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The Big Bang

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Technology may promise lowered costs, improved safety and streamlined operations, but it usually comes wrapped in new standardized workflows that upend well-worn clinician and administrator routines. That’s why healthcare organizations usually avoid moving too rapidly in implementing new systems; the so-called “big bang” approach—converting hundreds of users to new technology in one quick turnover—can be a recipe for disaster.

After 10 years on the job, this was exactly the scenario Pam McNutt faced. By 2004, Methodist Health System’s multiple legacy information systems, she recalls, had been "customized beyond recognition.” Methodist, which operates three hospitals in the Dallas area, had created a highly interfaced array of best-of-breed applications that was costly to maintain, says McNutt, senior vice president and chief information officer. So Methodist decided to replace its aging legacy systems with an integrated platform from a single vendor. The lure of efficient data exchange among the health system’s 3,000 employees and 600 affiliated physicians proved too strong to resist.

There was a catch, however. Given the highly integrated nature of the financial and clinical applications Methodist wanted to install, the health system had to turn them all on at once. “Otherwise, we’d be building a bunch of interfaces” and duplicating the very problem the health system was trying to eliminate, McNutt explains. That summer, Methodist staged a near-total IT makeover, launching 17 modules from its new vendor partner, Medical Information Technology (Meditech), in one fell swoop. “A ‘big bang’ was our only path,” the CIO says.

Introducing that much change to a risk-adverse culture could have easily backfired. But thanks to a methodically executed management strategy, Methodist survived. The system has joined the growing ranks of hospitals, health systems and medical groups that have managed to pull off healthcare’s Mission Impossible: making wholesale technology changes on a short timetable. Done correctly, rapid IT rollouts have transformed emergency departments, medical groups and entire hospitals, yielding both better care and improved financial performance. But it’s never easy. Here are six lessons learned by the IT risk takers who have made the leap and landed upright.

1. Get the c-suite involved

If there’s a common thread among healthcare organizations that have managed successful big bang deployments, it’s this: The ownership of the project should rest in the hands of a highly visible executive steering committee. Having the C-suite serve as champion of the project accomplishes two things. First, it conveys the seriousness of the commitment to the rest of the organization. Second, it assembles a group of executives who will invariably be needed to settle disputes or make deployment decisions that affect the entire organization. “If the executive leadership is not involved, you are not going to be successful,” says Praveen Toteja, CIO at George Washington (D.C.) University Medical Faculty Associates, a 280-physician multispecialty group practice. “Once the IT team is ready, you need a push from the CEO to get a rapid rollout done.”

Toteja served on a four-person executive group that led the rapid deployment of an electronic medical record system in the physician group. In less than a month, the group trained 99 faculty physicians and 130 residents and interns in its department of medicine on its EMR from Chicago-based Allscripts. The training set the stage for an ongoing deployment across the entire practice, which has virtually retired its paper charts.

The speedy conversion would not have happened without hands-on participation from the group’s CEO and the chairman of internal medicine, Toteja says. “The steering team discussed both the big picture and the details,” he says. “How to roll out, how to support, who would be answering questions—you name it.” For example, the steering team changed the practice’s scheduling method, shifting it away from individual specialties under the department of medicine to a centralized approach more befitting the EMR. Only executive leadership could have approved the move, Toteja observes.

The high-level team also pre-empted any doubt about the practice’s commitment to eliminating paper charts, adds CEO Stephen L. Badger, who served as the EMR project sponsor. “It eliminated the discussion of whether we would do it and on what timetable,” Badger recalls. “We said we will bring in additional resources and get the job done and that it is going to be good for us. Having the CEO and the chairman [of medicine] in sync eliminated any resistance from the subspecialties.”

