Change Management and Training

Change Management

Implementation of a new EHR will clearly change the way things are done in the practice. Every employee and patient of the office will be impacted. Management of change is an important factor to address in the implementation to avoid ultimately impacting patient care negatively.

In preparing for an implementation, it is not to be expected that everyone in the organization will embrace the new technology. A culture of change will need to be established. Thought leaders in the organization can be instrumental in achieving this.

A physician champion should be chosen. This individual's role is to be the driving orcs behind the implementation. This natural leader is first a clinician, yet understands the system and can bridge the gap between the different departments. It is not always the best strategy to select the most technologically savvy person for this task. This individual may be distracted by the fascinating new technology and divert attention to the actual software and architecture. While this is a needed role, the physician champion should be one who can instill a culture of change in the organization. <ref name="Carter">Carter JH. Electronic Health Records, Second Edition. 2nd ed. American College of Physicians; 2008. [1]</ref>

Clear, quantifiable goals must be established. This will help establish the measurements of success in the project plan. Goals must be attainable, yet challenging. One report identifies the "Three T's" of a successful EHR implementation: team, tactics, and technology. <ref>Adler KG. How to successfully navigate your EHR implementation. Fam Pract Manag. 2007 Feb;14(2):33–9. [2]</ref>

Four types of physician users have been identified by Carter. <ref name="Carter">Carter JH. Electronic Health Records, Second Edition. 2nd ed. American College of Physicians; 2008. [3]</ref> These qualities can be expanded to all individuals involved in the operation of a clinic.

Resistant users
While it is tempting to focus on these individuals to achieve complete buy-in, it may not be strategic to do so. In shifting the culture of the workplace toward an electronic environment, these individuals will start to see the benefits through other users' experiences. Over time, many of these users will learn to accept the technology. Eventually, the use of electronic health records will become standard of care. Those still unwilling or unable to provide this standard of care may not have a place in the fully electronic clinic.

Variable users
These users will be more willing to adapt if evidence suggests a benefit in efficiency or quality of care. A strategy with these individuals is to support them in the functions that they embrace while slowly introducing other features to the workflow.

Consistent users
These users want to use an EHR, believing in the benefits. If supported well in this usage, these individuals can be one of the driving forces behind acceptance of the EHR by the more cautious or resistance users.

Technophile users
These users embrace the EHR and technology. They tend to be fast learners and capable of providing advice. They can be valuable resources for suggestions and planning of future feature enhancements. Perhaps they might even have the skills and motivation to join the OpenEMR development team or code some enhancements to the system. On the other hand, technophiles have the potential to be disruptive by attempting to advance the implementation too quickly or having unrealistic expectations of the technology.

A perspective on an implementation of a commercial EHR in a small internal medicine clinic addresses five areas to address: financing, interoperability, workflow redesign, training and technical support, and change management. <ref>Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic health records: just around the corner? Or over the cliff? Ann. Intern. Med. 2005 Aug 2;143(3):222–6. [4]</ref> Many of the issues discussed involved human, rather than technical problems.

The experience in the model implementation demonstrated that a slow, gradual approach may be suitable for many clinics. Once the previous steps outlined in this manual have been addressed, OpenEMR can effectively be introduced one module at a time. The calendar is a good place to start. Use of the calendar will detect some issues with the demographics and be a test on how disruptive entering each patient will be on future workflow. With a new charting system, every patient is a new patient. This will increase workload for some time.

Training

Training is an essential part of making an implementation successful. A Users Guide is available on the wiki. Superusers in each department should be trained from this manual, and then proceed to train the other staff. A test server can be helpful in learning and training, so users do not need to worry about "messing up" the live installation. There is also a demo available on the OpenEMR website. Another resource is the OpenEMR forums.

Training requires additional resources. There may be need for temporary help or overtime. This should be in the budget for the project. It can be anticipated that departmental meetings will be held, tying up all staff in a department. Frequent meetings and focus groups can help discover workflow redesign issues. These meeting may be over lunch or after hours, requiring overtime pay. Alternately, the clinic can be closed to patients during certain times, requiring planning and communication.

Everyone learns at a different pace. Identify the quick learners and take advantage of their skill by having them mentor other users. Scheduling of staff may need to be adapted to ensure proficient users are present at all times after implementation.

Training does not stop when OpenEMR goes live. There are always new functions to learn. Difficult situations may occur at first. Plan on decreasing patient load for some time after the system goes live to allow for people to settle into the system.

While auditing is important, it is counterproductive to maintain both the paper and the OpenEMR workflows for any length of time. Double documentation wastes time and efficiency, and may contribute to omissions or errors. When training a new process, audit using both systems for a short time and check that the information is accurate and retrievable from OpenEMR. Be specific with the auditing plan, and once it is completed satisfactorily retire the paper workflow and move forward. Some users will tend to hold on to the old way. Use individuals embracing the new technology to promote the culture of change.

Discussion

The human response to advances in technology can be challenging. Many times a failed implementation is not a weakness with the technology, but with the workflow around it. Maintaining a healthy workplace is crucial to success. This may cost time, resources, and ultimately money from the budget, but the cost of failure is much greater. As evidenced in the OpenEMR forums, there are many different types of clinics and practitioners successfully reaping the benefits of open source medical software. OpenEMR is adaptable to most practices, if the practice is adaptable to OpenEMR.

References

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