T How to the Avoid

CHAPTER 4
How to Avoid the
Train Wreck
hor Thorssen recalled that his assistant had put together some clippings
on EHRs and placed them in his briefcase. Thor opened his briefcase—
on the top of the pile was an ominous article entitled “Physician
Ultimatum Forces Health System to Turn Off New Electronic Medical
Record After Only Three Months.” The next article in the stack read “Down for
the Count—Hospital’s Network Grinds to a Halt Under Weight of New
Electronic Health Record.” After reading the stories, Thor was struck that if this
could happen to highly regarded organizations, what would Dynamic need to
do to avoid the same fate? Were there lessons learned from these
organizations’ experiences that Dynamic could apply? Was Dynamic ready to
move forward with an EHR project? Thor made a note to ask his CIO if there
were objective means to assess Dynamic’s state of readiness prior to making a
decision to move forward with implementation.
T
HOW TO AVOID THE TRAIN WRECK
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Success has a thousand fathers,
but failure is a motherless child.
— Ancient Proverb
Healthcare in the United States now
consumes more than 15 percent of
gross domestic product, yet we
generally do not live longer nor are
we healthier than other developed
nations that spend less than half that
amount on healthcare (Goldman and
McGlynn 2005). The reality of these
statistics, along with the IOM’s
report on preventable deaths in this
country, has energized the federal
and state governments in ways that
will continue to put pressure on
healthcare organizations (Kohn,
Corrigan, and Donaldson 1999).
Plans for reduced reimbursement
rates will put a crimp on the bottom
line, increasing pressures to ensure
that any investments in capital have
envisioned returns. Clearly, just by
their sheer size, seven-, eight-, or
even nine-figure EHR projects
(depending on the size of the
organization) should create an
automatic heightened need for due
diligence among healthcare
executives. Nothing can get an
executive fired faster than spending
$50 million with nothing to show
for it.
54
In their 2006 American College of
Healthcare Executives (ACHE)
Congress on Healthcare Leadership
presentation, “IT Disasters: The
Worst IT Debacles and the Lessons
Learned from Them,” Ciotti and
Hunter (2006) provided ample
evidence of clear risks associated
with large-scale IT projects if not
properly executed. But as noted in
Chapter 1, the opportunity costs of
doing nothing are clearly mounting.
So, given that EHR projects are not a
walk in the park, we present a
number of critical success factors
that healthcare executives can use to
increase the chances for a successful
EHR implementation and avoid “the
train wreck.”
TECHNICAL AND
ORGANIZATIONAL
CAUSES OF IT
FAILURE
IT projects fail for both technical
and organizational reasons.
Technical factors are those
connected with the actual
information systems and supporting
technical infrastructure.
Organizational factors include
issues connected with the work
setting and the individuals within
it.
| THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
Some Technical Causes of
Train Wrecks
software that you can go see in stable
operation at a peer organization.
BUYING THE FUTURE. One of the
technical reasons for failure is that all
EHR systems still lack many desired
functionalities. Likely, the most
common train wreck of the past
decade has involved buying the
proverbial “vaporware”—software that
you can see in demonstrations at
trade shows and in slick sales
presentations but cannot find being
successfully used at any healthcare
organization similar to your own
anywhere in the country. The scenario
for such a train wreck typically plays
out like this—key executives of the
healthcare organization are wined and
dined and sold on the product, but
actual users are kept as far away as
possible from “kicking the tires.”
Typically, the vendor offers significant
discounts for the healthcare
organization to be a “beta site,” or an
early adopter. A contract without any
delivery penalties is signed, and then
the organization waits…and
waits…and waits…pouring people’s
time and the organization’s money at
the continuing development efforts
that never seem to materialize. The
lesson learned from this generic case
is that if you want to minimize risk,
only purchase tried and proven EHR
BUILDING A HOUSE ON A FOUNDATION OF
SAND. While clearly not a sexy topic,
the IT network infrastructure is the
cause of the next most common train
wreck. If your organization is like
most, the IT network grew
organically and eclectically.