In the hospital environment, the executive steering team can be even more crucial as large-scale IT deployments cross numerous departmental boundaries. When Community Hospital of the Monterey (Calif.) Peninsula did a big bang deployment of a suite of clinical and financial applications from Eclipsys Corp. in 2004, it leaned on an executive steering team that included the CEO, CIO, CFO and CMO, recalls Charlene Webber-Schuss, director of clinical informatics. The leadership team allocated funds to support 30 staff members who worked on the project full-time. For 18 months prior to the go-live, the group holed up in a conference room about five miles from Monterey’s main campus. “The executive steering committee freed up the resources to enable us to succeed,” she says.

2. Test, test, test

Because big bang deployments have so many moving pieces, testing the applications prior to go-live becomes paramount. Dissatisfied with its testing, George Washington waited nearly four years before launching its EMR. The software, Badger explains, was simply not ready for prime time. “We delayed until we got sufficient upgrades so when we went through the aggressive rollout we would not frustrate the physicians,” he says.

But even when hospitals are confident in the software, end-to-end testing is critical. Take HealthAlliance Hospitals, which operates two hospitals in Leominster and Fitchburg, Mass. In December 2005, HealthAlliance replaced its longstanding clinical and financial information system from Siemens Medical Solutions with the vendor’s Soarian suite, an integrated package that includes clinical and financial applications. Soarian’s workflows varied substantially from Siemens’ legacy system, recalls Rick Mohnk, vice president and chief information officer. “The change was huge,” he says.

Two years in the making, HealthAlliance’s big bang went fairly smoothly, Mohnk says, thanks in part to rigorous system testing. HealthAlliance ran multiple tests with the new financial application to ensure compatibility with Soarian’s numerous system components that would be feeding data to the hospitals, says Margaret Campbell, director of applications and project manager. Undertaken with the hospital departments, the testing ensured the smooth exchange of electronic data while exposing department managers to Soarian’s new workflows, she says. In hindsight, Campbell adds, more high-volume testing would have been helpful; even though HealthAlliance had tested the applications, the system struggled under the load of 2,000 concurrent users. “We had immediate performance issues, so we added more memory,” Campbell says.

3. Train, train again

Hospitals and medical groups that manage massive IT makeovers don’t skimp on training—before, during or after the go-live. Many big bang veterans say training is the most important success factor. After new applications are turned on, “you need to be ready to support clinicians around the clock for a couple of weeks,” says Edward Kamens, M.D., information systems medical staff advisor at HealthAlliance. “Real life is the true training ground.”

Kamens was among some 50 “super-users” HealthAlliance put to work during its deployment. Having a physician champion available to help physicians understand new applications and workflows is crucial, Campbell says. “Physician training was our toughest challenge,” she explains. “Prior to go-live, we did classroom and one-on-one training with them, but it’s difficult to reach every physician before the live event.” That’s why, during the go-live event, Campbell dedicated multiple support staff to working with physicians. Any calls to the help desk were automatically routed to this group or to Kamens, she explains.

Prior to the transition to Soarian, HealthAlliance ran training courses at three centers for a three-month period, Mohnk says. Each nurse received a mandatory eight-hour classroom training sequence, and HealthAlliance granted staff access to the new system in training mode across its corporate intranet. But Mohnk emphasizes that clinicians may not always have time to use online training modules. “People do not always practice on new systems after going through the training, so we went to ‘just in time’ training as well. We kept Soarian trainers available around the clock for three weeks.”

Campbell says HealthAlliance would have benefited from even more training for department managers, who inherited new reporting tools under Soarian. For example, some financial managers needed additional training after the go-live because of confusion over how the system reported charge errors. “With our integrated training, we were able to identify weak users,” she says.

4. Bank on human nature

Resistance to change is a common tale of woe when it comes to automating healthcare operations with IT. But rapid deployment veterans say large-scale change in the right environment can also capture the imaginations of hospital staff members. To launch its IT conversion, 178-staffed-bed Community Hospital of Monterey held a contest to name the project. The winning entry, “Luna Project,” was a reference to the vendor, Eclipsys. “We wanted to get enthusiasm up and help spread awareness,” says Webber-Schuss, the clinical informatics director.

