The Cleveland County Health Department is located in Shelby, North Carolina and serves a population just under 100,000 people. Our population is concentrated in three large municipalities which are Shelby, Kings Mountain, and Boiling Springs, leaving the northern end of the county very rural. Two major limitations our county faces are limited transportation for patients, and a low median household income. Due to these limitations clients frequently do not show up for appointments, which makes it necessary for us to try to maximize every minute that patient is actually here to provide the best possible care. Our health department serves the population through 20 specific clinics, including Child Health, Maternal Health, STD, Family Planning, etc.
Cleveland County Health Department
Best Practices for EHR Implementation
Public Health Issue
Achieve compliance to federal mandate for Meaningful Use EHR
Implement electronic charting across all programs
Challenge was that there are not many resources for selecting and implementing Public Health EHR
In order for us to provide the best possible care to our patients while utilizing clinical time to maximize efficiency as well as achieving compliance to federally mandated meaningful use, The Cleveland County Health Department was faced with the task of finding a user-friendly and affordable EHR system. All clinical and financial documentation was completed the traditional way via paper charting and manually running financial reports. The staff frequently experienced issues tracking down patient’s paper records which ultimately resulted in a frustrating and time consuming process. One challenge we ran into was that there were not many resources available for selecting and implementing an EHR system.
Goals/Objectives of proposed practice
Goal: Our ultimate goal was to implement an EHR software system that was user-friendly and cost-effective to maximize clinical time with the patients. By strategically analyzing every step of the selection and implementation process we hoped to avoid the usual pitfalls of adopting a new software system.
Objective #1: Engage staff as much as possible during the selection process since ultimately they would be the end user of the product in their daily routines. Including staff’s input and opinions not only made the employees feel valued and a part of the decision process, but also minimized the resistance of change.
Objective #2: Utilize the EHR system to its max potential and capabilities and not create workarounds under any circumstances.
Objective #3: Encourage continuous growth and learning among staff of the EHR system.
How was practice implemented / activities
To best prepare our staff for the challenge of transitioning from paper documentation to an Electronic Health Record the following steps were followed:
We formed two critical teams:
o An Implementation Team, to make high level decisions regarding implementation, training, workflows, etc.
o And a Super Users group to provide support to frontline staff and relay any messages or concerns to the Implementation Team.
Utilized the vendor decision matrix
Conducted an in-depth workflow analysis of all clinical and clerical departments
Assessed all employees’ computer skill levels via a computer skills assessment survey
Conducted multiple site visits to other health departments
Customized the vendor’s quick guides
Organized each clinic team practice sessions
Developed cheat sheets for each clinical and clerical areas
Developed a plan for Go Live
Celebrated staff’s achievements and hard work
Continuous analysis of ways to improve the system and workflows
Developed a repeatable and measurable internal process for ongoing quality improvement
Developed best practices for implementing EHR in a local health department
Developed best practices tool kit for sharing with other health departments.
Yes, all of our objectives were met.
Objective #1: By engaging staff throughout the entire selection and implementation process the objective to minimize the resistance of change as well as ensuring staff felt that their opinions were heard was definitely met.
Objective #2: By discussing, analyzing and addressing all issues that arise in a timely manner allowed us to eliminate workarounds and successfully implement a user-friendly and affordable EHR system, for more than 125 users. We have successfully been actively using our EHR system for 1 year and 2 months!
Objective #3: Through assessing staff’s computer skill levels and offering refresher courses in needed areas as well as our continuous analysis of ways to improve the system and workflows allowed us to meet the objective of continuous growth and learning among staff.
What specific factors led to the success of this practice? The biggest factors that contributed to a successful implementation of an EHR was the formation of the Implementation Team and Super Users group as well as holding staff accountable for attending and learning the new EHR system. The Implementation Team continues today, to serve as the initial point of contact in the chain of command managing, analyzing and alleviating any situations or issues that may arise, as well as continuously brainstorming and troubleshooting future options to work towards maximum patient care and efficiency in the workplace.
