Implementing electronic health records: 10 factors for success.

Over the course of the past 20 years, I have been a member of a leadership team that has driven the adoption of electronic health records (EHR) at Partners HealthCare. Substantial progress has been made:

* Ten of our 11 hospitals have implemented computerized provider order entry.

* The outpatient EHR has been adopted by 85 percent (3,600) of our eligible physicians.

* Our patient portal has 50,000 users.

* The Partners Clinical Data Repository has data on 5.1 million patients.

* We have made extensive use of clinical decision support.

In addition to progress on adoption, we have also focused on ensuring that these systems have been leveraged to improve the quality, safety, and efficiency of our care. For example, the implementation of computerized provider order entry (CPOE) at the Brigham and Women's Hospital reduced serious medication errors by 55 percent.

From these experiences, I have learned that there are 10 factors that are essential to successful implementation and use of EHRs.

10 Factors for Success

The organization's clinical and administrative leaders are responsible for understanding, establishing, and managing the following 10 factors for EHR implementation success. These factors are in addition to two givens: an adequate-to-superior EH R application and competent IT staff. If these two "givens" are not present in the organization, they must be addressed before there is any major effort to implement an EHR system.

The organization's strategies, objectives, and plans are clear and well conceived. Investments in IT should further the organization's strategies, objectives, and plans. These strategies become the lens for examining the usefulness of any

IT investment and making tradeoffs between IT investments. Does a proposed investment further a goal of improving patient safety, and is the investment an important contributor to achieving that goal? Are there other investments, IT and non-IT, that would accomplish the same objectives?

If the organization's direction is murky, volatile, shallow, or nonexistent, then it is highly likely that any IT investment would simply create an expense for the organization. The implementation of a system might be successful, but it is doubtful that the newly installed system will have addressed a strategically salient area.

Ways to link of the IT agenda to the organization's strategies are discussed by management. Few IT investments are so automatic that an organization can effortlessly make the leap from "improve quality of care" to "implement an outpatient EHR." The EHR may be a necessary investment, but management and clinical discussion is needed to understand how that investment will improve quality, what other factors must be addressed for that investment to be successful (e.g., physician support), and the tradeoffs of devoting capital to the EHR instead of other candidate investments.

These management discussions should occur in formal settings (e.g., board meetings) as well as through informal conversations such as those that occur over the coffee pot. CIOs should be able to engage clinical and administrative leadership in discussions of strategy and clinical and business issues. The rest of the leadership team also should make the effort to participate in such discussions.

The organization holds itself accountable for its performance. Requiring accountability for results is good management. IT investments are no different. If the EHR investment is intended to reduce medication errors, there should be measures that track progress toward this goal, with oversight by individuals or a committee responsible for achieving this goal. The decision to implement the EHR does not automatically lead to improved care outcomes. Nor does the completion of implementation mean that outcomes have been improved.

At times, the desired results are clinical or business outcomes (e.g., improved management of diabetic patients). These results are often supplemented by measures of effectiveness of EHR use, such as the percentage of all prescription are written using ePrescribing, and measures of adoption, such as the percentage of nurses trained on the new acute care documentation application.

Efficient and effective IT governance is in place. The implementation of an application, the management of technical infrastructure and the development of IT-centric policies must be governed. The board and senior leadership will need to make decisions about the portfolio of applications to be funded in the next fiscal year--e.g., Should we invest in the next phase of the EHR system, or should we replace the accounts receivable application?

EHR projects will require that decisions be made about screen design, data standards, and changes in workflow. Organizations will have to decide whether they will support a new technology, such as voice recognition for note dictation.

IT governance involves determining which IT-oriented decisions will be made, and by which groups or individuals. The resulting governance structure and processes must be clear, efficient, and viewed as legitimate by the organization. For governance surrounding the EHR, it is critical that clinicians be extensively involved. For example, consider having clinicians chair EHR-centric committees.

The organization has determined which processes require IT-enabled improvement--and measures performance. The fundamental value of IT is its ability to improve the efficiency and effectiveness of important organization processes. These processes can be those involved in scheduling an appointment, managing the revenue cycle, ordering a medication, or documenting care.

At its basic level, the improvement of processes requires that the organization understand which processes need attention, measure the performance of those processes, design and implement any needed process changes (including the implementation of an information systems), and monitor the impact of those changes on process performance.

An organization's skill at assessing, reengineering, and monitoring the health of these processes has an enormous impact on the ability of its IT investments to deliver the desired value.

Care delivery processes form the backbone of provider organizations. These processes also are often the most difficult to assess and effectively redesign. Moreover, the consequences of a poor redesign can be severe. However, the improvement of these processes is often the central strategic imperative for the provider.

