Archive for category: EHR

What Happens After Go-Live

You’ve spent months and months preparing for this day. Hundreds of thousands of dollars have been invested in software, technology, and internal capital upgrades to make it possible. Staff have invested dozens of hours training, practicing, and readying themselves. It’s go-live day for your EHR.

A few hiccups aside, things go well. Line staff are happy and excited about the new technology. Administration is thrilled about new ways to easily view census, incidents and other crucial operational information. Implementation looks like it has gone better than expected. So what now?

At this juncture, organizations typically go in one of two directions. Successful organizations see go-live as the mid-point in an adoption strategy. It’s a time to celebrate a significant milestone, for sure, but also a time to begin the evaluation of the system implementation, measurement of workflow improvements, refresher trainings for staff, and planning for future improvements and changes. Even more crucially, it’s a time to listen carefully to staff, to ask probing questions like, “Is there anything that isn’t working like we thought it would?”, “What tasks are easier with the EHR? What tasks are more difficult?”, and “What are some questions you’ve had and have you been able to find the answers you need?”

The other direction, unfortunately, is more common. In the chaotic environment that most healthcare organizations exist in, go-live day represents a giant relief, the end to an over-time, over-budget project that was thrust on top of many other crucial priorities. Things seem to be running smoothly, and you hear few complaints, so you close the project and move on. 90 days after go live, your vendor implementation manager calls, asks if everything is going well, and then quickly closes the implementation and passes your organization on to the support team. Done and done. You return to the everyday challenges of caring for residents.

Oftentimes, when called in to optimize an existing installation, we see the aftermath of organizations that chose the second direction. We find EHR systems that are underutilized, redundant storage of knowledge (Excel spreadsheets, homegrown Access databases, paper files), and staff that have begrudgingly accepted impaired workflows. It’s a long process to re-implement systems, rebuild staff trust in technology, and finally capture the crucial business intelligence essential to an organization’s success in today’s market.

A Better Way Forward

Here’s what successful organizations do after go-live:

  1. Begin the next phase of the EHR project. Ideally, the post-go-live phase was already built into your project plan, and you’ve already established clear goals for the system, plans to measure against those goals, and a proactive strategy to understand how the EHR is integrating into workflows and how to adjust as necessary.
  2. Commit to one place for data. Many organizations are loathe to give up their trusted Excel-based census tracking worksheets and paper-based incident tracking systems. Resist the urge to keep data in different places. To fully capitalize on the business intelligence and analytic features of EHRs, you need to have all the data in one place to properly guide future decision-making. Data analytics is quickly reshaping all of healthcare. For LTPAC providers, this means you must have accurate data on rehab outcomes, rehospitalization statistics, and efficiency of operations. If your EHR solution is a barrier, press your vendor for added functionality. Chances are good they either have a solution from another provider, or, more likely, other providers are struggling with and clamoring for the same solution.
  3. Ask staff probing questions. It’s not enough to ask, “Is everything okay?” At one organization where I served as administrator, I discovered months after implementation that some of our med aides were not following the proper procedures to chart their med pass. In researching why the staff had not mentioned the deviation before, I discovered that they had never been able to follow the process as described, but quickly found a workaround that seemed to work. When I would ask if everything was okay in the months after go-live, naturally and honestly they answered, “Sure!” Ask staff directly if things are working as expected. Ask regularly if staff are finding different ways to accomplish tasks. Encourage your superusers to report common questions and issues so you can examine whether there are organization-wide trends.It’s also crucial to note, you must approach problems with usage of the EHR with a “just” mindset. This means if staff are not following established protocols, it’s crucial to understand why in a way that doesn’t place blame on individuals when the problems are system-induced. (And in our experience, virtually all problems with EHR usage are system-induced.)
  4. Stay curious. EHRs vendors are quick to promise their system will do everything under the sun. It won’t, trust us. EHRs currently on the market are clunky adaptations of LTPAC operations. For some processes, you will ask how to do something and receive an answer of either the EHR can’t do that, or it can, but requires a complex set of steps. Push your vendor to simplify steps and improve workflows. What EHR vendors lack in user experience design and functionality, they more than make up in attention to customer needs. So be vocal about what you need and what you’d like to see. Remember Robert Kennedy: “Some [people] see things as they are and ask why—I dream things that never were, and ask why not?” Ask why not. Often.
  5. If something doesn’t work, don’t give up on it. This part is a little shocking to us, but we find many organizations that, after struggling to adopt a certain feature or workflow, simply decide an EHR can’t support this part of their business and drop it. One time, we worked with a client that had paid for the billing/ finance module of an EHR, but had completely abandoned it in favor of staying with Quickbooks because they weren’t able to get the system to bill correctly for their independent residents. Resist the temptation. If a billing module doesn’t support your CCRC model, talk openly with your vendor about what you are trying to accomplish. Take a look at your internal process, as well, and be open to reconceptualization of your processes. While current EHRs are clunky, they are hardly impotent. Don’t give up on such a big investment.
  6. Be open to—brace yourself—replacing your shiny new EHR. Most vendors work hard to ensure client satisfaction, but if you find yourself with a vendor who refuses to work with your struggles and challenges, go back to your shortlist and reexamine other vendors. The cost to replace a system is truly less than continuing to use a beast that doesn’t actually improve your operations and ability to care for your residents.

