Successful EHR Implementation—Big Bang vs Phased Approach

EHRBy Cynthia Davis, MHSA, RH, and Marcy Stoots, MS, RN-BC

Part of the impetus in establishing large integrated health systems is to develop a coordinated approach to provide patient care efficiently and effectively with the patient as the center of focus. A common EHR is a key enabler to making this happen.

The value of cross-communication between hospitals, physician offices, and other care delivery sites is clear. A clinical and organizational transformation initiative needs to fully engage the culture for years to come. Nothing short of that will markedly improve the quality of patient care far into the future.

Acknowledging where you are and what you already have is essential to any transformation.

This month, we are publishing several blog posts based on our book A Guide to EHR Adoption: Implementation Through Organizational Transformation, which provides proven methods, insights and best practices for instituting checks and procedures that dramatically improve a hospital’s ability to dispense timely, high-quality, safe patient care through successful EHR adoption.

In this post, we will compare two approaches to EHR adoption—Big Bang and Phased.

A Phased Approach vs. Big Bang

Healthcare information is the key enabler for effective healthcare transformation. Choosing which approach to use, whether it’s phased or a ‘Big Bang’ approach, is a critical organizational transformation decision. There are pros and cons to each, and the approach needs to align with your organizational culture and tolerance for change.

One option is a phased approach, which is often chosen to reduce overall adoption risk and brings certain parts of the organization live with various system applications to establish specific functionalities in a planned sequential manner. This approach allows a health system’s end users to adapt over time to a culture of electronic documentation and practicing to a standard. One example of a phased approach is outlined next:

Phase 1: Clinical Core. This initial phase involves implementation of the EHR system within health information management, surgery, and pharmacy departments and adding nursing and ancillary documentation, computer provider order entry (CPOE) and other physician documentation in focused areas such as the emergency departments and electronic medication administration records (eMARs).

Phase 2: Outcomes Optimization. The second phase involves implementation of hospital-wide inpatient CPOE and structured physician documentation, anesthesia documentation and/or some of the other more challenging areas such as maternity, clinical decision support (e.g., alerts, rules, etc.), bar-coded medication administration, and quality reporting.

When planning to implement inpatient CPOE, it is key to implement this in a later phase. This decision ensures that the organization will have in place the best support and complementary technologies to optimize efficiency for physicians when completing electronic documentation and order entry.

Progression toward implementing full functionality of an EHR is vital, but equally so is helping people move effectively through a major transformation process. The phased approach, combined with a change management methodology, is fundamental in helping an organization ease into an EHR-driven environment.

A second option is a Big Bang approach, which brings up all applications and functionality at one time.  This allows for a quicker migration to new workflows and decreases the hybrid paper and computer state.  It also increases the amount of stress on the clinican team as they transition to a new world.  It is key to have strong executive leadership for this approach as well.

Note that there is no right or wrong approach to implementation. It is really dependent on your organization’s tolerance for change, as well as available resources and funding.

Insights and Lessons Learned

  • Change agents need to work with the culture as it is and be aware of people’s predispositions to respond; no organization exists in a vacuum and acknowledging where you are and what you already have is essential to any transformation.
  • Progress toward full implementation and helping people move effectively through the transformation process are equally vital; thus, a multi-phased approach can be more advantageous than a big bang approach.

This post was adapted from A Guide to EHR Adoption: Implementation Through Organizational Transformation (HIMSS Books, 2013). Print and eBook editions of this book are available at a 20 percent discount in October.)

Cynthia Davis, MHSA, RN, is a Principal with CIC Advisory, a clinician-led Informatics consulting services firm that specializes in delivering informatics, analytics, implementation, optimization, strategic planning, executive coaching, and American Recovery and Reinvestment Act (ARRA)/Meaningful Use Readiness.

Marcy Stoots, MS, RN-BC, is a Principal with CIC Advisory, a clinician-led Informatics consulting services firm that specializes in delivering informatics, analytics, implementation, optimization, strategic planning, executive coaching, and ARRA/Meaningful Use Readiness.

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