the organizational profitability and, in the Medical Center, redound positively to employee benefits and development.
Expanding the implementation coverage of the EHR system to the Center’s entire medical system, to cover the non-hospital care units (e.g. pharmacies, coordinated care, etc.), normally presumes a thorough testing of the existing EHR system in the medical areas and much of the initial implementation issues adequately addressed, if not fully resolved. Since it is a strategic decision that expects to reap profits in the medium term, it is illogical to push for an expansion when several issues continue to haunt the existing EHR system and its performance cranky and barely reliable at best. Thus, the move involves a complex maneuver that should be grounded on a realistic assessment of the current EHR state so as to avoid bringing the problem to the non-medical area. However, should the issues hounding the system are tolerable and do not seriously hinder the routine care and cure services of the Center, then perhaps the expansion may prove strategic and profitable.
This case study attempts to highlight in the Discussion the standard implementation procedure recommended by the U.S. Health and Human Services ([USHHS], 2014) as model and in a concise step-by-step narrative to shorten an otherwise long document when comprehensively written. It is followed by a series of nine barriers to implementation, condensed to the most essential items. Then followed an attempt to provide management options meant to address these barriers and to facilitate a non-problematic implementation of the EHR system into the non-medical areas of the Medical Center here in Stevensville, Kansas.

Discussion

Implementation
The following steps are patterned and modified from the recommendations of the U.S. Health and Human Services (2014). For instance, the numbers of steps are more (7 instead of 6) than what can be found in the USHHS outline.
Step 1: Assessing the current practice: The current medical practice is assessed in areas such as level of administrative processes (in terms of organization, efficiency and documentation quality); clinical workflow (in terms of efficiency, high organization, and staff knowledge); data collection and reporting status (in terms of efficiency); staff computer literacy (level of knowledge, skill and comfort); access to high-speed internet connectivity; access to adequate financial capital; congruence with clinical priorities; and the presence of specific specialty requirements. Although most of these areas had been assessed during the first implementation of the existing EHR system, going through the process is beneficial in assessing the state of medical practice to detect weaknesses that should be corrected when expanding to the non-medical areas. New visioning and goal-setting are usually unnecessary. The same implementation leadership team will oversee the expansion.
Step 2: Establishing an expansion plan: The EHR expansion plan identifies new work practices, work practices to discontinue, and work tasks to sustain in the non-medical areas to which the EHR system will be expanded. Seven major sub-steps are needed in the implementation planning: (1) analysis of the Step 1 assessment outcomes; (2) establishing new workflow patterns adapted to the EHR system; (3) establishment of a contingency plan; (4) creation of a transition (old system to EHR) project plan; (5) establishing an abstraction plan to address the transformation of data from the old system to the EHR system; (6) identify data elements for migration to the EHR system; (7) identify issues and obstacles in patient privacy and system security that may be relevant in the non-medical areas.
Step 3: Upgrade of the EHR system: The upgrading of the current EHR system to cover non-hospital care areas should involve certain considerations: understanding on the approach the vendor will take to expand the coverage; and determination of additional costs for more hardware, software, maintenance, associated cost, option for phased payments, etc.
Step 4: Conduct training for non-medical staff: The non-medical staff that had no previous exposure to the EHR system in the medical areas should undergo relevant training. This includes relevant technical and software use training (e.g. mock ‘go-live’), meaningful use objectives, and compliance requirements and standards.
Step 5: Implement the EHR system: The implementation is overseen by the multidisciplinary leadership team according to the prescriptions found in the expansion plan. Special attention should be placed in the implementation of the chart abstraction plan and other data migration plans. There should be conducted a pilot testing of the EHR system in the non-medical area before full implementation and use.
Step 6: Ensure meaningful use: The achievement of ‘meaningful use’ may have financial incentive implications from the government Medicare and Medicaid incentive programs. This incentive can help cut on the expansion cost to non-medical areas, depending on certain requirements. Nonetheless, the ‘meaningful use’ goals involve achieving improved quality, safety, and efficiency (QSE); patient and family engagement; enhanced care coordination; improved public and population health, and; guaranteed privacy and security for patient health information.
Step 7: Continue quality improvement: This step is expectedly integrated with the same activity in the existing EHR system in the medical areas. It usually involves an initial reassessment of the learning levels and system use among the non-medical staff with a focus towards the continuing workflow improvement program. Areas of evaluation include goal-need achievement; data migration performance; staff roles and responsibilities adjustments as necessary; and feedback mechanisms on technology area propriety, reliability, speed, and hardware sufficiency.

