Running head: LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 1

Lessons Learned During an Electronic Health Record System Rollout

at a Primary Care Setting

Maab Khalil

University of San Diego

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 2

Abstract

The purpose of this report was to determine a successful approach in implementing EHR

system from a paper record system in a primary care setting and its evaluation. A primary

medical practice using outdated paper record system in Arkansas has been providing outpatient

medical care for the past five decades. The paper record system has seen several shortcomings

and limited services that resulted in a decrease in patient metrics in the primary practice.

The approach was a 2.5-year report on EHR project implementation study. The approach

was to understand the lessons learned regarding the steps in implementing an EHR system in the

primary care setting. The EHR implementation resulted in an efficient workflow process, storage

of patient records, and understanding how the benefits of EHR implementation can have

significant outcomes in patients, community, and increase the standard of care. Post collection

data have yielded lessons learned during EHR implantation, which includes, staff not able to

conform with the new deployment, identifying an efficient EHR workflow that acts as a

blueprint to practical implementation.

In understanding and analyzing the financial benefits and outcomes of this new

deployment due to the short post-implementation phase; we could not know the financial

outcome. Understand how patient metric and lessons learned played a crucial role in evaluating

the success of EHR implementation. The EHR implementation led to patient engagement in their

care, increased coordination of care, and improvements to the health status of the population

while ensuring privacy and security.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 3

Lessons Learned During an Electronic Health Record System Rollout

at a Primary Care Setting

The United States (U.S.) healthcare evolution is the result of decades of reform due to the

influence of health information technologies and exchange in healthcare organizations. One of

the essential shifts is the adoption of electronic healthcare records (EHR) into the U.S. healthcare

system. An electronic health record (EHR) is the systematized collection of electronically-stored

patient and population health information in a digital format (Gunter & Terry, 2005). These

records distributed through different health care organizations (HCO) and applications. EHRs are

shared through a cloud-based server of a vast library of information systems influencing a health

information exchange (HIE). EHR systems are used in a variety of functions in HCOs, for

example, populous community demographics, medical histories, medication and anaphylaxes,

immunization status, laboratory test results, radiology imaging, vital signs, biometric summaries,

and financial billing and summaries (Top Mobile Trends, 2014).

The signing of the 2009 HITECH Act allowed the expenditure of $25.9 billion to

promote and expand the adoption of health information technology. Under HITECH, monetary

incentives program to health care providers for the “meaningful use” of implementing EHR

system software modernized with Clinical Decision Support Systems (CDSS) providing up-to-

date medical knowledge and evidence-based guidance to the physician at the point of care. This

proposal is to guide successful implementation to an efficient EHR adoption at a private family

medicine healthcare center. The EHR system and its features will help improve the ability to

diagnose diseases and reduce medical errors, hence, improving patient outcomes and standards

of care (Milstein & Jha, 2017).

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 4

Problem Statement

A primary medical practice in Little Rock, Arkansas has provided outpatient medical care

for community residents for the past five decades. The primary practice still uses an outdated

paper medical records and financial billing system. The paper medical records are stored in file

cabinets behind the receptionist’s desks and storage rooms. The paper record system has seen

several shortcomings in the primary practice, which include (a) the cost of copying, transporting,

and storing patient records; (b) the damage or loss of records; (c) the difficulty in interpreting

and analyzing records due to legibility; (d) and the negative impact of the use of paper on the

environment. These shortcomings have resulted in the request of an EHR system from the

providers in the primary practice.

The primary practice limited services have resulted in a decrease in patient metrics,

including an increase in patients’ length of stay (LOS), the average time of admission and

discharge, and waiting time, leading to reduction of standards of care to the practice. Our

proposal introduces automated EHR system technology to revamp the entire primary practice

workflow process and improve quality of care.

Literature Review

The literature review will highlight articles that supports the adoption EHR systems,

financial benefits, and incentives programs essential to the growth of the HCO.