What Next?

Are you considering an EHR? Struggling with a recent implantation? Learned some other lessons? Get in touch! We’d love to hear about your experiences and talk about how we might help you succeed.

Beginning the Search for an EHR

Choosing an EHR is a significant investment in time, resources, and staff goodwill. When advising clients, we typically suggest building an EHR project around a six sigma model for clarity and control of outcomes.

This article won’t go into the details of project management, but if your organization is inexperienced in this area, we highly recommend bringing in an outside consultant to reduce the risk of project failure or cost overruns. As with any project, choosing the project team, identifying the appropriate project manager and sponsor, and clearly chartering the project are all front-end requisites to success.

The EHR project should specifically include a post-implementation or “go-live” phase, which is oftentimes skipped or marginalized by EHR vendors. This post-implementation phase should include measurement of progress towards goals, user adoption and satisfaction testing, and initial ROI calculations. After all, you hopefully are designing for adoption, not just implementation.


Organization Review and Goals

To begin, you need to adequately define your current state (assess IT infrastructure, map workflows, measure staff engagement and readiness, quantify funding sources). The following websites have some great resources for beginning this process:

Stratis Health (a QIO based in MN):

LeadingAge CAST EHR Selection Tool:

You should also explicitly define goals for the EHR system: what do you want it to do? What areas of performance do you expect to improve? Be specific and measurable in selecting goals. Vendors are never happier than when they are explaining how their solution will save time, money, lives, etc, oftentimes with very little commitment to helping you actually achieve these efficiencies.


EHR Vendor Considerations

Hosted vs. Local Installation

Most EHRs offer a hosted version of their service (either through purchase or as a Software as a Services (SaaS) option, and some allow for software to be installed locally. Each option has advantages and challenges:

Hosted Solutions:

  • Vendor managed storage, reliability, upgrades and security reduces infrastructure and capital needs. Most vendors offer uptime guarantees and automatic upgrades to the latest version. In addition, vendors typically conduct ongoing, comprehensive security and penetration testing, meaning, somewhat counterintuitively, the data is typically more secure than with local installations.
  • Usually offered on a monthly contract or service charge basis, which can lower initial deployment costs substantially.
  • The ownership of data varies, and it’s important to clarify at the onset. When a vendor owns the data, migrating to another solution in the future can prove to be an expensive proposition.
  • Usage of the software is dependent on internet access, and reliability at the community site, thus, is crucial. Most organizations are not able to afford redundant solutions or direct internet pipelines, which can lead to some risk of downtime. Many EHRs have ways to mitigate the risks and challenges of internet disruption, such as local backups for time sensitive items like resident facesheets and MARs.

Local Installations:

  • Software is oftentimes more customizable for a particular organization’s needs.
  • Though it requires a higher up-front investment, purchased solutions may be less expensive over time, especially for organizations with already expansive IT capabilities.
  • Less reliance on internet connectivity, which may be crucial for locations with intermittent or unreliable access to the internet.
  • In addition to software, hardware investments and ongoing IT staff costs may be significant.

Platform/ Browser Dependence

Some EHR solutions are dependent on Microsoft Windows and/ or Internet Explorer. Additionally, EHR vendors are beginning to develop mobile applications, which may be only available on either iOS (Apple) or Android platforms. In general, dependence on a particular platform or browser is not recommended, though many otherwise good LTPAC EHR vendors are designed in such a fashion. Unfortunately, this practice can raise the cost of hardware, particular if using specific mobile or tablet technology. Software that is only capable of running on a desktop environment is not recommended, as the technology is quickly being surpassed by tablet technology with lowers costs and more person-centered design options.

Reporting Features

EHRs capture a tremendous amount of data. Using this data in a meaningful way, however, is a very different proposition. It’s important to review report writing capabilities of EHR systems thoroughly, as this area has been significantly overlooked in the vendors’ rush to capture market share. Specifically, you want to understand:

  • How does reporting work in the EHR? What reports are standard? How are options controlled? What export formats are available?
  • What options are available for customized report writing? Can the data be segmented and can multiple data fields be included in report writing?

