“Change is inevitable, and the only constant”. However, not a lot of people – individuals and teams are naturally disposed to embracing change as part of everyday living. This resistance is more accentuated within the healthcare sector because of the complexity of its operations and inherent risks associated with healthcare service delivery, more so in developing countries and low resource settings. For this article, a Nigeria-based Electronic Health Record (EHR) Optimization project will be used as a case study.
The EHR Optimization project was an initiative sponsored by the Institute of Human Virology Nigeria (IHVN) to transition affiliated healthcare facilities rendering HIV/AIDS prevention and treatment services to people living with HIV from a paper-based documentation system to a real-time provider-entered Electronic Health Record to be used at every point of care.
There had been so many failed attempts in the past due to high levels of resistance by healthcare professionals at these facilities, including other factors such as infrastructural deficiencies, bureaucracy and politics, and fear of changing the status quo. Despite these challenges, we were able to strategically introduce the change initiative, and successfully deploy EHR systems at all selected facilities. It is true that any change, even a change for the better, is always accompanied by drawbacks and discomforts. Nonetheless, every progress experienced in life is brought about by a change.
There are two major kinds of organizational change: change imposed by circumstances, and change planned to encourage growth or improvement. Unfortunately, the Nigerian healthcare system is undergoing a change imposed by circumstances, especially following the mass exodus of medical professionals, despite the country’s growing educated population with diverse health needs. To get ahead of these circumstances, change is mandatory. To achieve a revolutionized healthcare environment for sustained high performance, a few guiding principles need to be employed, which are outlined below.
- Define what needs to be improved: The catalyst for transformation, which focuses on pursuing value, improving efficiency and reinvesting in growth must be clearly defined and communicated to the team. Every organization’s underlying quest should be choosing direction that will lead to greater value generation and leadership capabilities.
- Engage key stakeholders: This is important to find those who will direct or finance the endeavor, champion the process or institute the change.
- Plan for the change: This involves having a common framework, language and set of tools for managing change; a set of definitions, approaches and checklists that are familiar to everyone as well as having measurable targets and incentives, including measurement and analysis of work done. The change management must be made part and parcel of the system strategy.
- Understand the human aspect of change management: Plans themselves do not capture value, but only through the collective and sustained actions of the many employees within the system who are responsible for the many moving parts can the desired results be achieved. Failing to plan for the human aspect of change can lead to even the most visionary of leaderships to fail.
- Hold middle management accountable not external experts: The positive impact of visionary leadership breaks down when middle managers are not aligned with the strategic vision from the top tier management as they are responsible for driving the key change among their teams and aligning them with the overall strategy.
- Leverage the power of low-level workers: Harnessing the power of low-level workers has been shown to have wide reaching implications especially in organizations employing professionals e.g. enlisting the aid of physician/medical assistants to effectively alter the behavior of doctors to encourage them to adopt a new system.
- Provide resources and data for evaluation of the new system: Create accountability by monitoring results, review, revise and continuously improve.
Mitigating the current circumstances of the Nigerian healthcare system will require increased multidisciplinary collaboration among healthcare professionals, and managing such a large-scale culture shift will require anticipating and addressing resistance to change. This is known as ‘checking the collaborative blind spot’, and can be done by reinforcing the identity and reaffirming the legitimacy of the individual professional groups, reasserting their control by granting groups greater ownership over areas closely related to the groups’ identity.
As the global healthcare industry looks to digital transformation to optimize their processes and procedures, the need for change management has also become more apparent due to the number of processes that are needed for a more streamlined and automated approach.
Implementing change in a healthcare system however requires a high level of visibility into efficient organization and secure documentation and storage of confidential information. As the demand for improved standardized processes increases, so does the need for a more collaborative, visible and real-time tool to achieve this.
Having executed multiple successful projects in the Nigeria Healthcare technology space over the last couple of years, here are a few key steps of project execution we have employed for anchoring change management to an institution’s culture, and sustaining the effects of the change initiative.
It is important to note that these recommendations have applied directly to the deployment of electronic health records for HIV/AIDS care in health institutions and hospitals, but are easily extendible to other areas of the health sector, and even to non-healthcare projects.