One of the most important benefits of EHR systems is legibility. Historically, illegible

handwriting has been a prime source of medication errors. The Center for the Advancement of

Health (2007) stated that more than 60% of medication errors in hospitals could be traced to poor

handwriting. Therefore, managing medications through an EHR improves patient outcomes over

time and increases the standard of care.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 5

Another way an EHR improves treatment and clinical outcomes is by reducing the

number of duplicate tests and improving overall efficiency (Heath, 2016). An EHR system files

radiology imaging results, which can be accessed from within the application if clinicians need

to view the actual X-ray and the radiologist analysis. All EHR reports are available to all

providers involved in the patient’s healthcare and can be accessed at any time. It is essential to

indicate that EHR systems provide the same features. However, some features, such as the ability

to view X-rays in the EHR is a design feature and advancement cost for the facility (Bolan,

,2012).

Hospitals are increasingly adopting hospital information systems (HIS) with the evolution

of information technology (IT). The effective use of HIS reduces costs and improves patient care

in the healthcare industry. According to a 2005 nationwide survey on HIS development in Korea,

almost all Korean tertiary hospitals were equipped with hospitals were equipped with a HIS with

the following features such as, computerized provider order entry (CPOE) System, a picture

archiving and communication system, insurance claims by electronic data interchange, and

admission/discharge/transfer. However, only a few hospitals had adopted an EHR (Murphy,

2014).

According to Wilson (2018), before an EHR system can be implemented, there is a need

to evaluate the financial and employment status of the HCO. If the firm is at a stage where

technological advancements can be made successfully, and the employees are capable of

learning how to manage EHR, only then the implementation should be processed. The ability of

the firm to afford the infrastructure required to implement the electronic health record should be

assessed before it is implemented. This way, the process can be a smooth transition for both the

firm and its employees.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 6

To establish a smooth transition, every long-term implementation of an EHR system must

begin by setting up goals to be fulfilled within a specific timeframe. The goals should take into

consideration the present and future impacts of the implementation on the firm, making it easier

to avoid any unplanned issues. Once the goals are set, roles can be assigned to each member of

the staff along with clear guidelines on what needs to be done (Wilson, 2018).

Implementation costs of EHR systems vary according to circumstances and the project

plan. According to Fleming, Culler, McCorkle, Becker, & Ballard (2011), a typical multi-

physician practice would spend about $162,000 to implement an EHR, with $85,500 for first-

year maintenance costs. They estimated that the implementation teams spent approximately 611

hours "preparing for and implementing" the EHR system.

When implementing an electronic health record for patients, a revision of the HIPAA

regulations will become necessary. Initial deployment with patient records is a security risk if a

firm is unable to provide the necessary security to safeguard patient records. Loss of a patient’s

medical record is strictly dealt with under the HIPAA regulations, and without proper security

measures, firms may encounter serious legal litigation. Electronic health records make it much

easier for identity thieves to steal information if proper security measures are not put into place

(Wilson, 2018).

EHR system updates are essential for the growth of HCO in the healthcare landscape.

Wilson (2018) explained that for EHR software to be fully functional, it will need to be

constantly revised and improved in accordance with the changing needs of the firm. Making

regular plans for revision and assessment of the software will be necessary, as well as for fixing

any bugs. Regular upgrades, when necessary, will keep the system from going obsolete (Wilson,

2018).
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 7

An EHR system can aid HCO organization during extreme volume of patients in the

workplace. Kennebeck, Timm, Farrell, and Spooner (2015) analyzed a variance study on the

impact of EHRs on patient flow metrics in the pediatric emergency department at CCHMC

during rollout. ED patients were observed in four-time events of 2-week duration and nine

months after EHR implementation. The results showed that during implementation of the EHRs

system with increase of volume and stress there was a decrease in the LOS.

