Introduction of electronic health records

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Introduction:

The New Life Clinic is a primary health care clinic providing service to the local community. NLC also provides consulting services to international patients, who seek medical in the UK and US for specialty treatment. NLC, with three doctors, two nurses and five other staff members, handles more than 5000 patients every year. NLC is busiest in primary healthcare and, there is an increasing need to provide links to specialist clinics and hospitals regarding referrals. NLC refers patients to specialist clinics both local and International.

NLC defined its vision of a patient-centric information system to meet the objectives of an Electronic Health Record, EHR-system. NLC is working with medical technologies to achieve EHR-System and, develop its medical information technology for the future.

Q.1, Briefly describe a significant organisational change which has occurred within the last 5 years. What were the main objectives in making the change? (10%)

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The major significant organizational change in New Life Clinic was introduction of Electronic Health Record -system in 2005.As many patients travel to the UK and US for specialty medical treatment. Sharing information with International hospitals via paper medical record is time consuming. The management of NLC realized this need of international healthcare standards and decided to introduce a system that supports the delivery of clinical services and meets high standards of reliability. The system needed to be cost-effective, reliable and affordable within the NLC's limited funds.

To move towards this goal, in 2005, NLC developed a new information strategy of introducing Electronic Health Record system. An Electronic Health Record (HER), also called Electronic Medical Record (EMR), is computerized health information of an individual patient in a digital format. EHR includes, patient's medical history, medications, allergies, immunization status, laboratory findings, radiology images, and billing information. Clinics and hospitals create EHRs, store, and share with different health care providers. Clinics and hospitals create EHRs, store, and share with different health care providers. Electronic Health Record-system enhances automation as well as streamlines workflow with increased safety, as well as reliability through an evidence based decision support system.

B-The main objectives in making a change were; Replace paper medical records with an electronic health record to increase physician competence, standardize patient care, and reduce medical errors and cost.

Physician competence; EHR-system provides physicians a strong clinical decision support system, based on clinical guidelines to prevent diagnostic errors, and improve the quality of treatment. Having access to HER-system physicians can get comprehensive health information to physicians on fingertips rather than chasing paper records. HER-system enables Physicians to make online referrals, share medical histories, and data of patients with other service providers in the UK, and US.

Standardized patient care; HER-system enhances patient-physician interaction; provide patients a secure access to their EHRs to view key component of medical records, laboratory test results. EHR-System provides patient online access to communicate with physicians to request prescription renewals, and make appointments request prescription renewals and make appointments. EHR-system replaces manual handwritten prescription with electronic medical prescription to avoid medical errors. Reduce healthcare costs by avoiding duplicating of expensive imaging procedures.

Q.II)

Identify the main drivers of the change and using the most appropriate models and frameworks from the course materials demonstrate how these drivers created a need for the change which took place. (30%)

New Life Clinic is under management of medical professional. Continuous improvement in quality is the core of its policy. International medical regulations had influence on the practice conduct of New Life Clinic due to due to international referral services. The fast changing medical technologies and changing patient preferences forced healthcare providers to redefine their patient care goals and objectives.

I)-The main drivers of change were; 1) New technology of Electronic Health Record .2) Changing business model of medical practice.

As part of the Clinic's review of data, patients had problems with prescriptions and delays in referrals. There were also some reports of errors in prescriptions. Therefore, in an effort to understand the issues, and identify opportunities for a change, a root cause analysis was completed using the fishbone diagram.

II)- Fishbone Diagram: The main objectives of using fishbone diagram analysis were:

1) Determine the root cause of a problem using a structured approach.2) Indicate possible causes of variation in a process. 3) Encourage group participation and everyone to learn more about the factors at work and how they were related. 4) Identification of areas where data need to be collected for further study.

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Process: The senior member of clinic led the process of root cause analysis. He had extensive experience in modernizing medical practice and quality improvement concepts.

The procedure had representation from each section of the clinic, and involved doctors, nurses, administrators, coordinators, and patients. As part of the process, data from Clinic's CQI program were reviewed, past strategies were discussed, and lessons learned were explored.

The Clinic administrator defined the problem of delay in referrals, and errors in prescriptions.

