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June 27, 2012
Lessons learned

We're continuing to implement our new EMR, with the go-live at our main hospital scheduled for November. In the year that I've been working on this implementation, I've learned some hard lessons about change management and the perils of imposing change on doctors.

And I do mean "imposing." Even though the need for an EMR should be obvious in this day and age, some doctors still flinch at the idea of spending any more time in front of a computer.

In part, I don't blame them. While we have to stay up to date with the latest medical and scientific information, procedures, equipment and guidelines, we are risk-averse. And change entails risk.
That's why I've relied on several key strategies during this planning phase. Here are my lessons learned:

1. Enlist potential saboteurs. It doesn't matter if you have 10 members of one department involved in the planning process. If you haven't engaged No. 11, you'll be sure to hear some version of this refrain: "They are planning things behind closed doors" and "They don't want my opinion." This person, who may become a chronic complainer, can impede progress.

Solution: Identify the people who are the usual complainers and involve them early in the process. Make them have a stake in the success of the implementation.

A recent survey from the online publication healthsystemCIO.com found that independent physicians are the most resistant to change. Group members who may already have an EMR in their office will not want to invest the time to learn a new system. (Our rollout is covering not only the hospitals in our system, but outpatient practices as well.)

If this group admits to your hospital, explain to them the benefits of the new system. Evaluate ways they can access the system from their office or create a clinically integrated network, emphasizing their connection to the hospital (marketplace recognition!), their role in the overall success of the enterprise, and shared roles and outcomes. Take their suggestions for improvement, and make them true partners.

2. Be firm. Don't change deadlines or goals. Instead, draw a line in the sand and stick to it. If you decide that everyone needs 16 hours of training before you go live, don't start making exceptions. Be ready for threats from some providers that they'll leave the staff if they can't get by with less training.

Solution: Think both carrot and stick. Establish CME for training hours. Offer to increase support staff during the implementation. But don't suggest that you'll compensate physicians financially for their lost productivity or you won't see any end to that type of bribe.

Tell people that if they do leave, they will face the same situation wherever they go, so they might as well just train with you. Don't sugarcoat the challenges; admit that change is painful, but stress that this is the right thing to do for patients. A consultant recently told us that no implementation is really a success until at least three doctors have left the staff. Be ready to accept this possibility, prepare for it and move on.

3. Establish your priorities. During implementation, you'll run into plenty of challenges as you sun-set legacy systems and reconfiguring older work patterns. On the other hand, no EMR is perfect, and specific departments may need to retain older systems to be able to function.

Solution: Be very selective about this. Everyone's initial reaction will be that the new EMR won't help his or her specific department. Bring those people in and, with the EMR implementation team, map out their concerns. Then show them how the new EMR can help them—with the proper training. If you do find out that the new EMR can't function for a specific task or work pattern, bite the bullet, keep the old process and move on.

Allow short-term use of older solutions like faxing in orders, but set a firm deadline—say, in three months—when all those processes will end. Make sure the departments using the older systems know about the deadline and the ways the EMR will replace their old way of doing things, and train them specifically around those changes.

The writer W. Somerset Maugham, who himself trained as a doctor, wrote a great quote regarding change: "Nothing in the world is permanent, and we're foolish when we ask anything to last, but surely we're still more foolish not to take delight in it while we have it. If change is of the essence of existence one would have thought it only sensible to make it the premise of our philosophy."

I know it's easier to write about change than to implement it. But we'll be more successful with implementation if we focus on the positive aspects of change, engage those people (early and often) who may reject it, and establish clear and consistent goals. Doctors aren't unique in being afraid of change; they're just more vocal about it. If you listen, you'll hear in their voices the motivation to succeed.


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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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