Hospital EMRs:

Getting it Right the

First Time
Thomas G. Zimmerman, DO, FACOFP, CPHIMS
South Nassau Communities Hospital
Oceanside, NY

Hospital Demographics
440-bed community hospital in suburb of NYC
1023 Medical Staf
850 Physicians (of which 75 are hospitalemployed)
3000 Employees
720 RNs
Dually-Accredited Family Medicine Residency

(18)
Visiting Residents (OB, Surgery, Peds total
18)
Thomas Zimmerman, DO, FACOFP, CPHIMS

Do your homework!!
Thoroughly evaluate the projects feasibility
Preliminary architecture and design
specifications
Informed consent of all stakeholders
Consider the financial impact of the project (as

well as work-hours involved)

Complete EHR, or phased approach
Phase 1 Orders and Results
Phase 2 Clinical Documentation
Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Clarify Project Objectives and Scope
Proposed Timeline
Cost and Quality objectives
Scope of Project
Deliverables
Verify that all stakeholders agree to these

guidelines to avoid confusion, wasted efort or

duplication, and/or project failure.

Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Identify a single leader of the project
A large steering committee by itself does not
allow for personal responsibility and action.
CMIO / CIO / VP EMR/HIM should take the lead in

monitoring progress and addressing obstacles

Steering committee can serve as a resource to

the project leader to discuss issues and find

solutions
Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Full-Time Project Manager
Day to day management, execution, and
delivery of the implementation
Reports to Project Sponsor / Steering

Committee
Should have experience with IT

implementations

Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Interdisciplinary Implementation Teams
Executive Sponsors
Department or section leaders
Experienced Subject Matter Experts

(SMEs)
Physicians,

IT techs, EMR consultants

End-users with AND without IT

experience
Department of Medical Education
Residents,

students
(of all types)
Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Strong Administrative Sponsorship and

Involvement
Ensures that each implementation team (not

just the Steering Committee) has the authority

to make decisions that will stick
Expresses the strong commitment of the

hospital for this implementation (to the endusers)

Ensures better communication and awareness
Thomas Zimmerman, DO, FACOFP, CPHIMS

 Thomas Zimmerman, DO, FACOFP, CPHIMS

Planning
Core Analyst Team
Hire flexible thinkers who have a sense of perspective and a
sense of humor you will need both.
Consultants Caveat Emptor!!
Enlist

their services judiciously, respect and

acknowledge their expertise, but make sure that
hospital staf retain ownership of the project
Interfaces
Lab / Rad / Dietary / Admitting
Make

sure the time and costs for the

development/testing/verification for all of these are
appropriately accounted for in negotiations, contract, and
scope
Thomas Zimmerman, DO, FACOFP, CPHIMS

10

Identify Risks
Technical interface issues, equipment

compatibility issues, delays in upgrades

End User Acceptance resistance to change

(computerized physician order entry,

medication reconciliation, etc.)
Recognize, monitor, and address these risks

in a timely manner, and ensure

communication between stakeholders (no
surprises!)
Thomas Zimmerman, DO, FACOFP, CPHIMS

11

Question the Vendor

Dont accept its hard coded or its working

as intended
Clinicians need to drive the train for patient

safety

Thomas Zimmerman, DO, FACOFP, CPHIMS

12

Staffing Concerns
Clarify time commitments for staf

members involved with the

implementation
Identify times where their hours will need

to be back-filled with other staf to meet

daily operational needs
If activities will occur after work hours,

consider what type of compensation will be

13
provided
Thomas Zimmerman, DO, FACOFP, CPHIMS

Review Policies
Practice and policies will need to reflect the

new world order

Dont feel that you need to own the practice
of the entire hospital
Users will ask you to make the doctors and
nurses do. Avoid the temptation!

Thomas Zimmerman, DO, FACOFP, CPHIMS

14

Remember
Everyone still needs to talk
Avoid the illusion of communication that

follows implementation of an EMR

Thomas Zimmerman, DO, FACOFP, CPHIMS

15

Scope
Define the scope of the project, and really

think it through
In-patient only?
Out-patient areas?

