An Alternative to Straight Implementation Milestone Driven Adoption

Mandated functionality use with a Live date without a plan to get there are begging for user adoption failure.   There are few organizations that have the ability to staff “Big Bang implementations.”  Whether big bang or some portions of the functionality, I think having just a live date can be very frustrating for users.  There are several factors coming into play on effective EHR adoption of functionality that are not accounted for in a situation where there is only a Live date and not a plan around what “Live” means.  For instance if we “go-live” on e-prescribing, what does this mean?  Some groups never define what this means and get several flavors of compliance or non-compliance.  What does it mean?  Does it mean that every patient from go-live forward will have a complete EHR medications list or all new prescriptions will be ordered from within the EHR or does it mean that the module is now available for use.   Come up with a fair solution that enables compliance without setting an expectation that is not realistic.

There are variables which vary by practice type or specialty affecting what makes sense for the implementation or adoption of functionality.   For instance, if I see 15 patients a day the expectations could be different than someone who sees 40 patients a day.  Some more variables include the first which I will call “Patient Repeat Value” or PRV a ratio that has to do with how often patients will return for a visit defined by number of visits divided by number of unique patients over a given period of time, and second which I will call “Patient Population Cycle Time” or PCT is the amount of time it takes to cycle through your active patients.

Volume is more obvious so let’s look at PRV.   If a clinician sees 40 patients a day but his PRV is high any pain associated with new functionality that is driven by items that are maintained list such as the various items on the paper face sheet like medications, problems and allergies will be more short term than someone who has a lower PRV that sees the same patient load, because they have a larger population and ergo more lists to maintain.  PRV may not be as relevant in items like electronic noting where it comes down more to practicing and repetitions to become efficient.

Let’s look at PCT as it applies to the first go-live of the EHR.  The best way to explain how PCT comes into play is that it makes every patient’s first visit in the EHR almost like a new patient visit.   We know that visits for New Patients typically take longer and their appointment times typically plan for this.  A logical conclusion from this comparison would be that schedules need to be changed to accommodate these “New to the EHR” patients.  If the PCT is 60 days, like it might be in an Obstetrics office or perhaps even lower in a Nursing Home, it could be practical.  However in Family Medicine it isn’t practical if some of my patients might not come in within 18 months but they are still considered active patients.

Since all practices aren’t created equally with regard to these variables it isn’t realistic to expect the same results from different groups.  Required utilization should be mapped out to accommodate the differences.  Come up with a strategy that allows the practice to step through to full utilization.   Sometimes it is simply something like applying the new functionality to every third “New to the EHR” patient for 60 days and then you’ll have a majority of your visits utilization compliant.  In other situations the logic is broken down by seeing different appointment or patient types initially and then working into the other types as you progress.  The main logic is to come up with steps that are easier to swallow than doing everything different than what was done yesterday.

Worth equal consideration, is a realistic timeframe for supporting an in progress EHR.  We have to coach the users through the implementation, to do more than what they think is possible.  Having an approach just as defined above will serve as the roadmap for the end user to get to some where they have never been.  Having never been there they don’t know what to expect.  Users can’t be allowed to always take the easy way out.  This sometimes involves repetitive reference to the gains and benefits that will be available.  If you don’t get the medication lists and problem lists in for the patients, notes can’t automatically cite from these lists etc.

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