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Keywords:

  • electronic medical record;
  • perinatal nursing;
  • lessons learned;
  • before and after comparison

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

Implementation of an electronic medical record (EMR) system is a complex process with broad implications. In a Midwestern hospital perinatal setting, EMR implementation involved several critical steps: strategic planning and project goal setting; project structure and governance; system requirements analysis; vendor selection and contract negotiation; and EMR training. No difference in patient care activities and communications among clinicians was found between pre- and post-EMR implementation; however, nurses’ perceptions of EMR were more negative afterward. Lessons learned and implications are provided.

The adoption of an electronic medical record (EMR) system has become imperative for many health care providers based upon the recommendation of the Institute of Medicine (IOM, 2001) to improve care quality and reduce costs through health care information technology. Another driving force is the recent change in the Centers for Medicare and Medicaid Services (CMS) reimbursement and incentives payment for meaningful use of a certified EMR through the American Recovery and Reinvestment Act of 2009 (Rishel, 2009). However, the development and deployment of health information systems such as EMRs have been predominantly technology oriented. With growing consensus that EMR implementation is not simply a technical project but rather one that affects multiple levels of the organization (Callen, Braithwaite, & Westbrook, 2008; Kaplan & Harris-Salamone, 2009; Rosenthal, 2002), a broader perspective on the implementation of health information systems is needed.

In this article, we describe the process and outcomes of EMR implementation in the Perinatal Services Department of a community teaching hospital in a midsized city in the Midwest. Over the years, several information systems have been implemented at this hospital, such as patient admission, discharge and transfer management, and medication management. Prior to the implementation of an EMR in 2011 in the Perinatal Services Department, some clinical workflow was already computerized, including a fetal monitoring and archiving system and a laboratory and ancillary service ordering system. Additionally, 15 years earlier this department purchased an EMR that was new on the market, but the system failed to deliver a comprehensive package. The department intentionally waited several years before searching for a new EMR.

We address two shortcomings in extant literature. Existing studies on nursing documentation frequently focus on the impact of EMR, such as changes in time spent on documentation and patient care (Asaro & Boxerman, 2008; Eden et al., 2008; Hakes & Whittington, 2008; Saarinen & Aho, 2005; Wong et al., 2003), while the process of implementation, which offer valuable insight and guidance on project planning, governance, and deployment, is often overlooked. Furthermore, few implementation studies were conducted at community hospitals, which have different circumstances and constraints than government and large hospitals closely affiliated with medical schools. These differences include respective missions, patient profiles, and access to resources (Chaudhry et al., 2006).

To begin, we gathered information from formal, audio recorded interviews with key project personnel, including the perinatal services director, the labor and delivery (L&D)/postpartum nurse manager, the neonatal intensive care unit (NICU), the newborn nursery and pediatrics nurse manager, and a systems analyst responsible for the outpatient EMR that interfaces with the perinatal EMR. Several informal interviews with these key informants also provided valuable insight into the implementation process. Since the EMR was rolled out in phases in this department, with the L&D unit being the first phase (as patient admission and patient charting begin in L&D), this investigation focused primarily on the effects of EMR implementation on the L&D nurse.

Implementation of a health information system is a social-technical process of organizational change, and focusing only on technical aspects may contribute to failure.

Project Startup

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

Strategic Planning and Perinatal Services EMR Project Goals

The decision to adopt an EMR is a key part of information technology (IT) strategic planning. To ensure maximum contributions of key IT resources in achieving organizational goals, IT must be aligned with overall organizational strategies and priorities and take into consideration external environment variables (Glaser, 2008; Hoyt, 2004; Thorman et al., 2006).

While the vision for EMR and specific project goals are determined by the executive steering and project committees, the following two considerations influenced the administrators’ and committee members’ decision to use EMR in this health care facility.

Deployment of EMR to Gain Competitive Advantage. In the institution under study, utilizing cutting-edge technologies in patient care and ancillary services has been a strategy to achieve its goal of being the community's premier medical care group. Considering external driving forces such as the shift from fragmented care to integrated care provided in both ambulatory and inpatient settings, the increasing demand for services among patients who were previously uninsured (Booz, Lefebure, & Rishel, 2010), and recent health care IT legislation (Rishel, 2009), the decision to adopt EMR for the Perinatal Services Department was made in 2009.

