EMR Implementation & Change Management:Lessons from primary care

Presentation to the COMOH EMR Steering CommitteeApril 18 th 2018

Carolyn Steele Gray, PhDScientist, Bridgepoint Collaboratory for Research and InnovationLunenfeld-Tanenbaum Research Institute, Sinai Health SystemsAssistant Professor (status), Institute of Health Policy, Management and Evaluation, University of Toronto

Overview

• The role of EMRs in care delivery

• What does implementation science tell us?

• Supporting change

Role of EMRs

EMR vs EHR vs PHR

• Electronic Medical Record (EMR):

• Real-time patient health record

• Access to evidence-based decision tools – clinical decision support

• Support clinician workflow • Electronic Health Record (EHR):

• Longitudinal record of patient health information across care delivery settings

• Demographics, progress notes, problems, medications, vital signs, history, immunizations, labs, radiology

• Personal/Patient Health Record (PHR):

• Health record controlled by the patient/individual

• Data is owned, managed, and shared by the individual

Lots of potential uses

• Track individual patient data• Support clinical decision-making

• Built-in evidence-based guidelines

• Support inter-professional communication and collaboration

• In-EMR messaging systems

• Population health management and tracking

• Within (EMR) and between (EHR) system

• Performance measurement and QI

EMR Adoption in Primary Care

https://www.infoway-inforoute.ca/en/component/edocman/supporting-documents/i-infoway-i-corporate/media-backgrounders/2860-2016-electronic-medical-records-emr-progress-in-canada

EMR Adoption in Primary Care

https://www.infoway-inforoute.ca/en/component/edocman/supporting-documents/i-infoway-i-corporate/media-backgrounders/2860-2016-electronic-medical-records-emr-progress-in-canada

How EMRs are getting used

https://www.infoway-inforoute.ca/en/component/edocman/supporting-documents/i-infoway-i-corporate/media-backgrounders/2860-2016-electronic-medical-records-emr-progress-in-canada

Adoption vs. Meaningful use

Healthcare Information Management Systems Society (HIMSS) - EMR Adoption Model

http://www.himssanalytics.org/emram/

Progress in EMR adoption in Canada

• Time savings• Improved record keeping• Improved patient safety• Improved confidence

(when used efficiently)

• Financial constraints• Time constraints• Lack of support• Interoperability

Chang & Gupta (2015) CFA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677946/

What does Implementation Sciencetell us?

Implementation Science

• Promoting the uptake of evidence into routine health care delivery in clinical, organizational or policy contexts.

• Examines what works, for whom and under what circumstances, and how interventions can be adapted and scaled up in ways that are accessible and equitable

• Theoretical frameworks and models often point to factors we need to consider when implementing new models

Consolidated Framework for Implementation Research (CFIR)

Damschroder et al (2009)https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-4-50

Factors influencing implementation of eHealth

• Adaptability (related is interoperability of systems); Complexity; CostInnovation

characteristics

• External policy and incentives (absence or inadequacy of legislation, liability, government incentives)Outer setting

• Compatibility (workflow fit); Leadership engagement (can help improve this); Available resources (infrastructure); Access to knowledge and information

Inner setting

• Knowledge and beliefs; personal characteristics (professionals computer skills)

Individual characteristics

• Planning for implementation; change champions; reflecting and evaluating Process

Ross et al (2016) Implementation Science.https://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0510-7

Supporting change

Society for Human Resource Management Change Management Survey 2007

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Site leads to support process

• Decision-making partners at a system/network level

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Engage providers (clinical leaders)

• Create ongoing strategy (meetings, communications)

• Co-design where possible

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Face-to-face meetings (relationships)

• Email and newsletters

• Supportive materials (short!)

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Observations of workflow

• Document analysis• Directed

conversations with frontline

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Train, train, train…• Then train again

(refreshers)• Find peer support

within organizations

Canada Health Infoway Change Management Toolkit

https://www.infoway-inforoute.ca/en/resource-centre/toolkits/change-management

• Readiness assessments

• Try to build in touchpoints with sites for feedback (can be used to support engagement)

• Embrace distributive leadership

John Kotter on “Change Management vs Change Leadership”

“Change management, which is a set of processes and a set of tools and a set of mechanisms that are designed to make sure that when you do try to make some changes, A, it doesn’t get out of control, and B, the number of problems associated with it… don’t happen. So it is a way of making a big change and keeping it, in a sense, under control.”

“Change leadership is much more associated with putting an engine on the whole change process, and making it go faster, smarter, more efficiently. Change leadership is going to be the big challenge in the future, and the fact that almost nobody is very good at it is—well, it’s obviously a big deal.”

Change leadership

• Greiner’s Change Process Model (1967) identifies the importance of a change agent who takes a leadership role in initiative the change process.

• Practice facilitators!

Implementation learning from our work

• Critical implementation determinants at all levels • Systems must be meaningful to users• Consistent ongoing engagement is critical • Establish adaptable change management strategies

• Careful selection of change agents/champions• Find a balance between fitting user flows and encouraging innovation

• Tension between user-centredness and disruption• Challenge in addressing policy level determinants (e.g. data privacy and

security legislation)

“Electronic health systems must be built in a way to facilitate the exchange of data; disparate systems using separate disease definitions, for example, are of little value. Standards must be applied to the data and the systems themselves to allow for and facilitate the exchange of data between various sources.” (WHO, 2012)

http://apps.who.int/iris/bitstream/handle/10665/76794/9789241504645_eng.pdf;jsessionid=94B47EE638EE4ECBF323458F48DD5744?sequence=1

Thank you!

Carolyn.SteeleGray@sinaihealthsystem.ca