Free Hospital EMR and EHR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to Hospital EMR and EHR for FREE!

The EHR Dress Rehearsal: Because Practice Makes Perfect

Posted on July 14, 2017 I Written By

For the past twenty years, I have been working with healthcare organizations to implement technologies and improve business processes. During that time, I have had the opportunity to lead major transformation initiatives including implementation of EHR and ERP systems as well as design and build of shared service centers. I have worked with many of the largest healthcare providers in the United States as well as many academic and children's hospitals. In this blog, I will be discussing my experiences and ideas and encourage everyone to share your own as well in the comments.

Over the past year I have been leading the implementation of Epic for University Medical Center of Southern Nevada (UMC). On July 1st, we went live at our primary care and urgent care clinics. The go-live was a great success. While no go-live is flawless, we encountered minimal issues that could not be quickly resolved and user adoption was excellent despite the majority of the users using an EHR for the first time.

Today is July 8th, and I’m spending a quiet day in our command center just one week after go-live and reflecting on the factors that made this transition exceed even our optimistic projections. By Day 3, users were comfortable with basic workflows and bills were going out the door. One week into go-live, we are scaling back our on-site support and discussing closing down the command center earlier then expected. Our team universally agrees that the most significant factor in our success was a last minute addition to the methodology – what I refer to as the Workflow Dress Rehearsal.

In my experience regardless of the quality of training that is provided, the classroom is not enough to prepare the staff for what happens when the patients start to walk in the door. Learning in your actual environment helps staff to gain comfort and uncovers challenges in technology and workflow that even the best testing will not reveal.

The concept of doing a true dress rehearsal that mirrors the real experience as closely as possible is one that dates back to retail point of sale and inventory implementations that I did 20 years ago. During those projects, we would shut the doors of the operation and have the staff go through a “day in the life” on the new system – doing everything as they would do it on go-live day – using their actual workstations and logging into the production system. We decided to apply this same concept to an EHR implementation and provide a full-day experience for the entire clinic staff as the final component of their training.

The logistics of making this happen across 8 physical locations and 15 busy clinics required extensive planning and execution. We created a full-day experience starting with scripted patients who would be represented by a clipboard that moved from the front desk and to triage before being roomed. Nurses and physicians went in and out of rooms as they would with real patients, completing the appropriate steps in each room. Later as they gained more comfort, we substituted the clip boards with actual people who represented patients – making up symptoms to help the staff learn how to navigate the EMR and be prepared for what would happen with a real person answering questions, such as providing information out of order of the screens. By the end of the day, the staff was gaining confidence in the application and in themselves. They were also learning how to work as a team in an EMR environment. Most of all, they found the experience more fun, and more directly beneficial then their classroom experience.

The benefits to this process were numerous, and the key contributor to the reduction in our support needs at go-live. Here are just a few examples of the benefits it provided:

1) Security was validated – Every user had the chance to log into production and do actual work just as they would on go-live day. As a result, security issues were resolved during the rehearsal and we had less then a dozen security calls during the first week.
2) Hardware was tested – Taking the previously completed technical dress rehearsal one step further, every workstation and ancillary hardware device was used just as it would be on go-live day. The result was we identified gaps in available hardware, incorrectly mapped printers, and configuration issues that could be resolved the same day, eliminating issues during the actual go-live.
3) End to End Workflow Validation – Nurses, Front Desk, and Physicians had received training individually as each had different content to learn, but didn’t fully appreciate how it all came together. The Workflow Dress Rehearsal allowed them to understand the full life cycle of the patient in the clinic and how their documentation impacts others later in the process. Through this process, they gained an appreciation for each of their respective roles in the EHR experience.
4) Practice, Comfort, and Speed – Working on the system in their actual work environment helped them to gain confidence and get faster using the application. While our mock patient experience is not the same as having a real sick patient in front of them – it was the closest experience that we could create so when the actual patients walked in the door, they knew what to do.
5) Content – We encouraged physicians and nurses to try common orders and medications that they use on a regular basis to make sure they were available and setup properly. Inevitably, we uncovered missing or incorrect information and were able to correct them well before go-live. The result was minimal missing content at go-live as we had already worked out those issues.