Barrier Management

Barrier 1: Limited access to large financial resources: This barrier limits the possibility for expansion to the non-medical areas. However, it is usually not as large compared to the requirements in the initial EHR system, depending on the size of the non-medical services the center provides, the nature of services, and the location of these units.
Barrier 2: Limited EHR-systems knowledge and trained-staff availability: This barrier increases uncertainty in the use of EHR systems and disruption for users (Boonstra, Versluis, & Vos, 2014). However, this barrier is not as challenging in the context of expansion to non-medical areas as the medical center already possesses technical knowledge of the system (i.e., non-medical staff may be allowed to join ongoing EHR system trainings with medical staff as part of their developmental program even before expansion happens) and trained staff may be transferred to the non-medical areas to spearhead the transition during expansion implementation. This includes real-time technical support when needs arise.
Barrier 3: Limited support from hospital management and staff: This barrier is easily manageable in the context of expansion due to the potential prior exposures of non-medical staff to the EHR system information and even operation in the medical areas. Even if the non-medical staff think the EHR system implementation as a mere technical project, they would find no basis in refusing to adopt changes in their existing work practices because those in the medical areas had already successfully adopted the new system (Carayon, et al., 2009; Boonstra, Versluis, & Vos, 2014). Moreover, the system should be customizable and adaptable to meet specific user needs (Cresswell, Worth, & Sheikh, 2012). More importantly, the management had already shown strong leadership support to the expanded implementation of the EHR system.
Barrier 4: Adaptive attitude towards change: Since the major source of known change resistance came from physicians and clinical staff, EHR system expansion into the non-medical areas may not encounter as much resistance. However, resistance may still be expected. To soften this resistance, their concerns should be heard by the multidisciplinary implementation team and address them effectively. Another approach is to identify champions among the non-medical staff and encourage them to push compliance among staff in their specific areas of assignment (Boonstra, Versluis, & Vos, 2014).
Barrier 5: Unfavorable organizational culture: This barrier consists of a culture that does not engender trust between employees, a condition required to foster success in the implementation of EHR systems. It may continue to exist within the organization even after the initial EHR system had been implemented. Highly bureaucratic organizations, for instance, hamper change, slow down the process, and often encourage inter-departmental conflict. Addressing this cultural issue cannot be accomplished in the non-medical areas only. It should be part of the overall culture change strategy of the medical center. However, to facilitate change, the organization should first develop a collaborative culture where teamwork is high among the employees and trust paramount between stakeholders (Boonstra, Versluis, & Vos, 2014). These conditions minimize resistance to change. To cut through bureaucracy, the multidisciplinary team can act independently from the bureaucracy. This team should consist of the software developers, members of the IT department, and representatives of the end-users (both in the medical and non-medical areas), and is tasked in ensuring better system delivery with fewer problems.
Barrier 6: Healthcare continuity requirements: This barrier pertains, specifically, to the transition period between pre-EHR information system use and the implementation of EHR systems (Boonstra, Versluis, & Vos, 2014). Unlike medical care, which requires continuous cure and care activities, this issue may not be as crucial to the services of the non-medical units. Still, that depends on the services provided. Nevertheless, the rate of old data exporting should be multiple times faster than the rate of new data entries into the still-actively used old system. The most conceptually effective and efficient approach to resolve this barrier is to use the new EHR system for new clients and the old system for old clients; while simultaneously exporting the unused records to the EHR system. In this manner, the new database of patient records should eventually catch up with the ongoing demand for non-medical services until full data migration is accomplished. At times, though, workarounds may be employed to resolve certain issues: e.g. tricking the system it stops working and could not bring the process to the next step (Cresswell, Worth, & Sheikh, 2012).
Barrier 7: Insufficient hardware availability, system reliability, and user-friendliness: This content barrier will result to unsatisfactory use or use failure when not addressed. Adequate hardware should be available to users so they can use the EHR system (Boonstra, Versluis, & Vos, 2014). To avoid system failures and inefficiencies, the system needs to be logically structured, reliable, and compatible with the existing EHR system used in the medical areas. It should also be a mature technology, and not ‘in development’, as unpredictability and reliability would be high (Cresswell, Worth, & Sheikh, 2012). Beyond that, the software should be user friendly to encourage widespread use and staff support.
Barrier 8: Weak privacy and confidentiality safeguards: This barrier should have been addressed already in the medical area before expanding the use of the EHR system to the non-medicals while avoiding patient complaints, which may daunt staff use. Safeguards should be strong in protecting the confidentiality of patient files and information while providing secure access to authorized non-medical staff (Boonstra, Versluis, & Vos, 2014).
Barrier 9: Lack of comprehensive implementation strategy: Like Barrier 8, this should have been addressed already at the beginning of the EHR system implementation in the medial areas. Unavailable, it will cause multiple problems that can jeopardize its non-medical implementation and maintenance (Cresswell, Worth, & Sheikh, 2012). A good strategy is a minimum and should consist of careful planning and preparation, a sustainable business plan, effective communication, and a policy of mandatory implementation. A well-constructed strategy should be flexible enough to work in handling unforeseen contingencies due to expected unpredictability present during implementation. It should ensure that unplanned contingencies should not significantly hinder the crucial EHR system functioning.

Conclusion

A few of the implementation steps based on the USHHS (2014) model and suggested for the expansion of the EHR system to the non-medical areas had to be relatively less extensive than those used in the initial implementation, such as steps 3 through 7, due to conditions already accessible in the existing system. However, certain steps (1 and 2) had to be preserved, at least in its shortened form, in order to ensure adequate details that are crucial in the effective implementation of the expanded coverage.
Likewise, certain barriers of expanded EHR system implementation, such as vendor issues, may be no longer as relevant for the coverage expansion as it should be during the initial implementation. If the current vendor’s software, for instance, are working well, then there will be no necessity to switch vendor. Those that still influence the implementation (e.g. those mentioned in this study) had proven significantly attenuated as most of the factors involved had been addressed adequately in the initial implementation phase.
Evidently, the issues expected to encounter in the execution of an expanded EHR system coverage depends largely on how far issues had been effectively addressed, or better resolved, in the initial implementation of the system. The more effective the initial implementation was, the less issues would be expected in the expansion phase.

References

Boonstra, A., Versluis, A., & Vos, J.F.J. (2014). Implementing electronic health records in
hospitals: A systematic literature review, BMC Health Services Research 14(1): 370-396.
Carayon, P., Smith, P., Hundt, A.S., et al. (2009). Implementation of an electronic health
records system in a small clinic: The viewpoint of clinical staff, Behavior & Information Technology 28(1): 5-20.
Cresswell, K.M., Worth, A. & Sheikh, A. (2012). Comparative case study investigating
sociotechnical processes of change in the context of a national electronic health record implementation, Health Informatics Journal 18(4): 251-270.
U.S. Health and Human Services. (2014, March 20). How to implement EHRs, HealthIT.gov.
Retrieved (19 March 2015) from: http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr.