Above: My amazing physician, APP and nurse informatics colleagues having a well-deserved break from improving healthcare.
Below: An updated set of lessons from an EHR go live in 2022: https://ctlin.blog/2022/03/05/parkview-health-system-4am-epic-go-live/
Parkview in Pueblo is 350 bed hospital and about 25 outpatient clinics. (In 2022) UCHealth partnered with Parkview to provide EHR services and to grow our clinical collaboration. They would be a Community Connect partner to UCHealth. What this means is that UCHealth and Parkview are financially independent entities agreeing to work together, where UCHealth extends their EHR and provides implementation and support services to Parkview. In some ways, we are their EHR vendor/supplier. [2024 update: Parkview has agreed to become part of the UCHealth organization].
UCHealth is implementing the Epic EHR in the Parkview hospital and clinics, replacing the prior EHR and associated technology, to inspire improved clinical collaboration between our organizations.
Go live is March 2022: Saturday. What goes into the clinical work of an EHR go-live?
We send hundreds of people to Pueblo, book many rooms in a local hotel, and plan to spend weeks living in the hospital and clinics, building relationships and solving technical and clinical problems. These UCHealth people include: database analysts, EHR application analysts, EHR trainers for non-clinical staff, medical assistants, nurses, technicians, physicians and APP’s. Every role in a hospital has a part to play in the EHR, and the EHR hosting team from UCHealth must come with skills to support all the personnel.
(In 2022) This was our fourth Community Connect hospital go live (beyond the 12 hospitals already live on our Epic EHR within the UCHealth organization), but by far the largest hospital to partner with us as an independent entity (at that time). What did we learn?
2023 LESSONS: Go live at Parkview:
* You will see lots of paper at the hospital undergoing the change. Frequently, hospitals using an EHR will still have many clinical processes requiring paper. In this hospital, we found large blue 3-ring binders for handwritten notes and orders, filing cabinets full of manila folders and fax machines on every hospital unit. Our job: unlock important medical information from paper so that it can flow smoothly between relevant team members. Stop the paper chase. Sweep away the old dust.
* Training is necessary but not sufficient. Regardless of all the preparation, the first month of EHR go-live is difficult for all. We have moved EVERYONE’s cheese. New habits must replace the old.
* Everyone goes through the “Valley of Despair.” Some individuals breeze through the valley, spending only a few moments as they adapt to new circumstances, new computer screens and new ways of working. Others will spend days, weeks, months struggling to adapt. Respect the difficulty. Everyone makes the switch at their own pace. Our goal: leave no doctor behind.
* Expect surprises, resistance and strong emotion. As an implementer and agent of change, bring your resilience and patience. You will need it. Reread the books Crucial Conversations and Managing Transitions. You can always be more skillful as an agent of change.
Some clinicians adopting a new EHR are quickly stressed, potentially overwhelmed, and may require individual hand-holding, a decompression of their clinical schedule, or additional colleagues to take on clinical work to give space for learning. Every day is different; be ready to pivot your plans and help these individuals survive this transition.
* Don’t take it personally. Listen more than you speak. Bear witness. Be a good ear. And then, when the emotions have run their course in a conversation, ask if this is a good time to talk about the new way. Sometimes, it is not the right time, and you can come back later.
* Be flexible but adhere to minimum standards. Prepare ahead of time: what is negotiable, what is non-negotiable? What is the absolute minimum that a physician must do for your EHR to function? Some of your physicians will test these limits. For example: We don’t accept illegible orders or illegible notes or operative reports with chickenscratch handwriting. We will accept that an APP or nurse could enter orders on behalf of an individual physician or surgeon. We will accept that a physician could use speech recognition to write a note. However, we do require that doctors have an EHR login and use their password to sign progress notes and orders.
* Expect to walk 10,000 to 20,000 steps per day. Wear your most comfortable walking shoes. Carry a mobile phone, a VOIP phone if available and a mobile charger. Keep an index of all the mobile numbers of roving physician/APP/nurse informaticists. This is your SWAT team; when you have a hot-spot problem, a physician-to-physician or nurse-to-nurse conversation goes a long way. We repeat throughout the day: “it will be okay. We are your teammates and we will figure this out together.” When the partnership between organizations goes well, like this, it is a pleasure to build on that collegiality.