The Workflow Dress Rehearsal process allowed us to uncover many of the issues that would have happened at go-live while also allowing the staff to gain comfort with the new solution in a lower-pressure environment. The result? A quiet go-live with minimal complications and a happier staff. Encounters were all being closed the same day, and staff were going home on schedule. These rehearsals also created an educational experience that was fun and motivating to the staff and was of more value to them then another day in the classroom would have been.

I believe that this process can be applied to the implementation of any software solution in any environment. Its not always easy, and we realize that it will be much more complicated to create this experience as part of our hospital go-live later this year. However, the time invested paid off as it saved us so much time in the support of the system during go-live, and created a better experience for our patients during our first week on Epic.

Consider how you can create a Workflow Dress Rehearsal experience for your ERP, EHR, and other solution deployments and you may find that it is a critical success factor to your go-live as well.

If you’d like to receive future posts by Brian in your inbox, you can subscribe to future Healthcare Optimization Scene posts here. Be sure to also read the archive of previous Healthcare Optimization Scene posts.

Avoiding Revenue Crunches During EMR Transitions

Posted on May 23, 2016 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Most healthcare leaders know, well before their EMR rollouts, that clinical productivity and billings may fall for a while as the implementation proceeds. That being said, it seems a surprising number are caught off guard by the extent to which payments can be lost or delayed due to technical issues during the transition. This is particularly alarming as more and more hospitals are looking at switching EHR.

Far too often, those responsible for revenue cycle issues live in a silo that doesn’t communicate well with hospital IT leadership, and the results can be devastating financially. For example, consider the case of Maine Medical Center, which took a major loss after it launched its Epic EMR in 2012, due in part to substantial problems with billing for services.

But according to McKesson execs, there’s a few steps health systems and hospitals can take to reduce the impact this transition has in your revenue cycle. Their recommendations include the following:

  • Involve revenue cycle managers in your EMR migration. Doing so can help integrate RCM and EMR technologies successfully.
  • Create a revenue cycle EMR team. The team should include the CFO, revenue cycle leaders from patient access and reimbursement, vendor reps and someone familiar with revenue cycle systems. Once this team is assembled, establish a meeting schedule, team roles and goals for participants. It’s particularly important to designate a project manager for the revenue cycle portion of your EMR rollout.
  • Before the implementation, research how RCM processes will be affected by the by the rollout, particularly how the new EMR will impact claims management workflow, speed of payment and staff workloads. Check out how the implementation will affect processes such as eligibility verification, registration data quality assurance, preauthorization and medical necessity management, pre-claim editing and remittance management.
  • Pay close attention to key performance indicators throughout the transition. These include service-to-payment velocity, Days Not Final Billed, charge trends and denial rates.

The article also recommends bringing on consultants to help with the transition. Being that McKesson is a health IT vendor, I’m not at all surprised that this is the case. But there’s something to the idea nonetheless. Self-serving though such a recommendation may be, it may help to bring in a consultant who has an outside view of these issues and is not blinkered by departmental loyalties.

That being said, over the longer term healthcare leaders need to think about ways to help RCM and IT execs see eye to eye. It’s all well and good to create temporary teams to smooth the transition to EMR use. But my guess is that these teams will dissolve quickly once the worst of the rollout is over. After all, while IT and revenue cycle management departments have common interests, their jobs differ significantly.

The bottom line is that to avoid needless RCM issues, the IT department and revenue cycle leaders need to be aligned in their larger goals. This can be fostered by financial rewards, common performance goals, cultural expectations and more, but regardless of how it happens, these departments need to be interested in working together. However, unless rewards and expectations change, they have little incentive to do so. It’s about time hospital and health system leaders address problem directly.

EMR Replacement Frenzy Has Major Downsides

Posted on May 16, 2016 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Now that they’ve gotten an EMR in shape to collect Meaningful Use payouts, hospitals are examining what those incentive bucks have gotten them. And apparently, many aren’t happy with what they see. In fact, it looks like a substantial number of hospitals are ripping and replacing existing EMRs with yet another massive system.

But if they thought that the latest forklift upgrade would be the charm, many were wrong. A new study by Black Book Research suggests that in the frenzy to replace their current EMR, many hospitals aren’t getting what they thought they were getting. In fact, things seem to be going horribly wrong.

Black Book recently surveyed 1,204 hospital executives and 2,133 user-level IT staffers that had been through at least one large EMR system switch to see if they were happy with the outcome. The results suggest that many of these system switches have been quite a disappointment.