The goal of the root cause analysis was to identify the primary reasons for delay in referrals and medical errors.

Issues were explored using the following five main causes:

1) Environment 2) Procedures, 3) People 4) Equipment,5) Technology

The first cause explored was the environment and four related ideas found by this group were:

1) Time available 2) Waiting time 3) Physical space 4) Availability of services

The team discussed the environment and found that all the services were good and in time. There was less waiting time at the reception for confirmed appointment. However, there was less physical space available for storage of medical records and X-rays film.

2) The second cause explored was procedures, and included both policies and procedures that did contribute a lot to the existing problems of delays in referrals, and appointments. The three related ideas found by this group were;1) Referral procedure 2) Identification of errors in prescription 3) Appointment process

The team discussed and found that procedures used within the clinic for appointments and referrals were very time consuming. Appointment staff was very busy in making appointments and answering patients' questions. International partners in the UK and US were insisting to send electronic record. The psychical store for medical records was less and patient's demands were very high. The team analyzed procedure of appointments and decided that procedure could be a possible cause. The team also suggested that technology should be linked with the procedure. As staff was unable to handle all the things manually and meet high demand of patients.

3) The third cause explored was, people. This was categorized by staff and patients. Some of the related ideas identified were competing with priorities, fear, staff expectations, liability, and billing issues. The team agreed on the issue of people handling mails ineffectively. But, there was very few evidence of delay in referrals due to negligence.

4) The fourth area explored was equipment, including what was needed to conduct medical examination, test and generate reports. The two related ideas found by this group were:

1) Trained staff was available to help the patients.

2) Physical equipment needed to carry out the procedure were new and in good conditions.

5) The fifth area explored was Technology, including data storage, software, and access to internet. The three related ideas found by this group were.1) Software for medical prescription is required. 2) Computerization of all medical records. 2) Online access to patients on website and access to medical records.

Technology: The team analyzed the data input and access to the system and postulated the fowling findings.

1) The technology had the capacity of sharing data with other service providers.

2) Patients requested access to their medical records through a secure website.

3) The current technology system had a capacity to store all medical records.

4) Communication with Hospitals in the UK, and US was the main issue and technology was definitely required.

5) There was a need of experienced IT team to run the system effectively.

All the team members agreed, in principle, that IT was the issue which could improve the situation. Less use of technology and some unskilled IT persons were the main issue and root causes of problems.

Outcomes; Based on this root cause analysis using the fishbone diagram, the team conducted brainstorming sessions identify the root cause of this complex problem. The team discussed all the issues at length with evidence and possible reasons.

The results led to a wide range possible causes and reasons that created a need for the change.

1) The reason for delay in referrals, medical errors were due to manual handling of records.

2) Physical records usually required significant amounts of space which could be replaced with electronic health record system. Some new experienced IT staff should be hired and exiting members need more training. Furthermore, collecting and transporting them to a single location for review by a healthcare provider was time-consuming. When paper records were required in multiple locations, copying, faxing, and transporting costs were significant concerns. There was also a problem in updating file, photocopying, locating files and attaching papers was a very time consuming.

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4) There was also lack of patient-physician interaction due to lack of effective online communication. Telephone lines were too busy to answer patients' calls about updates on results, renewal of prescription and making appointments.

5) The coordinator for international patient services told that Hospitals in the UK and US were demanding electronic records instead of paper medical records.

Evaluation:

After detailed discussion, inputs from all stakeholders, and evidence from the collected data it was possible to come up with a consensus from the team on one possible major root cause. The major cause identified was the manual handling of paper records, and it was time consuming procedure. The other reason found was that clinic had good IT infrastructure, but it was not being used effectively. Therefore, team suggested the effective use of Electronic- Health Record- EHR-System and hiring some experienced IT staff will improve the situation. These findings were the main reason that created a need of an Electronic Health Record System and new business model of medical practice i.e.: online services.

Q.III) A

Change managementis a structured approach to transitioningindividuals,teams, andorganizationsfrom a current state to a desired future state.

John P Kotter's 'eight steps to successful change'

Increase urgency- inspire people to move, make objectives real and relevant.