Methodist Health System’s executive steering team and department leaders also adopted a space-age mantra for the project: the Apollo 13 slogan, “Not on my watch.” The phrase refers to the moon probe’s failure-is-not-an-option philosophy, which helped it survive a near-disastrous in-flight explosion. Behind the slogan is friendly competition, says CIO McNutt. “Once our excitement got going, the big bang became like the Apollo 13 mission. People said it won’t fail on their watch.”

A savvy management structure helped Methodist live up to the slogan. The executive steering team set overall direction while multiple department project teams led the deployment of individual modules. Setting aggressive deadlines kept everyone on their toes, McNutt says. “Nobody wanted to be the one who said their group delayed the project,” she says. There was an incentive, as well; all vice-president-level and above staff were rewarded if the project met its deadlines. “When you are doing a big bang, you need to make sure everyone has incentives,” McNutt says.

For medical groups converting from paper to electronic charts, a speedy deployment can be a psychological tool when it comes to winning over physicians. That’s what the Murfreesboro (Tenn.) Medical Clinic found out when it brought nearly 60 physicians up on an EMR in two weeks. “We didn’t want half of the practice doing one thing and the other half doing another, so we decided to bite the bullet and convert to the EMR real quick,” says Joe Castelli, M.D., a physician IT champion who became medical director of information technology after the November 2004 deployment of Allscripts software. “It created an organizational feeling that we are all in this together. Otherwise we could have run into problems.”

5. Set milestones

Even though a rapid deployment may precipitate its own organizational momentum, the project must measure up against various checkpoints to stay on track. In successful big bangs, flipping the switch on a host of new applications is one of many carefully planned stages. At Community Hospital of Monterey, for example, the final decision to activate the Eclipsys suite of applications was made three months before the actual launch. Prior to that, key milestones had been reached, including acceptable screen design, interface testing among the various modules, a test of the integrated applications, and a system freeze after which no more design changes could be made. “You cannot anticipate every problem with a big bang, because so many pieces are affected,” says Webber-Schuss. “But with our project structure, you can resolve issues as they happen.”

When it set out to automate its emergency department, 335-staffed-bed Good Shepherd Medical Center in Longview, Texas, followed a similar course of IT milestones. Treating some 75,000 patients annually, the emergency department implemented a management system from MedHost that included patient tracking, clinical documentation and orders. Because the ED system required multiple interfaces with Good Shepherd’s core hospital information system from Meditech, the project timetable included several testing milestones, says Wiley Thomas, CIO. The milestones also included testing hardware and making sure staff had passed competency tests on the new software. “We had to hit the milestones we laid out to proceed,” says Thomas.

Unlike some CIOs, Thomas had a cooperative group of physicians driving the project. Some 40 strong, the ED physician group pushed for the automation as a way to improve documentation and complete their charts more quickly. Both goals were met, Thomas says. “Once the nurses saw the doctors using the system, getting them on board was easy.”

6. Know what not to do

The hallmark of the big bang IT deployment is speed—rapidly bringing up multiple users on new applications. The breadth of the project, however, is another question. And for most CIOs, it pays to be choosy. Methodist Health System, for example, did not implement a physician order entry system, even though it was part of the Meditech package. As James W. Langley, M.D., director of medical informatics, explains, “Many hospitals have jumped into CPOE without seeing where their medical staffs are. I realized we were not ready, so we pushed it off.” As a precursor to order entry, Methodist brought up electronic signature capabilities for physicians, in part to demonstrate to them the value of IT tools. Now, with physicians comfortable looking up results and signing off on charts electronically, Methodist is in the early stages of launching CPOE, he says.

Likewise, two years after it quickly brought up its physicians on an EMR, the Murfreesboro Medical Clinic has yet to implement the automated charge capture feature of its Allscripts system. Instead, the group’s 61 physicians use a paper form to track billable services. “I’m overcautious and want to make sure nothing hurts our cash flow,” explains CEO Joey Peay.