According to researchers, hospitals doing new EMR implementations have encountered a host of troubles, including higher-than-expected costs, layoffs, declining inpatient revenues and frustrated clinicians. In fact, hospitals went in to these upgrades knowing that they would not be back to their pre-EMR implementation patient volumes for at least another five years, but in some cases it seems that they haven’t even been keeping up with that pace.

Fourteen percent of all hospitals that replaced their original EMR since 2011 were losing inpatient revenue at a pace that would not support the total cost of the replacement EMR, Black Book found. And 87% of financially threatened hospitals now regret the executive decision to change systems.

Some metrics differed significantly depending on whether the respondent was an executive or a staff member.

For example, 62% of non-managerial IT staffers reported that there was a significantly negative impact on healthcare delivery directly attributable to an EMR replacement initiative. And 90% of nurses said that the EMR process changes diminished their ability to deliver hands-on care at the same effectiveness level. In a striking contrast, only 5% of hospital leaders felt the impacted care negatively.

Other concerns resonated more with executives and staff-level respondents. Take job security. While 63% of executive-level respondents noted that they, or their peers, felt that their employment was in jeopardy to the EMR replacement process, only 19% of respondents said EMR switches resulted in intermittent or permanent staff layoffs.

Meanwhile, there seemed to be broad agreement regarding interoperability problems. Sixty-six percent of system users told Black Book that interoperability and patient data exchange functions got worse after EMR replacements.

What’s more, hospital leaders often haven’t succeeded in buying the loyalty of clinicians by going with a fashionable vendor. According to Black Book, 78% of nonphysician executives surveyed admitted that they were disappointed by the level of clinician buy-in after the replacement EMR was launched. In fact, 88% of hospitals with replacement EMRs weren’t aware of gaining any competitive advantage in attracting doctors with their new system.

Now, we all know that once a tactic such as EMR replacement reaches a tipping point, it gains momentum of its own. So even if they read this story, my guess is that hospital executives planning an EMR switch will assume their rollout will beat the odds. But if it doesn’t, they can’t say they weren’t warned!

Mayo Clinic’s Shift To Epic Eats Up Most of IT Budget

Posted on May 6, 2016 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Mayo Clinic has announced that it will spend about $1 billion to complete its migration from Cerner and GE to Epic. While Mayo hasn’t disclosed they’re spending on software, industry watchers are estimating the agreement will cost hundreds of millions of dollars, with the rest of the $1 billion seemingly going to integration and development costs.

The Clinic said in 2014 that it would invest $1.5 billion in IT infrastructure over multiple years, according to the Minneapolis/St. Paul Business Journal. Then last year, it announced that it would replace Cerner and GE systems with an Epic EMR. Now, its execs say that it will spend more than $1 billion on the transition over five years.

Given what other health system spend on Epic installations, the $1 billion estimate sounds sadly realistic. Facing up to these costs is certainly smarter than lowballing its budget. Nobody wants to be in the position New York City-based Health and Hospitals Corp. has gotten into. The municipal system’s original $302 million budget expanded to $764 million just a couple of years into its Epic install, and overall expenses could hit $1.4 billion.

On the other hand, the shift to Epic is eating up two thirds of the Mayo’s $1.5 billion IT allowance for the next few years. And that’s a pretty considerable risk. After all, the Clinic must have spent a great deal on its Cerner and GE contracts. While the prior investments weren’t entirely sunk costs, as existing systems must have collected a fair amount of data and had some impact on patient care, neither product could have come cheaply.

Given that the Epic deal seems poised to suck the IT budget dry, I find myself wondering what Mayo is giving up:

  • Many health systems have put off investing in up-to-date revenue cycle management solutions, largely to focus on Meaningful Use compliance and ICD-10 preparation. Will Mayo be forced to limp along with a substandard solution?
  • Big data analytics and population health tech will be critical to surviving in ACOs and value-based payment schemes. Will the Epic deal block Mayo from investing?
  • Digital health innovation will become a central focus for health systems in the near future. Will Mayo’s focus on the EMR transition rob it of the resources to compete in this realm?