The change agent had clearly defined problem and need for improvement. The change agent had personal experience, credibility and authority to direct the change. The leader shared the knowledge and views that he had about the situation. The leader formed a task force of champions to shape ideas into practical solutions.

The change agent did it in another way of mobilizing team's commitment and arranged for the team to look outside the box. He took them on a tour of a leading organisation to see other ways of doing the same thing first hand. The team was very much impressed with the work and expressed more interest in knowing the further details. Besides this there were other financial incentives, security of job, better working, and opportunities to develop new skills and extend influence. Workshops were e very useful processes to develop collective understanding. This helped the team to reach the same conclusion that the change agent had arrived.

Staff surveys were also a helpful way to repair damage and mistrust among staff. Management training, empathy and facilitative capability were priority areas .The management was crucial to the change process; therefore they facilitated the process of learning.

Management empowered people to find their own solutions and responses, with facilitation and support from managers, and tolerance and compassion from the leaders and executives. Management's leadership, and behavior were encouraging and employees had a firm trust in organization.

The objectives were real and relevant:

The change was necessary and urgent, and the benefits of change were explained: The present paper system was to be replaced with an electronic health record system. The top issues related to the change were, training and further familiarization with the E.H.R-System.

Business benefits EHR-System::

  1. Reduce healthcare costs; effective way to avoid duplicating expensive imaging procedures, and reduction of medical errors.
  2. Improve the quality of care: It is claimed to help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine are hypothesized to enable the proliferation of ongoing improvements in healthcare efficacy.
  3. Promote evidence-based medicine: EHRs provide access to clinical data for research that can accelerate the level of knowledge of effective medical practices.

The reason for improvement was clear and benefits were measureable. Moreover the project was within clinic's fund limits.

Build the guiding team- Get the right people in place with the right emotional commitment, and the right mix of skills and levels

Management hired a team of IT experts in healthcare whose roles were to deliver the change and assist the staff to execute the change. This assisted greatly to execute this type of change without greater resistance. The hired consultants had experience and reputation of managing Electronic Health record projects. The co-operation and pro-active support of stakeholder was important. Essential Stakeholders and sponsors were identified and their level of influence assessed and mapped through stakeholder analysis. Workshops were conducted to address the issues and stake holder agreed to support and commitment. There was a good communication and common understanding amongst the stakeholders about the degree and scope of change needed.

Get the vision right- get the team to establish a simple vision and strategy focus on emotional and creative aspects necessary to drive service and efficiency.

Getting the vision right, this was the leadership, who was taking their team to where they cannot go on their own. At this step learning was kicked into play in this process of change. By having teams with new goals and accountabilities the leader facilitated learning through all members of the team. The changes in roles and responsibilities. Changed patterns of coordination increased employee participation, collaboration, and information sharing. This step helped agents of change to identify those who cannot fit in the new organisation.

There was a clear and detailed vision of the future. The change vision was aligned with the organization's strategy of continuous improvement. It involved key stakeholders in defining and detailing the change vision. Again, workshops were conducted in developing the change strategy. High-level benchmarking was conducted to identify best practices, reference sites and competitor information.

The management team set out the "7 S" framework to help diagnose the current health of organisations and to help develop their visions for the future.10their research suggests that any intelligent approach to organizing should involve the following:

  1. Structure (roles, responsibilities, organisation, structure)
  2. Strategy (direction)
  3. Staff (numbers and skills)
  4. Management style (leadership and management approach)
  5. Systems and procedures
  6. Guiding concepts and shared values (ways of doing things, operating style)
  7. Corporate strengths and skills (general competencies).

Developing and presenting a vision had a key role in motivating staff as well reassuring them about the journey and how they might be involved.

A vision can be expressed in different ways and these are important at different stages of change.

High level visions of achievement and outcomes.

High level visions play key roles at the start. They build on the problems and threats that provide the case for change, but address them positively. They can motivate staff by showing benefits.

Outline visions of service that helped move staff from finding problems to building solutions without involving detailed negotiation on changes.

A detailed vision of service and organisation: This allows staff to imagine how their work life will be in the future. Building on the details may allow them to have some influence on their destiny.

