Lessons Learned from the EHR Upgrade
Ooops, I almost wrote Upgrace instead of Upgrade in the title. Pardon me. Hard habit to break, I guess, haha!
Kidding aside, our team has been busier these few past weeks because of our scheduled electronic health record (EHR) system Summer Upgrade. Clinical informaticists from all of our sites have been working collaboratively with so many stakeholders to bring about this change. Analysts, principal trainers, information technology (IT) folks, hospital and system leaders, and vendor representatives are some of our stakeholders.
To echo some frontline nurses’ questions during our rounding this week:
What is an upgrade? And why is it necessary to do it? Just when we are just getting familiar with using the EHR system, here you go again and change it! Don’t people like you who are sitting at your desks every day have anything else better to do? Ever heard of the line: “Don’t fix what ain’t broke?“
To be fair, they apologized to me after realizing that I was just the messenger. Nevertheless, I totally understand where they are coming from. It was not too long ago when I used to utter the very same lines, a little tactful maybe, but the same exact sentiment.
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Why the Need to Upgrade?
The Webster dictionary defines upgrade simply as an improvement. Anyone, unless that anyone has been living under the cave for the last 20 years or so, has an electronic device. With that being said, it is safe to assume that the device has undergone at least a few upgrades to keep up with the technology.
Lest we forget, the EHR is a technological innovation in and of itself. Therefore, it is just as vital for it to be upgraded to be responsive to the call of the times. With patients’ lives depending on the accuracy of these technologies for clinical setting use, wouldn’t you agree with me that it is much more important for it to continuously improve?
What if the intravenous pump (IV) pump is not integrating well with the EHR and infuses the wrong amount of Heparin? Will you just wonder why your patient all of a sudden is having internal bleeding?
If the scanner used to scan human milk does not interoperate appropriately and you ended up administering the wrong milk to the wrong baby? How will you discuss that with a worried mother?
The Role of Clinical Informaticist during an Upgrade
In reference to the comment above:
No, the clinical or nursing informaticists (CI/NI) don’t just sit on our desks trying to find ways how to make the lives of the frontline clinicians miserable. In contrast, we actually advocate for improvement that will complement the workflow of the nurses. Remember, our aim is to help clinicians work smarter not harder!
Meetings…and so Many of It
Prior to initiating anything, we sit through so many virtual meetings with the stakeholders stated above. We review the current application, its usability, how it fits with the workflow, and the challenges. Next, we look into the proposed change, any required alteration in workflow, and the way to implement it with as little disruption as possible. Timelines and roles are defined as well.
Testing, Testing
Once the analysts build the proposed change/s, then there is a need to test. There are two necessary testings needed: integration testing and regression testing. The first one is to ensure that the change will work as expected. The latter is required because you would want to know if the change breaks anything that is currently existing. An example of integration testing is the auto-association of the cardiopulmonary monitor to the correct patient for data to flow into the EHR. Regression testing is used to ensure that the monitor also auto-disassociates upon discharge of the said patient. Otherwise, if it doesn’t, then the data may flow into the discharged patient’s chart. This is despite the fact that the monitor is now associated with a different patient.
Planning for End-user Education
After the stakeholders complete the build and testing phases, CIs/NIs then work with the Principal Trainers to plan how to educate the end-users. Depending on how extensive the changes are, CIs and/or trainers may conduct virtual classes or formulate computer-based training. Additionally, end-users can access the education materials in several places within the organization’s online pages.
Personally, I like the fact that our Learning Home Dashboard includes upgrade materials. To me, the convenience of having it within the same EHR makes it accessible and therefore, easy to use. Additionally, we “advertise” it extensively during leadership huddles to increase the buy-in of clinical leaders and end-users alike.
Navigating DownTime
Prior to instituting change, the EHR system is scheduled to have a downtime. Depending on how much change needs to take place, downtime can range from a few minutes to a few hours. Planning for that is of utmost importance. Questions like the ones below should be answered:
- How long is the scheduled downtime?
- Are clinicians able to back chart when the system comes back up?
- Or should they use paper flowsheets to document in real-time instead?
- Is there a need to print out paper forms (e.g. medication administration record [MAR], etc.) for clinicians’ use?
- Is there a downtime computer that can be used to view results (e.g. labs, imaging) to manage patients appropriately?
Providing At the Elbow Support
During the week of Go-Live, CIs round more frequently to provide hands-on support for end-users. We review where they can easily access their resources. Otherwise, we patiently walk them through the process changes. As a pay it forward gesture, they have to share it with their colleagues through their shift change huddles so that everyone will be on the same page.
Other CIs also provide Secure Chat support. While they are working remotely, they answer questions that are being asked by the endusers through chat. Having a mix of newer and experienced CIs monitoring the chat provides learning opportunities for everyone. We compare notes and bounce off ideas amongst ourselves to come up with the most appropriate answers to the stated concerns. Just as we want to provide support to the endusers, CIs, especially the less seasoned ones, also want affirmation and assist from the more senior ones that we are giving correct answers.
After a week or so, stakeholders again meet in order to debrief and evaluate the upgrade process. They identify lessons learned, challenges encountered, and better ways to carry out future upgrades. In essence, the job doesn’t stop once the end-users adopt the change. Rather, it just marks the commencement of yet another upgrade in the next defined period of time.
Final Words
So, as you can see, CIs/NIs are just not proposing change just for the heck of it. If it is hard for end-users to adopt the change, CIs have harder responsibilities all throughout the planning, testing, implementing, and evaluating phases. That is the reason why I just smiled when I am confronted with complaints from end-users. Yes, if only you know…
Personally, my favorite memory of the past week is this:
A resident informed me that he didn’t like the change (e.g. appearance, font, etc.) and asked if he can opt to revert back to the old view.
My answer?
Doctor, just as your iPhone updates regularly, our EHR is the same. Technology changes, thus the need for upgrades. With that being said, have you ever called your Apple tech support if you could revert back to the old view?
He smiled at me and said:
Well, if you put it that way…
What about you? How do you deal with technology changes as an end-user? Are you in favor of periodic and scheduled updates? Or would you rather have a one-time grand redesign of the EHR and learn all the changes all at once?