Public Health Impact:
By implementing an EHR we were able to make clinics and patient care more consistent and efficient which impacted our entire current and potential patients. Another benefit was improving data collection and billing capabilities which impacted our entire county in regards to statistical evidence to support current and future programs, grants and organizations to improve the health and quality of life in Cleveland County, North Carolina.
The Problem: The Federal and CMS regulations and incentives was what originally prompted us to start looking into purchasing an EHR, but the opportunity to make clinics and patient care more consistent and efficient played a big role as well. Improving data collection and billing capabilities was an added benefit we couldn’t pass up also. Once the decision was made to purchase an EHR system we knew we were going to be embarking on new territory and we wanted to be as knowledgeable as possible in regards what to look for in an EHR. We collaborated with the Charlotte AHEC’s HIT/REC and Quality department and an education specialist, who offered technical assistance with the EHR selection and meaningful use navigation processes.
Activity #1: One of the very first decisions that was made before we even started conducting demos was to form an Implementation Team and Super Users group. The Implementation Team is comprised of a Project Manager, Clinical Expert, Clerical Expert, Billing Expert and Management Representative. This team was developed to conduct high level decisions regarding implementation, training, workflows, etc. The Super Users group was developed to provide support to frontline staff specializing in their specific clinical area’s and relay any messages or concerns to the Implementation Team. Since inception of Patagonia Health, the Implementation Team continues to serve as the initial point of contact in the chain of command managing, analyzing and alleviating any situations or issues that may arise, as well as continuously brainstorming and troubleshooting future options to work towards maximum patient care and efficiency in the workplace.
Activity #2:After researching all possible EHR systems available on today’s market, we invited representatives from the top 3 EHR systems to demonstrate their software for us. After the completion of all demos we utilized a Vendor Decision Matrix where all of our staff ranked the 3 EHR systems to ultimately narrow it down to 2 EHR systems. We visited several health departments to view the 2 types of EHR systems. Conducting these site visits allowed us to see firsthand the systems at work in an actual clinical setting and obtain feedback from staff at those health departments. We pulled all our staff together again and discussed pros and cons of the 2 EHR systems and it was nearly unanimous at the end of that meeting to go with the EHR system we now currently have.
Activity #3:One of the first things we completed after we finalized our selection process was to evaluate staff’s computer skill levels through a Computer Skills Assessment Survey. The assessment survey covered everything from basic computer operations, word processing, file management, internet/email operations and basic printing. We analyzed the answers and found what areas majority of our staff needed additional training on and utilized some online courses that were available through our county IT department and requested all staff to complete them. Once everyone completed all of the refresher courses, we had them retake the computer skills evaluation survey to reanalyze the data to see if our staff learned and felt more knowledgeable about basic computer operations, which they did. While analyzing the data we realized that we were able to turn this into a QI project for our health department as well. I truly felt assessing our staff’s computer skills was a great first step for preparing to implement an EHR because it confirmed with staff that they were knowledgeable more than they realized with basic computer operations which help cut down on the fear of an Electronic Health Record system.
Activity #4:Another step in the preparation for implementation included conducting an in-depth workflow analysis. The Implementation Team felt that conducting a complete Workflow Analysis of all clinical and clerical areas would allow us to make adjustments prior to implementing EHR so staff could become familiar with the adjustments and then integrate the EHR into the workflow, ensuring that changes were incorporated in gradual steps. Our workflow analysis consisted of every clerical and clinical areas documenting on a spreadsheet we had created in house, every single step a patient would take from the time they stepped into our health department to the time they left. Including what documents or forms would be completed and who that patient would come in contact with. This process was completed on every single type of possible appointment our health department offered. Everything was organized in specific clinic binders so we could easily reassess them as we needed to.