Incentive programs for encouraging implementation and use of EHR systems have

benefited many HCO. Ruggles (2012) explained that the HITECH Act, financial incentives for

adopting an EHR system, and the concept of “meaningful use” provided an EHR deployment

financial incentive plans through awards from the Centers for Medicare and Medicaid Services

(CMS). This voluntary incentive program was designed to encourage widespread EHR

deployment, promote innovation, and avoid imposing excessive financial burdens on healthcare

providers. Starting in 2011, these incentive payments have ranged from $44,000 each over five

years for the Medicare providers to $63,750 each over six years for Medicaid providers

(Ruggles, 2012). CMS grants these incentive payments to eligible professionals (EPs) or eligible

hospitals (EHs), either of which can demonstrate that they are engaging in efforts to adopt,

implement, or upgrade certified EHR technology.

With these guidelines directing the project to a safe EHR deployment, the project

followed a strict knowledge of HIPPA regulation, security measurements, and implemented a

strong EHR foundation in the Davidson Medical Center.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 8

Goals

The scope of this project focused on the successful implementation and deployment of an

EHR system in a primary medical practice in Little Rock, Arkansas. The cloud-based EHR was

designed to meet the challenges of value-based care. The project outcomes provide:

Interoperability

• Improving patient and provider interaction and communication, as well as health care

convenience.

Decreased Work Load

• Enabling providers to improve efficiency and meet their business goals;

• providing accurate, up-to-date, and complete information about patients at the point of

care;

• enabling quick access to patient records for more coordinated and efficient management;

• helping providers improve productivity and work-life balance; and

• helping providers more effectively diagnose patients, reduce medical errors, and provide

safer care.

Legibility

• Helping promote legible records; and

• providing complete and accurate documentation.

Patient Safety

• Enabling safer, more reliable prescribing; and

• reducing medical errors through electronic clinical documentation.

Security

• Securely sharing electronic information with patients and providers through HIPPA.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 9

Financial Incentive

• Financial incentive program through grants from the CMS; and

• Incentive payments ranging from $44,000 each over five years for the Medicare

providers to $63,750 each over six years for Medicaid providers.

The implementation will contribute resolutions for patient engagement and health

outcomes which will increase standards of care and assist providers to recognize patient needs,

risk, and promote efficient processing of clinical data and outcomes (EClinicalWorks, 2019).

Baker, Baker, and Dworkin (2018) stated that technology and patient engagement work together

and this combination will make patients become active participants in EHR healthcare.

EHR Implementation Plan and Participants

This report highlights a 2.5-year, three phase EHR implementation at the primary

practice. The approach was to understand the steps used in guiding the EHR implementation and

its development.

• Preparation Phase: Interview provider regarding EHR request and features. Develop and

design a workflow process that will aid in implementing and strengthening the EHR service

to reach the highest standard of care for the community. Recruit doctors and nurses,

technician, and billers. Complete simulation EHR implementation training with EHR

credential trainer. Implement a pre-go-live for training environment purposes for the staff.

Collect staff feedback review.

• Go-Live Phase: EHR enters operation.

• Post-Go-Live Phase: Collect feedback from the end user about their experience and concerns

with the go-live phase. Meet with stakeholders regarding the data collected from end-users

and the results. Update policies, procedures, and get approval to adopt changes with

stakeholders and staff.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 10

The participants of the EHR implementation include:

• Stakeholders—members of the primary practice who are financing the deployment and

development of the EHR design and implementation.

• EHR implementation manager—an expert of lean management training who will help in

managing the design of the implementation and the implementation.

• EHR credential trainers—EHR trainers who will develop and design courses for staff

training and development for the EHR system.

• Physician champion—EHR champion who will be used to influence other physicians in

accepting the EHR implementation and workflow process.

• Nurse lead—a nurse committed to the choice, plan, advancement, implementation, and

evaluation of the EHR system at the primary practice.

• Scheduler lead—an employee involved in the shift scheduling design.

• Billing staff lead—an employee involved in the financial billing and design of the EHR.

• Workflow redesign lead—an employee responsible for taking the lead design in the

workflow process for the EHR workflow.

• Super-user/Training lead--expert users of the system who understand the design, user-

interface, and commands. They help in the training and influence of other users.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 11

Project Timeline and Deliverables

The project timeline highlights the project plan Gantt chart of the EHR implementation

and the duration of time spent on each step of the three implementation phases.

