eSSee Consulting

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:

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.
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.
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.)
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.
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.
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.

by Sean Carey

Policies and Practices Will Trump Your Rhetoric

The Atlantic recently published an enlightening article by veteran journalist Joe Williams, entitled, “My Life as a Retail Worker: Nasty, Brutish, and Poor,” where he writes about his experience working in a retail sporting goods shop after being laid off from Politico. It’s reminiscent of a phenomenal article Steven Lopez wrote in 2006: “Culture-Change Management in Long-Term Care: A Shop-Floor View,” which paints a similar picture of organizational rhetoric flatly denied by policy and practice.

Both articles highlight a common feature in highly bureaucratic organizations (which includes virtually all LTPAC providers): The rhetoric of person-centeredness, of genuine care about individuals, and of interest in the complexities of socio-economic conditions oftentimes falls flat in the face of organizational practices, strict “no-fault” policies, and unrealistic demands on individuals. In our work with providers, we constantly see discrepancies in the rhetoric of very caring leaders (We value our staff, we trust them to make good decisions, we put our residents first…) and the “machine” of the organization: inflexible attendance policies, collaborative discussions around all work issues except wages and working conditions, unrealistic labor demands on line staff… These two strong forces are like the legs of a person: if you don’t move too fast, you’ll probably drag each leg along without serious disruption. But try to run; try to walk quickly; try even to turn around: You’ll stumble and fall, like many well-intentioned providers.

Take this article published last month in McKnights. “Consistently assigning nursing home aides to particular residents could cause the aides to feel isolated and overburdened, suggests a study forthcoming in the Western Journal of Nursing Research.” Chris Perna, chief executive officer of the Eden Alternative, responded: “What the researchers can conclude is that the organizations involved did not do a very good job implementing these changes.” Pena went on to criticize the deployment of the program in the facilities studied, the sample size, and even that “the nursing homes in the study did not exemplify the principles of consistent assignment that Eden advocates.”

Pena is basically saying the organizations didn’t implement culture change correctly. It’s a common response to any criticism of the culture change framework, which intuitively feels right. And I get the feeling: my first job as a nursing home administrator was at a community lauded for it’s culture change practices, yet completely frenetic in staffing assignments. Through a long process, we developed a consistent assignment program that I felt was incredibly successful. From my vantage point as the administrator, I saw care outcomes were better (measure by incident numbers and the QI report), residents and staff were both happier (measured anecdotal and through satisfaction surveys), and absences were lower (measured through a detailed log we kept). But there was also roughness to this result. When a primary caregiver returned after a day off, they were invariably annoyed by small things the alternate did (or didn’t do). Teamwork was completely unaffected by consistency: those staff who helped extensive before consistent assignments continued to do so; and those who didn’t, didn’t. And the complaints about “certain groups of residents” intensified, as now it wasn’t luck if you were assigned “a hard group”– it was your fate. When we looked at outcomes on a microlevel, we found that one group consistently had lower staff satisfaction and higher turnover. Did we fail in our implementation? Did we not exemplify the principles well enough? No, I don’t think so. I think we discovered how life is infinitely more complex than a consistent assignment program can encapsulate. I think we discovered that our attendance policy was doing more harm to consistency than our staffing practices. And I think we discovered that not all CNAs want the same thing, not all residents want the same thing, and sometimes the competing priorities between administrators, staffing coordinators, line staff and residents mean that not everyone gets exactly what they want. And this is the heart of it.

The problem with culture change interventions, fundamentally, is that they are typically constructed in a vacuum of what could be. This is a great environment for designing a best practice, and a lousy environment for integrating real-world challenges. At the core of culture change philosophy is the tenet, “Know the person.” And it’s here where the tension is greatest. Know the person means consistent assignments are not best for all residents and all staff and all organizations. Neither is any other intervention. Programs must be designed locally and in context. And part of that context is the rest of the organization. What Lopez and Williams point out is that if your organization values people, don’t insist on policies that treat workers like criminals or children. If your organization demands loyalty, don’t stand behind policies that inflexibly respond to outcomes rather than processes. And if you care about doing the best work possible for residents, don’t create avenues for discussion that a priori exclude topics (like wages and working conditions).

Here’s a good way to start a more complex evaluation of culture change in your community: look at either your organization’s attendance or counseling policy. Does it reflect the person-centeredness of your organization? Does it reflect the values you expect line staff to show to your residents? Does it reflect your organization’s heart? Or is it formulaic, adversarial and reminiscent of the care processes your organization is committed to changing?

by Sean Carey

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): http://www.stratishealth.org/expertise/healthit/nursinghomes/

LeadingAge CAST EHR Selection Tool: http://www.leadingage.org/ehr/search.aspx

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.

by Sean Carey

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.

by Sean Carey

Where is the Lean?