Activity #5:Also prior to our vendor coming to conduct the onsite training, we felt it was beneficial for the super users of each clinic to identify if there were any users that may need one-on-one assistance during the vendor training to help keep them from getting discouraged during the training. Everyone that had a buddy paired up with them came to the implementation team after the trainings and said they would not have been able to follow along as well if they didn’t have someone there with them assisting them with where to click and thanked the implementation team for thinking about each user’s needs to ensure they were successful.
Activity #6:After completion of the vendor trainings we took the quick guides that the vendor provider to each user and the implementation team sat down and went through each line and modified the instructions to be customized to our health department. We added screenshots and highlighted or bolded certain key steps so staff wouldn’t miss it. After we completed the modified quick guides the implementation team held follow-up training sessions where we took up the old quick guides and distributed the new ones to all staff and demonstrated any questions the staff may have needed clarification on. Realizing that there are 3 main styles of learning and retaining information, The Implementation Team wanted to ensure that we offered a mixture of all 3, (auditory, visual and kinesthetic) training and learning opportunities to the staff.
Activity #7:To promote communication and collaboration during the learning process prior to Go Live, each clinic was asked to sign up for a specific time slot to bring all of their staff to the library and spend half a day on training laptops utilizing test patients and working through all possible scenarios of their clinic. The clinics would bring actual patient charts and conduct that visit together on a test patient. We received feedback from our staff that these clinic specific practice sessions were a huge asset in analyzing the workflow of the clinic and allowing them to make decisions as a team on how to overcome any bottlenecks they encountered.
Activity #8: The next step was Go Live! Our goal was to keep staff morale up and try to keep our patients as happy and satisfied as possible. We completed this goal through a variety of ways. First we utilized walkie-talkies to cut down on overhead paging within the health department so staff wouldn’t get the misconception that the system was having problems and already get discouraged. The Implementation Team Members, the vendor representatives that were here during Go Live and the supervisor in each clinic had a walkie-talkie to communicate internally if there were any problems. Next, we had non-clinical staff, like our administration and finance departments, sign up for times to stand downstairs at the front doors as greeters, greeting each patient and informing them that we were starting on a new computer system and their wait times may be longer than normal and if they wished to reschedule they could. We also hung bright orange signs at all check-in and check-out areas informing patients about the new computer system and possible longer wait times.
Finally, the implementation team along with the supervisors of each clinic and the vendor representatives met twice a day to assess and address any issues that arose. These meetings allowed us to make needed tweaks to our workflows and at the next meeting we were able to see if those tweaks worked or did we need to reassess and develop new methods. These meetings allowed us to address crucial issues or concerns head on and make the necessary changes in a timely manner. Each afternoon of the Go Live Week, the implementation team walked around to each clinic and distributed candy with inspirational quotes like “Thanks for your commit MINT to EHR Implementation” or “Your hard work has been a LIFE SAVER during Implementation” to all our staff to let them know we appreciated all their determination and hard work. To celebrate and wrap up the week of Go Live, on Friday the Implementation Team and supervisors danced down each clinic hallway to “Happy” by Pharrell Williams and carried banners saying “You Did It!” while passing out candy! Our Go Live could not have gone any better.
Activity #9:The Implementation Team wanted to ensure that staff continued to grow and learn the EHR system well after Go Live, so cheat sheets were developed specifically for clerical and clinical users as a reference guide for most commonly used functions in their daily routines. Each item on the cheat sheets were demonstrated to staff by the Implementation Team at departmental meetings. Today, the Implementation Team continues to hold update meetings with all staff to demonstrate and reeducate on any reoccurring issues as well as any new changes that are added to the system.
Activity #10:Finally, the project manager developed an in-house newsletter called the “EHR Messenger” that is distributed monthly to all users. This newsletter is comprised of material that is from our vendor’s monthly release notes, our vendor’s monthly newsletter and also any Cleveland County Health Department specific changes that all staff need to be made aware of. The EHR Message also includes a quote of the month and a quick tip of the month to promote continuous learning of the system.