To be fair, Mayo’s Epic investment obviously wasn’t made in a vacuum. With the EMR vendor capturing a huge share of the hospital EMR market, its IT leaders and C-suite execs clearly had many colleagues with whom they could discuss the system’s performance and potential benefits.

But I’m still left wondering whether any single software solution, provided by a single vendor, offers such benefits that it’s worth starving other important projects to adopt it. I guess that’s not just the argument against Epic, but against the massive investment required to buy any enterprise EMR. But given the extreme commitment required to adopt Epic, this becomes a life-and-death decision for the Mayo, which already saw a drop in earnings last year.

Ultimately, there’s no getting past that enterprise EMR buys may be necessary. But if your Epic investment pretty much ties up your cash, let’s hope something better doesn’t come along anytime soon. That will be one serious case of buyer’s regret.

Thoughts on Leveraging EMRs Effectively

Posted on September 28, 2015 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Whenever I scan Twitter for #HIT ideas, I find something neat. For example, consider this intriguing tweet:

I say intriguing not because the formula outlined will surprise anyone, but rather, because it captures some very difficult problems in a concise and impactful manner.

Here’s some thoughts on the issues Portnoy raises:

* Optimization:  Of course, every healthcare IT organization works to optimize every technology it deploys. But doing so with EMRs is one of the most difficult problems it is likely to encounter. Not only do IT leaders need to optimize the EMR platform technically, they may also face external demands placed by ACOs, HIE partners and affiliated providers. And it’s also important to optimize for Meaningful Use functions.

* Workflows:  Building workflows that address the needs of various stakeholders is critical, as pre-designed vendor workflow options may be far from adequate. While implementing an EMR may be an opportunity for a hospital to redesign workflows, or to enshrine existing workflows in the EMR interface and logic, hospital leaders need to take charge of the workflow implementation process. Inefficiencies at this level can be costly and will erode the confidence of clinical teams.

* Revenue capture:  When properly implemented, EMRs can help providers generate more complete documentation for claims reimbursement, which leads to higher collections volume. As time has shown, difficult-to-use EMRs can lead to physician frustration, and in turn, cut-and-paste re-use of existing documentation — which is why carefully-designed workflow is so important. But if they are used appropriately, EMRs can boost revenue painlessly.

* Patient and provider engagement: True, IT needs to take the lead on getting the EMR in place, and must make some important deployment decisions on its own. Still, hospitals will have trouble meeting their goals if patients and providers aren’t invested in its success, and without patient interest in their data I’d argue that meeting long-term population health goals is unlikely. On the flip side, if clinicians and patients are engaged, the feedback they offer can help hospitals shape not only the future of their EMR, but also the rest of their clinical data infrastructure.

If there’s any common theme to all of this, I’d submit, it’s participation. Unlike most efforts corporate IT departments undertake, EMR rollouts are unlikely to work until everyone they touch gets on board. Hospitals can invest in any EMR technology they like, but if providers can’t use the system comfortably to document care, patients don’t log on to access their data, or revenue cycle managers don’t see how it can improve revenue capture, the project is unlikely to offer much ROI.

25% of EHR Budget Goes to EHR Training…At Least for the DoD EHR

Posted on August 14, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In all of the news surrounding Leidos and Cerner winning the DoD EHR bid, I was really struck by this one piece from Healthcare IT News:

Training. As is often the case in massive software implementations, training eats up a lot of the costs and, in the DoD’s case, “over 25 percent of the contract goes to training users and clinicians,” Miller said.

Think about how much training you can get for $1+ billion. I get that training is not cheap. I also get that the DoD EHR implementation is a massive project, but that’s a lot of money for training. Do you think that most EHR implementations spend 1/4 of their budget on training?

Hopefully people will chime in with their answer to that question in the comments. My experience is that hospitals probably should budget 1/4 of their budget for training, but most don’t get anywhere near that amount. Plus, the EHR training budget often starts much larger and then when the budget overruns start to happen, EHR training is one of the first places they go to cut the budget.

How much EHR training is enough in your experience? Should it be 25% of the budget? I’m not sure how much is needed, but I do know that most organizations don’t purchase enough. Sounds like the DoD might be the exception.

We’re Entering the 15th Year of Our EHR Implementation

Posted on June 12, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was recently talking to someone about a major progressive hospital system that’s been using technology and EHR for a long time. This person then told me that it felt like this hospital system was in its 15th year of its EHR implementation.

