Epic EHR Go-Live Lessons
Recently, I was involved in a EHR (Epic) Go-Live at a large multi-specialty community hospital, under the larger umbrella of an academic healthcare institution. This Epic Community Connect project was long in development, and finally, after all the stakeholders aligned, tech vetted, and go-live logistics sorted, the project was launched. To say a go-live is a massive undertaking seems to incompletely capture the complexity and teamwork that underlies this task. It is a huge project, requiring input from medical, technical, information, financial, and community leadership to do well. After 2 weeks of intense in-person informatics support during the Go-Live — troubleshooting technical issues, participating in daily leadership and steering committee meetings, and providing in- and outpatient clinicians and nurses at-the-elbow support — here are my big takeaways:
Lesson 1. Technical Dress Rehearsals Matter
Technical dress rehearsals are a crucial component of EHR implementation, and often fall under the purview of a CTO or CIO. They allow stakeholders to catch any potential issues before they occur, particularly with 3rd party integrations, which are often the most common source of problems due to the volume and versions of 3rd party software used. Therefore, it is essential to include vendors in dress rehearsals to ensure seamless integration with the new EHR system. Technical dress rehearsals should also include logistics of providing in-person Go-Live support, including staffing (and feeding the staff), hardware, connectivity, and more.
Ideally, these dress rehearsals are done at least 3 months in advance, if not earlier, of the go-live date. Vendors and a reliable point of contact on vendor teams should be identified and integrated early into discussions, so that their pipeline can be prepped for changes in data they may be ingesting from health systems, and their output can be mapped appropriately. For example, GI specialists use specialized 3rd party software for their endoscopy suites, which have specific integrations with the imaging PACS system used, which has a specific integration with the EHR. Changing the EHR sets off a chain reaction down to the endoscopy software that needs to be understood beforehand. Otherwise, you’ll have a whole endoscopy suite down while IT scrambles to fix other pressing matters.
Lesson 2. Phases of Conflict Follow Cycles of Grief
The emotions experienced by end-users during a Go-Live follow the 5 stages of Grief — Denial, Anger, Bargaining, Depression, and Acceptance/Future Thinking.
The first issue most end-users encounter is a technical problem — logging into the EHR. This hiccup can often cause reactions akin to denial and anger; “I can’t believe we’re doing this now of all times!” (as if there’s ever an ideal time to switch EHRs), “Why don’t this work the SAME WAY?”, “The hospital down the road would never have done this.”, “This is the worst EHR ever.” After that, technical issues may persist due to lack of a technical dress rehearsal beforehand, which can belabor the reactions most users have.
After technical issues are resolved, workflow issues, disguised as ‘limitations’ of the new EHR, arise. This often leads to bargaining and depression — “But we used to do it this way in our old EHR!”, “This is not going to be as good for us.”, “Can’t we just add a button to change it back the other way?” Often times, these issues are not limitations in the software, but just healthcare policy and best practices being realized thru software. While frustrating, as there is little to do to fix this from an informatics standpoint, this can be a great opportunity to re-focus end users on the future. By channeling their frustration into an opportunity to fix the EHR, you may have found yourself a new ally in the informatics field. I would re-direct end-users who brought up enhancement issues to discuss this with their department medical director, who can bring it up during leadership EHR steering meetings in the future.
Lesson 3. End-User Training
Another key component of successful EHR implementation is end-user training. Hospitals should plan for three phases of training — pre-go live, intra-go live, and post-go live. Pre-go Live activities include regular email updates regarding the upcoming switch, as well as generalized training for the EHR. I have yet to hear about a pre-go live training that was useful for providers, as most don’t have the new EHR to use independently to cement new skills. That being said, it’s still important to include as it teaches, at the very least, a vague understanding of UX.
To ensure that end-users are adequately trained during the Go-Live EHR system, hospitals should consider different support modalities. The most effective is at-the-elbow support with peers (this means provider informaticists), as it provides the most efficient, empathetic, and adaptive way to correct new user behaviors, troubleshoot technical issues, and, most importantly, give the IT department a ‘face’ with which to interact. This can make all the difference for healthcare providers who remain burdened with the same healthcare demands amidst an entirely new UX for their workflows. Virtual options here could work, but they require the end-user to know where to click to get virtual support, and it requires great connectivity for both the remote support staff and the healthcare providers.
In the post-go live period, scheduling provider-led EHR trainings using simulated cases, either in-person or virtually, can be quite helpful. This can also be helpful in improving adherence with best practices with EHR workflows, as well as allowing end-users time to customize their UI, tools, and more to their liking. These EHR training sessions can be a great way to assess end-user skills, providing more intensive instruction to those who seem to be laggard.
Additionally, micro-learning can be more effective than big picture training, and training nudges can be helpful to reinforce concepts. These are things like in-EHR links to training videos or nudges to customize UI elements. The timing and volume of training should be balanced with the need for clinical time and revenue generation. Burdening healthcare providers with the usual amount of healthcare delivery during and after a go-live is a recipe for disaster. Collaboration with the CFO to ensure provider salaries are covered, and evaluation metrics ignored or mitigated, during this reduced healthcare delivery period can go a long way towards freeing providers’ attention spans to focus on the EHR.
Lesson 4. Mitigation Strategies
Mitigation strategies are crucial to ensure a smooth EHR implementation process. One effective strategy we’ve already discussed — at-the-elbow support, which can include both technical and provider support. Additionally, prior to EHR implementation, is a hospital system can identify technological laggards or curmudgeons early, providing extra support both pre- and intra-go live, health systems can prevent delays and further complications.
Conclusion
Implementing an EHR system in a hospital setting can be a complex and challenging process. However, by focusing on technical dress rehearsals, understanding end-user psychology, providing adequate end-user training, and considering early mitigation strategies, hospitals can successfully implement EHR systems and improve patient care by minimizing healthcare delivery impact.