Person-Centered Practices and Assisted Living Environments

Most EHRs were initially designed as revenue cycle management platforms. Accordingly, the software and databases are well-attuned to catching and reporting MDS data at the expense of resident outcomes. As you explore vendors, consider how the user experience allows (or hinders) access to the data that is important in day-to-day operations. Are nurses able to easily manage resident health issues? Are care plan templates designed to allow for flexibility in display and reporting to suit different user needs (e.g., LN vs. CNA vs. family member)? Are point of care portals intuitive and easy to use?

On this note, if your community has an assisted living component, carefully examine any AL-specific modules. Does it reflect your needs and workflows? Does the system focus on the whole resident rather than just the medical record and ADL capture? Most EHR vendors took SNF modules and repackaged them for ALFs, which has led to unnecessary medicalization of these community-based-care environments.

Vendor Contracts and Post-Selection

We’ve seen countless organizations trust vendors to ensure a smooth transition only to struggle as customization takes longer than expected, costs run over budget, and the final product offers less than what was expected. An important way to protect your organization is to make the vendor contract contingent on project milestones and based on project outcomes, not hours involved. We also recommend adding contract language that allows an organization to refuse payment for any vendor-controlled cost overruns. (Vendor-supplied agreements typically promise only an “estimate” of implementation costs based on vendor-recorded hours, while calling for fees of up to $125 per hour for overruns– even when caused by the vendor!) Timeliness penalties are also becoming more common, and can help ensure a vendor keeps to the established timeline.

During the post-selection phase, it’s important to maintain open and honest communication with the vendor. If you run into issues or challenges, don’t be afraid to speak up. It’s also sometimes useful to keep 2nd and 3rd choice vendors engaged, as it’s never too late to change direction based on outcomes of the implementation process. While switching mid-stream may seem expensive or wasteful, it’s far worse to end up with a vendor not committed to your success.

Final Thoughts

Current EHR systems on the market are valuable tools to manage data more effectively and streamline some of the labor-intensive parts of LTPAC operations. At the same time, they are not perfect solutions, and unfortunately reflect too much history as revenue cycle agents and not enough experience in day-to-day operations. Worse, all complete EHR systems currently on the market suffer from a deep bias of chartopomorphism, or paper-centric thinking, which hampers the ability of much of the healthcare industry to leverage technology in the same way that other industries have done (think Apple, Amazon, Google, and Netflix). This means that we likely will see tremendous innovation moving forward, and some of the giants today will struggle or fall away in the near future. Staying on top of technology solutions, rather than clinging tight to a trusted vendor, will require LTPAC organizations to think differently than they have in the past and embrace change much more quickly and lightheartedly.

HIMSS14 Recap: Long-Term Care Absent, But Not Entirely Forgotten

HIMSS14 has been a great conference, and there are some amazing technologies and uses of data that will continue to push innovation forward in healthcare. Unfortunately– though predictably– the post-acute/ long-term care sector was sadly underrepresented. Of three sessions with a LTPAC focus, one was canceled, and the others, while excellent, were scantily attended.

A quick recap of some exciting ideas, products, and innovation:

  • Massachusetts has an exciting, ONC-funded program called IMPACT– Improving Massachusetts Post Acute Transfers– that has created a HIE-based platform for connecting long term care providers to secure messaging features, a universal transfer form, and a program called LAND and SEE (Local Adapter for Network Distribution and Surrogate EHR Envronment) . You can read more about the last piece and its architecture here, but it essentially provides a way for LTC communities without an EHR to receive, edit, and send CCDs through a portal connected with acute care EHRs. The pilot program is still being evaluated, but early feedback from providers in all areas of the healthcare continuum seems to be positive.
  • PracticeFusion, a fast-growing, web-based, free EHR has an impressive set of features and very thoughtful UX. We’d love to seem a similar program built out for assisted living communities that don’t require the revenue-cycle-heavy components of current LTPAC EHR vendors (and their associated focus on clinical documentation and ADL capture).
  • Speaking of LTPAC EHR vendors, it was interesting that HealthMedX (Vision) and MDI Achieve (MatrixCare) had a sizable presence in both the interoperability showcase and the exhibition hall; they’re definitely both very forward-thinking organizations. Answers on Demand had a small booth tucked away in the back (we almost missed them) and PointClickCare was nowhere to be found; we wonder if this is telling about the future of this market.
  • Real-time location services (RTLS) is big and growing. The price point of the technology is dropping quickly, and there are a variety of connection strategies, from wifi-enabled to passive IR to bluetooth/ RFID. There are a lot of applications in aging services, particularly in independent, assisted and dementia-specific communities. Additionally, it’s starting to show some promise with device interconnectivity and asset management. (Can’t find which room the Hoyer is hidden in? RTLS provides a cheap solution that will make CNAs’ jobs infinitely easier– and potentially reduce unsafe transfers.)
  • Ed Park, COO of Athena Health, delivered the best presentation of the conference: What Healthcare can Learn form Amazon. His slides are also fabulous. Park totally gets what’s needed in healthcare IT, and we hope he’ll push EHR vendors to adopt and publish open APIs, and collaborate with partners in a way that places persons served at the center of thinking.
  • Deb Fournier and Clint Davies shared the experience of the Maine Veterans Home EMR implementation. Their slides are worth a look by any organization considering an EMR in the near future. They also experienced some of the challenges when approaching an EMR as an implementation instead of an adoption.