I’m sure that most hospital organizations can relate to this statement. Each hospital system will replace the number of years with a different number, but I think every hospital probably believes that their EHR implementation is never complete. Certainly you might have a go live event with the initial installation of the software, but that’s far from a fully implemented EHR system.

This concept reminds me of two things we’ve talked about before. The first is a controversial post I did called The Tyranny of “Time” – EHR Efficiency Has a Lifecycle. I put up a chart which I think illustrates an important lesson about the lifecycle of an EHR implementation and many disagreed with the chart. I still stand behind the principle that time has a way of eroding even the best EHR implementation. So, you better have a long term plan to deal with the Tyranny of Time.

The second is a comment from a hospital CIO who made a comment on one of my posts many years ago. In the post I’d commented about how we’d implemented a new practice EHR in about 2 weeks time frame. The doctor was opening his practice in 2 weeks and so we literally crunched in the entire EHR implementation and purchasing process into those 2 weeks so they didn’t have to start on paper charts. The Hospital CIO’s comment on that article was “You lost me at 2 weeks EHR implementation.” Of course, this was an EHR implementation at a solo practice.

Although, even in the case of a small ambulatory practice, the EHR implementation is never done. At hospitals there’s always more that can be done to improve how you use your EHR. I don’t think it’s a bad thing to think that you’re in your XX year of your EHR implementation. As long as you still create milestones so that staff feel the sense of accomplishment in the process.

EHR Implementation Infographic

Posted on April 30, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Is this EHR implementation infographic no longer needed? Or are we about to enter a new EHR switching market where EHR implementation information is going to become really important?

I’d love to hear your thoughts in the comments.
EHR Implementation Infographic
Source: http://healthadmin.ohio.edu/

Biggest Threat to Patient Safety – EMRs and Hospital Handoffs?

Posted on April 28, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This tweet should drive an interesting discussion. Dr. Val tweeted that the two biggest patient safety threats are EMR and hospital handoffs.

In the links, a lot of the things discussed are issues that could happen even outside the electronic environment. However, with every change in system, there’s an opportunity for the users to abuse that system.

As I’ve said before, EHR requires change (not to mention managing EHR change). That’s just a feature of an EHR implementation and it’s something we should embrace. However, one challenge with change is that many of the systems we’ve created that deal with the weaknesses of our current workflow don’t work with the new EHR workflow.

The problem when change occurs is that we often don’t remember to also change the processes we created to ensure things like quality. We assume that this new tech system will somehow magically solve the problems that we’d been having before. In some cases, the technology can solve your problems. For example, if your office had a problem with doctors writing illegible notes in the chart. EHR will solve that immediately. However, if you have a doctor who doesn’t document the visit fully in the paper chart, do you think the EHR Is magically going to solve it? No, you still need programs and policies that improve the quality of your clinical documentation.

Back to EHR as a major threat to patient safety, it’s very true. Although, it’s not the EHR itself that’s the problem. It’s what we do or don’t do with the tool that causes the issues.

Has Meaningful Use Made EHR a Commodity?

Posted on January 8, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I had a really interested discussion today that had me asking the question of whether meaningful use was a commodity. The standards of meaningful use are the same and in the hospital environment we’re talking about a half dozen major EHR systems (only 2 in the top environment).

Per wikipedia, a commodity is “a class of goods for which their is demand, but which is supplied without qualitative differentiation across a market.”

There’s no doubt there’s now a demand for EHRs thanks to the EHR incentive money. The real question is whether there is a qualitative differentiation across a market. When it comes to meaningful use, there is very little differentiation. All of the top hospital EHR vendors meet meaningful use requirements.

I bet if we asked hospital CIOs what their goals were with their EHR implementation they’d almost unanimously say “meet meaningful use.” Sure, if we dug in some more we could probably find some bigger picture ideals, but the harsh operational reality is that hospital CIOs are implementing EHR to meet meaningful use.

Based on that concept, EHR certainly starts to feel like a commodity to me. We could dig into which EHR will get you to meaningful use quicker. The problem is that they are all hard and take work. I’m not seeing enough differentiation on that front and even if there is differentiation, I’m not sure how you’d measure it in any quantifiable manner.

What do you think? Is EHR now a commodity? What does it mean if it is a commodity?