STEP I: NEEDS ASSESSMENT/EVALUATION
The first step in any implementation effort is to conduct a systematic evaluation of the current state of affairs within the organization, while also assessing any potential gaps and staff competencies in preparation for change initiative.
There is significant value in utilizing an evaluation template for this assessment, so as to objectively identify and aggregate any areas that require intervention and more supervision.
For the EHR Optimization project, assessment template breakdown included the following: staffing structure, skill sets and competencies, governance and security, hardware, connectivity, power infrastructure, and space utilization to mention a few. To achieve this, we carried out the following activities:
- Filled and collated assessment checklist and identified gaps in infrastructure, so as initiate procurement process to address needs.
- Diagrammatically represented each of the physical components of each facility in a topological map, outlining rooms/cubicles, desktops, laptops, printers, servers, inverters, and general local area network architecture.
- Identified primary, secondary and tertiary sources of power, and percentage availability, so as to recommend potential power solutions for each facility.
- Liaised with facility Head of IT and Head of Maintenance to identify leverage points for hardware optimization opportunities with management team.
- Assessed computer proficiency levels of staff interacting with the system, to ensure that each individual is appropriately catered for during EHR go-live. Go-Live implies the full and smooth transition from paper-based system of patient documentation and care to a paperless/electronic system where providers attend to patients at the points of care (POC) in real-time.
- Reviewed sustainability measures with facility management in collaboration with organization’s team to ensure that facility staff could adequately support deployed initiatives without overdependence on funding organization.
- Outcome of evaluation activity was an accurate assessment of needs at each facility, and the development of a structured implementation plan for hardware and software integration.
STEP II: CHANGE MANAGEMENT
Change management processes were instituted to transition providers and clinical support staff from paper-based documentation to the EHR platform, and these included the following.
- Conducted advocacy visits to each participating facility to better understand key players and generate consensus on next steps.
- Established objectives, goals and strategies for implementation, and aligned with organization’s mission statement and organizational vision.
- Assigned a physician champion to lead implementation efforts from a workflow standpoint, and represent the interests of end-users. Physician champion also created and led EHR go-live team to facilitate all phases of deployment.
- Met with heads of department and CMDs of partner hospitals to communicate change vision and guarantee support for the implementation of EHRs at these sites.
- Disseminated change management recommendations to all participating facilities, to help guide key stakeholders and management on how to incorporate change initiatives into their corporate culture.
- Met consistently with EHR go-live team to define parameters for system customization unique to their facility.
- Identified resistance from staff and deployed mitigation strategies to counter and align with overall strategic direction.
- Worked with IT and Clinical leads to prepare and plan for implementation, and its short and long-term outcomes.
- Prepared EHR deployment plan in collaboration with EHR go-live team, and presented final copy to organization’s senior management for approval of plan and timelines.
- Developed a Go-Live-Readiness-Assessment (GLRA) template to track implementation progress and ensure success of initiative.
- Conducted focused group discussions, user acceptance meetings and dry-run sessions to iteratively receive feedback on system configuration options, while also ensuring that all stakeholders were in agreement with implementation deliverables.
- Provided consistent feedback to facility leadership on implementation progress and ensured that any concerns raised were addressed promptly.
STEP III: CAPACITY BUILDING/TRAINING
Capacity building is a critical step to educate all stakeholders on the effective utilization of EHR and best practices of electronic clinical documentation in clinical and public health settings.
A training curriculum and user guide was developed to address EHR fundamental domains, and training was done for all facility staff whose roles required them to interact with the system. The curriculum included the following topics.
- Introduction to EHR navigation and visit workflow basics.
- Overview of best practices on efficient utilization of EHRs in developed countries, and adaptability to the developing world.
- Reviewing patient information in EHR and basic charting maneuvers.
- Specialty tools of recently optimized EHR system.
- User and role settings for clinical and non-clinical users in the EHR system.
- Securities and privileges for specialty-specific actions in the EHR system.
- Smart documentation for patient findings in EHR and uses of “pull” functions.
- Ordering laboratory tests and pharmacy prescriptions for patients within the active encounter in EHR.
- Resulting laboratory tests and dispensing pharmacy prescriptions using the user assisted queuing platform on the EHR system.
