As you already know from a previous blog, I favor defining firm, challenging timelines in an EMR implementation.  These create intensity, momentum and discipline.

In his latest management book, John P. Kotter describes the paramount importance of people within an organization having "A Sense of Urgency." (Check out below a brief presentation of his concepts.) In part of the book, he focuses on the importance of engaging employees emotionally in a change project.  He cautions that a well-devised plan arouses little urgency in an organization. He goes on to explain that human brains are programmed much more for stories than for abstract ideas. He tells of using stories to create an mind/emotion understanding of the risks to the company and the employees should they not move forward.  

In my psychodynamic therapist hat, I know that intellectual insight alone does not bring about change. The mind content needs to be directly linked to an emotional experience for an "Ah Hah!" to happen.


I’m going to revisit my presentations to try for less PowerPoint and more stories.

As I wrote last time, when you are designing the content of an EMR you have to consider the dimensions of clinical culture, information flow, specific data capture and the use of controls. Good design also means finding solutions to meet the often competing needs of clinicians, management and, yes, the software.  It’s a complex process. I don’t claim to have all the answers, but over the past eight years as EMR implementation manager and then consultant for Netsmart Technologies, I have struggled extensively with the issues. 

First and most importantly, as the project manager for the implementation at UBHC, I did not struggle alone. We cast a wide net to recruit a workgroup of 30 members. The members were supervisors and line clinicians from all disciplines and levels of care as well as the leaders of all stakeholder departments. Here is a list of the participants if you want more details. Our charge was to design the structure and content of our electronic health record. We met for half a day a week for three months. The learning curve was steep. (more on workgroup education next time) The process was intense. The turf issues and, shall I call it, specialty narcissism were very much present. Together they created the major threat of “Content Creep.” This is a situation in which Staff want the details of their specific domains included and in their customary formats. The back-and-forth process eventually made it clear that to accommodate this range of domains would result in content that was too lengthy and complex. The phrase: “That item means 100,000 clicks per year…Is it worth it?” became a regular refrain.

By the time we were done, the participants had had the opportunity to understand the needs and concerns of wide range of functional areas and all LOC.  They were then able to make recommendations based on detailed knowledge of the information needs in balance with the realities of staff time and the software. The focused group process was powerful in setting the stage for the necessary compromises. Patience and determination were essential to discovering the solutions.

 So get your clinical leaders and line clinician “best minds” together and jump in. You don’t have to wait until vendor selection is complete. You can begin the content analysis and struggle now. They are generic.

So far I’ve written mostly about reasons and motivations for implementing an EMR. I’m feeling restless to get going with doing it, so I’m going to skip ahead to thinking about the design of your EMR.  I picked design because of the challenging article by Drs. Pamela Hartzband and Jerome Groopman I wrote about in my last blog.  In the article they described the risks of clinicians going brain dead (my word) while filling in standardized forms and templates.  They ardently support what they call “Thinking” medicine and called for the EMR to work for the clinician and not the other way around.  So do I. It is the main reason I decided to morph from practicing psychiatrist to EMR implementer.

The challenge for the content designers is that they themselves not go brain dead. This would look like them just assembling items and pick-lists based on requirements of payors, accrediting entities, states, their own management and so forth. Of course, these various data-masters must be satisfied.  But the designers must also think deeply about how to use the technology to help the clinician capture the essential story behind the patient’s presenting problem(s) and then abstract a formulation that leads to a plan.

There are several dimensions to consider in the design process, including clinical culture, information flow, specific data capture and the use of controls. There are irreducible tensions among the needs of clinicians, management and, yes, the software.  The trick is to find a sensible balance with support of the clinical work as the highest value. I’ll write more about finding the way in upcoming blogs.

Design is as complex as it sounds, but do not be intimidated. The very good news is that software development is never completed. It evolves as you learn from experience and user feedback and as new functionalities become available. Also it is great FUN to be a creator of software and not just a consumer.

When planning an EMR implementation, don’t be afraid to set brisk timelines and be sure that deadlines are known to be firm.