Primacy of Patient Safety and Quality of Care Improvement. The overarching goals of implementing an EMR were to improve patient safety and clinician productivity. With increasing patient volume, EMR improves legibility, accuracy, and efficiency in patient charting and facilitates patient information flow from physician offices to the Perinatal Services Department to outpatient post-delivery follow-up. We also expect that quality of care, clinical efficiency, and billing efficiency will improve since patient information is tabulated in a uniform and consistent format (Bates et al., 1999; Bates & Gawande, 2003; Pizziferri et al., 2005).

Perinatal Services EMR Project Structure and Oversight

Project governance is important in EMR implementation, as it provides oversight to the implementation process and ensures the project's alignment with overall organizational mission. A common governance structure consists of the executive steering committee and the project team. Typically, it is the executive steering committee, made up of senior executives and clinical leaders, who determine the overall IT plan and high level project goals, who secure resources for the project, and who remove organizational obstacles for the project (Barker & Frolick, 2003). Reporting to the executive steering committee is the project team, usually comprised of the department director, clinical champions, and IT staff.

In the institution under study, the executive steering committee included the CIO, CNO, and IT Director. The Perinatal EMR project team was led by the Perinatal Services director and included the nurse managers of each unit, both nurse educators, a systems analyst from the IT department, and several vendor consultants. Each nurse educator works 50% of her hours as staff and the other 50% as an educator. The director, both nurse managers, and one of the educators were staff nurses when the first EMR was installed and had first-hand experience with reasons the system failed. Specific responsibilities of the project leader included planning project tasks and timelines, monitoring progress, controlling project scope, coordinating resources, and driving the project forward through completion (Barnes, 2006; Pare, Sicotte, & Jacques, 2006).

Implementation Planning

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

The implementation planning process is made up of two key components: requirements analysis and vendor selection and contract negotiation.

Perinatal Services EMR Requirements Analysis

In requirement analysis, current clinical processes and data flows were analyzed to understand current workflow and identify improvements (Savory & Olson, 2001). The project team reviewed existing forms and reports for recording and sharing information about patients, treatments, orders, etc. In addition, EMR requirements including user interface (e.g., screen layout), reporting functions, data interchange with other systems, and security functions (e.g., authorizations and access privileges) were ascertained and prioritized. The project team determined that the EMR must have clinical documentation and reporting functions supporting all four units of Perinatal Service and integration of inpatient and outpatient clinical information via two-way data interchange. The integrated clinical data repository was expected to provide accurate, real-time, secure, as well as structured (where appropriate) clinical data to support patient care and secondary uses of data (quality improvement, clinical research, etc.). Clinical decision support (CDS) functions were also desired.

There were no differences in opinion during work processes mapping and EMR requirements gathering. The only exception was in vendor selection when one of the physicians preferred an EMR (due to its sophisticated functions) over another. However, he later yielded to the project team decision since the total cost of that system was beyond the budget.

Perinatal EMR Vendor Selection and Contract Negotiation

Vendor selection process often begins with the issuing of Request for Information (RFI). Vendors that offer systems meeting functional specifications (gathered from the previous step and listed in the RFI) are then asked to submit a formal proposal via Request for Proposal. While specific vendor qualifications vary, generally information to be considered in the vendor vetting process, besides functional and technical details, includes vendor reputation, staff experience and qualifications, and financial solvency (Gray & Felkey, 2004; Holbrook, Keshavjee, Troyan, Pray, & Ford, 2003; McDowell, Wahl, & Michelson, 2006). From the initial list of potential vendors selected by the project team, sometimes with assistance from internal IT resources and/or external consultant, no more than five vendors are invited to demonstrate their systems (McDowell et al.). Visits to vendor customer sites and vendor headquarters are also a critical to the system selection process.

In our institution, three vendors were considered based on extensive investigation at national conferences where products were displayed. Vendors presented at hospital campuses, and nurses and physicians had an opportunity to examine and evaluate each product. Vendors also made EMRs available for staff review. The project team, along with clinical champions, visited three hospitals to observe the systems in use, and the project team then selected the system that received the most positive feedback from physicians and nurses. After the system was selected, the project team encountered a snag due to miscommunication with the vendor. It was assumed that the system that was purchased included both inbound and outbound messaging between the systems used in outpatient clinics and the Perinatal Services. However, it was later discovered that inbound messaging connection (from outpatient to Perinatal Services) needed to be purchased and developed. This resulted in renegotiation of the contract and delayed project start up.

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Figure 1. Major Processes and Key Tasks in EMR Implementation.

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Perinatal EMR Implementation

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies
  • Strategies for implementation. The project team decided to adopt a phased roll out strategy. The first phase of the project was to implement nursing documentation in all four units of the Perinatal Services. Due to resource constraints and workflow consideration, the first unit to go live was the L&D unit and included nursing documentation only, which was followed shortly after by postpartum, nursery and NICU. Physician documentation, ordering, and integration with existing ordering system were slated for the later phases.
  • Systems configuration and data interface development. Configuration of the database, the EMR system, and user screens based on requirements were the primary activities. Since there were no dedicated resources for user screen configuration and a high percentage of information in existing paper charts was present in default user screens, the project team decided that only minimum modifications to user screens would be made. In addition, interface with the outpatient system was developed so that prenatal records could be merged with the EMR.
  • Equipment purchase and installation. Concurrent to configuration and interface development was equipment acquisition and installation. While hardware and software for the system was delivered one month prior to go-live, however, due to high patient volume and all labor rooms being continually occupied, installation of hardware was delayed for several weeks.
  • Testing. Data and systems integration testing, as well as user acceptance testing verifying the interface and systems configuration were done to ensure the system met user requirements.
  • Training. User training began toward the end of testing, about two months prior to go-live. A variety of training methods, including formal classroom training and personal demos, were used. Scheduling nurses for training was a challenge, due to high patient volume and staff shortage at the Perinatal Services Department. Multiple formal training sessions were scheduled in two-hour blocks to fit into clinician schedules. The training session provided a walk-through of the workflows in EMR and hands-on practice opportunities. All users were required to successfully complete training prior to using the EMR.
  • Go live. To ensure a smooth transition from paper charting to EMR and successful go-live, the Perinatal Services Department made the following accommodations: additional nurses were added to each shift to accommodate the learning curve of the new EMR system, and project team members, nurse educators, and “super users” were available onsite to support users during the first few weeks of go-live.
  • Post go-live. User feedback was gathered after go-live to assess satisfaction with the EMR and to identify areas for improvement.

The three major processes of EMR implementation, project startup, implementation planning, and EMR implementation, and key tasks in each process are summarized in Figure 1.

EMR Evaluation of Perinatal Services

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

Observation

To gain a better understanding of the organizational impact of the EMR, changes in perinatal nurses’ work activities and their perceptions toward the system before and after the implementation of EMR were studied. The main data collection method was observation. Pre- and post-implementation observations took place six months before and six months after the implementation of the EMR. Structured observations were conducted in five-hour time blocks over a three-week period for 35 hours (70 hours pre- and post-implementation observations).

Using the work sampling method (Fontaine, Speedie, Abelson, & Wold, 2000), clinician workflow activity (direct patient care, reviewing/updating patient charts, consultation with physician/nurse/specialist, etc.) was observed and recorded every 10 minutes during each observation time block. To develop the categories of workflow activities, clinical workflow observation studies and categories of clinical activities identified in those studies (Asaro & Boxerman, 2008; Eden et al., 2008; Fontaine et al.; Wong et al., 2003) was reviewed. An initial list of activity categories was developed, along with the definition of each category. The activity categories were then pilot tested in a five-hour observation. Based on the observation and input from the Perinatal Services director, the categories and their definitions were revised.

The observations were conducted by one of the authors who had previous experience using the observation study method. In addition, the observation process and procedures were modeled after previous studies by Eden et al. (2008) and Fontaine et al. (2000). The single observer had the benefit of minimizing the potential effect of inter-observer variation on data collection, and a structured observation sheet ensured objective and consistent data recording.

Procedure

All staff nurses in the L&D unit received a letter inviting them to participate in this study. The letter explained the study purpose and procedure and emphasized the voluntary nature of the study. Nurses who wanted to be excluded from the study were not observed. Nurses observed for workflow activity during each shift were identified by their roles (e.g., nurse 1, nurse 2, etc.) instead of their names on the observation sheet. This study was reviewed and approved by the Institutional Review Board prior to its commencement.

Survey Development

Pre- and post-implementation survey questionnaires supplemented data gathered from observations. Guided by the literature review (Pirnejad, Niazkhani, van der Sijs, Berg, & Bal, 2009; Törnvall, Wilhelmsson, & Wahren, 2004), the surveys were developed to measure clinicians’ existing computer experience and attitudes toward EMRs. The questionnaire included 11 items pertaining to the contribution of the EMR to patient care, clinician productivity, documentation quality, legal compliance, and billing. Using a five-point Likert-type scale, nurses were asked to indicate their agreement or disagreement with the EMR's contributions. Several open-ended questions pertaining to challenges, benefits, and/or changes nurses experienced in their charting and in their interaction with patients and other clinicians since EMR implementation were included in the post implementation survey questionnaire to collect nurses’ comments. These comments, along with nurses’ input during nurse managers’ rounding, helped the researchers understand the nurses’ experience with the EMR and interpret their survey responses. Before the questionnaires were distributed, they were reviewed by the Perinatal Services director and L&D nurse manager for wording clarity and content validity. In this study, the internal consistency of the survey instrument was established using Cronbach's alpha which yielded an alpha of .77.

The perceptions of labor and delivery nurses regarding electronic medical records were less positive after implementation.

Survey Administration

The pre- and post-implementation surveys were completed by L&D nurses six months before and after EMR implementation. Since there appeared to be no clear guideline as to the timing of surveys in pre- and post-implementation studies (Pirnejad et al., 2009), we decided to distribute the survey six months before EMR implementation when the nurses had been notified of the pending implementation but had not yet received EMR training and six months afterward to give the nurses some time to adjust to electronic charting. Of the 29 L&D nurses, 26 completed the pre-implementation survey, and 21 of 27 completed the post-implementation survey. As shown in Table 1, the average tenure of labor room nurses was 10 years before EMR implementation and 13.5 years after EMR implementation (due to staff nurse turnover). The difference was not statistically significant (t(44) = −1.714, = .09). Nurses’ general experience with computers (not EMR specific) was moderate to high (3.7 and 3.9 on a 5 point scale, post and pre implementation respectively, with1 being “limited to no experience with computers” and 5 being “very experienced and confident”). The pre- and post-implementation difference was not significant (t(43) = .978, = .33).

Table 1. Pre and Post Implementation Study Participant Characteristics
 Mean   
Participant CharacteristicsPrePosttMean Differencedf
  1. a

    Computer experience was measured on a five point Likert-type scale: 5 = Very experienced and confident, and 1 = limited to no experience.

Average Years of Experience in L&D10.413.5−1.71−3.1844
Average Computer Experiencea3.93.70.970.2443

Results

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

Impact of EMR on Clinical Activities

Labor and delivery nurses’ work activities before and after EMR implementation observed in 14 five-hour time blocks (half in pre- and the other half in post-implementation) remained largely unchanged, except in charting activities. As shown in Table 2, average patient care, phone consultations, and face-to-face consultations with other clinicians increased slightly after the EMR was implemented. However, the increases were not statistically significant. On the other hand, activities related to paper charting decreased significantly (t(12) = 2.33, = .038). Paper charting activities included printing and collating prenatal records and various forms. Since patient consent forms, medication reconciliation records, and physician orders were on paper, paper charts were still being used. In addition, outpatient offices of a few obstetricians were not computerized, and prenatal records received via fax were added to the paper chart. Another activity that changed significantly was computer charting (t(12) = −5.36, = .000). This change was expected as all nursing documentation, from initial assessment to labor progress, to delivery and transfer, were charted in the EMR.