Peay’s reluctance is borne of experience. The group’s first stab at an EMR, two years prior to its big bang, was a failure. After trying the EMR with four physicians—Peay declines to name the vendor—the clinic abandoned the effort. “Buying an EMR is like buying a car,” he says. “There is this post-purchase dissonance that comes about: ‘Oh, I should not have done this.’” With $1.5 million invested in the group’s latest EMR, Peay had little room for discomfort. That’s another reason he opted for the aggressive two-week rollout. “We wanted to remove any opportunity for second-guessing.”

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at gbaldwin@healthleadersmedia.com.



Three risks—and how one system overcame them

Experts identify three main dangers of big bang IT deployments. First, the amount of change being introduced can overwhelm an organization. Second, the size of the project—unprecedented for most healthcare organizations—makes it hard to manage. And finally, the new technology may prove to be unstable.

Although these may seem like formidable obstacles, they can be mitigated, says Pam McNutt, senior vice president and chief information officer at Methodist Health System. Dallas-based Methodist had plenty of incentive to reduce risk in 2004, when its $10.5 million big bang deployment of a suite of 17 clinical and financial applications from Medical Information Technology (Meditech) knocked out numerous legacy systems. During the 2006 annual meeting of the Healthcare Information and Management Systems Society, McNutt described how Methodist did the job.

Controlled Change. Even though Methodist introduced numerous new applications, the system was careful not to introduce new major process redesign as part of the go-live. “Our strict tenet was to replace existing functions,” McNutt says. “Nurses documented online before, so they would continue. We did not change how much they were documenting or what documentation standards they used.” After the staff adjusted to the new applications, Methodist began adding other integrated applications into the mix, such as electronic signature for physicians and an OR scheduling system. Even when clinicians were clamoring for new applications, Methodist took it slow. “ER nurses wanted to use the documentation modules, but we held back,” McNutt says. “When we could, we added some pia, something new and flashy that gave value but did not change workflow, such as a color-coded ED patient tracker.”

Decentralized Management. Although Methodist used an executive steering committee to monitor the project, it delegated ownership of the various modules to the department leaders most directly affected by them. Each department leader was paired with an “IT buddy” and one of the consultants Methodist hired to facilitate the IT overhaul. “We made sure we enabled people with a lot of resources,” McNutt says. “The department directors freed up their own staff to work on the project as well. That is important, too.” The departmental ownership of new modules created a pride of ownership—and sparked friendly competition, McNutt says. “If you’re just doing a new lab system, the department could say, ‘Let’s delay.’ But when you’re doing a big bang, nobody wants to go before the hospital board of directors and say their team isn’t ready.”

Background Checks. Before contracting with Meditech, Methodist sent departmental team leaders and executive management on three site visits to see the technology in action. “We wanted to ensure that everybody could validate functionality to meet their needs,” McNutt says. After doing the site visits, Methodist took an extraordinary step: Instead of considering other vendors, it looked for a consensus vote on Meditech. For McNutt, the vendor’s detailed implementation plan was a major plus, but her opinion was advisory. “We gathered all the VPs in one room and asked, ‘Why not?’” The group opted to stick with Meditech, thus sidestepping what would have been a lengthy RFP process evaluating other vendors.

—Gary Baldwin



Patience is a virtue—and a necessity

George Washington (D.C.) University Medical Faculty Associates may have set a land-speed record with its rapid electronic medical record rollout. In June 2004, the group practice brought up 99 department of medicine physicians, along with 130 residents and interns, on the EMR in less than a month. By the end of 2005, the majority of staff physicians in the 280-member group were using the EMR.

The conversion has paid off handsomely for the practice, says CEO Stephen Badger, who was named 2006 “Executive of the Year” by the Medical Group Management Association in recognition of the group’s innovation. George Washington is saving more than $1 million annually in salary and benefits, having laid off 33 people whose principle job was tending to paper charts and related processes. In addition, revenue is up, as the EMR from Allscripts has enabled improved charge capture, Badger says.