Recently, some fairly well-established
integrated delivery systems had some
well-publicized failures when
bringing up new EHR functionality.
These failures turned out to be
caused by a network infrastructure
that no longer could bear the weight
of the additional transactions that
the new EHR was trying to push
through its aging pipe works. To be
sure, network upgrades are not
cheap endeavors. They easily can
reach into the seven-figure range for
even medium-sized healthcare
organizations. However, rather than
consider needed IT network
infrastructure upgrades as part of the
EHR project, these organizations
either assumed the current network
could bear the additional application
or were not willing or able to shell
out the additional funds for both a
network upgrade and an EHR.
These organizations learned the
lesson the hard way, with days and
HOW TO AVOID THE TRAIN WRECK
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even weeks of downtime and
millions of dollars of revenue lost.
Not only is the loss of revenue a
major issue, but the loss of clinician
confidence in the system can lead to
future resistance to a new system
even after the network problems get
fixed. The lesson here is to have
your IT department fully assess the
impact of an EHR on the network
infrastructure and, if needed, build
network upgrades into the ten-year
total cost of ownership of the project
(see Chapter 1).
WORKING WITH INCOMPATIBLE “LEGACY”
SYSTEMS. In Chapter 2, we discussed
some of the back-end systems that
are needed to gain full advantage
from the EHR. Often, a new clinical
system is purchased without
sufficient thought as to how it will
integrate with the existing systems.
Failure to achieve full integration can
lead to the exclusion of key
functionalities. For instance, if one
wants to use clinical decision
support systems to avoid duplicate
laboratory test ordering, obviously
the lab and the order entry systems
must be integrated. Planning for this
integration should be done up front,
and, if extensive work is needed to
achieve the integration, it should be
factored into the cost of the project.
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EXECUTIVE TAKEAWAYS:
TECHNICAL CONSIDERATIONS
■
■
■
To minimize risk, only acquire tried and proven
EHR software that you can go see in operation at a
peer organization.
Shifting your core business processes from paper
to electronic requires much higher levels of up time
from the network infrastructure.
Accomplish an infrastructure assessment when
implementing an EHR, and be prepared to make
infrastructure upgrades/enhancements a part of
your EHR total cost of ownership.
People and Organizational
Factors
The support of top leadership is a
must-have for clinical IT project
success. While the CEO will usually
delegate to and rely on the IT
department for review of the technical
issues, the CEO’s involvement is
crucial to avoid the organizational
problems that are as, or even more,
significant than the technical issues in
leading to IT implementation failures.
Below we review some common
issues.
LACK OF PHYSICIAN LEADERSHIP AND
PARTICIPATION. EHRs with the key
essential components of CPOE and
CDSS absolutely require physician
leadership and participation.
Implementation of an EHR almost
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
always requires significant workflow
analysis and often requires a major
redesign of the processes. In addition,
the design of appropriate CDS tools
requires the input of the clinicians
whose work is being supported. The
IT department should not lead but
rather serve as facilitators for
physician leadership in the design of
order workflows or alert and reminder
settings. Weak physician leadership or
weak participation by a physician
design oversight team can lead to
poor decision making with regard to
system configuration settings. Fully
understanding the current “as is”
physician order work flow process
and ensuring that a representative
group of physicians is involved is
critical as the process is automated
into an EHR with CPOE and CDSS
(see Chapter 2 for more detail on
CPOE and CDSS). For instance, in one
organization, the alerts were set at
such a low threshold that physicians
quickly became frustrated with the
system’s constant alerts and
reminders, most of which were for
items that did not have a bearing on
treating the patient at hand. In that
organization, physicians threatened to
walk out if they had to continue using
the system. This might have been
avoided had physicians been involved
when decisions about alerts and
reminders were being built into the
system configuration. While the
organization could have gone back
and set the thresholds to alert only for
specific and germane patient safety
items, credibility and faith had already
been lost with the physicians.