Peter F. Drucker, the greatest (in my opinion) of business management gurus, wrote that to do their best work people must have an optimum amount of challenge. There should be enough challenge so they must push themselves and can then feel pleased with their accomplishment, but not so much as to overwhelm and demoralize them.

In my experience of a very challenging EHR implementation timeline without any wiggle room, the pressure of the deadlines focused the efforts of all involved.  In the large, inclusive workgroups there was no time for old rivalries and territoriality. Compromises had to be made, so decisions could be reached and the process could keep moving. Tight deadlines permitted the building of momentum and of enthusiasm for the tasks.  In the context of group process under the watchful eye of top management, no one wanted to be identified as an obstructionist. At the same time the process itself must be open and creative as well as disciplined. There are always legitimate competing interests and needs. The issues must be wrestled with until good enough solutions are found.  Keep in mind that an EMR is not a final masterpiece. If anything it is a living entity in that it will be made to grow and change building on the experience of the uses. 

By the way, we met our deadline to the day, and I still feel proud of it years later.

The short answer to the title question is: everywhere. One definition of corporate culture is "How we do things around here.” It is the collective behavior of people using common corporate vision, goals, shared values, beliefs, habits, working language, systems, and symbols. It is interwoven with processes, technologies, and learning. A successful EMR implementation necessarily impacts all these domains.

In the late 90’s my home organization, UBHC, was being transformed from a community mental health center to a managed care oriented corporation. This meant a dramatic change in corporate culture. An electronic health record was at the heart of this transformation. Here are some examples. Professional identity would be challenged as appointment schedules became centralized and electronic. Clinical information would become more standardized and monitored. Communication would move away from face-to-face, often group settings to electronic methods. There was new attention given to productivity and efficiency. The financial needs of the organization were now a necessary and valid priority, which required all staff’s participation.  Fiscal staff needed to respect the work of the clinician as the source of revenues and clinical staff needed to contribute in the effort to successfully bill services.

The EHR implementation itself became the main vehicle of this cultural change.  Leadership and inclusive process were the key elements. These will be the focus of future blogs.

Also among the clinicians an apt, tongue-in-cheek phrase emerged: “Psychotherapy begins at home.” By this they meant that the frequent psychotherapy themes of recognizing and adapting to change had now become their own challenge. It told a truth that was clarifying, but uncomfortable. 

An effective electronic health record implementation requires oodles of collaboration among every slice and silo of the organization. Ideally such collaboration would be a given. But all staff members are human beings who tend to develop identities and loyalties based in shared relationships and experiences. In other words, locally. Enter turf as a perennial resistance to the change that comes with the move to an EHR.

At the time of our EMR implementation, my home organization had been in operation for more than 25 years. Many of the staff had been there for > 10 years. Place and people already had a long history together.

Factional divisions were plentiful; blaming the other was usual.  Many staff groups believed that their function was the crucial operation and that other functions existed to service their operation's needs.  There were adversarial relationships between programs.  For example, Inpatient staff thought a hospitalization was central to the treatment and that they could more properly diagnose and treat a patient based on their 24/7 observation. Outpatient staff, meanwhile, believed a hospitalization was a disruption in care and that they better understood the patient because of long-term contact in the natural setting.  Then there were fiscal staff who thought clinicians were too lazy to do correct documentation for billing, while clinical staff saw fiscal staff as lacking compassion. … and on and on. I’m sure there are 100’s of choice examples out there.

So what to do?  My condensed answer is to get them in a room together, give them a task and a strict timeline and tell them they must be successful.  Details to follow.

A recent article in the New England Journal of Medicine surveyed 3000 outpatient medical practices on their use of an electronic health record.  Among the many results was the finding that nearly 400 of the practices had already purchased an EHR system, but had not yet implemented it. There are many possible explanations for this. I want to use the finding to segue to talk about motivation and the implementation leadership. (The leadership may be one or several people.  Both configurations can work, and these thoughts pertain to both situations.)

There are many, many elements necessary for a successful EHR implementation (or I wouldn’t have material for an ongoing blog), but the implementers’ determination and energy are the primary forces driving an implementation through to its completion.

