Brents IT Blog

Random thoughts by an IT GOAT


My EHR Deployment Experience

While we are still alive, no one has had a vacation in months, i thought i would post my experience with our EHR deployment.

The doctors are still in a tizzy because certain things are not in the system, nursing are free texting everything because its "easier", front desk staff can’t seem to enter complete information if their life depended on it and the software of choice seems to think freezing randomly on users is funny.

So why did we go to an EHR ( Electronic Health Records ) system?  The answer is complicated.  So let’s start from the beginning....

Using a practice management system is great, it keeps money flowing in and basic statistics provided to agencies who want it.  The problem is that time is marching on and the government has decided that they want anyone who is government funded to have an EHR system.  But as everyone knows, the government doesn’t usually come out and say it first.  The feds typically start requiring things that you know only an EHR will provide.  So you start installing different software or use customized software to get what they want.  Well they are not stupid, they see this, so they start asking for more and more, then subtlety say that *might* lose funding if you don’t have exactly what they want.  They then say, "Hey, you know there is some software called EHR which would easily record this information we need, you might want to look into it".  Well we are not stupid either, this means, buy an EHR system in the next five years, or your funding is most likely going to be gone.

The problem with this is that our company is a non-profit; they cannot afford the million dollars plus cost of deploying this type of system without making some sacrifices in the short term.  Well it just happened so that the upcoming elections seemed more favorable to possible future funding, then bills starting floating around the local legislature, then the senate and the house, then there was talk by Obama about providing funding incentives for companies who deployed EHR systems.  All this talk and hinting was enough for my company to finally "pull the trigger".

Thus we were off....  and when I say "off", it was like someone snapped at towel on our ass and jostled us into action.  Before I knew it, I was buying a half million in equipment, we were paying consultants another half million and yet another 300k for software to get us started.  Just in case you are a novice to this whole process like we were, let me let you in on something.  Make sure to check every nook and cranny of that software contract, the software support contract, and the third party contracts.  It’s crucial that you make sure they have set delivery dates, set expectations on third party interfaces, penalties for failing to meet deadlines, set prices on future enhancements and most importantly, set prices for at least the next three to five years for maintenance.  Think of it as you giving birth to a child, you have to love and protect is for as long as possible.

So now the consultants show up ready to make us ready to deploy this software.... in less than four months from contract signing.  Yes, I said four months to transition 300 users from an old antiquated system to a new system where doctors and nurses actually use a computer.  I have to give our staff credit here, while many had challenges during the training and deployment, a very good percentage of our users pulled through and are quickly on their way to being as productive, if not more productive, than before we had EHR. 

Anyhow, the consultants showed up.  I think they had less of a clue than we did about deploying an EHR.  They had the organizational skills to help and some useful insight, but I was pretty sure that we got their B (or even C ) team.  Many times I couldn’t get an answer.  They helped our clinical staff way more than my IT department.  Now, I must admit that I can usually take a project or concept and run with it.  I generally don’t need much oversight, just deadlines and a smile( also lots of money ).  Just about every time I asked them a question, I got the "we will get back to you on that", then a week later or so, they would give me some sort of vague answer.  Just like most logical rulesets, give me enough vague answers and I will start discounting everything you say to me.  They recommended against VMWare because they didn’t know much about it.  They even went to my boss after I decided to ignore them and told my boss, that a VMWare setup would go badly.   Luckily, I was able to convince by boss that I had done the research and they didn’t know what they were talking about.  They also recommended we buy the most expensive stuff, most of which turned out to be junk( I could go on for a long time on this subject ).  Personally, I think we wasted 200K+ on these mowtards( see planetside game for the reference). 

Besides their rather sad affect on IT, they also managed to fully confuse our clinical and financial departments.  Clinical was now fighting with finance over control.  Luckily our finance department won out, I think something about paychecks was said.  Finance did concede many things to clinical, but in general, finance drove the discussion and the consulting company tried to maintain some sort of order.  Yes, they again failed miserably.  I can say they were able to bill us correctly though.  Regardless of my feelings, it’s quite possible their constant prodding to keep other folks on target, helped make our target dates a success.  Their reassurance on some things may have also helped, though I wasn’t involved in the clinical or financial discussions as much.  I was a bit busy shoving equipment out the door as soon as I could get it configured.

I hope what I have said so far does not give the wrong impression.  I like the idea of EHR and what I can do for an organization. 


