Ready. Set. Go-Live!

“On go-live night, it feels like death,” sings Robert Schwab, MD, chief quality officer at Texas Health Presbyterian Hospital in Denton. In his “The Ballad of Go-Live,” set to the tune of a Simon & Garfunkel song, Schwab uses humor to share the story of “exasperation and ultimate success” in implementing an EHR system.

As Schwab’s song conveys, providers endure real anxiety and frustration during go-lives as they cope with new systems while still managing the day-to-day responsibilities of patient care. However, smart organizations can still lay the groundwork before go-lives to minimize glitches and prevent plunging morale despite the inevitable challenges ahead.

Laying the Groundwork

It’s essential to make sure everyone is ready for the first day on a new EHR system. The Department of Health & Human Services’ Health Resources and Services Administration (HRSA), which provides technical assistance to organizations during go-live, advises developing a customized checklist.

Basic preparation entails testing  networking, connectivity or compatibility issues on all new hardware, software and system interfaces. Moreover, HRSA recommends personnel training and possibly a pilot for a smaller unit within the organization to assess whether the new system is user friendly and sufficiently supports various clinical processes, and whether refinement is needed on the configuration of the application.

“Some organizations have it mapped out ahead of time and others are scrambling at the last second with issues that should have been thought of before go-live,” says Mitchel Schwindt, MD, board-certified emergency medicine physician, consultant and author, who has participated in four different EMR go-lives, including one at a 500-bed hospital and another at a small urgent care clinic.

He says while some organizations roll out a new system all at once, others opt for partial implementation.

For organizations going all in, “there must be a level of willingness to support the full scale of rolling everything out, which includes documentation, computerized physician order entry, pharmacy, radiology and all the factors that begin at the front door of the hospital and end at patient discharge. It really has to be well conceptualized.”

At Texas Health, Schwab says it took a full year to implement the EHR. “We had made a conscious decision not to simply switch and chose to keep a hybrid system for physicians slower on the uptake.” Having some paper still circulating “slowed down full implementation. We suffered for that.”

Go-Live Day

The first day is the most vital for everyone. Be sure to keep patients in the loop, says Erin D. Patrick, RHIA, technical and quality services manager at the Kansas HIT Regional Extension Center (REC).

“It’s critical that patients know what’s going on that day in the clinic,” she says, suggesting that providers create brochures and put up signs so patients expect and are more understanding of delays.

Providers vary on their choice of when to flip the switch. Texas Health opted for midnight on Friday, while Schwindt says, in his experience, healthcare organizations like to dive in head first on Sunday at midnight. Patrick says small physician offices or clinics, which predominate in Kansas, tend to pick quieter days, like Thursdays when they often only open for half-days.

Whatever day is chosen, no amount of training will prepare users for the actual go-live.  At Texas Health, physicians received four hours of training prior to implementation but that experience did not mean much, says Schwab.

During the first days, physicians often needed 15-minute refreshers on specific functions. Physician engagement team members, or super users, were on call during the first three weeks to provide assistance. Texas Health benefited from super users at other hospitals within its parent group, Texas Health Resources, which had already undergone the EHR implementation process.

But when in-house experts are insufficient, healthcare organizations may consider hiring consultants or bringing in vendor representatives, says Schwindt. “One of the biggest complaints I hear is that staff feel under supported. They don’t feel they have enough external or vendor help to allow them to do patient care while working with the new system.”

Inevitability of Glitches

Glitches are par for the course when it comes to go-lives, says Patrick. “Honestly, the best thing is to prepare the staff to have patience that it’s not going to go smoothly.”

At Texas Health, the biggest frustration on go-live day was difficulties with logins. When physicians had to repeatedly utilize “break in glass,” or log in with their security credentials to access the EMR, patient care delays and physician frustration peaked, Schwab says. “One orthopedist was so angry he could barely speak with anyone. It took hours to fix.”

As a consultant, Schwindt recalls glitches related to logins and security credentials. “I came in Monday morning at 6 a.m., and the night physician in the ER was ready to kill someone. He literally put his hand in my face and said ‘go away.’ But within 30 minutes, he asked for help and I resolved it.”
For all go-lives, problems accumulate during the day, he says.

Schwindt says medication ordering problems commonly arise. For example, in the new system, a staff member may incorrectly input a medication dose or spell it wrong. “If a physician orders two new chest x-rays, but the person who puts it into the system words it differently, you can’t find it. You spend 10 minutes trying to find something that should take seconds to locate.”

Meanwhile, workflow issues abound. “Before go-live, these are things that people haven’t thought about. They ask, ‘Can the system do it this way?” says Patrick. “Physicians and nurses really have to get into their own flow of using the EHR. Every staff member is going to go through this differently depending on their comfort level with the system.”

Schwab recalls workflow challenges, despite efforts to prepare order sets and develop structured methodologies before go-live. “It takes a long time to make a workflow change. It’s frustrating but in the end it works well.”

Administrative Support

Administrators should not be on the sidelines during a go-live, but front and center, around the clock, so clinical staff feel supported.

At the best healthcare organizations, “you see the CEO walking around the ER at 3 a.m. with his phone and beeper on him because it’s his shift,” Schwindt says. “They want to let physicians know they support them.”

Raising morale may be as simple as providing free food, say Patrick and Schwab. “Really, it’s the little things,” says Patrick, who says as an REC employee, she often brought food and merely served as a sounding board at many go-lives. “It’s establishing the least stressful environment that you possibly can for employees to keep morale up.”

Food boosted the mood at Texas Health as well. “We were walking the halls with a cart filled with candy,” Schwab recalls. He stresses the importance of strong administrative presence 24 hours per day. As the system went live, he says administrative teams led meetings two or three times per day for about three weeks to monitor progress and get feedback from those on the front lines.

While go-live may at times feel like death, Schwab says, “You might as well laugh as it’s difficult stuff.” If you want to hear his song, visit youtube.com/watch?v=lXWOTk79Zr4.