Organizations would do well to select
key influence leader physicians to
serve on the oversight team for the
EHR design/implementation team and
also to obtain participation from a
number of varied specialties. In fact,
most organizations set aside some
resources to compensate physicians
for their time in working on the order
and decision support design phase of
the EHR. The physician leader or
champion should not be what Dave
Garets of HIMSS Analytics calls a
“techno doc,” who never met a gadget
he didn’t want to have, but rather
should be a clinician who already
holds a position of influence within
the medical staff and who believes in
the rationale for the EHR.
INADEQUATE TRAINING AND SUPPORT.
Institutions that rely primarily on
residents to use the EHR may have an
easier time of training, because
residents are not only younger (and
more familiar with and therefore
receptive to new technology) but can
also be required to undergo training.
HOW TO AVOID THE TRAIN WRECK
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In most other settings, especially nonacademic hospitals or academic
hospitals with a large contingent of
community physicians, training may
have to be customized and the
physicians cajoled to get them to learn
the system. Failure to provide
adequate training, or failure to provide
adequate high-touch support during
the initial “go live” period, can lead to
lack of use of the system, inadequate
feedback for modifications, and
ultimate failure. Both the timing and
the mode of training are important.
Training should be done on a just-intime basis—with enough time for key
users to learn and practice before
implementation, but not so long in
advance that they will forget what
they have learned. Also, physicians
and nurses often have different
learning styles, and the same mode of
training may not work equally well for
both groups. Physicians are often
uncomfortable with group training
sessions and one-on-one training may
be needed. Support should be
available 24/7 during the initial
implementation period, even for users
who supposedly were trained in
advance. One famous early IT failure
in the news mandated minimal
training and certification on the new
system. Although training was
mandated, physicians were offered the
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opportunity to practice with the
system, but they were not required to
do so. The community physicians did
not take the time to become familiar
with using the system during the lead
up to implementation and then
complained that the system led to
unsafe care. Their resistance
succeeded in getting the system
dismantled four months after it was
rolled out.
FAILURE TO UNDERSTAND REASONS FOR
RESISTANCE. While any change in
process may meet resistance, if your
clinicians are anxious about using
computers, they will have specific
resistance to a new IT system. Don’t
underestimate something as simple as
typing or mouse skills. For an
individual who cannot type well, the
use of an EHR may be too
burdensome. This factor will likely
decrease if you use a combination of
other input strategies, such as voice
recognition, and as more clinicians
become comfortable using the
keyboard.
Another factor is what could be
called clinician role issues. This is
resistance based on considering direct
interaction with computers as outside
the role of the clinician. Many
clinicians see using a computer as a
technician’s or clerk’s job, not that of
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
EXECUTIVE TAKEAWAYS:
ORGANIZATIONAL CONSIDERATIONS
■
■
■
■
Select a senior, respected physician leader to
oversee the clinical configuration aspects of the
EHR.
Enlist and compensate a core group of
representative physicians to work with the senior
physician leader to make decisions regarding the
clinical configuration of the EHR and thereby
increase adoption.
Set realistic expectations, and anticipate and
reduce sources of resistance.
Arrange for customized just-in-time training for all
users of the system.
a professional. While that perception
may change in the future, for now
these issues—even if not stated
directly—can underlie resistance to
EHR implementation. If these
concerns are recognized, they can be
addressed through more
individualized training; but if they are
not recognized, they can create an
atmosphere that will exacerbate the
inevitable tensions.
ROSE-COLORED GLASSES. Because
computers can do many things more
quickly than people can, there may be
an expectation that the computer will
save the clinicians time when used to
record orders or documentation. In
fact, that particular part of the process
may actually take longer than the
manual process, which can lead to
disappointment. What should be
considered is the time taken for the
entire episode of care—from that
initial order being entered to the order
being implemented with the patient.
