Implementing the Second Electronic Health Record - Part 2

In Part I of our series, we examined common reasons why some healthcare organizations may decide to make a full replacement of their electronic health record (EHR) by implementing a completely different system. The most common reason is that the existing EHR is insufficient and doesn’t support the organization in the ways and means necessary. This can occur for reasons external to the organization as well as from within the organization. In this post, we’ll consider additional factors as to why an organization may or may not move toward finding the right EHR to suit their needs.

Leadership

A frequent but often overlooked contributor to unsuccessful EHR implementations is leadership or, more precisely, a lack of leadership. Many chief executives are woefully naïve about the critical role they must play in technology implementation. Some are technologically challenged or even technophobic and don’t fully understand what an EHR can do. Most understand the technology well enough but believe an EHR implementation is solely a technology project, and they delegate the implementation responsibilities to the CIO.

But an EHR is not just a technology play. It is a strategic tool that affects literally every part of the organization, including departments that don’t use the EHR itself. The strategic nature of EHR implementations and the critical role of workflow redesign create a perfect storm of preventable implementation risk. The importance of leadership to overcome this issue cannot be overstated.

Consider the following comparison. If an organization’s primary funding shifts from fee-for-service to capitation, wouldn’t a CEO require all staff members to change the way they provide and manage care delivery to meet the new funding requirements? If staff members resisted, should the CEO allow those who disagree to continue practicing as if they were in a fee-for-service environment?

More likely, the CEO would provide direction for how the organization will succeed in the new risk-based funding environment. This would ensure necessary changes occur, including possibly weeding out staff unable or unwilling to make the shift. Their rationale would be to change the way the organization does business.

However, when implementing an EHR, many CEOs adopt a very different set of behaviors. Except for receiving periodic updates, they don’t take an active part in the implementation process. Many will allow select (usually hard to recruit) staff members to be exempt from using the EHR. And there is no big picture message about why the organization is transitioning to electronic records – a message that only the CEO can deliver.

Unless these otherwise talented chief executives treat EHR implementations the same as any other strategic change management processes, they will get the same unfortunate results. Like the workflow example in Part I, organizations lacking the leadership to require organizational changes for the first EHR will fare no better with the new one – because the problem isn’t the EHR.

Dissatisfaction with the Vendor

Deteriorating vendor relationships are also a problem. Perhaps the relationship starts out rocky and doesn’t get better. In other situations, the relationship starts well but slowly degrades over time.

In either situation, from the organization’s perspective, the cause is often a lack of responsiveness on the part of the vendor. Promised or expected levels of service aren’t delivered. If there are written criteria for performance such as service level agreements (SLAs), they either aren’t met or are misinterpreted.

Finally, staff turnover by either party can disrupt the relationship. These changes can be at the front-line level of the people who interact regularly or at the senior levels. Vendor representatives change jobs, are reassigned or promoted, causing the client organization to feel the person who understood the nuances of the organization is now gone.

Too much of this will be frustrating to the organization and though the EHR itself is working, the vendor turnover is viewed as disruptive or even as a sign that things are amiss in the vendor organization.

Turnover at the senior levels of either organization can lead to changes with the EHR. When new senior leaders join a provider organization, they weren’t privy to the specifics of the vendor selection process. They may want to reassess that decision, especially if the existing contract is approaching a renewal date. Likewise, senior leadership turnover for the vendor may cause concerns about direction and commitment to this provider or market.

Strategic Fit

The need to move to a new EHR may have nothing to do with technical functionality or vendor performance as much as with strategic fit and future. Most EHRs are technically effective, although they can vary quite a bit in functionality and features. The prospective buyer must determine which features are important and then compare models and prices.

Comparing the functionality of EHRs isn’t much different than shopping for a car. You evaluate the vehicle based on what you need. If you have a long commute, you’ll look at gas mileage. If you will be transporting equipment, you may look at gross vehicle weight or trailering capacity.

But that’s where the parallel ends. Buying an EHR is a strategic decision that can have long-term consequences for an organization. You are entering a de facto partnership with the EHR vendor because the technology is integral to the workings of the organization.

At the most granular level, organizations are concerned about whether the vendor will still be in business in future. One CEO asked to see financials of every RFP respondent as part of the selection process so she could be assured the vendor would be in business in the foreseeable future.

Savvy chief executives take this concern to a higher level. They want a product roadmap and to understand the vision of senior leadership. These CEOs completely understand the strategic partnership aspects of their vendor relationship and are concerned, not just about the next few years, but about the vendor’s long-term plans. They want to know if the vendor’s corporate DNA matches their own.

If that match isn’t there, these CEOs will look for a vendor that more closely aligns with their own vision even if their current EHR is working perfectly well. These CEOs understand they must be prepared to respond to unforeseen challenges in the future and they want a partner that can help them do that. These leaders are qualitatively different than their less engaged peers. They understand the strategic nature of not only their EHR investment but in their vendor relationship.

Summary

There are a lot of reasons why organizations feel the need to switch EHRs. Externally imposed requirements and internally generated problems both contribute to this. The latter are particularly problematic because organizations that don’t do the necessary work on their first EHR are unlikely to do so on subsequent EHR implementations. Often overlooked are two key elements that contribute to successful EHR implementations: workflow redesign and leadership. Attending to these issues increases the probability of successful first, second and subsequent EHR implementations.