Looking back over the past year from the selection process, to the training process and finally to implementation, I truly feel communication, accountability and determination were our biggest key factors to success. From the start of the project and continuing today The Implementation Team encourages communication of ideas, suggestions and needs from frontline staff to super users and ultimately to the Implementation Team. This open channel of communication allows Cleveland County Health Department to continuously strive for efficiency and productivity.
In order to meet our goal to implement an EHR software system that was user-friendly and cost-effective to maximize clinical time with the patients, we knew we needed to utilize outside resources and communicate and network with other agencies.
1. Utilized local Charlotte AHEC We collaborated with the Charlotte AHEC’s HIT/REC and Quality department and an education specialist, who offered technical assistance with the EHR selection process. Charlotte AHEC continues today to be a huge asset providing meaningful use guidance and assisting with the navigation of attestation process.
2. Network with Other Health Departments Once the idea was mentioned to purchase an EHR system we started networking with other local health departments at regional meetings and conferences to get feedback on what systems other health departments were using and what they liked and disliked about it. We also reached out to local health departments with our top 2 choices of vendors to go and conduct site visits to see the system in an actual clinical and clerical setting.
3. Build a Relationship with Your Vendor From the start of the implementation process and continuing today, the project manager has continuous communication with our vendor to ensure a positive and productive relationship with them. By embracing the communication and building this relationship the project manager has been successful at reporting needed feature request and fixes to keep daily clinical workflows continues.
Developed best practices for implementing EHR in a local health department.
o Word has spread to local health departments that our county’s best practices for implementing an EHR were so successful that we have presented presentations at NCPHA and NCPHNA on our best practices.
o We also developed and presented a presentation on our best practices to the Health Director’s User Group.
o Our EHR vendor was impressed by our best practices and requested that we record a short video of our best practices of implementing an EHR.
Develop best practices tool kit for sharing with other health departments.
o Our county developed a best practices tool kit summarizing our 20 best processes/practices for other health departments to utilize.
o We have hosted 4 local North Carolina Health Departments to come and spend the day with our Implementation Team and Super Users shadowing and learning our best practices.
o We have hosted a Health Department from the state of Nevada to come and spend the day with our Implementation Team and Super Users shadowing and learning our best practices.
We have also conducted phone conferences with Health Departments from Alabama and Colorado with our Implementation Team and Super Users to explain our best practices to them.
Developed a repeatable and measurable internal process for ongoing quality improvement that can be applied to adopting anything into a local health department.
o After seeing how smooth our implementation of an EHR system was and how successful our first year of activity on the system has been, we feel that we have developed a repeatable and measurable internal process for ongoing quality improvement that can be applied to adopting anything into a local health department. For example we utilized these same processes to implement ICD-10 into our health department this month and have not had any issues regarding ICD-10.
Developed a system and processes to continue to learn and maximize value from EHR technology (Development of Clinical and Billing User Groups)
o At regional meetings and conferences we noticed that other health departments using our same EHR software would often ask us what our process was for a particular thing or if we were experiencing a particular issue they had been. Realizing the impact of collaboration and voices in numbers, we now coordinate and lead the CUG (Clinical User Group). The CUG is a group of representatives from each county in the state of North Carolina that uses our same EHR software, as well as a representative from our vendor. We meet monthly to discuss any and all issues, questions and concerns the counties have. We discuss them in an open round table discussion and if necessary changes need to be made to the EHR that affects all counties a vote is held prior to submitting the change to see if it is truly necessary. The CUG has been a huge success improving and maximizing our EHR system for all users from any county.
o Since the creation of the CUG has been crucial to maximizing our EHR value, we wanted to replicate that same type group but from a billing and finance perspective so we also created a BUG (Billing User Group) to discuss any and all issues and concerns in regards to billing and finance.
Through all of our research, hard work and development we have now became a resource for other Health Departments nationally and locally.