Not too long ago, doctors’ poor handwriting was notorious and a staple for jokes. But now, most of the record-keeping in medicine has transitioned to digital means. Over the last decade, thanks in part to the Affordable Care Act, electronic health records (EHRs) are used in more than 98 percent of hospitals and almost all physicians’ offices. EHRs can significantly improve the accessibility of patient information, but have also spawned their own challenges.
One of those challenges is the fact that health systems will need to transition from their current system to another, a challenge which will become more and more common as EHRs continue to age out from first or even second generation software. In the same way that a business might find it more advantageous to use a more modern computer or brand, these transitions will happen. But unlike most businesses making technology upgrades or transitions, health care systems don’t have the luxury of making a change overnight or over the weekend when things close or slow down. And most businesses’ switch from PCs to Macs won’t have a potential effect on the health of their clients either.
With that in mind, a pair of Penn Medicine researchers, veterans of the health system’s shift to its own EHR, PennChart, took a look at the existing literature on how health systems handled their transitions. As they examined the understudied subject, John D. McGreevey III, MD, an associate professor of Clinical Medicine, and Ross Koppel, PhD, an adjunct professor of Sociology and a senior fellow of the Institute of Biomedical Informatics, developed a 10-point checklist for health care system leaders to guide them as they move into an EHR transition. Their findings were published in Applied Clinical Informatics.
Below, McGreevey and Koppel distilled their larger ideas into a set of recommendations and cautions for what health care leaders should understand and anticipate when making a transition.
It’s incredibly expensive to leave one EHR system and transition to a new one.
There will be extraordinary costs, and a lot of them.
“You need to consider the extra personnel from IT, the clinicians, consultants, and extra resources, like databases, and all of the legacy systems that need to be connected,” Koppel said. “Often, you’re dealing with new software and new builds. None of this comes cheap.”
Koppel and McGreevey also pointed out that there will be massive training expenses, along with significant time commitments. Staff also often experience frustration tied to any large transition, even if it’s relatively smooth. For that reason, health systems will need to be ready to provide much more support than typical health system operations would require.
Every health system has workarounds and idiosyncrasies in their daily operations. That will inevitably create some headaches with a new EHR system
It would behoove a health system to make sure as many of the variations in its typical operations are standardized before a transition because these little changes likely won’t translate to the new EHR — at least not easily.
“Failure to attend to these often overlooked organizational ‘housekeeping’ needs can add time and complexity to the EHR transition process and potentially create some risks in patient care if they get lost in the process,” said McGreevey.
For example, when Penn Medicine made its transition over to the new EHR, PennChart, the orders for morning lab work presented a challenge. While there was one order across the system, different hospitals had phlebotomists on different shifts. Some were available for blood draws nearly 24 hours a day, while another had staff that could be asked to make a draw when necessary, and another used phlebotomists in the morning and nurses in the afternoon and night. Getting that order to route to the right people was complex, important, and ultimately successful because the transition team understood the situation.
It takes a lot of dedicated people to pull off a successful EHR transition, not just the IT staff.
“Hiring more IT staff for these transitions is sometimes necessary because EHRs can create new work as well as new maintenance tasks, McGreevey said. “Outside consultants for hire can help during a transition to a new EHR, but they may not have the cultural and political knowledge of the institution to be maximally effective.”
But an EHR transition is not confined solely to tech teams. A transition takes networks of clinical subject matter experts to assess and endorse the clinical content that will live within the EHR. This is true in the case of order sets and alerts, for instance. Transitions also take clinical informaticists to lead the many, important subprojects of the transition and to translate between clinical needs and the technical build itself.
On top of that, training in the new system is something that must be considered.
“Training is complex and a need that persists beyond the new EHR go-live date,” McGreevey said. “There are tasks that may not be covered in the basic training because of time limitations, but need to be covered later on.”
An EHR transition is an interdisciplinary venture. Recognizing that early on can make the whole process much smoother than attempting to troubleshoot at the end.
Patient safety is an important area to watch.
Patient safety threats arise from limited access to legacy records and different definitions or standards for data amid an EHR switch. Additionally, there can be mismatched data fields that arise from confusion resulting from converting information from one system to another. For example, EHRs may have different ways of classifying high blood pressure as “hypertension,” or as “essential hypertension,” even though the categories are similar. Combining data from two systems may resulting in data loss, or misclassification. This is painstaking work, but mirroring the information and reports from previous versions of the EHR is critical.
“Patient care relies on EHRs now, and that makes these data overhauls especially precarious,” Koppel said. “Teams need to be especially careful about how data is switched over and when, making sure that nothing is lost or accidentally buried.”
Additionally, health care systems need to be on the lookout for cybersecurity threats because it is a time of vulnerability and possible exposure.
Again, remember that this is still relatively uncharted territory.
“There’s no playbook for how to do an EHR-to-EHR transition well, even though these events are very common,” Koppel said. “We tried to offer a first-of-its-kind, practical guide for health care organizations undergoing such transitions. But each institution is on its own to figure out a path, which will hopefully lead to success.”
To assure that EHR transitions can be successful for health care organizations and safer for patients, both Koppel and McGreevey feel much more research is needed, and it would benefit the spread of that research to have a MeSH term — the search keywords researchers can use to look up academic articles — for EHR transitions. Ultimately, the authors believe a national clearing house should be created for information and recommendations for institutions planning to transition to a new EHR or merging EHRs from different facilities.
In the meantime, they hope their guidance will lead health systems down the right path. And they encourage those undertaking the changes to remember, again, that it isn’t a paint-by-numbers, passive activity.
“These transitions are time-consuming, costly, and challenging,” Koppel said. “They can be scary, yes, but it’s possible to do them well. You just need to be prepared.”