CNEA Report Question #1

1. How did you plan for and model the loss of staff and provider productivity during the initial implementation period?

a. Did this modeling/planning influence the tactics you employed to rollout the EHR (incremental, big bang or hybrid)?


As our clinics were at vastly different stages and sizes, each one was approached independently.

Clinic A
Clinic A was very small and a new clinic. They had very few paper charts and enthusiastic personnel. They were very interested in “going live” as soon as possible. Clinic A also had a very small patient base as they had been operational only 6 months. The big bang implementation (Practice Management and EHR) was planned due to the various reasons listed above.

Our training methods were based on a big bang process which meant that all employees had to be fully trained in every aspect of EPM and EMR. It required a more condensed training timeline to enable us to meet the requested “go live” date.

Planning for a loss of staff was difficult in this location as there was really only one full time and one part time nurse, one full time and one part time provider. Going to paper was an option, if necessary, even after the EHR implementation as the Patient Care Component (PCC) document and associated notes could be scanned until adequate staffing was in place and personnel trained.

We believed that a 50% reduction in patient visits was necessary for the first couple of weeks of implementation and that a gradual increase after that would be done based on comfort level.

Clinic B

There was a history of turnover in Clinic B so planning was crucial. Our biggest asset was having a sister clinic about 20 minutes away. We were allowed to utilize staff from there, if necessary, so this created a good safety net for us. For training purposes, however, this would create potential problems as all our training had to be done using consultants via WebEx. We were not allowed to close the clinic for more than a few hours every other week for training so we had to do our best to pre-plan for turnover and provide extra training for our “champions” so we had someone in place that could manage training new individuals (if there was turnover). We also sent newer staff to our sister clinic for shadow training, which became very necessary as the implementation process progressed. This also gave us another outlet for training if there was turnover after the implementation.

Clinic B had been using the EPM for a few years. They had a larger patient base and a large amount of abstractions and scanning to do as well as multiple providers many of whom were only part time. Our original idea was to employ a big bang approach, however two part-time (one day a week) providers made this difficult. The board did not feel that devoting a significant amount of training time to these individuals was necessary at this time. We basically employed an incremental approach after this although for most of the staff it was a big bang as everyone else would go paperless at the Go Live. Our idea now was that the providers who were only there one day a week would not be brought live on the EHR until everyone else (all other nurses and providers) were fully trained and utilizing the EHR. This would allow the other providers to become “champions” so that they could begin training the part time providers once they felt comfortable. The biggest issue we faced was with our part time providers and how to handle a “paper vs. EHR” system for them (addressed further in question 2). If they only saw patients unique to them then this were not an issue, however, the possibility for certain patients being seen by another provider that was using the EHR meant that we had to manage this process at some point in time before our go live date.

We planned for a minimum 50% reduction in patient visits for all providers for the first couple of weeks. The most difficult part of this is convincing the board it was necessary in the short term. The financial implications for smaller rural clinics like this are severe so it was very important that we were prepared and had a great deal of practice time allotted for the providers/nurses so that there would be the minimal drop in patient visits. We planned to increase the load by about 10% every couple of weeks if possible and hoped that we could get to 80% within a couple of months. Based on research and prior implementations we were not expecting to get to 100% for 6 months to a year.

b. How accurate were your predictions? What positively or negatively influenced the actual results?

Clinic A: Unforeseen circumstances in our smaller clinic presented issues with connectivity and clinic location issues but is being resolved in a more stable network environment through CRIHB IT enhancements. Although not at its peak we are undergoing essential changes in order to meet the demand and the obstacles. Our predictions were pretty close to the initial expectation for a small clinic; however, with Clinic A we have learned taking steps to improve training and address staff challenges would benefit future projects

Training was essential in THPs and must be done well in advance of go-live in order to accommodate changes in the Database to meet clinic workflow. Clinic A is a smaller clinic with 1 MD, 1 PA, 1 RN, and 1 MA and office staff. From the request from Clinic A, the front end and back end database was implemented at the same time instead of stages and resulted in unpredicted obstacles.

Following go-live date, we planned a patient flow of 4 patients per day for the first 2 weeks and gradually increased as the knowledge and skills improved on the EHR System, with the clinic at full patient load by the end of 3 months. However, a higher turnover in staff and resistance of personnel was not predicted so our expectations were not on target.

Workflow was not fully evaluated within the clinic prior to go-live which caused Clinic A to struggle with EHR processes. Additional training was offered but with little retention.

All in all, lessons learned is being documented and being taken into consideration for future implementations. Staging in all phases of the implementation is essential in all aspects of the Project.


Clinic B
As with all EHR implementations, nothing ever goes as planned. In the middle of the implementation process we discovered that there would be a “switch” of providers with our sister clinic. The problem with this is two fold; our sister clinic was already 100% live on the EHR so the provider they were sending us was already trained and using the EHR. The other side of the issue was that I had not completely trained the provider that was being sent to our sister clinic and he needed to “hit the ground running” using the EHR there. The time period I had to figure this out was about two half days of training time.

We had to set up some crash courses in training for our provider and get him some shadow training time as well. We had to keep in constant contact with him and alert the billing dept. to monitor for errors. This provider was a trooper and did a remarkable job adapting and has progressed very well.

Back at Clinic B we now had to figure out how to instantly “go live” with a new EHR trained provider or take the chance that the recent training he received would not be utilized and subsequently forgotten. First issue was to get the front office on board with how to handle both paper and EHR visits that were now going to immediately be split (more on this in question 2). Once the plan was in place for handling the paper charts and scanning etc. we allowed the provider to start using the EHR. The only part that remained on paper was the lab interface as that had to be an all or nothing so we decided to wait until everyone had adequate training.

The next problem was having a nurse properly trained to handle the initial visit for the patient. The provider agreed to attempt to do this himself. The problem we encountered was that the schedule hadn’t been reduced enough because of the short time frame and the load was too much. Encounters couldn’t be billed because they weren’t being completed. We had to reduce the patient visits for this provider significantly to allow him the time to properly document visits. We then had to assign one nurse champion to this provider who would handle all his patients. This allowed him to have more time in the visit to concentrate on things other than entering vitals and immunizations or patient history etc. Once this was in place the flow was much better and he began to see more patients after a couple of weeks.

Considering all of the initial turmoil this actually ended up being a successful implementation. Providers and nurses are using the system and working with each other to enhance their knowledge. Making sure that our patient visits were kept to a minimum allowed ample time to “ramp up” over the weeks that followed without overwhelming (other than mentioned above) any of our providers or nurses. There is also a fairly heavy load put on the front office staff which also had to be brought into the mix in phases. Conducting our training over a longer time period also helped by allowing us to have more practice time without doing the “3 day crash course” and into the fire method. I also believe that having buy-in from the CFO and Medical Director and their willingness to cut back on billable visits over the short term to allow for a greater benefit in the long term was essential. The turnover and provider switches were obviously detrimental, however, flexibility and proper proactive risk assessment allowed for alternate solutions that helped us to achieve our goals.

c. Can you share a spreadsheet or tool you used for analysis?

See the crihb.org web site http://crihb.org/health-resources/electronic-health-records/electronic-health-records-documents.html for documents used for this project.