A vision of the journey

This provides a structure for communication during the change.

The service model was made for building support for change. That outlined the change and also the benefits at the end. The benefits were; improved outcomes for patients, and better futures for staff. The service model helped subsequent translation of change in terms of:

  • Structure (new roles and responsibilities across professions)
  • Staff (changes in skill mix)
  • New skills (multidisciplinary working)
  • Systems and procedures (new protocols for referrals)
  • Management style (focus on outcomes as well as process)
  • Shared values (the emphasis on assessing and responding to the full range of patient needs).

Communicate for buy-in- Involve as many people as possible, communicate the essentials, simply, and to appeal and respond to people's needs. De-clutter communications - make technology work for you rather than against.

The managed involved all stakeholder, medical societies, and NGOs in healthcare, and also some international hospitals. The essential of change were communicated. Simply:

  • Electronic health records will become a "must-have" for healthcare organizations
  • EHR adoption will be inevitable due to internal as well as external factors
  • Improving the quality of care is a priority for healthcare organizations
  • Other healthcare players will "encourage" late adopters to implement EHRs
  • An overwhelming market is difficult for hospitals and physician offices to navigate

Change was communicated in a clear, concise way to capture the minds and hearts of the entire organization.

The co-operation and pro-active support of stakeholder was important. Workshops were conducted to address the issues and stake holder agreed to support and commitment. There was a good communication and common understanding amongst the stakeholders about the degree and scope of change needed.

The team had Coordination, Commitment, and Competence. These three components are essential for introducing change .Change is the external manifestation of transition .while Transition is the psychological aspect of change: how people feel towards change, their attitudes, their internal plans, and their personal vision of change.

Win Commitment to Change

Change was determined as its actions were consistent with the change vision. Therefore, effective Stakeholder Communications and Management are vital components of winning commitment to and delivering change. Ongoing effectiveness was traced through Staff Surveys.

  • Stakeholders were managed on an on-going basis. Communication was established through weekend updates, emails, letters and also mobile phone msgs.
  • A large part of winning commitment is also about managing change resistance. Understanding Human Responses, Change Resistance and Managing Conflict is vital.

Questionnaire and staff satisfaction surveys were quite effective in determining the views of employees and allowed people to voice their opinions about the change program.

  • Role of change agent was vital.

Empower action- Remove obstacles, enable constructive feedback and lots of support from leaders - reward and recognise progress and achievements.

Create short-term wins- Set aims that are easy to achieve - in bite-size chunks. Manageable numbers of initiatives. Finish current stages before starting new ones. Deliver Change

delivering change is the crux of the change management program.

Change is realised when it becomes the normal way of working, this requires proof that performance has improved and will continue in the future. Quick wins were identified in the forms of electronic health records being printed and stored in one location. That saved time and efforts that were used in compiling paper records.

Senior management communicated results delivered through quick wins to the organisation.

The quick wins increased the momentum and also early positive feedback was also t was very encouraging essential for the on-going success of a change management program. First milestone was celebrated after feedback was very positive.

  • Don't let up- Foster and encourage determination and persistence - ongoing change - encourage ongoing progress reporting - highlight achieved and future milestones.
  • Make change stick- Reinforce the value of successful change via recruitment, promotion, new change leaders. Weave change into culture.

QIII) B

When organizations are faced with opportunity of change, resistance arises in form of stability affection people and organization. An organization which facilitates learning manages the resistance as an opportunity thinking together rather than managing a conflict.

As New Life Clinic has a culture of facilitating learning, and this ensured learning throughout the process of change management. Therefore most of the ambiguity was clear at very start.

The credibility and experience of change agents, and strong support and commitment of stake holders made change straightforward. As it was urgent and aligned with the policy of clinic.

The fact of change is that irrespective of effective change management, people are affected by the change. When people are faced with ambiguous or uncertain situation they do resist in moving to that situation.

New Life Clinic management faced the same thing while implementing a new change .The resistance and its response is divided into three parts. To effectively manage resistance, the management constituted a compliance committee of experts to address the concerns, regarding technology, security, and other issues.