What the individual physician may
not recognize is, for example, how
much time he spends responding to
questions about the order from other
personnel or how long it takes for the
order to actually be implemented with
the patient. The entire care process is
often more efficient using an EHR, but
to an individual clinician it may not
seem so.
POOR EXECUTION. The single greatest
cause of EHR project failures, and all
IT project failures for that matter, is
poor execution. We have all seen
headlines in the popular press about
IT systems causing rather than
reducing medical errors. Reading the
original articles on which the lay press
reports were based shows obvious
design and implementation problems
(Koppel et al. 2005; Han et al. 2006).
A recent Standish Group study
found that only 29 percent of IT
projects achieved the envisioned
benefits (Hayes 2004). Organizations
that fall into the category of the 71
HOW TO AVOID THE TRAIN WRECK
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percent who fail to achieve benefits
often rely on the collected experience
of the individuals who have
previously implemented IT at the
organization but typically do not
employ disciplined project
management methodologies, such as
those suggested by the Project
Management Institute (www.pmi.org).
An EHR is an incredibly complex
application that touches virtually
every workflow process within a
healthcare service delivery
organization. Organizations that fall
into the 71 percent typically go live
and only then find out that large
stakeholder groups or key workflows
have been left out. These
organizations wind up scrambling
after the fact to reengineer processes
that easily could have been
proactively addressed had the
organization followed disciplined
project management methodologies,
as described below.
STEPS YOU CAN TAKE
TO PREVENT TRAIN
WRECKS
Assess Organizational
Readiness for an EHR
Just like our fictitious CEO, Thor
Thorssen, more than a few CEOs,
COOs, and CFOs have ample cause to
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worry about large-scale IT projects
such as enterprise-wide EHR projects.
What these executives will find
comforting is that an EHR
implementation can be similar to the
large-scale building projects with
which they tend to be more
comfortable. Very similar
methodologies and questions can be
asked to assess an organization’s
readiness for investing in and
implementing an EHR project. A highlevel EHR organizational readiness
assessment checklist follows:
■
■
Do all three ancillary
departments (laboratory,
radiology, pharmacy)
already have stable ancillary
information systems in place?
Does the organization have a
demonstrated successful
capability within its IT
department for interfacing
the various information
systems that are already in
place? Some day in the future,
vendors will begin to produce
“out-of-the-box”
interoperability, but because
many of your pre-existing
systems are built on old
technology, you will still need
the ability to interface the new
EHR with these other
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
■
■
■
■
pre-existing systems (such as
radiology, laboratory,
pharmacy, billing).
Is there enterprise IT
governance of some sort that
is representative of all of the
stakeholders of the organization
(we go into governance in more
detail later in this chapter)?
Does the organization have at
least one, if not more, senior
ranking physicians who are
strong supporters of IT and can
act as dedicated champions
and influence leaders for an
EHR project?
Does the organization have a
pre-existing investment in a
stable and active enterprisewide continuous process
improvement methodology/
function with demonstrated
success in cross departmental
workflow redesign (remember,
an EHR initiative is actually just
a large-scale organizational and
cultural transformation project)?
Does the organization
understand the TCO of an EHR
(see Chapter 1), and is it
financially prepared to invest in
an EHR? Cutting corners in an
EHR project is not suggested.
Analyzing the total long-term
capital and operating costs and
■
■
building a financial long-term
plan and commitment to support
the EHR project is vital.
Do you have access to or are you
willing to invest in short-term
legal expertise accustomed to
crafting and negotiating
large-scale IT projects and
preferably EHR contracts (see
Chapter 3 for best practices in
EHR contracting)? Many different
contracting models for EHRs
exist, so having experts with
experience in such contracts
can save you millions of dollars
and significantly minimize your
contracting risk.
Has your team, prior to signing a
contract, performed a workflow
analysis of each of the major
service lines (primary care, your
main specialties, etc.) and
identified opportunities for
reengineering?
