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How Clinician Engagement Can Make or Break an EHR Implementation

Active clinician engagement helped Virtua Health System quickly bypass problems during its Epic EHR implementation.

Clinician engagement can streamline EHR implementations.

Source: Thinkstock

By Kate Monica

- A poorly-executed EHR implementation project can cause myriad problems for healthcare organizations ranging from financial trouble to internal conflicts between hospital management and staff.

In the months after an EHR system go-live, hospitals and health systems can expect some delays in patient care delivery and disruptions in clinician workflows. These temporary snags are a natural part of the adjustment period that inevitably follows a system-wide change.

Shortening this adjustment period was top-of-mind for leadership at New Jersey-based Virtua Health System when the organization decided to replace its best-of-breed health IT with a single, unified Epic EHR system.

“Prior to Epic—you name a vendor and we probably had it,” Virtua Senior Vice President and Chief Information Officer (CIO) Tom Gordon told EHRIntelligence.com.

Virtua Health System used NextGen EHR for its ambulatory care sites, Allscripts for home health, and Cerner for its lab, among other systems. The need for improved care coordination and interoperability between healthcare providers, facilities, and care settings part of the Virtua network prompted health system leadership to consider switching to a single vendor approach.

READ MORE: Do EHR Implementations Have Negative Short-Term Effects?

From the very beginning, Virtua encouraged its clinicians to be as involved in the implementation as possible — starting with the EHR selection process.

Prioritizing Clinician Feedback in EHR Selection

Selecting the EHR vendor that best suits the specific needs of a certain healthcare organization’s patients and providers is key to successfully pulling off an EHR implementation. Virtua executives turned to its staff to provide expert feedback on which system best fit the Virtua environment during its own EHR selection process.

To ensure accurate staff input, Virtua invited over 1,500 health system staff members to attend 80 product demonstrations and scored competing systems on their performance against certain metrics. 

“We looked at two solutions: Epic and Cerner,” said Gordon. “We had a week-long process where we conducted 40 demos apiece — 40 Cerner demos and 40 Epic demos.”  

READ MORE: Smart EHR Implementation Decisions Key to Usability Improvements

Clinician engagement throughout the week of product demonstrations remained high.

“It was a paper-driven process, but we had about 90 percent of the scoring sheets filled out,” noted Gordon.

While both vendors fared well against each criteria, clinicians ultimately scored Epic higher than Cerner in almost every area. 

Virtua Medical Director of Informatics and primary care physician James Gamble, MD, said he and other physicians mostly wanted a system capable of easily sharing information between providers.

“You didn’t want to have to fax your information anymore,” said Gamble. “You didn’t want to have to switch over from one EHR to another to look up information. That was really the thing that drove the clinicians.”

READ MORE: How EHR Use Enables Effective Responses to Public Health Crises

Once Virtua staff resolved to implement an Epic EHR, the health system began an 18-month deployment phase. Again, health system leadership made sure to keep the clinician perspective at the center of the project.

 Clinician Engagement During, After Implementation

Virtua’s Epic EHR implementation project team comprised about 150 staff members dedicated to enabling as smooth a deployment as possible.

“Probably somewhere around 40 to 50 of those people came out of the clinical world, or out of operations,” emphasized Gordon. “So we had clinicians who came over to work on the project for 18 months and be part of the building process for the project.”

“We tried not to have it be an IT driven process,” he added.

Involving clinicians in the implementation process helped to ensure the Epic system was capable of meeting clinician’s needs surrounding health data exchange, EHR usability, and EHR integration.

“The value of integration was certainly a large part of the conversation,” said Gordon. “Having a single platform for not just the clinical side, but also the financial piece of the pie.”

At the conclusion of the deployment phase, Virtua went live with Epic at its ambulatory care sites, physician offices, and access center in October 2017. Six months later, Virtua launched Epic at its acute care hospitals, emergency departments, home health, surgical, and outpatient care settings.

“The value of integration was certainly a large part of the conversation.”

Virtua began training its clinicians on the system after the go-live — an imperative and oft-overlooked aspect of the EHR implementation process that can either set health systems up for success or failure.

Texas-based Medical Center Health System (MCHS) came to understand the importance of adequately training medical staff on a new EHR system the hard way. After a challenging 2017 Cerner implementation, MCHS leadership told the Ector County Board of Directors its persistent billing problems and rocky deployment were largely due to poor staff training.

Health system officials admitted they did not realize staff training had been inadequate until months after the Cerner system go-live, when management and staff began quarreling over errors and workflow confusion.

Virtua made an effort to avoid a similar fate by involving all 14,000 health system employees in a rigorous training process.

“We had 37 classrooms that we needed to complete the training,” said Gordon. “We were able to rent some space at a local college at a really good rate, and we took the clinical and operations teams and they gave as many resources as possible to become credentialed trainers for the process.”

Virtua executives encouraged staff members to become EHR super-users or subject matter experts to ensure they were able to troubleshoot problems with the Epic EHR system without outside help. These experts advised other physicians and Virtua staff members about how to properly use the system.