Table 2. Average Number of Activities Per Hour Before and After EMR Implementation
 Mean   
ActivitiesPre (7 observations)Post (7 observations)tMean Differencedf
  1. *p < .05. ***p < .001.

Patient Care10.5711.15−0.34−0.5812
Paper Charting4.022.402.33*1.6212
Computer Charting0.873.45−5.36***−2.5812
Phone Consultation1.371.48−0.32−0.1112
Face-to-face Consultation4.215.06−1.19−0.8512

There was no statistically significant difference in patient to nurse ratios before (1.06) and after (1.03) EMR implementation (t(68) = .432, = .667). This ruled out influence of workload on changes in nurses’ work activities.

Impact of EMR on Perceptions

Labor and delivery room nurses’ perceptions toward EMR were generally positive prior to implementation, as shown in Table 3. On a five-point Likert-type scale, 1 indicating strong disagreement and 5 strong agreement, the lowest mean score of the items was 4.00 (“EMR can help clinicians spend less time on patient documentation” and “EMR can help clinicians improve patient billing”), and the highest mean score was 4.50 (“EMR can help clinicians improve quality of patient documentation”). Overall, the high mean scores indicated very favorable EMR perceptions.

In the post implementation survey, nurses’ perceptions were less positive. Of the 11 items, only two items received mean scores of 3.5 or higher: “EMR can help clinicians improve quality of patient documentation” and “EMR can help clinicians comply with legal requirements,” but their mean scores were only 3.72. Three items with the lowest mean scores were all time related: “EMR can help clinicians spend more time on patient care, spend less time on gathering patient information, and spend less time on patient documentation,” at 2.94, 3.0 and 3.11 respectively. A t-test showed pre and post survey differences of all 11 items were statistically significant, indicating nurses’ perceptions of the impact of the EMR on nursing activities had changed significantly after implementation.

Discussion

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

Six months after the EMR went live in the L&D unit, with continual support from the project team, the nurses gradually transitioned from paper to computer charting. Observation of clinical activities showed no significant difference in the average number of patient care activities (per hour) before and after EMR implementation, thereby allaying some concerns about potential detrimental effects of the EMR on patient care. While the observations of clinical activities showed the frequency of patient care remained the same, the significantly more negative responses compared to those prior to EMR implementation may be reflective of the learning curve nurses must overcome when transitioning from paper to computer charting. One nurse made the following comment in the survey, “I find myself focused on where to click on the screen rather than my patient. I find my usual 20 minute. process to discuss the plan when the patient arrives now takes 30–40 minutes to get through.” Another nurse stated, “Feels like looking and interacting more with the computer than the patient. It's becoming better the more familiar we become with the system.”

Several contributing factors to the learning curve were EMR screen layout, timing of EMR training, and physical constraints. The EMR screen layout was generally well organized, but it took nurses some time to become accustomed to it. While the original intent was to modify user screens in the EMR so they would be more similar to the paper charts, the confluence of the push to implement EMR in every department of the hospital as soon as possible and the unexpected downward spiraling of the general economy and budgetary constraints resulted in fewer resources to tailor the EMR for the Perinatal Services. In order to get the system up and running, it was not possible to make the screens similar to the layout of the paper charts. Since the system is site-tailorable, it was decided that this could be done at a later time.

Another contributing factor was EMR training conducted three to four weeks before the L&D unit went live. The gap was due to high patient volume, which caused delayed installation of hardware in patient rooms and EMR go live. The time lapse between training and go-live negatively affected retention of information learned in EMR training sessions among some nurses and it may have also contributed to the steeper learning curve and the more negative attitude. The third contributing factor to the less positive perceptions of the EMR was the physical constraints of the L&D unit. Computer charting in several labor rooms was challenging due to the small room size or awkward room layout (e.g., documentation stations facing the wall and were too high for some nurses). Nurses expressed frustrations with providing efficient and safe care in a limited physical environment, while juggling an increasing number of patients and learning a new EMR. The physical constraints are expected to be alleviated when the Perinatal Services completes its renovation and expansion in 2012. Feedback from nurses has influenced several renovation decisions, including installation of height adjustable documentation stations facing surgical procedures and when interviewing the mother.

