Chapter 4
Implementation & Maintenance
Chapter 4
Implementation & Maintenance
‘Going Live’
Contents
At a Glance ... 56 4.1 EMR system installation
& training
... 57 4.2 Data conversion... 57 4.3 Acceptance testing ... 58 4.4 System & software user guides ... 60 4.5 Accessing support services... 60 4.6 Data entry, quality, & reporting – implementing best practices ... 60 4.7 Maintaining your EMR ... 63 Tools & Resources ... 65 4.8 Tools... 66 4.9 Further reading... 67 4.10 Chapter 4 checklist ... 67 4.11 User notes ... 68Chapter 4
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Chapter 4: Implementation & Maintenance
At a Glance
The Implementation & Maintenance phase acts on the components of the EMR project plan (developed while “Preparing for Implementation”) that address implementation: installing the EMR, converting data from existing paper and electronic systems, completing user training as defined in the training plan, testing the EMR and new procedures and policies in the practice, and “signing off” based on the acceptance criteria established with your vendor. Implementing and
beginning to use and maintain the EMR involves:
1. Installing any necessary hardware and software. This may include renovations to your offices to install network cables etc.
2. Completing user training to ensure all clinical and administrative users have the necessary skills to start managing patient charts
electronically.
3. Converting existing patient chart data (as little as necessary) to the new system’s format and establishing a timeline for all staff to have
completed their conversions.
4. Acceptance Testing to “sign off” on the installation – to be sure all aspects of the EMR software, hardware and network meet the requirements outlined in the Scope of Work (in the vendor contract).
5. Obtaining and maintaining all hardware and software documentation (electronically or on paper), and ensuring there is a means to keep the documentation current.
6. Establishing software/hardware support procedures for obtaining assistance with the system, i.e., do you have an “in-house” expert available and at what point do you contact the vendor for help?
7. Establishing best practices for data coding and data entry, for consistent, high quality data to support clinical decision making. Practical analysis (data- mining) of the data in the EMR can improve the derived value of the EMR, by improving patient care processes (which can lead to better patient safety and health outcomes) and practice efficiency.
8. Establishing and testing procedures for system backup, data recovery, and system maintenance.
...three EMR products were tried
and discarded before the current
product’s implementation. This led
to significant practice disruption,
cost, and staff turnovers, but has
resulted in the implementation of
an EMR which meets the clinic’s
needs. - Taber Associate Medical
Centre
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4.1 EMR system installation & training
Installation of hardware and network equipment is the most disruptive component of an EMR implementation. Try to schedule this work so it occurs outside regular office hours. If construction is required to install new network cables, this should be done first, since it often requires wall and ceiling repair and new paint.
Initial training for all clinical and administrative users is normally undertaken as soon as installation is complete. All clinical and administrative users should have the necessary skills to start using the EMR. Further training is undertaken as documented in the training plan (see “Preparing for Implementation”).
4.2 Data conversion
Data from the existing practice environment may need to be moved to the new EMR. The key question is “how much (or how little) data do you need?”; the key principle is “don’t convert any more than necessary.” A good heuristic on which to base data conversion requirements is to consider the new EMR as “volume 2” of a patient’s paper chart – once volume 2 is started with any essential information copied from volume 1, how often do you (really) go back to look at volume 1? Despite lack of consensus on the “best” method of converting data, there is general agreement on what paper chart data is essential. These include:
• Patient demographics. • Allergies.
• Medications. • Active problems.
• Recent significant diagnostic and lab results. • Significant personal and family histories.
Once you’ve determined the minimum amount of data requiring transfer into the new EMR, there are several common
approaches for converting the data: 1. Paper to Electronic:
• Have each provider enter a few records outside office hours, until all charts are entered, or to save time, only enter the
frequently seen and high risk
Ad hoc back-data entry is
manageable (when a patient has an
office visit, or the day before), and
there’s no unnecessary work
generated from entering data for
patients who do not return to the
practice. – Dr. Tom Bailey
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patients, e.g., those with chronic conditions and/or multiple
comorbidities. Enter the rest of the charts as the patients come into the office.
• Enter data for patients only as they come into the office. This approach has the advantage of avoiding unnecessary work associated with entering data for patients who never return to the practice but tends to prolong the conversion process and thus
possibly delay achieving the maximum usefulness of the EMR.
2. Electronic to Electronic – your previous systems (e.g., billing and scheduling software, or another EMR) may allow patient
demographic data and clinical data to be extracted in a format suitable for import to your new EMR. If this data cannot be imported from your current system, your
health region or Ministry of Health may offer a conversion service. In either case, ensure that the conversion requirements are documented as part of the vendor’s Scope of Work.
Providers in the practice may find that a different model works best for each of them. Whichever model is chosen, come to agreement with your practice team on a definite time limit for all providers to have completed their chart migrations.
Review the Canadian EMR Success Stories (see Chapter 6) for further examples of several Canadian providers’ experiences and advice regarding data conversion during their EMR implementations.
4.3 Acceptance testing
Acceptance testing is about ensuring the system functions in the practice setting as defined in the Scope of Work. It requires a formal, binding agreement by both the vendor and the practice that the criteria outlined in the Scope of Work have been met. Once completed, the project passes from the implementation phase to the operational. The EMR vendor’s role then evolves to providing post-implementation operational support and the service level agreement for support and maintenance comes into effect.
The clinic ran the old and new
EMRs in parallel for 18 months, in
order to permit staff to migrate
patient charts as patients came into
the clinic. Staff attempted to keep
both systems up to date, but found
this extremely difficult, and would
recommend a “clean cutover” to
“remove” (archive) the patient
from the old system, as soon as the
patient is entered in the new
system. - Haig Clinic
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As part of your training, and as part of the “go live” process, test each and every new procedure related to the EMR hardware, software, and networking in your own practice environment. For instance, test components such as the following (this is a sample list which would be developed in more detail in your actual Test Criteria):
• Logging in, changing passwords, locking workstations, adding and removing new users from the system.
• All aspects of EMR functionality including prescription writing, referral letters, intra-office messaging, reporting and recall functions, etc.
• System-to-system interoperability including all agreed upon electronic data imports and exports, e.g.:
o Billing for private and public payers.
o Lab results, medications, and diagnostic data from external sources. o E-prescribing.
o Diagnostic order entry.
o Data feeds and reporting to and from other provincial and regional systems, e.g., hospital information systems, registries (immunizations, chronic disease management, cancer, etc.).
Note: Interoperability is also addressed in “Chapter 5 Optimizing your EMR” , under