Electronic Health Records

Adoption & Implementation News

EHR implementation in a smaller hospital: A case study

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- Smaller, rural hospitals often face different obstacles than their larger urban counterparts when implementing technology, especially electronic health records (EHRs). Potential roadblocks like limited resources, competing priorities and lack of strong project leadership can make a large-scale EHR implementation challenging for smaller organizations, particularly those in rural settings.

For D.W. McMillan Memorial Hospital, a 49-bed community hospital located in Brewton, Alabama, implementing an EHR was not without its hurdles. However, the organization successfully on boarded a new system and is attesting for MU stage 2 during this fiscal year. Following are several key strategies that contributed to the hospital’s successful EHR implementation.

Gaining upfront buy-in

D.W. McMillan was an early adopter of EHR technology among smaller rural and critical access hospitals, starting implementation in October 2012. The hospital began the journey months before by pulling together a management team, which had previously led a project for installing a bar code medication administration system. The group discussed the need for an EHR, what it would take to get one up and running and whether the organization would be able to make a large-scale implementation work. Making sure that organization leaders were all on the same page was key, because without everyone’s full support the process could quickly fall apart.

From this group, an IT steering committee was formed and tasked with the job of guiding the organization through the EHR adoption process. Team members included the medical-surgical intensive care nurse manager, director of nursing, CFO, quality assurance manager, lab manager and revenue cycle analyst. To optimize the group’s performance, different team members began to specialize in various aspects of the system. For instance, the quality assurance manager became an expert in how to use the technology, particularly in relation to bar-coded medication. The medical-surgical intensive care nurse manager focused on informatics, including creating predefined order groups and seeking ways to use the technology to accomplish organization goals. This strategy enabled the team to effectively use their limited resources to become experts in all parts of the EHR system.

READ MORE: EHR Use Nearly Universal in Hospital Outpatient Practices

Making automated workflow mirror paper

In selecting an EHR vendor, the steering committee looked for one that would best meet the needs of physicians and nurses, finally choosing a system that offered easy-to-navigate screens that mirrored paper-based processes. The idea was to make the transition to electronic as seamless as possible for staff. For various workflows, such as pneumonia care, chest pain guidelines and restraint orders, the team examined existing paper forms and attempted to reflect the same approach in the electronic version. This strategy allowed physicians and nurses to recognize the forms faster and more easily learn how to use the program.

Executing a detailed training plan

The most important part of implementation was training. D.W. McMillan developed a four-session training program for nurses in which “super users” and a lead instructor worked with eight nurses at a time to provide hands-on training. The organization created a series of simulated patients, so nurses could train using actual scenarios, and the small group approach allowed nurses to get their questions answered easily.

Before each session, nurses took a test over the previous session’s content and prompted them to “teach back” what they learned. This is similar to the tactic nurses use when educating patients, and the steering committee found it to be a productive way to ensure staff fully understood how to use the system.

READ MORE: Physicians Divided on Benefits of EHR Implementation, Use

Physician training was structured a bit differently, offering one-on-one education in a group setting. The hospital held dinner meetings in which 18 physicians were paired with 18 super users, and they moved through the program together, allowing physicians to get comfortable with the system and ask questions in a one-on-one format.

During the system go-live, super users were available around-the-clock to provide support and answer questions. The organization identified its super users by different colored t-shirts and lanyards, which showed the individuals’ level of expertise. After three days, the super users returned to their regular schedules, as nurses and physicians became more comfortable with the system—although they continue to remain available to answer user questions.

Taking a phased approach

D.W. McMillan did not implement its EHR wholesale, but phased the technology in over time, bringing up medical/surgical, ICU and obstetrics first and then adding other areas later. Similar to other rural and critical access hospitals, D.W. McMillan has limited staff, and staging the implementation allowed the organization to focus on different areas without spreading the staff too thin. When selecting the areas to onboard first, the hospital chose to prioritize those that helped meet Meaningful Use criteria.

Realizing successful implementation

READ MORE: UK Hospitals See EHR Implementation, Data Transfer Issues

Although smaller organizations can face obstacles when implementing an EHR, these challenges are not insurmountable. Taking a well-considered approach driven by a core group of committed individuals, offering personalized training and education to nurses and physicians and spreading the project out over time will ensure any smaller organization can implement technology as effectively as its larger organization peers.


Chris Griffin is the chief executive officer and administrator and Scott Hillman is informatics nurse specialist at D.W. McMillan Memorial Hospital.

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