Another key finding was that the frequency of communication among clinicians remained unchanged. Disruption in communication was a concern because reduced face-to-face communication among clinicians was found in several EMR implementation studies (e.g., Aarts, Ash, & Berg, 2007; Ash, Anderson, & Tarczy-Hornoch, 2008). In the next phase of implementation when physicians begin charting and ordering tests in the EMR, patterns of communication among clinicians, both in terms of frequency and nature, will be closely monitored. Decrease in paper charting and increase in computer charting indicate re-allocation of nurses’ time on charting related activities. Paper charting activities are expected to decrease further, when all other Perinatal Services units go live with EMR and there would be no need to print certain portions of the patient charts.

Table 3. Perceptions Toward EMR Before and After Implementation
 Mean   
EMR can help cliniciansPrePosttMean Differencedf
  1. On a 5 point scale: 1 = strongly disagree; 5 = strongly agree.

  2. *p < .05. **p < .01. ***p < .001.

Improve communication and coordination of patient care4.423.264.19***1.1643
Spend less time on gathering patient information (prenatal, lab results, etc.)4.423.004.54***1.4243
Improve quality of patient documentation (e.g., legibility, completeness)4.503.722.53*0.7842
Spend less time on patient documentation4.003.112.70*0.9043
Improve quality of patient care4.043.262.94**0.7843
Spend less time processing orders4.153.323.05**0.8443
Monitor patient progress more easily4.153.532.05*0.6343
Access lab results more easily4.383.263.96***1.1243
Spend more time on patient care4.122.943.58**1.1742
Comply with legal requirements4.313.722.46*0.5942
Improve patient billing4.003.422.13*0.5843

Study Limitations

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

This study focused on the primary users of the EMR: the labor and delivery room nurses. Patients’ perspectives on whether EMR affected the care they received were not studied. To address this limitation, we plan to include patients’ perspectives in a follow-up study 18 months after implementation. Another limitation is the lack of a more comprehensive survey of staff nurses’ experience with the EMR during and after EMR implementation. In hind sight, a focus group soliciting feedback from the nurses about their experience with the system across all stages of the implementation process would have enhanced this study.

Successful implementation includes using clinical champions, developing change management strategies, and providing timely and thorough training.

Conclusions

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies

While the first phase of the EMR implementation at the Perinatal Services was completed within budget and received moderate user acceptance, delays were caused by issues with the vendor contract. The EMR selected was developed by the same vendor that developed the system already adopted by the outpatient offices. Two-way messaging capabilities between the inpatient and outpatient systems were assumed because of miscommunication.

The consequences of inadequate resources, in particular, the steep learning curve for nurses to adjust to new EMR screen layout, is a major lesson learned from this study. Inadequate resources also led to some delays in the EMR implementation. While dedicated resources for EMR implementation would be ideal, oftentimes this is not possible. Clinical and administrative staffs were asked to take on additional responsibilities, so workload adjustment, such as release time and hiring temporary help, and/or compensation are critical to avoid negative impact to staff retention and future recruitment. Another lesson learned is the timing of EMR training; it should coincide closer to the go-live date so that recall of the myriad documentation entries is less affected by time lapse. Staff nurses’ comments also suggested training location should be away from the unit and patient ward so nurses can give full attention to the training and not be interrupted. Further, we also suggest that the EMR system is available for nurses to practice on between training and go live to ensure learning retention. Finally, the phased implementation strategy appeared to ease the strain of limited resources and helped to build the momentum of subsequent rollouts.