The Gantt chart shows the initial steps of the preparation phase. The project implementation
had several delays during the preparation phase. The delays were seen during the “Choose
EHR vendor” and “Design EHR workflow process” and were 28 and 27 days, respectively.
These delays were attributed to understanding the list of EHR vendors and obtaining an
optimal workflow process.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 12

Gantt chart shows the second part of the preparation phase. The “Pre-Go Live
Implementation” saw several missteps in providers not understanding the EHR user
interface, which resulted in a delay in healthcare services. Therefore, a collection of
end-user feedback and reviews were vital to the update, tailoring the users’ experiences
to the EHR system.

Table 3 shows the Go-Live Phase and Post-Go Live Phase, both of which were the
culmination of one month of EHR development and updates in policies and procedures.
The Go-Live phase lasted for 153 days. During this time, staff members were not able
to adapt to the digital format which hindered the workflow.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 13

Lessons Learned

There were several lessons learned from this project :

• Before an EHR system is implemented, the HCO must evaluate the financial and

employment status of their organization. If the HCO is at a stage in which technological

improvements can be made successfully, and the employees are proficient in mastering

how to manage them, only then the implementation should be processed.

• Some staff members were not able to convert to the digital format, which slowed down

the sim lab training for several days. Providers rejected electronic formats when faced

with a technical difficulty and some returned to the outdated paper record. Therefore,

healthcare leaders and champions must consider an open discussion with the providers

and staff before bringing an EHR system into the practice or HCO.

• Organizational leadership, support, and communication from the start are keys to a

successful implementation. Leaders can be identified at all levels of the HCO and should

include those in the areas of compliance, legal, privacy, security, and patient safety.

• Implementation must support the needs and views of different types of end users. The

two main implementation approaches are a gradual rollout, in which components of the

EHR are exhibited over time, and a large-scale approach, in which all locations in the

organization begin using all the functionalities of the EHR at the same time. Each

approach has advantages and disadvantages. From a device perspective, it may be easier

to install everything in one physical location at a time. However, from a user perspective,

a provider typically wants to have the same workflow at each site where they practice.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 14

Conclusion

Since the implementation of the HITECH Act in 2009, the U.S. healthcare system has

improved quality, safety, and efficiency through EHR implementation (Menachemi & Collum,

2011). This led to patient engagement in their care, increased coordination of care, and

improvements to the health status of the population, while ensuring privacy and security.

Healthcare leaders and champions must understand the transitioning of EHR systems in their

workflow and must encourage others to accept and adapt to the electronic format on all levels of

HCO.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 15

References

Baker, J. J., Baker, R. W., & Dworkin, N. R. (2018). Chapter 3: The digital age: Changing the

landscape of healthcare finance. Health care finance: Basic tools for nonfinancial

manager (5th ed., pp. 23-24). Burlington, MA: Jones & Bartlett Learning.

Bolan, C. (2012, November 7). Tools for enhanced radiology workflow in an EHR environment.

Retrieved from https://www.appliedradiology.com/articles/tools-for-enhanced-radiology-

workflow-in-an-ehr-environment

Center for the Advancement of Health. (2007, June 27). Computerized doctors’ orders reduce

medication errors. ScienceDaily. Retrieved from

www.sciencedaily.com/releases/2007/06/070627084702.htm

EClinicalWorks. (2019). EClinicalWorks. Retrieved from https://www.eclinicalworks.com/

Fleming, N. S., Culler, S. D., McCorkle, R., Becker, E. R., & Ballard, D. J. (2011). The Financial

And Nonfinancial Costs Of Implementing Electronic Health Records In Primary Care

Practices. Retrieved from ttps://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2010.068

Gunter, T. D., & Terry, N. P. (2005). The emergence of national electronic health record

architectures in the United States and Australia: Models, costs, and questions. Journal of

Medical Internet Research, 7(1), e3. doi:10.2196/jmir.7.1.e3

Heath, S. (2016, January 14). Physician EHR use benefits quality performance, productivity.