Ambulatory areas vs. Procedural areas?

Consider areas that serve a combination of in-

patients and out-patients

Thomas Zimmerman, DO, FACOFP, CPHIMS

16

Scope (cont)
Will you use niche products in areas such as:
Cath Lab
Labor & Delivery Suite
OR
General EMRs are a mile wide, and an inch

deep while niche products are an inch wide

and a mile deep

Thomas Zimmerman, DO, FACOFP, CPHIMS

17

Create a detailed project plan

Gantt Chart or Excel spreadsheet
Document all major outcomes/deliverables
Target dates
Responsible Sponsor / Resources
Approximate work efort
Update these tasks as they are completed or

delayed/modified

Thomas Zimmerman, DO, FACOFP, CPHIMS

18

Scope Creep
The expansion of the project to include

additional products/functionalities not

originally accounted for in the project
plan and/or contract
Extra Time / work efort
Extra Costs
Increased complexity, confusion
Thomas Zimmerman, DO, FACOFP, CPHIMS

19

Change Control
Changes to the original software are

inevitable; the product must be tailored to suit

the individual needs of your organization
Be prudent in making modifications to the
core software
Document all changes in detail:
Date of change
Reason modification was needed
Exact description of the change (in case it

needs to be restored after an upgrade)

Thomas Zimmerman, DO, FACOFP, CPHIMS

20

Current State & Future State Design

All stakeholders involved better design,

more user acceptance/skills

Identify every workflow in every department
of the hospital: clinical, administrative,
financial.
Critically evaluate current policies and
procedures, and watch for opportunities for
improvement that the EMR may provide
Identify key issues / problems created by the
EMR
Document the future state of operations
Thomas Zimmerman, DO, FACOFP, CPHIMS
clearly

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Sample Workflow
Diagram

Thomas Zimmerman, DO, FACOFP, CPHIMS

22

Future State Design Guiding

Principles

Key Theme

Description

Clinical
Excellence
Quality and
Outcomes Focus

What will the approach be for identifying outcomes as

part of the EMR implementation? Which outcomes are
of the highest priority?

Care
Standardization

Determines the extent to which care and clinical

applications will be standardized.

CPOE Strategy

This defines the degree to which CPOE will be rolled out

as standard practice or policy. Medical executive
committee establishes expectations regarding
compliance and consequences for physician noncompliance.

Clinical
Documentation

Describes the approach to clinical documentation: what

types data will be entered, who will enter it, and how.

Clinical Decision
Support

Describes the approach to the tools that guide real-time

clinical decision-making.
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Future State Design Guiding

Principles
Key Theme

Description

Training

Identifies the approach and level of investment for how

the hospital addresses staf training for clinical quality
improvements to include use of advanced clinical
systems.

Access Strategy
Remote and
Internal

This defines the strategy for the placement of devices

to enhance adoption and also determines the extent
the physician portal and remote access will be utilized.

This will define the content strategy (order sets, clinical

Content Strategy documentation, and clinical decision support) to ensure
system utilization and improve quality and efficiency.
Workflow
Optimization

Redesigning current workflows with EHR as an enabler

will allow hospital to maximize the integration of
system utilization and clinical workflows.

Communication
Strategy

An institutional communication strategy that outlines

the audience, methods, tools and frequency of
communication must be developed to improve
institutional ownership.
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Timeline
Nov. 2009 Presentations by 2 Vendors
Jan-March. 2010 Site visits to nearby

Hospital using each system

July 2010 Contract signed with Vendor
January May 2011 Current / Future
State Design Sessions
August 2011 Present Physicians
Advisory Group Meetings
June 2012: Go-Live!
Thomas Zimmerman, DO, FACOFP, CPHIMS