There were other potential risks that could contribute to EMR project delays and even failure, including poor understanding of the impact of the EMR on workflow and resistance to change. These risks were anticipated and mitigated by adhering to strategies suggested by McCartney (2006) who urged active participation from nurses in the entire IT implementation process and offered the following strategies: involve all stakeholders, develop change management strategies, examine work processes, provide thorough training, and evaluate effect of IT on patient safety. At our institution, clinical champions and users who have intimate knowledge of the workflow were involved from the beginning of the project. Their input on a variety of decision points, such as system requirements and implementation strategies, was encouraged and accepted. This fostered a sense of control and buy-in for the project. Formal classroom training before go live and continual on-the-job user support also increased nurses’ comfort levels with the system.

The implementation of an EMR system is a complex process with implications for multiple departments across different care settings. The process and outcome of an EMR implementation at the Perinatal Services of the community hospital illustrated in this paper aim to provide insight for other hospitals embarking on an EMR implementation project. As indicated by the experience of this department, with careful planning and by employing proper strategies to overcome challenges, positive implementation outcome can be achieved.

EMR implementation requires organizational and technical considerations, including support from management and clinical champions, detailed analysis of workflow and system requirements to drive EMR selection, prudent deployment strategy, and inclusion of users throughout the process. Recommendations for future EMR implementations across all project phases, from startup to post implementation improvements, are summarized in Table 4.

Table 4. Recommendations for Future EMR Implementations
1. Gain full support from the executive steering committee and secure adequate resources for the project team to avoid negative consequences (e.g., delay, staff turnover) and to ensure achievement of project goals
2. Select physician and nursing champions who are well respected, knowledgeable, and have a positive (at least neutral) attitude toward EMR to help move the project forward and manage resistance
3. Document workflow and system requirements thoroughly to ensure selected system will meet department needs
4. Select a vendor that has a robust and mature product and strong customer service
5. Scrutinize all communication and negotiation with vendor to avoid miscommunication
6. Consider a phased implementation strategy to focus resource deployment and build momentum
7. Schedule EMR training as close to go live as possible to ensure learning retention
8. Provide nurses access to the EMR for practice prior to go live
9. Gather feedback from nurses and address all issues/concerns to improve user satisfaction and ensure patient safety

