Black Book Rankings dubbed 2013 “The Year of the Great EHR Vendor Switch” when its annual EHR user survey revealed that 17 percent of physicians practices planned to ditch their existing EHRs for new ones. However, if the first half of the year is any indication, 2014 promises to be rife with even more EHR replacement activity. This trend is being driven by not only customer dissatisfaction, but also the widespread merger and acquisition activity occurring among healthcare providers.
It’s no secret that when a health system acquires new hospitals or physicians practices, the parent company often requires its new affiliates to adopt the enterprise EHR platform in use throughout the system — regardless of the other EHR solutions that may already be in place at these facilities. Standardization on a common platform offers several benefits, including facilitated data exchange among providers and universal familiarity with a single software interface. However, a mandatory transition to a new EHR platform can cause pain for acquired providers and the health system at large if not handled properly. For example, a mismanaged conversion can result in corrupt or lost health data, create dissent among clinicians, and severely impede provider productivity.
EHR rip-and-replace activity is currently running rampant. UPMC Hamot’s recent transition to the health system’s Cerner EHR platform provides an inside look at UPMC’s winning EHR conversion formula.
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Black Book Rankings dubbed 2013 “The Year of the Great EHR Vendor Switch” when its annual EHR user survey revealed that 17 percent of physicians practices planned to ditch their existing EHRs for new ones. However, if the first half of the year is any indication, 2014 promises to be rife with even more EHR replacement activity. This trend is being driven by not only customer dissatisfaction, but also the widespread merger and acquisition activity occurring among healthcare providers.
It’s no secret that when a health system acquires new hospitals or physicians practices, the parent company often requires its new affiliates to adopt the enterprise EHR platform in use throughout the system — regardless of the other EHR solutions that may already be in place at these facilities. Standardization on a common platform offers several benefits, including facilitated data exchange among providers and universal familiarity with a single software interface. However, a mandatory transition to a new EHR platform can cause pain for acquired providers and the health system at large if not handled properly. For example, a mismanaged conversion can result in corrupt or lost health data, create dissent among clinicians, and severely impede provider productivity.
UPMC (University of Pittsburgh Medical Center) is well-schooled on the intricacies of an effective EHR transition. Over the years, the health system has acquired several hospitals and physicians practices throughout western Pennsylvania. Per its policy, UPMC requires each of the hospitals it acquires to adopt its Cerner inpatient EHR system. Initially, the health system used a staged or phased approach to move newly acquired hospitals over to Cerner one department or module at a time. However, in recent years, UPMC began to institute a “big bang” approach to the EHR transition — wherein all systems and departments go live on the new Cerner EHR at a single point in time. The “big bang” approach is logistically more complex and introduces more risk, but it also shortens an often painful learning curve and accelerates the benefits to be gained from a standardized system.
Hamot Hospital, a 446-bed hospital located in Erie, PA, is the latest facility in the UPMC network to go through the “big bang” transition to Cerner. Acquired by UPMC in 2011, Hamot (now UPMC Hamot) was required to orchestrate a complete shift from its Siemens Soarian EHR to UPMC’s Cerner platform by Sept. 22, 2012 — giving the provider a little more than one year to execute this monumental transition. This article chronicles how Hamot (in conjunction with UPMC) successfully addressed this challenge.
Preparation Is Essential
The Sept. 22, 2012 conversion date wasn’t pulled out of thin air. It was selected based on several factors. First, Hamot’s Siemens contracts were up for renewal at the end of November 2012, and UPMC couldn’t justify extending these contracts when it knew a switch to Cerner was inevitable. Therefore, UPMC was forced to expedite Hamot’s transition to Cerner to avoid this expense. This was particularly challenging given that Hamot was much larger than any of the other hospitals UPMC had converted to Cerner up to that point. Second, the fact that Sept. 22, 2012 was a Saturday made it appealing because it provided UPMC with at least some measure of control over its environment, ensuring the conversion would have limited impact on patient care.
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“Overall, hospital traffic is slower on weekends,” says Dr. Richard Long, SVP and CMO of UPMC Hamot. “We’re a trauma center, so we can’t close our doors, but our OR schedule tends to be lighter on weekends. Plus, we could purposefully limit the number of elective cases we added to the docket during the first full week after launch.”
The formation of a transition operations team was one of the initial steps UPMC took in preparation for the EHR switchover. This team was led by a UPMC-appointed project manager and also consisted of Hamot’s director of information systems, director of clinical and operation informatics, and director of infrastructure IT. This small team of individuals was responsible for the day-to-day planning and provisions related to the EHR conversion. Hamot’s CMO and COO were also instrumental participants in several aspects of the transition.
The transition operations team spent months meeting on a weekly basis and performing careful walkthroughs and impact analysis exercises. They detailed their findings in countless spreadsheets and flow charts that outlined exactly what was going to occur in every area of the hospital during the day of the EHR switchover. These meetings increased to a daily frequency during the month leading up to the launch date. The operations team was also charged with keeping Hamot’s staff educated and enthusiastic about this monumental event. Team members even placed clocks throughout the hospital that provided a real-time countdown to the EHR launch date in an effort to keep personnel focused on and invested in the task at hand.
