My name is Betsy Haines. I am a psychiatrist and an electronic medical record (EMR) implementation veteran. I am starting "Getting to Go Live" to help other people involved in implementing an EMR lead their organizations through a successful launch. The observations, lessons learned, best practices and thoughts I will share are based in my broad range of experience. 

I spent my 30+ year career on the clinical faculty of the University of Medicine and Dentistry of NJ. For 25 years, I did direct patient care with people with serious and persistent mental illness. My absolutely best days were when I saw patients in the railroad station and did initial contacts in McDonalds. I also supervised professionals of every disciplinary stripe and held a number of administrative positions.

Then for 6 years, I morphed into the project manager for an electronic health record (EHR) implementation. (BTW Aficionados hold to the distinctions between an EHR and an EMR, electronic medical record. We will use the terms interchangeably.)  The implementation was complex, arduous, challenging – your average EHR implementation. Happily, it was also successful.

The content of an EMR captures data to serve many masters. These include payors, regulators, accrediting entities, researchers and the organization’s managers. Most of all, however, it must serve the work between client and clinician. In my previous blog, I wrote about the need to recruit a workgroup of clinicians with a broad array of clinical skills and homes. Then what? Well, the next step is to educate them about the technical underpinnings of the project, namely about databases.

In my experience the early leadership in software implementations comes from IT professionals. So, since you are reading this blog about electronic medical record implementation, I assume that you are probably pretty computer savvy and technically informed.  But let me plead with you to assume that the clinicians on the design workgroup are neither. Sure they email, write documents, Google and shop online, but most likely they do not understand what a database is. Since clinical documents are one of the main EMR outputs, they think that the EMR is some sort of giant MS Word document.  Thus they make comments such as “Why can’t you spell-check the whole thing at once?” and they expect to read the clinical information that has been entered by accessing the inputs screens rather than by viewing a report.

When considering data capture and, especially, information flow it is essential for the designers to grasp the database basics: that information is captured in various data types in input screens and stored in columns and rows in tables and that reports pull the information from any available table.  

I have shown many clinicians this simple database schematic. The frequent responses have been as if it were a revelation. They told me that now they “got it;” that they felt enlightened and empowered; and that they were eager to get going on the design task. And all it took was about half an hour. 

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, I have struggled extensively with the issues. 

Comments (0)   

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.

I recently wrote about the concern of clinicians facing an EMR implementation of losing their professional autonomy. This concern came to mind as I read an article entitled “Off the Record -  Avoiding the Pitfalls of Going Electronic” co-authored by Drs. Pamela Hartzband and Jerome Groopman.  In the article, the authors rightly worry that the capacity to manipulate the EMR make it far too easy for trainees to avoid taking their own histories and come to their own conclusions about what is wrong with the patient. (This slippery slope, of course, applies to physicians in independent practice as well.) For me the exploitation of these capacities also speaks of the temptation for professionals to take shortcuts and thus to collude with the economic pressures of the current healthcare environment and abdicate their professional obligations to their patients.

The authors cite the glut of raw data not digested into relevant information; the practice of clinicians copy and pasting (essentially plagiarizing) from others and from their own previous content. They cite their experience that templates invite voluminous, unfocused notes, which may be efficient but not conducive for creative clinical thinking. As they note, writing forces us to think and formulate our ideas.

They observe that EMR’s can become a vehicle for perpetuating erroneous information that gains momentum when passed on electronically. In my 25 years practicing psychiatry, I often saw the written chart do the same disservice as clinicians uncritically accepted previous diagnostic formulations. Though the accessibility and interoperability will amplify this woeful practice.

They believe that the most disturbing effect of the technology is that it diverts attention from the patient during the 15 minute clinic visit. Surely the EMR is not the primary culprit here. Consider the time constraint itself plus the payor’s documentation requirements and possibly an inadequately trained and inexperienced user.

My overall and, admittedly somewhat defensive, response is that an EMR is neither an ethics auditor nor a supervisor. Nor can the technology be blamed for inadequate content design. I too am ardently concerned with the trends towards protocol driven, time-compressed, technology focused healthcare. However, I view the poor use and outright misuse of the EMR more as an enabling result than a cause.

In conclusion Drs. Hartzband and Groopman write “Practicing ‘thinking’ medicine takes time and electronic records will not change that. We need to make this technology work for us rather than allowing ourselves to work for it.”  Yes, indeed.