The management adopted following steps to mage the resistance:

  • The staff at medical record section had some problem with operating new system and was struggling. The support team managed through facilitation, working with them to achieve the goals of change
  • Resistance from p patients:. New patients resisted getting their data to be entered into computer; there was myth behind that it might be put on the internet with their name and diseases condition. Or it will be insecure and other person except doctor can view the data. This was managed through education explain them how it is used and how it looks like and how secure it was. The support team educated new patients through demonstration and seminars.
  • Involvement: all the stake holders were involved in understanding this system through repeated seminars and coaching classes.
  • Two members from customer service team were not taking interest and hardly participated in seminars. First they were dealt with negotiation and latter coercion was the last resort, and finally were fired from the
  • Physicians attitude: This was hardest task to assess physicians' readiness for new change. Keeping in view the fact that many costs -saving and quality improvement ideas have failed in healthcare sector due to lack of physicians buy -in. New life clinic was also faced with same situation especially specialist physicians who were not employee of clinic but attend clinics as external consultants.

That attitude was due to the lack of physician's familiarity with the changed environment of practice. Secondly specialist physicians are acknowledged. Thus, when they feel unfamiliar with system, they tend to perceive incompetence on their part. That attitude showed concerns about physicians' autonomy and also concern of quality care.

To dispel this attitude, management hired a senior clinical doctor who was some time a professor in the US and was very familiar with Electronic health records. This provided a forum for physicians to ask questions and learn with their colleague. This strategy was very successful and many senior doctors from other hospitals came to join the sessions.

Managing opposition to change relies on the same principles used in joint ventures and physician engagement-that is, early involvement, collaboration, and fairness.

QIV) A

Managers need to know how successful or 'effective' change was, and stakeholders want

Information on whether the objectives are being met. An assessment of management success or effectiveness can help to provide this information, and to identify where improvements are needed. This sheet describes the principles involved and introduces some of the methods available.

Assessing or evaluating management effectiveness means measuring the degree to which a proposed was achieving its objectives, and how successfully it is designed, planned and managed. An assessment can also help to identify threats and needs, improve planning, and raise awareness about the objectives and performance. It also identifies issues that were within the control of the manager and those that went beyond it, provided lessons learnt and allowed for comparison between desired goals achieved. Where assessments have been undertaken, managers have gained valuable insights into what worked well, as well as any shortcomings.

The success was assessed using the best practices for organisational-wide change management frameworks

Commitment from the top:

Vision: there was a compelling, and inspiring, vision of the future state, and there was link a direct link between the vision and the key drivers for the business

The vision has quantifiable measures for success and he vision has been authorized, and sanctioned, by higher authority

The change was led by an identifiable, senior management who had personal credibility, past experience and spoke enthusiastically about it. The chair of the committee had clinical credibility and a set of social skills that made him effective with a diverse set of stakeholders. The situation and the team needed an approach that emphasized flexibility, but which over time moved from setting the pace and negotiating to developing and coaching. He actively looked for leadership from others and in critical stages sought out advocates who could solve problems. On many occasions he immersed himself in the detail of changes, following through on discussions and decisions into the next phase.

During the project others began to play key roles in securing change. One of the most satisfying experiences was to see multidisciplinary colleagues start to take a high profile in meetings.

  • Stakeholder consultation: The co-operation and pro-active support of stakeholder was important. Essential Stakeholders and sponsors were identified and their level of influence assessed and mapped through stakeholder analysis. Workshops were conducted to address the issues and stake holder agreed to support and commitment. There was a good communication and common understanding amongst the stakeholders about the degree and scope of change needed.

Strategy: Senior management was clear and understood how the change will be achieved in broad terms. The risks of the project were considered and mitigating actions identified.

A structure was set up to guide and manage the change (steering group, project board, etc.)

Members of the senior team had taken on responsibilities for aspects of the change program

A high-level plan, with indicative timescales, has been produced for the change

Senior Team Commitment:_ All members of the senior team have discussed and understood all the implications of the change. They can all explain the vision in vivid and inspiring terms

Even in private they will speak supportively of the change programme

Other key influencers outside the change team have been contacted and they were supportive

Each member of the senior team has allocated sufficient resources

User involvement and business outcomes (related to the previous point. Changes must also be tied to definite and tangible business outcomes)

Performance indicator:

Performance improvement assessment helped physicians to assess current clinical care to their patients according to established evidence-based guidelines.