Stay tuned for more learnings and ideas from the conference; we’re still analyzing technologies and forging connections, and we hope to have more things to share soon. It’s been a full week, and we’re super excited about the future of healthcare IT, particularly in aging services.

Design for Adoption, Not Implementation

Talking with a colleague at UNC Healthcare (currently undergoing an EPIC adventure), I’m reminded that most healthcare organizations approach EHR transitions from a misguided perspective. Driven by software vendors’ implementation teams, providers try to recreate old workflows with the new systems.  The new processes, rather than being rethought for efficiency and effectiveness, are designed to closely resemble the old way of doing things, and either become more complex or, worse, fail to capture the massive power of EHRs. Occasionally, when blocked by the software (obviously not designed by anyone remotely connected to practice), a new process is developed and thrust upon staff. Not only does this complicate workflow, it tempts line staff to develop workarounds to retain their old way of functioning.

Predictably, providers struggle to realize the benefit of EHRs. In a recent study, HealthLeaders Media reported 27% of healthcare leaders felt EHR systems were a waste of money. In a great article written several years ago, Jon Roberts aptly describes the dilemma still true today:

Traditionally hospital staff learn to use a new IT system the following way: The IT vendor designs classes to teach staff how to use the new system. Classroom time and content vary based on the job that each person does. Some staff are anointed as “super-users” and meant to be a resource to the standard “end users” who will need help in the future. Once the coursework is completed, staff are given time to practice using the system, often with super-users present to help navigate through problems.


The problem with this approach is a matter of context. People are taught how to use the new system according to the system’s functionality, not according to how staff will use the system to do their job. That’s a major distinction. I’ve observed many of these classroom sessions, and when the instructor asks, “Does anybody have any questions?” the room gets quiet. People don’t know what they don’t know.


When the system is up and running, it becomes immediately clear to staff when they have a question, but it is rarely clear where to turn, and patients are waiting. This is when the hidden costs of a new EMR begin to reveal themselves and productivity drops.

I remember working with one community that had adopted an EHR several years before. CNAs charted bowel movements in the point-of-care application and in a notebook at the nurses station. Then, at shift change, the information was communicated yet again, verbally, to the next shift. Even though the EHR provided a system for tracking bowel movements, the nurses had found it too cumbersome to use the reporting feature and thus recreated a paper binder. Then, because not everyone looked at the binder, the information was communicated in person.

When the process was redesigned to incorporate the customized alerting feature of the EHR, the nurses were provided with more timely notice of needed action, and 1.25 hours of daily CNA time was recovered.

What can be done?

First, we need to stop thinking of the process of bringing on an EHR as implementation and start thinking about it as adoption. It’s a new way of doing work: expect it to be complicated; expect the EHR vendor to misunderstand your community; expect hiccups and roadblocks and brick walls. Implementation focuses on a “go-live” date, whereas adoption focuses on successfully achieving certain predetermined outcomes. Thus, adoption continues long after an implementation ends.

Second, evaluate your current practices carefully. Examine the new workflows proposed by the EHR system. Collaborative redesign workflows to integrate EHR tasks into other work without relying on one-to-one transition from old paper-based recording to electronic means.

Third, ensure the training plan is reflective of future users. The train-the-trainer model used by most vendors misunderstands communications practices, adult learning styles, shift-based schedules, and workplace dynamics. Instead, training should be designed for specific roles and tasks and include a process of evaluating mastery.

Finally, leadership must commit to actively supporting, monitoring, and adjusting the adoption as an ongoing priority, not as a delegated task or finite project. When adopted correctly, EHRs can vastly simplify cumbersome processes, drive enormous efficiencies, and increase staff satisfaction. Incorrectly, EHRs can drive exactly the opposite.

For further reading, I strongly suggest Beyond Implementation: A Prescription for Lasting EMR Adoption.

Ready to get started? So are we!