Section 4.1 Implement

Implementing Systems OverviewAdopting health information technology (HIT) involves implementing a broad scope of applications, technology, and operational activities that will vary depending on the nature of your organization and its goals. This tool provides an overview of a typical implementation of an electronic health record (EHR) system for a behavioral health clinic.

Time needed: 4 hoursSuggested other tools: Section 6.9 EHR and HIE Security Risk Analysis, Section 2.4 Visioning, Goal Setting and Strategic Planning for EHR and HIE

How to Use Use this tool to understand the broad range of topics that you will need to consider during HIT implementation. For each topic listed below, see the specific tools in the toolkit covering each topic in more detail.

Overview of ImplementationAlthough implementation specifics will vary by vendor and application, any implementation should follow a similar high-level structure:

1. Project management2. Workflow and process redesign3. Detailed project plan creation4. Issues management5. Preparing for and installing hardware 6. Network development/refinement7. Security risk analysis and controls 8. Super user training9. Software installation and system configuration (“system build”), including report writing,

change control, interfaces, data conversion 10. Testing11. End user training12. Preparation for go-live (go-live occurs when the HIT is first used by the organization)13. Go-live14. Monitoring goal achievement, benefits realization, and recognition15. Optimization strategies

Project ManagementEven though your vendor will supply significant project support, you need to designate an individual within your facility to be the project manager, representing your interests and ensuring that information learned during the process is retained within the facility for future reference (see Section 2.2 Project Management).

Your project manager will be responsible for many activities:

Managing the combined project plan, and making sure the project gets completed on time and within budget.

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Organizing your staff resources, team building, maintaining the project budget, approving invoices, and handling other elements of making sure the clinic completes the designated tasks on the project plan completely, accurately, and on time.

Carrying out your communication plan (see Section 2.1 Communication Plan), including reminding others to perform necessary communications and potentially scripting them.

Workflow and Process RedesignIdeally during the planning phases, you will map current workflows and processes. You will use these to initiate change management, create expectations to achieve goals, help you specify system requirements, and select the most appropriate vendor. You may even make adjustments in workflows and processes where streamlining or other improvements are feasible without HIT. Mapping current workflows and processes prior to vendor selection reduces work during implementation. This step is essential for selecting the most appropriate product, configuring the system to your specifications, and anticipating changes that will come with the new system.

Lack of attention to workflow and process redesign has been the root cause of most EHR failures. Over the past few years, the industry as a whole has come to recognize that not attending to workflow and process redesign during HIT planning and implementation has led to poor adoption rates and, sometimes, to serious consequences such as the health care organization’s unique considerations not being evaluated and addressed in system configuration. Some vendors now strongly support workflow and process redesign, while others still view it as the customer’s responsibility (see Section 2.6 Workflow and Process Redesign for EHR and HIE).

Create Detailed Project Implementation Plan Every vendor will provide you with some form of implementation plan. It outlines the steps for implementing your system and usually identifies what the vendor will do when, what the vendor expects you to do when, and what is performed jointly—incorporating specific meetings and milestones. You should take several important steps when you receive this project plan:

Review the plan against the contract to make sure everything you agreed to buy has been addressed and that nothing you did not buy is in the plan (see Section 4.2 Managing the Project and Section 4.3 Project Plan).

Review the plan thoroughly with the vendor’s implementation specialist, making sure any discrepancies are addressed. Make sure you fully understand each item in the plan— especially those that are your responsibility. Consider the staffing and other resources you will need to complete the activities in the time allotted.

Harmonize the vendor’s plan with your own. The vendor’s plan identifies only those elements the vendor is responsible for—directly or indirectly. You may need to conduct additional activities such as hiring staff or contractors, finding ways to release time for staff members to work on the project, remodeling an area to add work stations, remodeling the file room to become a therapist office, or adding backup Internet connectivity.

Issues ManagementEvery project will encounter some issues. Tracking issues is critical. Many vendors are starting to maintain issues management Web sites for clients. If this is the case, use it. Keeping your own list of both internal and external issues also can be very helpful. Internal issues that a project manager may want to track include: someone who is consistently late completing assigned tasks; end users who fail to master training for an application after several tries; a specific team seems dysfunctional when one individual is present; or one printer keeps having problems. If project managers don’t record issues, they can get lost and may never be resolved (see Section 4.4 Issues Management).