New EHR Education, Training Prove Challenging
Clinical education was a key area of emphasis for UPMC Hamot in preparation for the EHR transition, but it also proved to be a significant challenge. Hamot was no stranger to EHR technology. It had been a longtime user of Siemens Soarian for its clinical documentation. However, most Hamot physicians never used the platform for order entry. Instead, most still wrote their notes on a paper chart. The switch to Cerner would require Hamot physicians to begin leveraging CPOE (computerized physician order entry) as soon as the new system went live. Making physicians comfortable with a completely different workflow process and getting support staff familiar with a new EHR software interface required a great deal of training prior to the launch. This was a learning experience that was often painful for the participants.
“Frustration was palpable throughout the EHR training process,” says David Gibbons, EVP and COO of UPMC Hamot. “Employees that had been power users of the Soarian platform felt like the transition took them from performing at a collegiate level and knocked them back to kindergarten with the push of a button. The physicians were also resistant to change. They were set in their paper-charting ways and moving to CPOE was foreign to them. Furthermore, they felt like the added data entry slowed them down.”
Time and repetition using the new Cerner platform was enough to ease the frustration of Hamot’s nonclinical staff. However, gaining buy-in and adoption of the new software from physicians required a more strategic approach. UPMC assigned several physician champions (both internally and from other UPMC hospitals already using Cerner) to provide continual support to Hamot doctors throughout the transition process. A considerable percentage of physician training efforts was also focused on building EHR templates for specific specialties and disciplines. The thought process was the right templates could streamline data entry requirements and limit the pain the workflow change would have on physicians.
Balancing the preparations required for the EHR transition while maintaining the existing day-to-day hospital operations also proved to be a huge challenge for UPMC Hamot. “When involved in a project of this nature, there’s always an awkward period of time where you have to keep your feet in two different worlds,” says Lisa McChesney, director of information systems at UPMC Hamot. “You need to create the systems and processes necessary for the future, but you also have to keep everything working the way it’s supposed to until you get to that point. This is difficult because with an EHR, you’re not dealing with just one application, but with a number of moving technical components and associated human interactions.”
According to McChesney, there were notable technical challenges that came along with this balancing act. One was networking and reconciling Active Directory information for two different EHR systems.
EHR Transition Reveals New Hardware, Authentication Demands
Education, training, and technical infrastructure adjustments are expected elements of an EHR conversion. However, inevitably, some unexpected needs are uncovered during the transition process that must be addressed to ensure a successful launch. For Hamot, a particularly eye-opening revelation was the significant amount of new computing hardware that would be required to use the new Cerner EHR. Again, CPOE would be leveraged extensively with Cerner. Therefore, additional computers in various forms and locations were needed to effectively support the clinicians’ new CPOE and automated medication administration workflows. Long says the hospital purchased numerous new COWs (computers on wheels) to support the move to Cerner.
The increased hardware demands and clinical workflow changes also made it necessary for Hamot to completely redesign each of the nursing stations throughout the hospital. “We went from two or three computers at a main nurses’ station to six,” says Long. “Plus, we designated the main computers at the center of each nursing station for physician-use only to ensure a computer is always available for a doctor when they need it. This helps to streamline physician workflow.”
Heightened computer use among clinicians also introduced another potential workflow issue — overly complex user authentication and password management. To thwart this potential source of frustration, UPMC Hamot also implemented a single sign-on authentication solution so that clinicians can use a single password to access multiple applications and computer terminals throughout the hospital.
Extensive, Dedicated On-Site Support Required
While assistance was readily available to hospital personnel throughout the EHR transition process, UPMC greatly intensified and carefully choreographed its support efforts in the days prior to and immediately following Hamot’s “big bang” switchover to Cerner. In total, approximately 600 Cerner “super users” from other UPMC hospitals descended upon Hamot during this critical time to help with the launch of the new EHR. Some of these aides stayed in Erie for a day or two to support the cause, while others were on-site for two weeks or more. This support staff consisted not only of UPMC IT experts and Cerner technicians, but also physicians, nurses, and other clinical and administrative champions. While the help was diverse, they all had one thing in common — they all wore bright orange vests so they could quickly and easily be identified by Hamot personnel in the event assistance was required. The goal was that, if a Hamot employee needed help with some aspect of the new EHR system, all they had to do was raise their hand and someone in an orange vest would respond to assist. Most of Hamot’s on-site support was centralized in a temporary 24/7 EHR command center that UPMC established on the ground floor of Hamot a few days prior to and for two weeks following the Cerner launch.
Key UPMC and Hamot executives also got involved the evening prior to the switchover by personally equipping each patient staying at the hospital with a new bar-coded wristband. The new Cerner EHR required new patient ID bracelets for medication reconciliation, lab work, and other health data transfers. The act of key UPMC executives performing this necessary task helped to emphasize the significance of this event and also served to reassure patients that the EHR conversion was going to be a success.
