Small Hospitals are a Big Deal: The Challenges of Implementing Large Scale EHR’s at Smaller Organizations

It’s only been within the last few years that the top tier EHR vendors have actively pursued smaller health care organizations. Historically, the focus has been on implementing their integrated systems at large academics, IDN’s and Children’s hospitals. However, as the “whales” are slowly becoming extinct, there seems to be a foot race to gobble up the remaining patient populations into what boils down to one of two EHRs. As such, these vendors are far more interested in working with smaller organizations who want or need to move to a new/modern EHR than they have in the past. From the small hospital perspective, the gold standard EHR’s were previously out of reach due to cost constraints. However, those who remain independent are facing greater pressure due to interoperability requirements as well as local market pressure to keep up with the larger systems who have sexy patient-facing technology. It’s not lost on the smaller organizations that it’s becoming increasingly more important to health care consumers to be able to access and communicate with their health care providers through an EHR. As a result, Boards are investing more money into EHR implementations than perhaps they’ve ever imagined. In many cases these investments represent the biggest financial investment they’ve ever made. As a result of the aforementioned factors, the industry is seeing an uptick in the smaller organizations implementing the top tier EHR’s.

Intuitively it would seem that these small hospital implementations would be much simpler. However, in reality they pose a new set of challenges not often seen (or seen to a lesser degree) with large system implementations. This article outlines some key considerations when implementing a top tier EHR at a smaller organization.

Team size – One of the first things that really shocks a small organization is the size of the team that is necessary to implement a full suite of inpatient and/or ambulatory modules. Team size is not proportional to organization size. A 250-bed hospital will require only a slightly smaller build team than does a 1000-bed hospital implementing the same applications. Organizations need to truly understand staffing requirements to be successful. Do not take the sole word of the vendor, check with like-sized organizations and ask what the delta was between what was recommended vs. what they truly ended up needing at the end. If the team falls behind, often the only option is to augment with consultants who can hit the ground running. These positions are not budgeted and will quickly eat up the contingency budget.

Legacy System Management – Closely related to the above, smaller organizations are especially vulnerable to the pitfalls associated with legacy system management. Often times they are coached or determine on their own whether their staff can keep a foot in both camps (production support and implementation). The reality is that these complex implementations will require full time and attention and anything less will quickly put the project behind schedule. Ensure that you have staff who can focus on keeping the production systems maintained and a separate group to be involved in the implementation. Most commonly, smaller organizations don’t have the staff to do both. When that is the case outsourcing the legacy system support is the best option as it allows your current staff to learn and be a part of the future system.

Technology – Often times the big vendors and even consulting partners take for granted that certain “basic” technologies are in place prior to an implementation kicking off. However, smaller organizations can be greatly challenged with providing the team the tools necessary to be successful. Many smaller IT shops do not provide laptops to their staff. Laptops are truly essential and should be accounted and planned for with any large implementation. Team members of all levels will be in countless meetings and having a laptop while they are away from their desk will increase their efficiency exponentially. Additionally, a large scale implementation is not a 40 hour a week endeavor. It is often much more than that and as such team members will need to have the ability to work from home in the evenings and even some weekends as necessary. The build teams should also have dual monitors and a docking station for their laptop to maximize efficiency when building out the system. Additionally, implementing a good collaboration software such as SharePoint is of paramount importance. Teams will need to share, collaborate and update countless documents. A team site should be designed and in place at kickoff. EHR vendors and consultants will also need access so a streamlined provisioning process is critical. Finally, and related to the below is having basic equipment in place in meetings rooms. Overhead projectors and good quality speaker phones should be deployed to all meeting rooms.

Facility Space – Space space space! Lots and lots of it – that’s what is needed for these implementations. Space for the project team – ideally in one central location. Space for vendors/consulting partners – also near the team. Space for meetings – often the very biggest concern for an organization. Countless meetings will occur between and across the project team as well as with subject matter experts and operational leaders. There is no avoiding this. An organization will be doing themselves a disservice if they underestimate this need and fail to free up /lock down as many rooms as possible during the life of the implementation. The single biggest space need will be for end-user training. Having a rough estimate of rooms necessary to train nearly all end-users is critical. There is obviously a cost associated to this so planning for space during the budgeting process is key.

Governance – At first blush it may seem like a smaller organization would be more nimble and able to make decisions quickly. However, often times these same organizations pride themselves on their collaborative culture. They have historically vetted and re-vetted decisions across the organization. During an EHR implementation it is absolutely critical that an effective governance structure be put in place so timely decisions can be made. Leaders need to be empowered to make decisions if they are appointed to a governing council and strongly dissuaded from expanding the group to a broader audience. Also what you sometimes find in a smaller organization is the same individuals are involved in all decisions – regardless of nature. As such, the typical Physician, Clinical and Revenue Cycle type structure may not be efficient if it’s going to have all the same participants for each. There is no magic bullet for governance and it’s as much an art as science when forming the groups. As such, working with the vendor and consulting partners prior to kick off is essential. It is as, or even more important for the vendor and consulting partners to understand the organizations current structure and culture pertaining to decision making as it is for the organization to understand what decisions need to be made.

When engaging with vendors much of the above may either be taken for granted, not addressed or at best, underestimated. By having a thorough planning engagement prior to kicking off the project, many if not all of these concerns can be identified and addressed. It is when organizations try to plan and implement in parallel that these issues truly become critical as they gradually or even immediately cause project delays.