One Record, Many Lessons

Gary Baldwin, for HealthLeaders Magazine , July 10, 2008
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Allina Hospital made significant gains with its systemwide enterprise EMR. But the project cost more than just money.

Five years ago, Allina Hospital & Clinics declared an ambitious goal: Convert the entire 11-hospital system to a common electronic patient record system. Some $250 million later, Minneapolis-based Allina has achieved its vision of "one patient, one record." Allina's so-called "Excellian Project" is winding down to a handful of small community hospitals, and its 11 main hospitals and 70 clinics now share a common patient database that drive a core set of applications, including order entry, results reporting, pharmacy management, and picture archiving on the clinical side, and registration, scheduling, and billing on the administrative side.

The project was a massive undertaking that at its peak required full-time participation by 300 employees. Nevertheless, Allina is far from finished, having just begun to realize the efficiency of electronic data interchange (see sidebar, "What's Next"). Its accomplishments thus far, however, represent a textbook example of the big-ticket organizational makeover. During its hospital-by-hospital deployment, Allina learned plenty of lessons. They often came the hard way as the project upended the health system's traditions and conventions—sometimes with hard feelings.

Lesson 1: Implement enterprise governance—quickly
When Allina began its EMR journey, the organization had not yet jelled as a health system, recalls Susan Heichert, vice president of health information and systems. "Our hospitals had come together in bunches over the years," she says. "We did not have an efficient way to make decisions. When doing projects of this size, that becomes apparent quickly. The issues start coming fast and furious."

To respond, Excellian vice president Kim Pedersen formed a C-level leadership team that served as the steering committee. Members included Dick Pettingill, Allina's CEO, plus other corporate executives, such as the chief operating officer, chief medical officer, and presidents of local hospitals. "If the CEO was not 100% involved, we would not have been successful," says Pedersen, who left Allina in July 2007 after the bulk of the project was completed to become an independent consultant. Early on, for example, Allina needed to revisit its deployment timeline, as one of its key facilities was going to open a new heart hospital. A decision of such magnitude, with millions of dollars at stake, needed to go to the top leadership.

Lesson 2: Pay for physician leadership
Having the senior leadership behind the project is one thing. Getting physicians involved is another. That's why Pedersen underscores the importance of having a "well-thought, well-staffed, and well-executed" physician engagement plan. "You will either succeed or fail based on whether physicians accept the technology," she asserts. Allina's biggest mistake, she says, was leaning too heavily on physician volunteers to lead the charge with the medical staff. After all, the medical staff was about to incur a flurry of care documentation tools, from looking up results online to entering orders directly into the computer. Allina went from three part-time physicians to seven who were engaged practically full-time on the effort—and who were paid for their effort. "It was a big draw on our contingency funds," says Pedersen, adding that nurses, too, became part of the paid clinical staff. "It subtracted $5 million to $6 million over the life of the project."

In time, however, the physician champions became critical, especially when Allina began to mandate the use of the order entry system for the medical staff. Allina encompasses some 5,000 physician users, the vast majority of whom are independent practitioners. "If you don't set a date when the physicians are expected to go off paper, they won't," she says. "But the medical staff leadership has to lay down the law, not the administrative folks."

Lesson 3: Avoid design by committee
One of the thorniest problems in overlaying information technology onto a former paper-based system is defining the best workflows, says Heichert. Because information is passed from department to department, having representatives from across the hospital involved in screen and application design is important. Yet that can lead to a type of groupthink that may not serve users on the floor. For example, Allina assembled representatives from infection control, nursing, registration, and other departments to create a list of questions that nurses should ask a patient upon admission. The committee wound up with 200 questions, Heichert recalls. "It was overkill. That is what you get when designing by committee." Eventually, the list was pared down to 65 questions, and Allina altered its design process. The organization would call on the departments to create a template, but then put the prototype into a test setting so users could give feedback.

Lesson 4: Set realistic expectations
Allina's rapid roll-out goal relied on staff acceptance. And to help generate enthusiasm for the new technology—which was replacing a mixture of paper records and stand-alone legacy systems—Pedersen's implementation team played up the positive. "We sold the system by saying it would solve problems," she recalls. "It solves many problems, but the expectation ended up that the system would solve every problem out there. When it didn't, or didn't have the functionality, managing the scope became difficult. You need to be realistic about describing what the system is going to do."

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