The organization’s implementers have to face the resistance of staff, the scope of the task and the personal effort level involved. They will probably develop feelings, such as anxiety, anger, frustration and their own resistance, which may look like procrastination, over planning, even letting themselves be persuaded that an EMR just cannot work in their setting.

The implementation leaders need to discern a personally important mission in the EHR project to support the deep and steadfast commitment that is necessary. As I wrote here in an early blog, for me the mission was to make the electronic health record serve the clinical work. The passion for this mission still energizes me.  

I’d like to hear other people’s thoughts, feelings and ideas about the mission for EMR implementers.

We’ve looked at three groups of clinicians, their attitudes and needs and potential motivation for moving to an EMR, but what about the managers?  They too are not a unitary group.  Top-level managers are presumably willing, as they have made the initial decision.  Hopefully they will have grounded their decision in an important strategic goal of the organization, rather than in response to external pressures or popular trends. They are probably eager for the greatly improved operational control managerial reports can provide.  Even better for them, they likely won’t be entering any of the data on which the managerial information is based.  They will, however, have to accept the scope of the task.  They will have to budget the funding, confront the resistances and allocate the resources for the implementation.  They will have to be open to the recommended changes which should result from the content design and workflow revision stage. They will have to be patient with stumbles and protests, but not too patient – more on this on this last later when I write about the crucial role of top leadership.

Mid and lower level managers may or may not be willing.  They too have to face the resistances while being closer to the resisters and to figure out how to accommodate the demands of the implementation on their local resources.  An effective EMR implementation involves clinical staff in content design and in training. In my experience the clinical program managers feel the most pressed regarding the time it takes to accomplish these tasks well.  They may want to reduce the time of the training sessions or suggest that staff be trained informally on the job. They must be engaged around the value of line clinician input and thorough preparation.  Also top managers must support line managers and clinicians by considering the necessary training time when reviewing productivity standards during the implementation.

Managers at all levels must work together to create an workable balance between the ongoing needs of the operation and the requirements of a well-executed implementation.  It calls for flexibility, discipline, imagination, fortitude and a sense of humor – the list could go on, but you get the idea. This all may sound rather dreary. It is certainly a challenge, but I found it to be energizing and with a good team it was even fun.  

Last time I described that when thinking about clinical staff facing the move from paper to an EMR, I find it useful to think of three groups of people and ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

I went on to write about "the Excited:" the younger clinicians who bring computer skills, a positive attitude, energy and impatience to an implementation.  Now comes the group to which I, myself, belonged at the outset of my journey from clinician to EMR implementer.  I call this group the More or Less Willing.

These clinicians are bit older. They still have kids at home, so they are exposed to the contemporary computer world. They use email and shop online. In their professional lives, they have longer tenure at the organization and in their professions. They are used to established roles and methods in their work. This group is computer comfortable.

When facing an EMR implementation, they have an open attitude about the contribution of computers. They understand the advantages of computers in terms of accessibility and legibility. But they also have important concerns. They fear the therapeutic process will become dehumanized. They worry about the loss of authority over the flow and content of their work.  They are concerned about threats to client confidentiality. How about the impact on their time? Maybe they are skeptical about the organization’s capacity to actually pull it off. And more…

The wise implementer will address these concerns. Every stage of the implementation process offers opportunities to woo, communicate, engage and reassure.  I’ll be writing about my experiences, strategies and ideas for each stage.  It just occurred to me that this group is the equivalent of the independent/swing voters and that the crucial goal is to help them to become confident and positive enough to “vote” for and maybe even work for the implementation. Without them, you cannot win.

At a workshop a couple of years ago, a behavioral health executive contemplating an EHR implementation asked me, “How can I get my clinicians excited about this implementation?” My short answers are “Be realistic” and “It depends.”

Clinicians have different needs for information and a different relationship to an EHR than executives. Managers need information to lead the organization. I would also add that they do very little of the direct data input, so they get the benefit of the reports without much personal effort.  Not so for the clinicians who, along with support staff, are the main sources of the content being entered into the EHR. So what might get a busy clinician excited about an EMR implementation? Let’s think about this question from the point of view of salaried clinicians in a behavioral health organization.