Multiple supporting initiatives have been incorporated. Major IT initiatives are targeted toward core process improvements-improvements that are necessary to further an organizational strategy. All such initiatives require more than the implementation of a new application. Work flow must be redesigned; roles may be changed; incentive structures may need to be reconsidered; and new skills must be developed.

A management decision to embark on an EHR implementation should be accompanied by an identification of the wide range of related initiatives that will need to accompany the implementation of the system. These initiatives will include senior leadership communication about the rationale behind the implementation decision, establishment of the needed capital and operating budgets, the creation of teams of providers and other staff engaged in developing new work flows, and training of staff about the new system and work processes.

The organization understands the complicated nature of the value proposition of an EHR. EHR implementation can help reduce the costs of clinical operations and improve the revenue cycle-gains that can be seen in the margin. In addition, implementation of an EHR can result in reduction of medication errors and lead to more effective ordering of radiology procedures and laboratory tests-gains that may not be seen in the margin.

Most of the care value of the EHR will not accrue to the provider. The provider may see improved documentation of care and, hence, an increase in revenue; however, the reduction in medication errors may be a value that accrues entirely to patients and purchasers of care.

EHR value can also dissipate. Imperfect process change, suboptimal use of the EHR by clinicians, and external factors such as patients' uneven compliance with their medication regimes can lead to the intended value of the investment being only partially realized.

Regardless of who receives the value or the magnitude of the value, IT value will rarely be realized unless some person or group is responsible for making sure that value is achieved from system implementation. For example, if the organization intends to improve care documentation, who is responsible for ensuring that such an improvement occurs? If the organization cannot answer that question, the value of the investment will be diminished.

The successful implementation of an EHR is not the end of the journey. Rather, the implementation has installed the tool that enables the real journey to begin--the achievement of value.

Clinicians are continuously engaged in improving the systems and related work flows. Physicians, nurses, and other health professionals are the users of the EHR. If the organization intends to realize the value from its EHR investment, use of the EHR by clinicians should be effective and efficient.

Regardless of the quality of the software, the skill of the process changes, and the caliber of training and support, the implemented EHR will almost certainly have imperfections. The organization should establish mechanisms for listening to clinician concerns about screen designs, work flow glitches, the time required to use the system, and the speed of the application. Then, the organization should take action to address the issues, and the results of such improvement initiatives should be assessed.

Efforts to engage clinicians should be ongoing, and their feedback should be taken very seriously. Failure to engage clinicians in an EHR initiative can lead to adverse outcomes ranging from outright revolt to passive-aggressive nonuse of the system.

Investment in infrastructure is supported. Few things can undermine EHR use faster and more effectively than a system that is unreliable, slow, or unable to take advantage of new, powerful advances in IT. Users can lose faith in the implementation (and the organization's strategy that led to the decision to implement the system). Moreover, an erratically performing application system can damage care processes and operations.

The implementation of an EHR or any major application requires the installation and management of technical infrastructure, servers, networks, operating systems, and workstations. Unfortunately, this infrastructure is expensive and requires continuous upgrading and investment. Faced with capital budget challenges, an organization may be tempted to under invest in infrastructure. Although the IT department should not be given a blank check, the organization should hesitate to starve investment in infrastructure.

The organization invests in modest, thoughtful IT experimentation. Constant innovation characterizes the field of IT. Ten years ago, the Internet was a non-factor in most of our lives. Six years ago, few of us had cell phones.

Although technology innovations can be surrounded by exquisite hype, and many innovations can be adopted before they achieve acceptable maturity, the organization should engage in a modest level of IT experimentation. Such experimentation can be done in ways that do not jeopardize the organization should the experiment fail, which allows the organization to learn more about the potential value of new technology. For example, the organization may decide that it should conduct a trial of personal health records (PHRs) so it can learn how a PHR system might improve patient satisfaction and provider office work flow.

Making a Good Investment from an EHR

Increasingly, the EHR is becoming a central contributor to the strategies, objectives, and plans of healthcare providers, The ability of the EHR to be leveraged or to improve care quality, safety, and efficiency can no longer be questioned,

However, the implementation of the EHR and the achievement of desired gains in care and operations performance are difficult undertakings, No amount of advice can eliminate the risks and challenges of these undertaking, but these 10 lessons may result in the EHR investment becoming more of a good investment than a form of organizational torture.

AT A GLANCE

Strategies for maximizing the value of an EHR implementation include:

* Establishing clear strategies, objectives, and plans for EHR implementation

* Including managers and clinicians in discussions on ways to tie the EHR in with the organization's strategy and areas requiring improvement

* Continually measuring performance of EHR-enabled processes

* Investing in critical infrastructure * Maintaining efficient and effective IT governance

John Glaser, PhD, is vice-president and CIO, Partners HealthCare, and a senior adviser, Deloitte Center |or Health Solutions, Boston (jglaser@partners.org).