But to achieve those gains, George Washington endured multiple delays that were beyond the practice’s control, observes CIO Praveen Toteja. First, the EMR software itself needed considerable upgrading. The practice bought its initial version from IDX Systems Corp. in 2000, agreeing to be a development partner in exchange for a discounted price, explains Badger, who declines to state the cost. Later IDX sold the software to Allscripts, which eventually upgraded the system to fit with a multispecialty academic group practice.

But even after the group deemed the software viable in 2003, it ran into roadblocks from other vendors. George Washington’s lab vendor declined to submit its results to the group electronically, recalls Toteja—despite the fact it had been providing them on paper. “They said it was their data and we had no right to get it,” he says. “We had to talk to the president of the company.” Eventually the lab capitulated, but George Washington had to pay to set up the interface, which enables lab results to flow in directly to the patient’s chart. But that was just the beginning. CVS, a major pharmacy supplier for the group, balked at receiving prescriptions via a fax connection with electronic signature, which is part of the Allscripts set-up. “It took weeks to work through,” Toteja recalls.

Having the lab and pharmacy connected paved the way for the group’s EMR launch. The department of medicine went quickly, but other specialties were delayed due to software limitations, Toteja says. For example, documentation forms for OB/GYNs were not available until later. And the practice’s ophthalmologists had to wait for special monitors that allowed them to use the software’s graphics features. The eye doctors began using the EMR after Toteja found compatible monitors from Planar, which the physicians mark with a stylus. “The software lets you pull up a diagram of the eye and draw fine capillaries on it,” he says.

Limited resources also constrained the practice’s ability to deploy the EMR beyond its high-volume department of medicine. “After they went live, the biggest problem we faced was that everybody wanted to use the EMR,” Toteja says. “We had to spread the deployment out because of our limited staff.”

—Gary Baldwin



Clinic’s regret: No big bang

When Nancy Wilkes joined UCI Medical Affiliates in summer 2006, she inherited a new practice management and claims system. Based in Columbia, S.C., UCI uses the system from Companion Technologies to manage 56 clinics scattered throughout the Southeast. Installed on a region-by-region basis over a one-year period, the new claims management system works well, says Wilkes, the vice president of practice management technology. But in hindsight, she says the clinic would have been better off to first test, then implement, the new system across all clinics at once.

The gradual deployment meant that UCI’s billing staff were using two systems simultaneously, she points out. The clinic avoided having to convert old patient files to the new system—a transition that Wilkes acknowledges is risky. But for one year, the collections crew had to send out statements from two different systems. Running dual systems made it difficult to know where to post payments. Handling follow-up inquiries from health plans was also more challenging, she says. “We did not lose any claims, but we were doubling the amount of work without doubling the staff,” she says.

—Gary Baldwin



Big Bang Banter

Experts’ thoughts on high-speed IT makeovers

“You need to empathize with clinicians over their anxiety related to the significant changes associated with new technologies.”

—Edward Kamens, M.D., information systems medical staff advisor, HealthAlliance Hospitals

“Don’t try this at home unless you know your organization really well and your IT staff has an appetite for change.”

—Pam McNutt, vice president and CIO, Methodist Health System

“There is a lot of risk to a big bang. We were lucky with ours, but it was planned luck.”

—James Langley, M.D., director of medical informatics, Methodist Health System

“As corporate ‘cheerleader,’ I stayed hugely optimistic and positive. I needed to keep our project leaders excited and not allow us to get bogged down.”

—Stephen Badger, CEO, George Washington University Medical Faculty Associates

“I felt uncomfortable telling physicians the EMR go-live would be so soon, but one of our department chairs upheld me, saying if we had given the doctors enough time, they would have found an excuse not to do it.”

—Praveen Toteja, CIO, George Washington University Medical Faculty Associates

“Physicians become frustrated with things that impede their ability to take care of patients. If technology stands in their way, they will put it aside. The challenge [of the big bang] is that it changes what physicians do. We had a little weeping and gnashing of teeth, but we got through those.”

—Joey Peay, CEO, Murfreesboro Medical Clinic

—Gary Baldwin