•Short survey evaluating knowledge, attitude, and competence of physicians showed significant improvement in the new system.

• Patient surveys were also conducted evaluating, convenience, interaction with physicians and waiting times. Results showed there was increased patient-physician interaction, and patients felt the personal touch of care was improved and waiting time was markedly lessened which otherwise were wasted in collecting paper records.

. The staffs' survey showed increase in work out put, workload of paper records was lessened with electronic health recur system. The time wasted on compiling paper records was being spent on further learning of system.

Employees were awarded with rewards, new roles and responsibilities and equipped with new skills.

The was ultimately improvement in professional practice and patient care by implementing changes.

•Communication (communication is key to the success of change strategies. Communication informally from the top, as well as well as formal and explicit communication of change strategy)

The effective Stakeholder Communications and Management were set to win the commitment change. Ongoing effectiveness was traced through Staff Surveys.

  • Stakeholders were managed on an on-going basis. Communication was established through weekend updates, seminars, emails, and letters. Questionnaire and staff satisfaction surveys were quite effective in determining the views of employees and allowed people to voice their opinions about the change program.. The essential of change were communicated in clear and simple manner.

Technology and culture alignment: the current culture of New Life clinic was conducive to proposed change of Electronic health record system. The staff had skills to use IT technology and good technology infrastructure to accommodate the change.

Quick wins and measurable results:

Quick wins were identified in the forms of electronic health records being printed and stored in one location. That saved time and efforts that were used in compiling paper records.

Senior management communicated results delivered through quick wins to the organisation.

The quick wins increased the momentum and also early positive feedback was also t was very encouraging essential for the on-going success of a change management program. First milestone was celebrated after feedback was very positive.

Continual learning (provision for continual learning - both 'training' and development)

Learning outcome 6: ensuring a process of learning throughout the period of change: The What is likely to produce the most effective conditions for learning?

a. Preplanned audit and learning, performance reviews as part of normal business, and external audit and inspection

Risk assessment: It was made that problems don't happen or their impact will be minimized by

a. Proactive risk assessment, establishing clear criteria for success

b. Gathering information on agreed metrics, Audit and assessment,

c. Reactive fire fighting

Alignment and integration throughout the business: the need for a group of champions who can work well together to ensure direction, support, and drive for change.7 Senge looks for dispersed leadership within the organisation.

When the success of change was measure in the light of Beckhard's definition of OD

'Organisation Development is an effort planned, organisation-wide, and managed from the top, to increase organisation effectiveness and health through planned interventions in the organization's processes, using behavioral-science knowledge.' Beckhard, R (1989).

The statement of success was established, that proposed change of electronic health record System in the New Life Clinic was:

  • Planned: continuous improvement is New Life Clinic's core policy
  • Organisation-wide: from clinical staff to entire departments and then customers and to patients
  • Managed from the top: was managed by the Chair
  • Increase organisation effectiveness and health: increased medical staff's performance and improved patient care.
  • Planned interventions: it was very well planned with evidence based guidelines
  • Behavioral science knowledge: The value of health education practice is in effective use of behavioral Science Knowledge. Therefore, it was managed using knowledge of behavior science. Today behavioral science is part of medical curriculum for medical doctors.

Conclusion: Introduction of Electronic health Records in medical practice replaced the paper based records. The change was a business process transformation, a fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical, contemporary measures of performance, such as cost, quality, service, and speed. This change had almost achieved all the desired goals. The success of the change is supported by:

  • The clear vision of future and its goals
  • Stakeholders' support and keen involvement throughout the process.
  • A well organized communication system and learning environment.
  • Improved performance indicators of medical practice
  • Quick wins and measurable results
  • A well managed risk assessment plan to avoid any surprises
  • Continuous learning culture managed by behavioral science knowledge principles.

In the light of established facts of successful change and organization development .It is suggest that change was very successful in achieving desire objectives of Electronic Health record system in due time and within fund limits.