CHIME: The difficult life after CPOE, EHR go-live

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SAN ANTONIO—When Hospital Sisters Health System, a 13-hospital system in Wisconsin and Illinois, implemented computerized physician order entry (CPOE) and EHR, everything seemed fine—for a little while. Just a couple of months after the installation, William Montgomery, CIO, received a letter from the physicians listing 38 issues that they wanted fixed within two weeks.

Montgomery and Robert Schwartz, MD, MPH, physician executive with Dearborn Advisors, discussed Sisters’ situation during CHIME11, the Fall CIO Forum last week. The organization, with a $1.8 billion budget, 15,000 employees and 2,800 beds moved to “care integration” in 2008.

Half were known issues at other hospitals in the organization and another quarter were related to training, he said. The installation team was taken aback by the letter, including the physician champion.

“There’s a method to doing it right,” said Schwartz. “When you prepare, it can usually go well. You have to look at process redesign. If you don’t look at the processes that will change, you’re likely in for some disasters.” That includes looking at how the tools will impact the medical environment.

After receiving the letter, Montgomery began a recovery effort. Because the issues were really related to training and workflow, they utilized workgroup leaders to get the leadership re-engaged. It worked because after just three meetings to the hospital board detailing the efforts, they received a standing ovation.

There were, however, many lessons learned. For example, “the devil is in the details. From 30,000 feet, the project might look good but there can be lots of problems when you take a closer look,” he said. “Beware if it seems that a project is going too well.”

“What did we miss?” was the big question. “A lot of [the problem] was the culture component.” Although everything was feeling good right after the go live, there was implied disengagement. Physicians and other users were having conversations behind the scenes that led to the demonization of the project. Part of the problem was communication.

“Just because I understood the issues didn’t mean they were clearly communicated to everyone,” Montgomery said. “During the downward spiral after the go-live date, most people didn’t know the efforts behind the scenes and the plan to fix things.” That reinforces the idea that just because the implementation is done doesn’t mean a project is over.

Montgomery said the distance between the hospitals and the multiregional aspect of the organization made it difficult for him to be on site and fully aware of all the issues. “We do all the things we’ve been trained and taught to do but things will go wrong.” Again, culture plays a role. People are accustomed to projects that have a beginning and end but “these kind of technological projects don’t really have an end. They need ongoing optimization support.”

Schwartz discussed the dip in productivity that occurs after implementation. “There are incremental productivity hits that impact the clinical environment.” Typically, immediately following an implementation, users are enthusiastic. Then the command center shuts down but there are still productivity hits. “You really have to pay attention to that. People stop rationalizing the changes and the implementation. I recommend intermediate support for three to four months after the implementation. It’s very important to success."

Montgomery agreed that he should have thought of the project as long-term. “You should define measures and report them frequently so that people know the benefits of the implementation.”

That information didn’t get back to the physician community so they could understand that the implementation was making an impact. Communicating all the improvements can go a long way to making the productivity dip shallower and shorter, Schwartz said.