Here is a list for those who still think EHR is bad:
1. Records can be accessed by any doctor anywhere the doctor is, securely.
2. Access to records by staff that should not be looking at medical records, can be revoked and monitored.  Yes auditing on record access, no more paper charts sitting all over the office.
3. Medical records are now backed up.  Before, if there was a fire, your records were gone.  I consider this a major liability diffused.
4. Reporting becomes available!  You can now extract non-patient-specific statistics regarding your patient base.  With this information your organization and get more grants and spend less time fulfilling the requirements of those grants.
5. External data can be imported.  Lab data can be instantly available to a doctor or nurse for quick response.  High quality data like x-rays can be attached to a record and viewed anywhere with the record.
6. Doctors carry a tablet, that’s it.  No more wagons full of charts sitting around, no need to go "find" a record.  Records are now secured completely at night.
7. No more reason to store records in some storage facility for 10 years, just scan it and shred it.  We waited a week to ensure the data was backed up.
8. Patient data sharing becomes easier, assuming the patient agrees to have their information shared with a specific facility.  This is great for ER cases with local hospitals.  They can see we have the patient record and request the record on the patients’ behalf.  ( we spend allot of time making sure the patient has authorized this though, don’t want to violate patient rights ).  This makes me happy to be the IT Manager, I can help protect those records as if they were my own.
9. Continuity of Care!  No more lost labs or patient information, if a test was performed, it’s in the system!  Test results are there and a history is filled in automatically!
10. Doctors are now forced to code their charts correctly!  No more tracking them down to figure out what they were trying to say.
11. Everything is electronic!  No more trying to decipher handwriting!
12. Prescriptions can be sent electronically to any pharmacy the patient desires or printed to paper locally.  Again, no more trying to read a providers handwriting.  This also helps pharmacies reduce errors in dosage or drug.
13. No more wasting paper!  Paperless means, no paper costs, well ok, a receipt is printed, but if you looked at a standard chart setup for a new patient, the ink and paper used is astronomical over just one year.
14. Integration with financial systems!  Integration with pharmacy software!  Integration with various labs, all at once!
15. Patient outcome tracking!  These tell us if we are doing is effective for patient care!  This is very important, patient care is the top priority.
16. User management controls.  You can granularly select who gets access to what.  Our old system had access levels... the new one has roles which make setup easier, but you can setup as many roles as you want!  Immediately remove user access to records.


With the above said, there are some challenges:
1. Doctors and Nurses who normally don’t touch a PC or may never had touched a pc, will go from using all paper, to using no paper.  Sometimes the challenge is too great for them and they need extra training to get them caught up.
2. Training all your users on the new system
3. Making sure your network is able to handle the load and its uptime is assured.  This may require you to provide backup connections to all or some of your facilities.  We changed over from T1 to Fiber and plan to use backup over-the-air connections.
4. Power backups required for everything.  We actually bought a generator for our main location to ensure we were not a single point of failure.
5. Besides being able to handle the load, your IT infrastructure has to be manageable, no more unmanaged switches.  Ensuring latency to specific types of protocols is absolutely necessary to ensure data keeps flowing.
6. Batteries, batteries, batteries.  You will need to provide extra battery packs for all your providers.  Nursing may also need them, but if they are doing their job, they should be sitting on a charging station most of the day between patients. 
7. Solid wireless network.  I cannot stress this enough.  If you have to add another $200+ access point, do not hesitate.  Make sure your tablets are turned to quickly jump to the strongest signal.  We used three bars as the minimum connection, though I recommend four out of five bars instead.  Also make sure your wireless latency is kept to a minimum.
8. Test and retest everything.  Nothing hurts a deployment more than having to go back constantly to change a setting or a piece of equipment.  We didn’t have enough time to thoroughly test some of the equipment we bought, luckily there was only one device that really caused us problems and it didn’t affect all users.
9. Redundancy, VMWare architecture was built to be redundant, do not be afraid of new technology.  Just because you haven’t used it, doesn’t mean it cannot do what you need.  If you don’t have time to test it, at least research it before tossing the idea out.
10. Listen to feedback, don’t discount anyone opinion.  Just make sure that when you make a decision, you do not change it later without a really really good reason.  Don’t allow people to use your heart strings to change your mind, your decision affects everyone and it may even set your timeline back.
11. Be open with people, if you don’t tell anyone what’s going on, they will fight you on everything.  Explain why you are doing something, it doesn’t make you weak, it solidifies your position and there is no harm in making sure everyone is in the know.  Just make sure not to get carried away with this.  Too much information can also confuse people.  Give them what they need and answer their questions.  If you don’t know the answer, find it, document it and move on.
12. Be prepared financially to take a few months in losses.  Besides putting out tons of money, all the users learning a new system will kill your productivity.  Do everything you can to get them up to speed as soon as possible, your bottom line depends on it. 
13. Be prepared to drop dead weight. As much as you might like someone, it’s their job to keep up with the times and your job to do as much as you can to make their transition easier.  However, at some point you have to cut your losses.
14. Providers require special attention.  Sometimes they also require special grooming.  Let them help each other.  We found that provider champions could get another provider up to speed much faster than weeks of training.  It may cost you up front to take a provider off the front line to help another, but in the end, this will help both providers to succeed.  You never know too, you may even solidify their commitment to your organization and to each other!
15. Spend your money wisely.  Don’t just buy something because someone else says it’s what you need.  Demo it against cheaper solutions and find the one that fits.  We spend thousands on tablets only to have doctors use them as laptops.  While we hope to get them up to speed and using them as tablets, they might be considered end of life by the time that happens.


Our EHR deployment was successful!  Yes, it was rushed, but we were able to meet our goals.  As of this update, we are now back to productivity goals after 7 months of shortage.  Everyone is much happier now, though not everything is 100% yet.  Just like any large system, it’s never 100%, never expect it to be either, you will be changing things constantly.  Just make sure you are changing them for the right reasons.