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies
  • Aarts, J., Ash, J., & Berg, M. (2007). Extending the understanding of computerized physician order entry: Implications for professional collaboration, workflow and quality of care. International Journal of Medical Informatics, 76(S), S4S13.
  • Asaro, P. V., & Boxerman, S. B. (2008). Effects of computerized provider order entry and nursing documentation on workflow. Academic Emergency Medicine, 15, 908915.
  • Ash, J., Anderson, N. R., & Tarczy-Hornoch, P. (2008). People and organizational issues in research systems implementation. Journal of American Medical Informatics Association, 15(3), 283289.
  • Barker, T., & Frolick, M. N. (2003). ERP implementation failure: A case study. Information Systems Management, 20(4), 4349.
  • Barnes, J. (2006). Implementing a perinatal clinical information system: A work in progress. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35(1), 134140.
  • Bates, D. W., & Gawande, A. A. (2003). Improving safety with information technology. New England Journal of Medicine, 348(25), 25262534.
  • Bates, D. W., Pappius, E., Kuperman, G. J., Sittig, D., Burstin, H., & Fairchild, D. (1999). Using information systems to measure and improve quality. International Journal of Medical Informatics, 53(2–3), 115124.
  • Booz, R. H., Lefebure, S., & Rishel, W. (2010). U.S. healthcare industry must prepare now for post-reform market. Gartner Report: G00175591. Stamford, CT: Gartner, Inc.
  • Callen, J. L., Braithwaite, J., & Westbrook, J. I. (2008). Contextual implementation model: A framework for assisting clinical information system implementations. Journal of American Medical Informatics Association, 15(2), 255262.
  • Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., … Shekelle, P. G. (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144(10), 742752.
  • Eden, K. B., Messina, R., Li, H., Osterweil, P., Henderson, C. R., & Guise, J. M. (2008). Examining the value of electronic health records on labor and delivery. American Journal of Obstetrics & Gynecology, 199, 307.e1307.e9.
  • Fontaine, B. R., Speedie, S., Abelson, D., & Wold, C. (2000). A work-sampling tool to measure the effect of electronic health records implementation on health care workers. Journal of Ambulatory Care Management, 23(1), 7185.
  • Glaser, J. (2008). Creating IT agility. Healthcare Financial Management, 62(4), 3639.
  • Gray, M. D., & Felkey, B. G. (2004). Computerized prescriber order-entry systems: Evaluation, selection, and implementation. American Journal of Health Systems Pharmacology, 61, 190197.
  • Hakes, B., & Whittington, J. (2008). Assessing the impact of an electronic medical record on nurse documentation time. Computers, Informatics, Nursing, 26(4), 234241.
  • Holbrook, A., Keshavjee, K., Troyan, S., Pray, M., & Ford, P. T. (2003). Applying methodology to electronic medical record selection. International Journal of Medical Informatics, 71, 4350.
  • Hoyt, J. P. (2004). The do's of IT strategic planning. Healthcare Executive, 19(5), 815.
  • Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
  • Kaplan, B., & Harris-Salamone, K. D. (2009). Health IT success and failure: Recommendations from literature and an AMIA workshop. Journal of American Medical Informatics Association, 16(3), 291299.
  • McCartney, P. R. (2006). Using technology to promote perinatal patient safety. Journal of Obstetric, Gynecologic, &Neonatal Nursing, 35(3), 424431.
  • McDowell, S. W., Wahl, R., & Michelson, J. (2006). Herding cats: The challenges of EMR vendor selection. Journal of Healthcare Information Management, 17(3), 6371.
  • Pare, G., Sicotte, C., & Jacques, H. (2006). The effects of creating psychological ownership on physicians’ acceptance of clinical information systems. Journal of the American Medical Informatics Association, 13(2), 197205.
  • Pirnejad, H., Niazkhani, Z., van der Sijs, H., Berg, M., & Bal, R. (2009). Evaluation of the impact of a CPOE on nurse-physician communication: A mixed-method study. Methods of Informatics in Medicine, 48, 350360.
  • Pizziferri, L., Kittler, A. F., Volk, L. A., Honour, M. M., Gupta, S., & Wang, S. (2005). Primary care physician time utilization before and after implementation of an electronic health record: A time-motion study. Journal of Biomedical Informatics, 38(3), 176188.
  • Rishel, W. (2009). Meaningful use and certification of EMRs: Tracking evolving targets. Gartner Report: G00171243. Stamford, CT: Gartner, Inc.
  • Rosenthal, D. A. (2002). Managing non-technical factors in healthcare IT projects. Journal of Healthcare Information Management, 16(2), 5661.
  • Saarinen, K., & Aho, M. (2005). Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care? Acta Anaesthesiologica Scandinavica, 48, 6265.
  • Savory, P., & Olson, J. (2001). Guidelines for using process mapping to aid improvement efforts. Hospital Material Management Quarterly, 22(3), 1016.
  • Thorman, K. E., Leask Capitulo, K., Dubow, J., Hanold, K., Noonan, M., & Wehmeyer, J. (2006). Perinatal patient safety from the perspective of nurse executives: A round table discussion. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35(3), 409416.
  • Törnvall, E., Wilhelmsson, S., & Wahren, L. K. (2004). Electronic nursing documentation in primary health care. Scandinavian Journal of Caring Sciences, 18, 310317.
  • Wong, D. H., Gallegos, Y., Weinger, M. B., Clack, S., Slagle, J., & Anderson, C. T. (2003). Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system. Critical Care Medicine, 31(10), 24882494.

Biographies

  1. Top of page
  2. ABSTRACT
  3. Project Startup
  4. Implementation Planning
  5. Perinatal EMR Implementation
  6. EMR Evaluation of Perinatal Services
  7. Results
  8. Discussion
  9. Study Limitations
  10. Conclusions
  11. REFERENCES
  12. Biographies
  • Chia-An Chao, PhD, is an associate professor at the Scott College of Business, Indiana State University, Terre Haute, IN.

  • Joanne Goldbort, PhD, RN, is the director for Maternal and Child Services, Union Hospital, Inc., Terre Haute, IN.