Begin With the End in Mind: Common EHR Activation Risks and How to Mitigate Them

No matter the size or scope, thorough electronic health record (EHR) implementation planning should begin with determining your desired end-state, what is needed to reach it, and the potential hurdles you may encounter along the way. Identifying potential activation risks before implementation allows for time to proactively and appropriately plan, budget, and communicate resource needs and expectations. You can alleviate surprises that may negatively affect clinician satisfaction and limit the full benefit of your new EHR.

What follows are several common activation risks and how you can address them upfront.

1. Ambulatory Acquisition Scope Creep

Risk: As more physician groups are added to the potential user base through acquisition, affiliation agreements or EHR extension initiatives, the temptation is often to accommodate these additional providers in the original activation timeline. This increases resource needs for build, testing, and go-live support and introduces additional risk to the timeline.

Solution: Develop an implementation strategy for ongoing acquisitions, affiliations and private practices to minimize the impact on activation budget and plans. This will also set expectations with the newly acquired and affiliated groups as to how they fit into the implementation strategy. For example, create a schedule to add new providers to the beginning of the last clinic group’s testing cycle. Determine how many clinics the implementation team can handle to determine when to create the next grouping – whether the current strategy is “big bang” or phased. This requires reviewing the existing team resources to ensure the right number of resources are available to support ongoing implementations and clinics that are live on the system.

2. Scheduling Reduction Trickledown

Risk: To provide physicians with time to adapt to a new system and workflows as they gain expertise with the new EHR, many organizations allow for a scheduling reduction in operating cases, office visits or scheduled procedures. Physicians who receive RVU-based compensation could see a reduction in their compensation. Scheduling reductions may also trigger revenue loss for ancillary departments such as radiology, laboratory and surgical services due to fewer referrals – a common trickledown effect from schedule reductions.

Solution: If you choose to reduce scheduling, you need to determine how or if you will bridge the gap in compensation or bring in external clinical staff with EHR experience to maintain existing schedule loads. It is also a good idea to provide insight about potential budget impacts (e.g., up staffing, vacation planning and schedule reduction) to the finance department as soon as they are identified to help them plan for the impact. By proactively communicating the trickledown impact of revenue loss for ancillary departments to executive leadership and governance bodies, the reduction in revenue will be anticipated and planned for accordingly.

3.  Conversions

Risk: Clinicians and staff will be required to participate in manual conversion activities before activation for inpatient chart conversion, scheduling and registration of appointments, schedule template build, surgical case block and case creation, pre-op order entry, etc. Manual conversions will result in overtime due to after hours and weekend work, as well as hospitality costs, which are often overlooked.

           Solution:  A hybrid approach to converting appointments is possible by using an electronic format for simple appointments and manual conversion for more complex appointments to save time. Staff will be needed to validate electronic conversion results as well as participate in backfilling for those participating in manual conversion activities – either with internal or external resources. Early communication with clinical and business departments about the need to participate in these activities will help them better manage their staff scheduling. Prepare for additional staffing and their needs in the budget.

4. Command Center Planning

Risk:  Allocating adequate space for command centers can be challenging, especially for large scope activations. Dedicated space is necessary to accommodate large groups of people (120+ for a “big bang”) before and after activation. It may be necessary to reserve space well ahead of time to ensure it will be available. For ambulatory activations, there are challenges with where to locate the command center to best meet the needs of the end users. Command center space must be equipped with network access, telephony and hardware. Additionally, there are physical security considerations, increased parking needs and workspace considerations, such as tables and chairs, and hospitality costs for the command center which are typically an afterthought and under-budgeted.

Solution:  For large scope activations, identify and reserve a command center area one year before go-live to ensure you have the necessary space. Approximately four months before go-live, identify all of the resources needed to equip the command center to plan and monitor logistics and communications. Adjust budget line items with the actual costs being incurred. Depending on the current configuration of the space being used, it may require relocating existing users or running wiring and cable. Consider HVAC requirements for afterhours work as well. The complexity of the command center preparations may require that the work begins several weeks before the space is needed. Getting this space set up prior to activation will also allow it to be used for manual conversion work efforts to better facilitate communication, training and support. Define in advance what hospitality (e.g., food and beverages) will be offered and for how long including manual conversion activities and post activation needs.

5. Outsourcing for Coding and Legacy Accounts Receivable

Risk:  Billing and coding staff will be focused on learning the new system and work queues, as well as new workflows for accounts receivable management. This will affect their ability to continue accounts receivable work and coding in the legacy systems.

Solution:  By outsourcing the legacy accounts receivable tasks, billing staff will have time to focus on adjusting to the new system. Additionally, outsourcing coding for four to eight weeks post go-live gives coding staff time to learn the new system and workflows.

6. Go-live Support Resource Planning

Risk:  Large numbers of staff are needed to provide support for go-lives – whether they are internal super users or external resources brought in to assist with support of staff and physicians. Both types of resources are expensive. Internal super users have been pulled away from their regular responsibilities and must be backfilled. While, competing implementations in your area could increase competition for external resources driving up costs.  

Solution:  Carefully estimate the resources and budget needed to provide support for staff learning the new system being careful not to underestimate what is needed. Assume that super users will need to be backfilled for two to four weeks post go-live and that you will be using external resources for the same timeframe. Continue to monitor the numbers of super users that will be available to provide support in order to more accurately determine how many external resources will be needed. Understanding what competing priorities may exist for external resources in your area will allow for proactive contracting of these resources. Finally, don’t forget logistics and the ability to manage all of these resources.

When done in a thorough and thoughtful manner it is possible to determine your activation needs upfront during EHR implementation planning and reduce risks at activation. It alleviates unexpected budget overruns and prevents organizational frustration with the activation process. Additionally, it minimizes negative perceptions by clinicians that can impact early adoption of the EHR and realizing its full value potential.

Aspen Advisors is an IT advisory services firm that works with healthcare organizations across the country to enhance performance through the strategic and effective use of information technology. In November 2014, Aspen joined The Chartis Group to bring clients thought leadership and capabilities in strategic planning, accountable care solutions, clinical transformation and information technology.

Dana Kimmel has 20 years of project management experience in the healthcare industry working in hospitals, integrated delivery systems, managed care organizations and pharmaceutical benefits management organizations, and with a variety of applications. Before joining Aspen Advisors, part of The Chartis Group, Kimmel provided implementation and strategic consulting services to large, complex healthcare organizations.