While information about lean healthcare is rapidly expanding, from books to conferences to blogs, long-term care predictably remains largely absent from the conversations and resources. This is unfortunate on many levels, as the field would not only benefit from embracing the core value of respect for all people, but it also has so many fewer resources than other sectors of healthcare already and desperately needs to utilize those resources more effectively and efficiently.

First, a look at a few reasons why LTC is once again lagging behind the healthcare industry:

1) Long-term care organizations invest less in innovation. This unfortunate reality may have as much to do with scale as interest, but the end result is stark. According to a recent survey, 64% of large healthcare organizations have a Chief Innovation Officer— a position virtually unheard of in long-term care organizations. Meanwhile, most acute care organizations have adopted EMRs, while– though it’s difficult to know exact market penetration (itself a sign of lack of interest)– LTC implementation of EMRs may be as low as 6% (2012), though likely closer to the 50-60% range (2013 in MD). Even the resources that are spent– for instance, LeadingAge’s Innovation Fund— rarely result in replicated projects.

2) Long-term care organizations, more so than others in healthcare, rely on rigid, hierarchical management philosophies and strong command and control styles of operations. This not only stifles line staff involvement in change operations, but creates a culture of doing only what you are told to do and an atmosphere where fear of standing out leads to conservative and reactive action.

3) Long-term care is governed by a punitive system of survey and certification that values documentation of work and the following of rigid policies and procedures over quality outcomes and resident satisfaction. Because many problems are buried deeply within the established system, it is much easier to rely on blaming of individuals rather than fixing systems. (Indeed, I’ve had many surveyors demand to see records of disciplinary action when errors have occurred despite evidence of systemic root causes.)

4) Metrics of performance are based largely on payment realities (census, PPDs, case mix) rather than satisfaction, effectiveness of operations or continued improvement. Additionally, trade organizations representing communities focus on eternal realities, like Medicaid funding shortfalls, rather than driving more efficient deployment of existing resources.

5) Many nursing homes exist in a perpetual state of near or semi crisis, fueled by unconscionably low wages and high turnover of line staff, insufficient labor, organization- and industry-wide financial strain, and near-constant threat of adverse regulatory and legal action.

In a recent article in the Gerontologist, Bishop et al notes:

Frontline service production in some traditional nursing homes exhibits many of the features of a classic “low road” enterprise, where management attempts to keep labor costs as low as possible through fragmented jobs and close supervision (Handel & Gittleman, 2004). Nursing home direct care jobs have few skill requirements, minimal selectivity in hiring, cursory initial orientation and on-the-job training, low wages and benefits, and supervision focused on completion of defined tasks (Bishop et al., 2008). Nursing assistants describe the work itself as repetitive, taxing, and demeaning. Workers are treated as unreliable and easily replaceable. High turnover justifies low on-the-job investment in workers’ skills, because internally trained workers are likely to leave for better opportunities.

Some culture-change adopters will point to their organizations’ success in overcoming some of these challenges. However, as Lopez (2006) noted in “Culture Change Management in Long-Term Care: A Shop-Floor View,”

resource limitations also forced management to adopt a series of punitive personnel policies that actively undercut the rhetoric and aims of culture change, turning culture change into a rhetorical device for shifting blame for care problems from structural resource limitations onto the attitudes of nursing aides.”

We’ve found this to be the case more often than not, with culture change-oriented organizations blissfully unaware of how their embrace of culture change principles is only skin-deep.

Where Lean Comes In

Building a lean culture offers many, connected benefits, from designing systems that support residents to valuing, respecting and trusting front-line staff to make improvements that bring benefits for everyone:

Creating or sustaining a culture of respect for people: Lean requires organizations to rethink the value of line staff, trusting those staff as both the experts and the agents of improvement.
Focusing on value: Lean thinking helps identify waste that is endemic in long-term care from poor inventory management to convoluted admission practices to absurd meal delivery systems.
Placing the resident first: Lean is, by nature, resident-centered. Using tools like VOC (voice of the customer), value stream mapping, and gemba visits, Lean helps identify areas where organizations are wasting resources or failing to meet needs.
QAPI-ready: Lean, especially when combined with six sigma, is a perfect method to drive QAPI programs, fully meeting CMS QAPI requirements and indeed building the very culture QAPI envisioned.
Operational edge: Lean helps organizations use the resources they already have to do better work. It leads to higher resident and staff satisfaction, higher census, reduced turnover time and better leveraging of human and capital resources.

The Affordable Care Act will continue to put pressure on long term care organizations to perform better, smarter, and more efficiently. Lean is the best way to make all of these things happen at once.

Ready to get started? So are we!