New EHR Brings Huge Benefits
At 12 a.m. on Saturday, Sept. 22, 2012, UPMC Hamot removed the Soarian EHR and all of its ancillary systems (e.g. radiology, human resources, finance, patient registration, etc.) from its production environment. The hospital then immediately enabled all of these systems on UPMC’s Cerner platform. Overall, the transition went off without a hitch, and the associated benefits were realized in the days and weeks that followed.
“Since going live on Cerner, our patient records at Hamot are now accessible to physicians at any other UPMC hospital and vice versa,” says Long. “This is beneficial for several reasons. For one, it eliminates redundancies in clinical documentation. Secondly, since they have access to our records, we can easily secure second opinions from specialists in Pittsburgh on difficult patient cases. Finally, all patient data is entered into a universal UPMC health record regardless of which UPMC hospital a patient is seen or treated at. The care coordination and data visibility advantages this provides are significant.”
While the benefits of the new Cerner platform have been wellreceived by UPMC Hamot, the EHR transition didn’t come without some pain. For instance, Hamot executives admit that despite all the training and education, there was still a learning curve for physicians using the new software. Overall, the new EHR slowed physicians down for a while. However, Hamot executives state that this temporary lull in productivity was partially offset by the heightened accuracy of the data being entered into the record.
“Nobody is coming back to the physicians saying they can’t read a doctor’s writing anymore,” says Long.
EHR Conversion Best Practices And Lessons Learned Uncovered
UPMC Hamot’s “big bang” EHR switchover was an unmitigated success, and there were a couple of key best practices that the hospital believes were instrumental in producing this outcome. The first is strong project management leadership. UPMC Hamot executives stress that a leader with exceptional organizational skills is vital to a conversion of this magnitude. The second best practice is to dedicate ample time to the discovery effort surrounding the EHR transition.
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“No two hospitals are exactly the same, and therefore, no two EHR conversions should be handled the same way,” says McChesney. “Each hospital staff needs to understand its current state, envision the desired future state, and map out a path to get there. There is no problem that is not solvable. However, if you don’t fully understand a problem, you can get blindsided by it. You don’t want this to happen during the EHR go-live when a clinician is taking care of a patient.”
While UPMC Hamot undoubtedly applied some effective strategies during its transition to Cerner, there are also a few things the provider admits it would have handled differently if it had to do it all over again. Primarily, the hospital would have provided even more support to its personnel throughout the conversion process.
“Even though we had nearly 600 UPMC support staff on hand at some point during the transition, you can never underestimate the need for assistance both during the transition and after the fact,” says Gibbons. “In hindsight, we could have used even more support in our ED [emergency] and patient registration departments during the conversion. Furthermore, we could have been more agile in supporting the ongoing needs of our staff after this wave of support personnel departed. It’s clear now that we should have provided a bit more knowledge transfer about the new EHR applications we were adopting from the temporary support staff to our permanent internal resources.”
UPMC will get the chance to apply these lessons learned in the coming months when it executes its next “big bang” Cerner transition with recently acquired UPMC Altoona Hospital.
What About The Practices?
Hamot’s acquisition by UPMC not only required the hospital to adopt the health system’s enterprisewide Cerner inpatient EHR, it also required physicians practices owned by Hamot to adopt UPMC’s Epic ambulatory EHR. However, the outpatient EHR transition didn’t lend itself to the same “big bang” approach the hospital employed. Dealing with several separate physicians’ offices in multiple locations throughout western Pennsylvania (and their respective staffs) required a phased approach to implementation.
UPMC focused its efforts on getting UPMC Hamot’s PCPs up and running on Epic first. These providers were given priority because PCPs generally enter most of the information that populates a patient record. Plus, PCPs tend to interact most with patients by providing ongoing care. The conversion process for each PCP office was demanding. First, UPMC Hamot sent local IT and support staff to each physicians practice to educate and train the staff and migrate patient data from any existing EHRs into Epic.
“The data migration process for each office took time, and it actually forced some practices to cut back on their office schedules until complete,” says Dr. Richard Long, SVP and CMO of UPMC Hamot. “Schedules were interrupted not only as a result of the data backlog, but also because of the learning curve the physicians and office staff were going through.”
The transition of affiliated practices to Epic has been a lengthy process that is still under way. To date, most of UPMC Hamot’s practices are live on Epic, and the health system is now turning its attention to getting affiliated specialists operational on the new ambulatory EHR.
“Overall, hospital traffic is slower on weekends,” says Dr. Richard Long, SVP and CMO of UPMC Hamot. “We’re a trauma center, so we can’t close our doors, but our OR schedule tends to be lighter on weekends. Plus, we could purposefully limit the number of elective cases we added to the docket during the first full week after launch.”
“No two hospitals are exactly the same, and therefore, no two EHR conversions should be handled the same way,” says McChesney. “Each hospital staff needs to understand its current state, envision the desired future state, and map out a path to get there. There is no problem that is not solvable. However, if you don’t fully understand a problem, you can get blindsided by it. You don’t want this to happen during the EHR go-live when a clinician is taking care of a patient.”