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Preparation for and Installation of HardwareMany small organizations hire someone to prepare and install hardware (see Section 1.6 IT Staffing Inventory). This may be a contractor, or you may outsource your hardware to a hosting company. As with project management and issues management, do not abdicate all responsibility for hardware. You need to understand enough to anticipate problems or pinpoint issues. In the future, you will have to address maintenance and replacement issues. Local hardware issues always arise, even when a remote data center is used (see Section 1.4 EHR Technology Readiness, Section 1.5 HIE Technology Rediness and Section 2.13 Space Planning).

Selecting input devices is a major factor in implementing clinical information systems. Study the options and evaluate, in advance, to the extent possible

Printers and scanners also should be considered. Even though you want to minimize printing, some is still needed. Scanners may be used extensively, especially early in the migration path toward an EHR system. Scanning paper chart forms is essential to fill gaps when electronic applications that replace the paper have not yet been implemented (see Section 2.12 Chart Conversion and Pre-Load Planning).

Network Development/RefinementMost facilities have some form of network infrastructure, but this often needs to be upgraded as clinical information systems are adopted. Network infrastructure—wired or wireless—goes hand-in-hand with input device choices. Usability and security are also major considerations. Wireless can sometimes be slower than a wired network and more prone to drop-offs, but enables greater portability. Wireless also requires more attention to security, although protections in wireless standards are improving. Connectivity becomes an increasingly important issue as more HIE is performed. Remote connectivity is essential to conduct health information exchange (HIE) with other behavioral health facilities, area hospitals and physicians, e-prescribing networks, commercial labs, and imaging centers. Remote connectivity is needed for electronic data interchange (EDI) of claims, eligibility verification, and other transactions (see Section 4.10 Using Direct for HIE and Section 4.11 Using CONNECT for HIE). While, many facilities outsource the design and installation of their connectivity, understanding the basics is critical to any troubleshooting that may be necessary later. If you are acquiring EHR in an application service provider (ASP) or software as a service (SaaS) mode, connectivity becomes mission critical. This is one area you absolutely cannot skimp on. Slow response time does more to dissuade professionals from using information technology than almost any other factor.

Security Risk Analysis and ControlsAs EHR and HIE are implemented, a security risk analysis should be performed that:

Identifies threats with respect to confidentiality, data integrity, and availability of data that may occur with changes in the environment, such as new HIT, EHR, and HIE.

Identifies vulnerabilities or gaps in controls to address threats. While no one can provide total security for any information, identifying where your systems, policies, and procedures are weak or lacking this is essential both for correcting weaknesses and supporting your decisions about levels of security.

Considers the likelihood that a threat will exploit a vulnerability, and the impact that could result from such an exploitation. Although gaps in security should be filled to the extent possible, you may find instances where vulnerabilities or gaps in security controls are unlikely to be exploited, or where the impact of such exploitation would not be significant. In these cases, you may identify suitable lower-cost alternatives, policies, or other ways to address the gaps.

Considers the cost of controls and capabilities to implement them. The security risk analysis will help identify the security controls most suitable for your organization. The security risk analysis

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is meant to expose security/privacy weaknesses and help develop a risk mitigation plan. The HIPAA Security Rule does not expect that every covered entity or business associate will apply precisely the same controls, but they should be commensurate with your risk.

All privacy and security measures must be attended to as you approach enhancing your use of HIT and acquire EHR and HIE services. For more information on privacy and security see Section 6.9 EHR and HIE Security Risk Analysis.

Super User TrainingA super user is an individual who will be using the application extensively, have a interest in the value of information technology, have an aptitude with technology and have learned how to use technology. Some vendors provide facility-designated super users with special training to assist in system configuration and helping other end users learn the system. This training may occur any time before system configuration. In general, super users are provided some release time to perform their duties—from 20 to 60 percent during system configuration to 60 to 80 percent while preparing for and during go-live. Over time, super user release time can be reduced to as little as 5 to 10 percent (see Section 4.15 Training Plan).

Software Installation and System Configuration If you are using an ASP or SaaS to acquire software, installation refers to establishing a specific version of the host’s software that will be configured with your specific requirements. The configuration process is often referred to as system build (see Section 4.8 System Build).

System configuration, more commonly called system build in healthcare, includes setting up the system parameters that are unique to your organization. These include filling database tables with the names of your staff members and their user log-in processes and permissions; locations where clients may be seen; diagnostic tests facility orders; and many other pieces of information needed to support EHR and HIE.

Change control (also called configuration management) should be a formal program that establishes a priority system that assures the resources of the organization are appropriately used and that when changes are made (either during the initial system build or subsequently as the system is used) all elements of the change are performed, including updating the data dictionary, retaining security measures, etc. Change control also ensures that applicable upgrades, patches, and other controls are implemented when they become available. Change control permits rollback to a previous version of a system in the event a new version is found to be faulty. See 4.9 Change Control for additional information and tools.