* Attend an EHR go-live. Go-lives are humbling and instructive. All newbie physician/APP informaticists should go to at least one. If this is not available in your organization, join a go-live somewhere else. You will realize how little you know. You will realize how much good leadership matters. You will appreciate the things that work well in your own organization’s culture. You will see the entire spectrum of human experience among physician colleagues: early adopters to technology laggards.
* A cohesive go-live team is essential. During go-live, local hospital leaders work hand-in-hand with EHR clinical and technical leaders. Every go live has its unique glitches and unexpected trouble. Hundreds of issues will be raised and solved, most of them in minutes. Informatics never moves as fast as it does in the first days of an EHR go live.
* Build relationships during go-live. These relationships will sustain you for future years of partnership between hospitals and health systems.
* Our clinical colleagues are amazing: pause to appreciate their humanity, their calling and commitment to their patients. We can feel great about the future of medicine.
* An EHR go-live lives and dies by the Social 80. What do I mean by the Social 80? Only twenty percent of the success of an EHR deployment is due to the technology; eighty percent is due to the social, political and communication skills of those doing the implementation and change management work. The necessary skills are patience, persistence, and constantly pursuing a long-term win-win solution.
The result: Another successful go live, another 1000 healthcare colleagues using our common EHR. Our family grows.
2024 UPDATE: Scottsbluff (188 bed hospital and 28 clinics). Lessons from our 17th hospital go live:
1. The year in prep is everything. Experienced analysts lead effective meetings with clinicians, gather deeply understand specialty workflow, and design excellent departmental configurations. Excellent preparation dramatically reduces go-live chaos. Don’t underinvest in prep time and effective analysts.
2. Stick to your timeline. Effective managers are crucial. Anticipate and mitigate delays and avoid slipping the go-live date. Otherwise, a last minute go-live date change means your best people will not be available; they will have been tightly scheduled and allocated to other projects.
3. Clinical informaticists at go-live are worth their weight in gold. RN’s and MD’s/APP’s can have the clinical conversation about what is needed and also the IT conversation about how to fix EHR to match workflow. The Informaticists are needed both in the year of prep, leading clinical go-live preparation meetings, as well as during actual go-live. They are also crucial in the years after, for maintenance and upkeep. Encourage each hospital to fund a designated local physician to be the eyes and ears in the community, and to represent local interests in the global governance of the EHR.
4. Local leaders must know how to lead change calmly and effectively. They must anticipate the valley of despair and set a good tone for their colleagues to follow. A leader who can exhibit patience and good cheer can influence how others feel about the success of the go-live. This was the case in Scottsbluff. The CMO and CMIO and nurse leaders were calming influences. Consequently, every physician and surgeon at Regional West Medical Center was pleasant to work with. As hiccups occurred during go-live week, each one nodded and said things like “I understand that we will get this fixed soon. We’ll get through it.” For those who know about the emotional chaos of EHR go-lives, you know this is nothing short of amazing!
5. Pre-flight sessions consistently show value where clinicians can practice their new EHR skills, and also save their preferred orders: those who attend pre-flight have much less trouble at go-live than those who do not. Set preferences. Learn common potholes to avoid.
5. Be consistent and give gratitude and grace to everyone for the months after go-live. Be outstanding representatives of your organization. Do large organizations shake hands and decide to work together? No: Individual leaders do. Do leaders do the actual work of connecting the dots? No. Managers and analysts and trainers and clinicians do. Every single interaction adds up to an overall tone of the success of a project. Are you improving that tone or detracting from it? A successful project requires constant feeding.
The lesson learned.
Change is difficult. However, if you have an excellent game plan, change can be joyous and way to grow relationships toward better teamwork and better clinical care.
Try this yourself:
Yes, an EHR go live is technically difficult, but technology is only 20% of the work. Apply the Social 80, with all the examples above, to your next major project. What examples do YOU have of your use of the Social 80?
