Change Management: Top EHR Concern
Leslie Ann Fox, MA, RHIA, and Patty Thierry sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: Last year we began our column promising 2003 to be a challenging year for health information management (HIM) professionals. National attention to health care information technology (IT) began early in the year and continued throughout truly making it "crunch time" for all health care professionals who are responsible for bringing components of the electronic health record (EHR) to fruition in their organizations.

Patty: Crunch time is still an appropriate phrase for 2004 because of the sense of urgency for HIM and IT professionals to lead their organizations through the complexity of preparing for and implementing an EHR.

Leslie: At the 2003 American Health Information Management Association (AHIMA) convention, Care Communications Inc. conducted a survey of attendees regarding their role in the EHR and the challenges they face. Seventy-two percent of the HIM respondents indicated that they have been involved in EHR activities each step of the way. A large number of respondents, 38 percent, indicate they are playing a leadership role in EHR initiatives. More than 300 attendees participated in the survey with the majority citing change management issues as their biggest challenges.

Patty: That's great news that so many respondents are involved in some way, and it's not surprising to hear that change management is their biggest hurdle. What types of change management issues did they cite?

Leslie: Topping the list of issues is physician buy-in, as well it should be. In a sense physicians' documentation habits are hard-wired into them during their training. The change to producing and using electronic documentation is a dramatically different way for them to accomplish their work and is not a trivial change. Documenting and accessing data can be slower until new skills become habits. Designing workflow in a way that increases physician productivity rather than decreasing it is a huge challenge. When the EHR is not demonstrating this outcome, it is unlikely that you will find them to be a very cooperative group.

Patty: However, physicians should not be thought of as obstacles to the implementation of the EHR because nothing could be farther from the truth. They are interested in using the tools that help them to practice smarter and more efficiently. And, the patient safety aspect of EHRs is extremely attractive to physicians with whom I have spoken.

Leslie: This is where sound change management practices become essential to the success of the EHR. Even if EHR components are phased in over time, buy-in can be achieved if there is a clearly stated EHR vision and it aligns with the clinical vision. In addition, the organization must demonstrate that it is moving toward the stated EHR vision with technology deployed that is accessible, mobile and improves performance.

Patty: How people communicate about the EHR is important as well. The EHR shouldn't be considered a project but an ongoing set of tools used to improve quality of care and patient safety. Involving physicians from the beginning of the EHR journey will help to ensure that workflow is designed to meet their needs and is congruent with the workflow supporting health care providers such as nurses, therapists and pharmacists. I realize this is obvious but organizations keep failing in this area. Many organizations and/or vendors don't have an understanding of how physicians organize and perform their work and the effect of automation on others' workflow. The literature is full of examples of organizations that did not spend enough time on this critical step of the EHR change management journey.

Leslie: We have often talked about the importance of having good relationships and the role it plays in leadership and change initiatives. This holds true for EHR change projects. The relationship between the organization and its physician community will make or break EHR implementations. In our experience, organizations that have physicians leading quality and patient safety efforts generally have a smoother transition from paper to electronic documentation tools. This is generally because the organization has internalized the goal of quality and patient safety and seeks primary leadership from the physician community and integrates them in the decision-making process. In addition, organizations that have a culture, which includes collaborative relationships between medical staff and other patient care providers, IT, HIM and executive leadership, are in a better position to manage change.

Patty: What was the next issue on the minds of HIM survey participants?
Leslie: The second biggest change management issue is helping people increase their computer skills to meet the computing requirements of an automated record environment. Delivering training programs that meet the various needs of a diverse health care workforce is a significant challenge.

Patty: That makes sense to me because health care workers who have long used paper and pen to document in patient records have not had the opportunity to develop the degree of computer literacy that others in today's workplace take for granted. Therapists, nurses and physicians have not needed computers to do their work other than to perhaps look up information. Some health care professionals have worked in DOS environments so just getting used to a mouse can be a challenge.

We have seen training models that are very successful. The key to success is often a buddy system program, in particular physician buddy programs. Other program characteristics include training that occurs on the spot to complement structured training sessions, the use of online games is a popular technique to help people become familiar with the mouse and interacting with a computer. In a recent report prepared by First Consulting Group on the digital hospital, they site training as "probably the most overlooked component of introducing new processes and new technology into any setting."