- Clinical decision support infrastructure for the EHR system.
- Communicating within the EHR to facilitate instantaneous transfer of patient centered information amongst providers and ancillary staff.
- Inventory, billing and financial (cost/revenue) processes within optimized EHR system.
- HIPAA (Health Insurance Portability and Accountability Act) requirements and confidentiality when interacting with digitized patient information, and mitigating patient privacy issues when using EHRs.
Assessment and evaluation tools were also designed and distributed to participants to measure learning needs and knowledge gained after training respectively.
STEP IV: SYSTEM DEPLOYMENT AT EVERY POINT OF SERVICE
In collaboration with organization’s team, Optimized EHR was implemented/operationalized at all 7 points of care (HCT, Registration, Nursing, Physician, Laboratory, Adherence, Pharmacy, and M&E) across all selected sites. Deployment activities included the following:
- Coordinated the installation of hardware and software products at all facilities per infrastructure requirements.
- Customized the EHR platform in alignment with specific workflows, and aggregated modules based on assigned user roles. All customizations were aligned with statutory requirements.
- Commenced implementation at all selected HIV/AIDS service delivery sites.
- Set up Command center to triage issues encountered at go-live sites and resolved workflow or system issues as they arose.
- Measured indicators of system performance using the following metrics – # patients seen, # total encounters, # transactions (clinical, laboratory, pharmacy), # users logged in, average system response time etc., daily for the first two weeks and weekly afterwards.
- Iteratively fine-tuned system requirements based on feedback received from end-users.
- Hosted Top-3 issues call with organization’s management team and clinical leads to ensure all stakeholders are well informed of implementation progress.
- Monitored assumptions, risks, dependencies, and cultural issues as implementation progressed.
- Developed a plan for post-live enhancements and future optimization efforts in collaboration with organization’s team.
- Worked with organization’s team and facility staff to sustain change and anchor new initiatives into the organization’s culture, while strengthening EHR systems at all facilities.
STEP V: MONITORING, MAINTENANCE AND SUPPORT POST EHR DEPLOYMENT
Following the successful deployment of EHR systems at all facilities, there was need to support and maintain deployed systems to ensure that all post go-live issues were resolved in a timely manner. Activities included the following:
- Provided go-live support services in collaboration with organization’s team to field and manage all issues that arose from EHR deployment within facilities.
- Directly engaged the Quality improvement teams (QITs) at each facility to facilitate at-the-elbow support for end users, and evolved the roles of data assistants/clerks to provide real-time support post go-live.
- Escalated issues that could not be resolved immediately on-site to the organization’s central team for further troubleshooting and resolution.
- Adopted the train-the-trainer model to facilitate the transfer of knowledge for new staff as they joined the facility structure following system deployment.
- Worked with organization’s team to install updates to system configuration at specified intervals, so as to optimize EHR performance and efficiency.
- Designed platform for medium to long-term support availability during working hours, with Service Level Agreement (SLA) for issue resolution set at 8 hours.
- Created data recovery and back-up systems in place to recover all patient information in the event of total outage, fire or disaster.
- Facilitated thrive after go-live capacity building programs for staff 6 months post EHR go-live, so as to keep them abreast of the new features of EHR and best practices for efficient utilization.
New technologies, shifting demographics, government reforms and frequent modifications within Nigeria’s Healthcare system are some of the predominant characteristics of our society in recent times that make change so prevalent.
Globalization, being an irreversible process calls for innovation and diversification, and will continue to reshape our perspective. The rate of change in healthcare is accelerating and not slowing; and the powerful forces that are transforming healthcare can generate vast potentials for those who are able to employ effective techniques in the short-term, and at the same time plan for success in the long-term.
To achieve success in healthcare in this modern era, a system well-grounded in surveillance and medical intelligence as the backbone of the health sector is necessary, including an effective management team steered by strong leadership principles.
We must harness the enhancing forces that drive transformation and use them maximally to our advantage.
Implementing an EHR involves more than the application of technology. Change management, capacity building, maintenance and support, as well as sustainability post-deployment are also very essential. When successful, it results in the transformation of systems, processes, and workflows of any practice.
Dr. Adetola Olateju MBBS, MBA, MS, PMP