“Eighty percent of the training was done by Virtua staff,” said Gordon. “We didn’t want to bring in consultants and vendors to do the training. We wanted people who knew Virtua, knew our processes and could say, ‘I know your workflow a little bit—let me show you how this works.’ And they’re not leaving. So they can be our trainers and advocates forever moving forward.”

While Virtua’s rigorous training paid off, hospital staff members were temporarily required to stretch and make up for a loss in numbers while certain clinicians became certified Epic users.

“There were some pain points,” admitted Gordon. “Staff juggling needed to be done on the hospital side — the hospital had to figure out how they would do their staffing. But looking back it was the right thing to do. And now the people that were doing the at elbow support are back in their units so they can be that go-to person.”

As a physician, Gamble strongly supported the decision to involve clinicians heavily in the training process despite the increased demand it placed on some hospital staff.

“It was great to have all of those who did the training before go-live as our first line of support after the go-live,” said Gamble. “Those people you trained with were also the people answering the phones to help you use the system, and they knew the system inside and out.”

Adequate staff training helped to ensure clinicians felt comfortable consulting other providers who understood their workflow about any technical problems. Virtua also made a concerted decision about the date of the go-live based around how well staff members would be able to identify and resolve trouble tickets.

“We knew if we went live on a Wednesday, Wednesday would be disruptive,” said Gordon. “Thursday would be disruptive. Fridays might be slower. And then Saturday and Sunday are definitely slower. So we’d have this disruption, we’d get a bulk of tickets, and then Saturday and Sunday would give us time to catch up. From a go-live perspective, it really worked out well.”

After a short period of adjustment, providers were quickly able to adapt to the new system and begin utilizing a variety of Epic modules to improve care coordination, patient engagement, and clinical decision-making.

Leveraging EHR Use to Streamline Patient Care

Physicians are notoriously divided over whether EHR use is a boon or a hindrance to patient care delivery. While some see the benefit of easily accessing and exchanging health data for better-informed patient care, others feel the technology is depersonalizing medicine and ruining the patient-provider relationship.

Clinicians at Virtua have largely taken to the technology since the Epic go-lives in October 2017 and March 2018. Gordon and Gamble attributed this positive reception to the Epic EHR-integrated apps and modules specifically designed to enable more efficient care.

“When we went live with Epic, we also went live with tap-and-go so the clinicians can tap into the machines with their badges,” said Gamble. “We also went live with voice recognition at the same time. We’ve had really good input from the physicians and all the clinicians on the tap-and-go piece with efficiency, but the voice recognition stuff has been phenomenal.”

The voice recognition software is part of Nuance’s new Epic EHR-integrated virtual assistant powered by artificial intelligence (AI).

The technology is designed to improve physician productivity and clinical efficiency by streamlining clinical documentation. Epic users can utilize the software for voice-activated clinical documentation within the Epic Haiku, Epic Rover, and Epic Cadence modules.

“Transcription has decreased significantly,” said Gordon. “The doctors are just using voice recognition right into the system to do their notes.”

Gamble said Virtua had been using voice recognition software to some extent for years. During the Epic implementation, the health system opted to upgrade to the newest Nuance version and invited providers to attend extra training classes to teach them how to use Epic optimization tools—including voice recognition.

“On day one, all the providers knew how to use Epic and all the Epic smart tools,” said Gamble. “It was extra work but it has absolutely has paid off.

Gamble has also seen improvements in clinical efficiency and patient engagement by encouraging patients to sign up for Epic’s patient portal, MyChart. About 40 percent of Gamble’s patients are now actively engaged with the tool.

“I’ll log into Epic this afternoon, and I’ll have a copy of one of our patient’s records who saw one of our specialists,” said Gamble “The same day the patient is seen, I’ll get that reply.”

“That’s why I push it on my patients,” Gamble continued. “I do absolutely believe engaged patients are healthier patients. When a patient knows their blood sugar and cholesterol, it makes them healthier.”

While MyChart has clear benefits for improvements in patient engagement, the feature can also save administrative and clinical staff members a significant amount of time when delivering lab test results.

“When I get a test result, it is so much easier for me to type a few lines and send it off to MyChart than to send a letter to the patient with a copy of the results, or call my office to call the patient,” said Gamble. “I can get through my inbox so much faster if the patient is on MyChart.”

Ultimately, Gordon emphasized the importance of communicating with clinicians prior to the EHR implementation to ensure they understand the end-goal of the project. If providers believe the health system is needlessly investing in new technology, clinician engagement will remain lackluster.

“To just go out and switch an EHR just for the sake of switching is a disaster waiting to happen,” concluded Gordon. “You need to clearly define what you need to accomplish. We knew we wanted to better align with healthcare reform, increase communication and care coordination, and integrate to best tell the patient’s story.”

“It wasn’t about implementing Epic—it was about the things we wanted to get at the end.”

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