Employ Disciplined Project
Management Methodologies
Many organizations are adopting
formal project management
methodologies to decrease
execution risk and assure
themselves prior to going live that
they have done everything in their
power to cover the bases. Figure
4.1 provides some high-level
HOW TO AVOID THE TRAIN WRECK
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Figure 4.1—Project Management Processes
Project Management Processes
Initiation and integration
•
•
•
•
•
•
•
Develop project charter
Develop scope statement
Develop project plan
Direct and manage execution
Monitor and control project work
Integrate change control
Close project
Scope management
•
•
•
•
•
Scope planning
Scope definition
Create work breakdown structure
Scope verification
Scope control
Time management
•
•
•
•
•
•
•
•
•
Activity definition
Activity sequencing
Activity resource estimating
Activity duration estimating
Schedule development
Schedule control
Cost estimating
Cost budgeting
Cost control
Quality management
•
•
•
Quality planning
Quality assurance
Quality control
HR management
•
•
•
•
HR planning
Acquire project team
Develop project team
Manage project team
Communications management
•
•
•
•
Communications planning
Information distribution
Performance reporting
Manage stakeholders
Cost management
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THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
Figure 4.1 Project Management Processes (cont.)
Risk management
•
•
•
•
•
•
Risk management planning
Risk identification
Qualitative risk analysis
Quantitative risk analysis
Risk response planning
Risk monitoring and control
Procurement management
•
•
•
•
•
•
Plan purchase/acquisition
Plan contracting
Request seller response (RFP)
Select seller
Contract administration
Contract closure
Source: Project Management Institute (2004).
guidance regarding the formal
processes that should be built into
any IT project and particularly an
EHR project.
While the items in the table are
not intended to be overly granular,
insisting that your organization run
the EHR implementation while
employing disciplined processes
will ensure that key aspects that
have been shown to be major
causes of EHR and IT project
failures in general (e.g., stakeholder
management and involvement,
contract administration, scope
creep) are explicitly addressed via
the methodology.
Establish Champions,
Leadership, and Governance
Effective leadership and oversight is
often a top-of-mind reference in any
coverage of success in any topic
area, and EHR implementation
projects are no exception. As
mentioned earlier, physician
leadership and participation is vitally
important in an EHR implementation.
We’d like to elaborate on that topic
and add the element of effective
governance of an EHR project.
Some organizations tend to pick
the techno doc physician to oversee
an EHR project—unless that
physician is a highly respected,
HOW TO AVOID THE TRAIN WRECK
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influential leader as a clinician, the
project is already at undue risk.
Remember an assertion that we make
over and over in this text—an EHR is,
in reality, a large-scale organizational
transformation project first and
foremost. An EHR project will ask
your organization to redesign longstanding clinical workflows. Change
on that order of magnitude absolutely
requires a respected physician leader
who can influence changes in
behavior not only among the
physician population but also among
the entire cast of characters involved
in the patient care process. Typically,
the medical director or chief medical
officer is ideally suited to act as the
champion leader of an EHR project.
Many hospitals, in fact, are developing
the position of chief medical
information officer (CMIO), or some
similar title, for that purpose and as
an ongoing liaison with the physician
community in regard to IT projects. If
you do hire for such a position, you
need to make sure that the individual
has the ability to address and manage
the issues discussed in this chapter
and is not just a physician who loves
technology.
Given that you are able to enlist a
respected physician leader, you need
to establish a governance structure to
leverage that physician leader.
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Typically, an EHR steering team is
chartered by the executive committee
of the healthcare organization and
seeded with representatives from
throughout the healthcare
organization and physician group.
Figure 4.2 depicts a sample EHR
governance structure along with
representation from a number of areas
of the healthcare organization.
Note that in this structure, the EHR
steering committee is made up of
senior influence leaders who will
make key decisions regarding the EHR
implementation, including but not
limited to timing of events, major
workflow redesign decisions, attempts
at scope creep, and differences of
opinion with respect to design and
configuration. On the other hand, the
EHR implementation team is ideally
made up of individuals who are
highly respected within the
organization but who also will be the
hands-on users of the system.