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.

A recent article reports findings that uncertainty about Return on Investment (ROI) is a significant barrier to the adoption of Electronic Health Records. In my last blog, I introduced a monograph, “Measuring the Business Value of IT Investment,” by Craig Symons. He believes that financial measures are not enough when making decisions about IT investment.  In that blog, I presented his view about the lack of precision inherent in the financial measures.

Symons further describes that IT investments often provide intangible benefits which are hard to measure and so are left out of financial measures. Let’s think from the clinician’s perspective: No more trips to the record room; no more searching through pages of lab results for the crucial information or struggling to read months even years of hand-written progress notes to get the big picture of what is going on with a patient. (FYI I worked mostly with schizophrenic people who had long often-complex histories.) Confider that such delving into a difficult case would likely not occur at all with a paper chart because the process is so cumbersome and time-consuming. A well-designed EHR also provides decision support tools and links to the universe of knowledge on the Internet.

Symons also notes that IT investments produce not only immediate benefits but also provide opportunities for future benefits.  Consider the benefits to quality and cost of care in the potential for communicating with other providers. There is also the exciting opportunity to bring web-based interactivity to the patient-provider relationship.

Seems that the intangible and potential benefits truly deserve a place when thinking about an EHR implementation. 

Yet another look at the article on Electronic Health Record implementation from the New England Journal of Medicine. It presents a survey of nearly 3000 physicians in outpatient medical practices nationwide. The results showed that just 4% had extensive electronic records systems in their practices, and 13% had basic systems. The survey asked respondents to identify the barriers to moving from paper to an electronic health record. The second most frequent response after cost was uncertainty about return on investment (ROI).

ROI is a commonly used formula-based numeric measure, but it is not as straightforward as one might think. Sure maybe you can project a definite positive ROI before the fact. The EHR implementation I managed at UBHC was in the black after the first two years thanks to bringing all billing in-house and discontinuing all transcription services. But such initial cost-saving opportunities may not be available to your organization. Your situation may be unclear. Time to pause and think about the place of ROI in IT decision-making.

Using ROI as a factor in decisions about an EHR is problematic. As Craig Symons states in his monograph “Measuring the Business Value of IT Investment,” purely financial measures such as ROI imply a precision that does not exist. He describes that the calculations used in the measures are based on estimates of benefit, which in turn are based on assumptions. So the accuracy of the calculated ROI is only a good as the underlying assumptions. He presents other shortcomings of purely financial measures, which I’ll touch on soon.

Symons presents several alternative approaches to evaluating IT projects. Have a look.

Let’s look again at the article on EHR implementation in the July 3rd issue of the New England Journal of Medicine. It presents a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient medical practices nationwide. I discussed in my last blog the results showing that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

The survey asked respondents to identify the barriers to their moving from paper to an electronic health record. Unsurprisingly, the most frequently mentioned barriers were financial, namely the amount of capital needed and uncertainly about return on investment. The size of the capital investment is a straight up problem. Governmental policy makers, insurers and vendors are all exploring solutions in various brews of requirements and inducements as fit their areas of authority and self-interests. For example,legislation was recently proposed calling for a national inter-operable electronic health record (EHR) system. Some sources consider the proposed legislation could be used as a back door approach to force doctors and hospitals to implement EHRs.

Since you are looking at this blog, I assume you or your organization are at least thinking about implementing an EHR. If funding is currently an insurmountable barrier, you can still begin preparing. Learn more about the benefits others have gotten from EHRs. Think about the areas of greatest inefficiency or communication failures in your organization and how the problems could be addressed by improved processes assisted by an EHR infrastructure. Think about the impact on the organization and the barriers and resistances.

It's not too early. A successful EHR implementation begins in the minds of the leaders.

As to Return on Investment, I'm going to write some thoughts on that one in the next blog.

While there has been much discussion in healthcare policy and political circles as well as media buzz about Electronic Health Records, the actual implementation of EHR’s in the U.S. remains low.  An article in the June 18 New England Journal of Medicine cites a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient offices nationwide. The results show that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

There are lots of details in the article. Here are some highlights regarding usage. There were higher levels of EHR use by younger physicians and those who worked in primary care or large group settings. Interestingly,  providers serving higher proportions of minority, uninsured or Medicaid patients were not significantly different in their EHR adoption than other physicians. Also adoption was higher in the Western section of the country.