Such clinicians are not much interested in organization finances, compliance and other executive concerns.  They too want information, but of a very different sort. They want an efficient method to capture relevant client history.  They would appreciate tools that could help them define the treatment and track progress. They need to communicate with themselves and with other staff treating the client both currently and in the future. Approaching these needs will be experienced as helping them do their core job, providing the best care they can for their patients. So far, so good.  Clinicians further need to capture data and document their work to satisfy all the various data masters of the universe, eg payers and accrediting entities. This is experienced as extraneous to their core job. (They feel grumpy about doing it and will feel grumpy about the EHR that ensures they do it.)  And, of course, they want EHR content to be easy to access and navigate.

If you are an implementer, don’t set yourself up for disappointment by expecting clinicians to be excited about the EHR implementation itself. Moving from paper to computer involves lots of changes for clinicians. A well-executed implementation is critical in getting the EHR off on the right foot. Do understand, though, that the long-term success of the EHR you are implementing depends on how well the system you deploy serves the work the clinicians are doing.  It depends on their having ready access to a computer, on the functionality of the software you have chosen, the design of the content, the usefulness of the outputs, the adequacy of the supports.  None of this is magic. Digging down into the details and finding good solutions at the level of the clinicians at their jobs is the work of the implementation.

I’ll write about my experiences and thoughts on these challenges in future blogs.

During this electrifying political season, there is a flurry of attention being given to Electronic Health Records. Nationwide implementation of  EHR’s is a core component of candidate plans to reform the American health care system. The main reasons put forth include to save money, reduce medical errors, avoid redundant testing, identify previously ineffective treatment,  and provide access to current medications from any point of care.   The media is high profiling phrases such as “interoperability,” “RHIO’s” and “Personal Health Record (PHR).”

Adding to the intensity of the EHR discussion, the federal government is proposing penalties for EMR non-adopters. Our largest technology companies, namely Microsoft and Google, are charging into competition to capture the hot property of the PHR.

Some of the enabling technology for these high level goals is in place. Some crucial components are not. What are the providers of healthcare to do? More particularly, how can those contemplating software for behavioral health, addictions, MRDD and public health approach the question of why should they embark on such an undertaking? Here is my thought. To borrow a saying:

Plan globally and for the future………Act locally and for the present

An organization’s top planners must be aware of the national vision and policy trends concerning EHRs. They must be informed about technology trends. Only then can they define their own plans and make decisions. For example, they should not cast their lot with a vendor which cannot demonstrate its ability to lead or at least keep up with technical developments over the long haul.

The person leading an Electronic Medical Record (EMR) implementation must know both the clinical and IT terrains. Since these two sets of knowledge don't ordinarily come in the same individual, who is best prepared to lead the EMR implementation effort, a clinician or a techie? I vote firmly for a clinician. Here's why.

At its heart, an EMR implementation should be a clinical and business processes undertaking, not an IT project. While an EMR crucially depends on technology, the ultimate purpose is to advance the quality and efficiency of care provided by people for people. The essential  knowledge underpinning an EMR is an intuitive grasp of the flow of the clinical enterprise: how to think, what to ask, how to decide, how to plan, execute and document. Next in line of importance is understanding the requirements of the complex business environment of health care. Then comes technical knowledge: how to exploit the rich computer systems toolkit to capture and enhance the flow and requirements.

This is NOT to say that technical knowledge is unimportant. It is essential for an EHR implementer to grasp the core concepts of networks, client-server, databases and reporting. When I began my transition from practicing psychiatrist to EMR implementer, I identified my computer naïveté to be a serious deficiency. So I promptly  enrolled in the introductory computer science course at a local college. I learned about hardware, networks, operating systems, reporting… I even became competent at very basic programming. On my own, I studied databases and taught myself MS ACCESS. I participated in many IT meetings. With focused effort, I learned enough to be an effective member of our IT team. To my surprise I found that computers are great fun – and very useful.  

I have talked with many people embarking on an EHR implementation. I routinely ask, “ Is it easier to teach a clinician the technical side or a techie the clinical side?” The answer is always, “It’s easier to teach the clinician.” What's your vote?