Typically, the implementation team
also should be led by a physician
champion. The EHR implementation
team is charged with overseeing the
disciplined project management
processes outlined previously—in
essence, they do the yeoman’s work
in designing the system, developing
business rules for the order sets and
alerts and reminders, and generally
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
Figure 4.2—Example of EHR Governance Structure
Hospital or IDS
Executive Committee
EHR Steering Committee
– Medical director (chair)
– Group practice leader
– Primary care physician
– Surgeon
– Key specialty physicians (2–4)
– CIO
– Key senior IT subject
matter experts (1–3)
– Purchasing/contracting officer
– Revenue cycle leader
– Legal counsel
– Privacy officer
– Director, records department
– Professional project manager
EHR
Implementation
Team
moving the project through its paces.
Additionally, the EHR implementation
team is charged with periodic
performance monitoring and reporting
to the EHR steering committee.
Develop Strategies to
Reduce Resistance
The inevitable resistance to change
for projects of this magnitude can
be reduced. In addition to training
and post-implementation support,
showing the benefits of the system
to the user and aligning incentives
will help achieve clinician
commitment.
IDENTIFY THE BENEFITS FOR USERS.
Some of the benefits mentioned
earlier, such as improved access and
efficiency, may impress some users,
but if a user is content with the
present system and finds it efficient
enough, efficiencies may not be a
sufficient motivation to change. The
added capabilities that using the
system can provide for the individual
user may be more persuasive. For
HOW TO AVOID THE TRAIN WRECK
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instance, in addition to the potential
for decision support and although the
order entry process may take a little
longer, a variety of types of reports
can also be generated as soon as the
data are entered. And, of course, the
data are likely to be more accurate.
Another benefit is customizing the
view that is presented to the user.
Several users can work with the
same underlying database, but to
save time and to adapt to individual
physician needs, systems can often
be set up to customize the way the
information is displayed, the order
sets, the preferred medications, and
so forth. This is where the
investment in high-touch support
staff that can individually work with
physicians to set up their own
customized views will pay off in
much higher adoption rates.
We have said before that one way
to decrease resistance is to encourage
user involvement. To accomplish
this, the implementation team should
not only seek the input of the
clinicians but may also want to
observe the actual process of care. In
many cases, the physicians may not
be aware of all that goes on between
their placing an order and having it
implemented. Observation by an
outsider can identify ways the
process itself can be improved
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because you certainly don’t want to
automate a process that is inefficient
to begin with. As an example, a
research study (Murray et al. 1998)
showed that pharmacists had to
correct more errors with physician
order entry. The reason was
discovered to be that they allowed
free text entry of orders but had not
built an automated correction
mechanism into the system.
Previously, the errors related to
medication dosages may have been
corrected by the personnel who had
entered the orders into the system;
this issue might have been detected
before implementation of CPOE with
careful observation of the whole
process of order entry. A study that
did such observations with a paperbased system found that physicians
frequently did not provide complete
information on the orders, leaving
the nurses to fill in the details
(Beuscart-Zéphir et al. 2004).
Obviously, in some cases, the process
itself needs to be modified or the
information system needs to be
designed to fit the actual, not the
theoretical, processes. In the
examples described, for instance, free
text might not be optimal for order
entry, or some other mechanism for
correction might need to be
incorporated.
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
EXECUTIVE TAKEAWAYS:
STEPS FOR SUCCESSFUL IMPLEMENTATION
■
■
■
■
■
Assess the readiness of your organization as part
of the planning for the EHR project.
Overcome failures of execution by employing
professional project management methodologies.
Make sure EHR project steering committees and
implementation teams have adequate and engaged
physician leadership and representation.
Put in place an effective EHR governance structure
to leverage your physician leader and provide him
or her with the support structure for success.
Reduce resistance and encourage adoption of the
EHR by demonstrating benefits and aligning
incentives.