Building templates, order sets, clinical decision support rules, and reports are other system build activities. While most vendors supply standard sets of most of these, behavioral health facilities generally want to review and approve these, or modify them, at least putting the name of the facility on the documents. Once the templates, order sets, rules and reports are designed, they are loaded into the master files and tables that make up the underlying database of the application. System build also includes writing interfaces between applications and data conversion where an existing information system application may be retired.

While some configuration will be needed for the system to operate properly in your environment, you should resist the urge to significantly modify standards provided by the vendor. Vendors have created standard, evidence-based tools and workflows that have been successfully implemented by many organizations. Too much modification is costly because a change in a template or function has a ripple effect, impacting other templates, functions, reports, etc. Tracing the change throughout the workflow and making necessary adjustments is tedious and error-prone. Also, system upgrades may need to be modified to fit the originally modified specifications. Many organizations find that their users urge

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modifications that essentially result in returning workflows and processes to the old way of doing things—thereby not achieving the intended goals.

TestingAs system configuration is performed, unit testing is needed. This is the checking that a specific table, master file, template, screen, or other element has been built as desired. Just as super users are critical to system configuration, they are usually the primary people engaged in working with the vendor on unit testing. Super users should be expected to sign off on each of these tests. As interfaces are built, their ability to integrate data from one system into another also needs to be tested. Finally, the overarching system workflow and processes need to be tested. Some vendors do not support this level of testing. Understanding the different types of testing and identifying how you want testing to be performed will provide peace of mind that the system is ready to go live (see Section 4.16 Testing Plan).

End User TrainingEnd user training should be performed in as just-in-time a manner as possible. For this to work successfully, end users need to be ready to accept training. This requires continual communication and engagement of end users throughout the process, including system demonstrations, goal setting and expectations, change management, computer skills building, assistance in reviewing standard elements of the system configuration, and much more (see Section 2.1 Communication Plan). Training is greatly enhanced when new workflow and process maps are available, as well as tip sheets, screen shots, and other devices. End users must be reassured during training that direct support will be available during go-live. Many facilities—and even some vendors—are starting to use role playing to provide a “dress rehearsal” on the day before go-live (see Section 4.15 Training Plan).

Preparation for Go-LiveGo-live is the day end users use the system for the first time in actual work. Preparing for this should be carefully orchestrated. Develop a checklist and validate it the day prior to go-live (see Section 4.17 Go-live Checklist).

Go-LiveGo live is the big day. Users need to be swarmed with support. Everyone must be on the job (no vacations, meetings, time off, etc.). It is better to have many people waiting to provide support and nothing goes wrong than to have little support and new users have to wait for help. Your go-live day will be stressful. Do anything you can to relieve stress, for end users as well as clients who will be expected to be patient with the facility while the new EHR or HIE is “under construction.” Build in times for breaks and debriefings, and be sure to celebrate any and all activities accomplished that day.

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Monitoring Goal Achievement, Benefits Realization, and RecognitionAfter go-live, ensure that the system is used as intended and goal achievement is not forgotten. Sometimes organizations are so relieved to have the process finished that they do not plan or carry out monitoring that assures benefits are realized, or ways to ensure that staff members are recognized for their efforts. Despite lessons learned and significant improvement in implementation processes, some issues will not be fully resolved, new issues will arise, one or two users will continue to be resistant. Taking the time to monitor how well goals are being achieved is not only gratifying, but provides evidence that the investment was worth it or that there are issues that can be resolved. Benefits realization should engage all users and recognize success (see Section 5.3 Monitoring SMART Goal Achievement to Assure Value from EHR and HIE, Section 5.4 EHR and HIE Adoption Milestone Results, Section 5.5 EHR and HIE Satisfaction Surveys, and Section 5.6 EHR and HIE Return on Investment Analysis/Benefits Realization).

Optimization Strategies More than simply a second step for phasing in system use, optimization means finding new and innovative benefits to be achieved with your new HIT. This may be as simple as setting higher goals for quality improvement than you have had in the past. Or, it may be as big as adding a new service line due to new-found efficiencies with the EHR or new HIT, such as for telepsychology. You may find that your clients are interested in a personal health record component. Your professionals may find it much easier to acquire patient information from different sources and decide to adopt a new model of care, such as the patient-centered medical home (PCMH) model. As time goes on, you will have many ways to achieve more using your EHR and HIE. The vendor likely will add enhancements, as well (see Section 6 Optimization tools).

Copyright © 2014 Stratis Health. Updated 04-03-14

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