Happily, a large majority of the physician users were satisfied with their systems – 93% for fully functional system users and 88% for basic system users.

Among the 83% of respondents who did not have electronic health records, 16% reported that their practice had purchased but not yet implemented such a system at the time of the survey. An additional 26% of respondents said that their practice intended to purchase an electronic record system within the next 2 years. So, many practitioners are on the path to implementing an EHR. It is not too late to be a leader in your field and in your community by joining this group.

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.  

In my last two blogs I’ve presented my ideas about implementing an EMR with three groupings of clinicians in mind. First we covered the “Excited” but impatient, then the “Willing” but concerned and skeptical.  Now let’s focus on the “Frightened” and again ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

These clinicians are definitely mature. They have no kids at home and are less likely to have embraced new technology. They’ve had long professional careers and been at their organization for years. They are settled into established roles and methods in their work.  They may be eying their pensions and counting the years to retirement.  They are the elders of the community whose wisdom and experience bring such value to a clinical team.  They are computer naïve, intimidated.

When faced with the move from paper to computer, their initial response will probably be resistance, as they share the Willing group’s concerns about computerization diminishing the work and disrupting functional routines.  They may also present as grumpy.  Beneath these reactions, they are mostly worried they will look dumb and feel embarrassed as they learn. Some will fear they will never be able to master the machine.

These organization elders must be approached with great respect and sensitivity.  They must be extravagantly supported.  One-to-one on site tutoring is a frequent plan.  Training in a peer group setting by a peer rather than a whippersnapper preserves dignity and creates support. Use your ingenuity to help these clinicians become less anxious about giving the EMR a try.  My favorite success vignette is of a psychiatric elder who in the beginning protested mightily about computerization. After personalized training, he was so delighted and energized by his mastery of the software that he evolved into an enthusiastic local champion.  So rewarding for both of us.

Please share any tips and happy outcome stories you may have. 

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.

I’ve been writing about “the clinician” as if this word represents a homogenous group of people. Of course, this generalization is not correct, especially when it comes to individuals facing the move from a paper chart to an electronic medical record.  So I like to divide my one big generalization into three smaller ones.  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?

This blog will focus on the third I call “the Excited.”  These clinicians are younger, computer-philes from our modern computer culture.  They are the kids of the organization. (Is my age showing?)  They are newer to their work and not greatly invested in established roles and methods.  They are also newer to the organization, and less identified with the organization’s history and culture.

When facing an EMR implementation, the excited group will probably be – well - excited.  A wise implementer will draw their enthusiasm and knowledge into the implementation effort.  Make sure they are represented in planning groups and tapped to be local champions. I enjoyed a mentoring relationship with two of our up-and-coming clinicians who became great boosters of the EMR in their clinical units.

But, no surprise, with the energy and computer skills comes impatience. These computer-philes are used to interacting with action packed graphics, to intuitively following their bliss through hyperlinks and to expressing themselves extensively on MySpace.  The content of the EHR is structured and controlled through required fields and software procedures.  They need help to be patient with the restrictions of the software.  They need help to see that the content designers are not dolts and to accept that there are legitimate clinical and compliance reasons behind design decisions.

It is the implementer’s job to ensure that these two last statements are correct.

I recently had two useful pieces of information come to me that illustrate my thoughts on achieving user buy-in to an electronic health record.

One was a tip on blogging from our blog host. It introduced me to the acronym WIIFM. The tip reminded us that readers search for and look at blogs, asking, “What’s in it for me?”

The other information was told to me by a nurse turned techie/implementer in a large system with over 10 institutions. She described the implementations in two of their facilities. In one, the implementation focused on creating reports for the needs of the top managers. In the other, the implementation team created reports designed to meet the needs of the clinical staff. For example, they created a shift change document for nurses and a report showing treatment permissions coming up for renewal. She described that in the first facility, the implementation had a difficult time winning over clinicians. In the second facility, the clinicians had a much more positive attitude and the implementation went much more smoothly.

I believe WIIFM is an absolutely legitimate attitude for a CEO, a supervisor, or a clinician using an EMR. After all we’re talking about the relationship of a user to an electronic health record system It may be long-term but it is not an intimate relationship.  WIIFM is OK. So, implementers, ignore it at your peril!

I’d love to hear more stories about where WIIFM fits into your implementation.

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.