ALIGN INCENTIVES AND REWARD
ADOPTION. Another key factor in
reducing risk to your EHR project is
to fully understand where benefits
accrue and, therefore, where you
need to focus incentives to reward
adoption. As we noted in Chapter 1,
most of the benefits of an EHR
accrue to the hospital and to
managed care organizations,
insurers, and employers.
Downstream benefits do accrue to
physicians in the form of actually
having the information they need to
practice more informed medicine
and gaining accounts receivable via
cleaner, information-supported
billing. However, some physicians
are burdened by the electronic entry
required by CPOE and therefore
continue to shun adoption.
Additionally, prior to the new
safe-harbor Stark provision, many
physicians found investment in EHRs
too high for their practices. In its
review of financial, legal, and
organizational approaches to
achieving electronic connectivity in
healthcare, the Markle Foundation
suggests that “financial incentives,
regardless of the way in which they
are derived (e.g., pay for
performance or another incentive
structure) for small and mediumsized practices will need to cover
most of the initial costs of the EHR.
Incentives in the range of $12,000 to
$24,000 per full-time physician per
year should achieve broad adoption
of EHR on an accelerated timetable”
(Markle Foundation 2004). With
respect to opportunity costs
discussed in Chapter 1,
organizations that have EHRs in
place when the Stark safe-harbor law
is enacted will be poised to attract
community physicians that may not
want to invest in an EHR for their
office setting but would be willing to
adopt the EHR of their preferred
referral hospital. Even before the
safe-harbor provision is put in place,
organizations like the Cleveland
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Clinic are providing incentives for
unaffiliated community referring
physicians to use their EHR for the
market rate of $7,200 per physician
per annum (Harris 2006). While the
Cleveland Clinic boasts modest
adoption among these physicians,
the new safe-harbor provision will
allow them—and all healthcare
organizations—to offer the EHR at
greatly reduced rates, thereby better
aligning incentives for adoption and
rewarding the physicians for using
an EHR that will greatly benefit all
of the actors and stakeholders in the
care delivery process.
SUMMARY
■
■
■
The causes of an EHR project train
wreck are not that dissimilar from
other IT project failures. If risk
mitigation is an important
consideration, then healthcare
executives are cautioned to absorb
lessons learned about the success
and failure of EHR projects described
in this chapter. These include the
following:
■
■
Beware of “buying the future.”
To minimize risk, seek out
proven vendor products that are
in productive use at other
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healthcare organizations that
are similar to your own
organization.
Do not build your house upon
a foundation of sand. Recognize
the need to assess your
organization’s IT infrastructure
for necessary upgrades to
sustain the new EHR transactions.
Recognize the need to interface
the new EHR with some of your
pre-existing, legacy
applications. Ensure that your
IT department has assessed the
interface needs and is
comfortable that the vendors’
products can be successfully
interfaced.
Recognize the need for strong
influential physician leadership
(not a techno doc) for the EHR
project. Remember that EHRs
are large-scale cultural and
clinical workflow
transformation projects and
need influential leaders to gain
the needed changes in
workflow design and caregiver
behavior.
Do not skimp on training and
high-touch implementation
support. Physicians in
particular need one-on-one
training and high-touch
THE EXECUTIVE’S GUIDE TO ELECTRONIC HEALTH RECORDS
■
■
■
implementation support to
increase adoption.
Plan to proactively address the
likely resistance to change you
will encounter in an EHR project.
Minimize EHR project failure
risk by instituting professional
project management
methodologies as prescribed by
the Project Management Institute.
Create a strong EHR project
governance to oversee all aspects
of the EHR project; the EHR
steering committee should be led
by a strong, influential physician
■
and be seeded with equally
strong representatives from
throughout the organization.
Be sure to align rewards and
incentives in a way that
increases the likelihood of
adoption of the EHR.
While no prescriptions for complex
IT projects are fail-safe, employing
these measures will significantly
reduce your organization’s risk
exposure and increase the
likelihood of a successful EHR
implementation.
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