EHR intelligence. Retrieved from https://ehrintelligence.com/news/physician-ehr-use-

benefits-quality-performance-productivity

Kennebeck, S. S., Timm, N., Farrell, M. K., & Spooner, S. A. (2011). Impact of electronic health

record implementation on patient flow metrics in a pediatric emergency department.

LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 16

Journal of American Medical Information Association, 19(3), X-Y. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341791/

Menachemi, N., & Collum, T. H. (2011). Benefits and drawbacks of electronic health record

systems. Risk management and healthcare policy, 4, 47–55. doi:10.2147/RMHP.S12985

Milstein, J. A., & Jha, A. K. (2017, August 7). HITECH Act Drove Large Gains In Hospital

Electronic Health Record Adoption. Retrieved May 9, 2019, from

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.1651

Murphy, E. V. (2014). Clinical decision support: Effectiveness in improving quality processes

and clinical outcomes and factors that may influence success. The Yale Journal of

Biology and Medicine, 87(2), 187-97. doi:

Ruggles, W. S. (2012). Electronic health records (EHR) deployment projects: A three-year

retrospective of the best and worst project management practices. Presentation at the

meeting of the PMI® Global Congress, Vancouver, British Columbia.

Top Mobile Trends. (2014, May 22). Mobile Tech Contributions to Healthcare & Patient

Experiences. Retrieved from http://topmobiletrends.com/mobile-technology-

contributions-patient-experience-parmar/

Wilson, M. (2018, October 23). 7 Steps for successful and efficient EHR implementation [web

log post]. Retrieved from https://www.healthworkscollective.com/7-steps-for-successful-

ehr-implementation/
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 17

HCI Program Competencies

By successful reporting and analyzing the experience of a primary clinic EHR rollout, all of

USD’s HCI program competencies were achieved.

1. Health Sciences Knowledge and Skills: This program competency was met by

demonstrating graduate level writing skills and knowledge of healthcare technology relevant to

the capstone topic. I learned practical professional knowledge and gained a better perspective of

project implementation at the primary care setting. I developed a clear understanding of how

EHR systems can play an essential role in an adequate standard of care to patients.

2. Leadership and Systems Management: This program competency was met through concepts

of ethical leadership principles to solving human systems applications and issues. The project

included the development of a project plan implementation. I interviewed several personnel from

the primary care setting and took account of their facts, goals, limitation, and roles they play in

the project implementation plan. I identified the project plan participants and their contribution to

the EHR project implementation at the primary care setting.

3. Systems Design and Management: This program competency was met by demonstrating an

understanding of failure mode effects analysis (FEMA) applied to the design and implementation

of the EHR system at the primary care setting. The “System and Design” and “Lean Six Sigma

Green Belt” was an essential component in understanding and analyzing the primary practice’s

project plan implementation. I learned that many missteps occurred during the project plan;

however, the transitioning of the EHR system changed the daily workflow and end-user

experience at the primary care setting. As a future clinical informaticist, it is essential not to lose

focus on the project goal and to adapt during the project implementation process.
LESSONS LEARNED DURING AN EHR SYSTEM ROLLOUT 18

4. Data and Knowledge Management: This program competency was met by demonstrating

proper technique for gathering, formatting, and storing data to investigate a given question or

problem. The project implementation phases highlighted the many steps and process of an EHR

system vendor approval, EHR training, workflow design, and policies are repeated modified

during the project plan. This taught me that changes occurred was essential to the success and

maintenance of the EHR system implementation.

5. Quality and Regulatory: This program competency was met by demonstrating methods for

the design of quality programs and performance improvement programs as applied to the

implementation of EHR systems. Through the design of the project plan, I learned that an

essential knowledge skill in identifying the quality outcomes that occurred in the EHR

implementation. This perspective showed how clinical analysist use mistakes that occurred in the

project plan to modify the direction of the project implementation.