25

Site Visits
Two hospitals with similar demographics
Community hospital with residency programs
Bed size, service lines, patient population
Evaluation Team
HIM (VP HIM, EMR Manager, Coding Director)
IT (CIO, Network specialist)
Financial (VP Finance and staf)
Medical Staf (President of Med. Staf, Physician
champion)
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Site Visit Itinerary

Presentation by Hospitals CMIO
Divide and Conquer:
Medical Team: Floors, ICU, ED, Ambulatory
Clinic
IT Team: IT dept., floors
Finance: Administration, Billing/Coding
Coding: HIM department, Billing/coding

Thomas Zimmerman, DO, FACOFP, CPHIMS

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Core Build
Extensive work efort to establish the pharmacy

formulary
Order sets Diagnosis Based
Core measures (VTE assessment, time to treatment,

etc.)
Meaningful use measures
Convenience
Congruent to Paper forms (for downtime episodes)

Communication / Workflows for ancillary processes

Respiratory therapy, Floor-obtained samples, Codes
Discharge Process
Thomas Zimmerman, DO, FACOFP, CPHIMS

28

Pharmacy Build
Have a pharmacy build that reflects:
Front-end needs, i.e.
Physician needs for ease of item selection and
understanding of order guidance. Will you build brand
name synonyms?
Nursing needs for clarity on the orders tab and eMAR

Back-end needs
Pharmacy needs consistency of build and a full view of the
medications ordered and access to the patients clinical
picture
TEST each item from order entry, to dispensing and

delivering, to display on the orders tab and eMAR, to

medication administration
Thomas Zimmerman, DO, FACOFP, CPHIMS

29

Downtime Plans
Have firm downtime plans and tools well before

Go-Live
Devise a method of running reports in the

background that can be printed on demand in

advance for a planned downtime, and just in time
for an unplanned downtime
Patient list by location
Orders report with all active, on hold, suspended
orders
MAR with a list of all medications administered within
the prior 48 hours, with a list of all tasks for the next
24 hours

Thomas Zimmerman, DO, FACOFP, CPHIMS

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Downtime Plans
Create a Meaningful Use Checklist
Ensure all MU measures during downtime are
correctly entered during recovery period
(backfill)
Strongly consider building a redundant

database on a local server to be viewable

during downtimes/no internet access

Thomas Zimmerman, DO, FACOFP, CPHIMS

31

Training
No amount of training is too much!!
Combination of delivery methods to

account for diferences in end-user

preferences and schedules
Live,

classroom-based sessions (at hospital or

office)
Web-Based Training Modules (auto-tutorial)
Remote webinar sessions
One-on-one
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Superusers
Essential to have key team members receive

extra training and practice with the system

Creates a cadre of first-line support at the
unit level during Go-Live and thereafter
Improves end-user acceptance, they serve
as ambassadors of the EMR team
Helps identify issues in the system earlier
in the process (these people know what
works and what wont work!)
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Preparing for Go-Live

Big-Bang vs. Phased Approach
Entire House or Unit by Unit
Central Command Center
Embed IT and EMR support personnel

throughout the building

Superusers, hospital IT/EMR staf, vendor

support
Deploy more staf in busier or more critical
units
Two weeks minimum, 24/7
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Activation
Telephone Support Center
Have the Informatics team (Level 2 Help Desk)
and the IT team (Level 1 Help Desk) share a
Telephone Support Center where they handle
calls from the users during Go-Live. It will pay
of later with increased knowledge and
compassion on both sides later
Keep detailed logs of all issues (as well as their

solutions)
Thomas Zimmerman, DO, FACOFP, CPHIMS

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Allow for Decreased Productivity

Overstaf units (especially ED, ICU, OR, other

critical areas of the hospital

Consider Go-Live on a weekend, to avoid

elective surgeries and imaging procedures

(although ED may be busier)
If a weekday, reschedule as many elective

procedures as possible

Thomas Zimmerman, DO, FACOFP, CPHIMS

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Questions?

Thomas Zimmerman, DO, FACOFP, CPHIMS

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