Leslie: At least with training programs one can get very creative! It is a great opportunity for relationship building as people get engaged in learning together and helping each other. But it is a challenge to have 24/7 training available.
Patty: Are there any other change management issues noted by the survey respondents?

Leslie: Yes, they included challenges such as organizing a project for start-up, losing momentum and/or focus, emotional processes around transitioning from the old to the new, being afraid to fail and the challenges around communication.

Patty: John P. Kotter discusses many of the challenges the survey participants are facing in his change books: Leading Change and The Heart of Change. The change principles he writes about help you think through the appropriate structure and strategy for change projects. In 2001, we wrote a three part series, which appeared in the OctoberDecember Hands on Help column, on designing a remote coding program (See www.ADVANCEforHIM.com ). Those articles introduced many of the change management principles described by Kotter.

Leslie: Change management is a topic we hear a lot about and will become more front and center as lessons learned emerge. A great goal for 2004 would be to strengthen skills sets in this area. HIM professionals are perfect for the role of "EHR Change Leader" in their organizations. They understand data and its relationships can help bring the right people to the table and have a history of guiding organizations in the collection, storage, protection and retrieval of health care data.

Patty: In addition to change management skills, HIM competencies are also important to strengthen. In the fall of 2002, AHIMA launched the e-HIM initiative and shortly thereafter in 2003 distributed the report "A Vision of the e-HIM Future." The report outlines 16 e-HIM competencies that include leading business process redesign efforts, and a number of competencies that include establishing and implementing organizational-wide standards.

Leslie: The report also states that the e-HIM initiative "signals the need to advance HIM practice to fully utilize standards-based technology and adopt best practices." The significance of this is echoed in the latest Institute of Medicine (IOM) report released this fall, titled Patient Safety: Achieving a New Standard of Care. The report can be read online or purchased at www.nap.edu/books/0309090776/html . The report focuses on the function of information technology in improving patient safety and on the need for national standards.

Patty: I just finished reading this report and think it's a must read like the reports before it. The report includes many new thoughts on technology and health care and summarizes the problem of patient safety included in previous IOM reports: To Err is Human: Building a Safer Health System (2000) or Crossing the Quality Chasm: A New Health System for the 21st Century (2001). Of particular interest to me was the health care data standards chapter.

Leslie: This chapter is important to HIM professionals because of its broad perspective on data standards. When one thinks of data standards they often think of data interchange formats like HL-7 or classification systems like ICD-9-CM. The report describes data standards to "encompass methods, protocols, terminologies and specifications for the collection, exchange, storage and retrieval of information associated with health care applications including medical records." Sound familiar?

Patty: It sure does, which reinforces why HIM professionals are needed at the EHR design table. This chapter goes on to say that "data standards are about the standardization of data elements: 1) defining what to collect; 2) deciding how to represent what is collected; and 3) determining how to encode data for transmission." Designing standards has always been part of the HIM domain but more professions are beginning to get involved in standards design. This presents a great opportunity for HIM professionals to collaborate with these professions and to provide leadership. It will take our collective content knowledge and understanding of health care data uses to pull this off.

Leslie: The report also includes "Key Capabilities of an EHR System," which are EHR functional standards developed over the summer by the IOM Committee on Data Standards for Patient Safety. AHIMA and HIM professionals are involved in shaping these standards, which are to be voted on and finalized early in 2004.
Patty: 2004 is starting off with a bang like last year, but the good news is there are more resources than ever to draw from to help you navigate and lead the changes.

Leslie: AHIMA volunteers and staff have been busy developing e-HIM standards, as well as actively participating in national standard setting activities. The communities of practice and AHIMA's body of knowledge are rich with resources, and opportunities to attend conferences on e-HIM and EHR are plenty. Reports on the state of health care and health care technology seem to be published monthly!

Patty: Lots to keep up with, but that is why we enjoy what we do. It is never boring; always challenging. The survey participants are evidence of that!

Leslie: We are very appreciative of the people who stopped by the CARE both at the AHIMA convention and took the time to complete the survey (results available on our Web site at www.carecommunications.com ). We learned about the challenges you face on a daily basis and will follow these challenges and technology trends through the year. Happy New Year to all our readers!

Leslie Ann Fox is president and chief executive officer and Patty Thierry is vice president of operations and chief information officer, Care Communications Inc., Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com.