Most hospitals opt for an incremental approach to implementing EHR systems, often out of fear of joining the line-up of horror stories in the media about big IT project failures. But if the right elements are in place, the big bang approach – implementing everything all at once – can work.
Toronto’s Centre for Addiction and Mental Health (CAMH), an organization with over 3,000 staff, successfully went live in May, 2014 with its new EHR and data warehouse system with virtually no hiccups – and under budget.
“Over the course of the four-year period from procurement to implementation, our budget was about $50 million, and we even came in slightly under by $1 million on completion,” says Tracey MacArthur, CAMH’s CIO.
Although big bang implementations are not common in Canada, several U.S. hospitals have successfully used this approach in recent years, and CAMH’s team carefully studied these models, says MacArthur. “It really needs an all-hands-on-deck approach. But even with that, I believe there are some constraints on the size of the organization that can do big bang. I’m not sure a very large organization could manage all the logistics.”
MacArthur says project leaders weighed several factors in making the decision to go with the big bang approach. Cost was a big factor. “We would not need to support two different systems at the same time, or incur all of the interfacing and other technical costs of supporting two systems, or the costs of a long-term project team being in place – almost 60 percent of the project’s costs were labour costs.”
But cost wasn’t the only consideration. CAMH’s clinicians were eager to move from a paper-based system to an EHR. Mental health patient records require even more documentation than medical ones, and clinicians were frustrated with dealing with reams of paper files and the inability to pinpoint relevant information quickly.
“One of the huge advantages of the project was streamlining and standardizing our clinical documentation. We went from about 700 types of assessment forms to under 200. Our clinicians put a great deal of effort in completing that work in advance of the technical system implementation, so they were really ready to move forward,” says MacArthur, adding that CAMH has been contacted by mental health institutions internationally to share its innovations in standardizing assessment forms.
This pre-implementation work was also good preparation for the collaborative effort needed for the technical implementation. “The main ingredient for a big bang implementation that we found is that the clinicians really need to be prepared for the intensive training and work.”
CAMH’s project team chose the Cerner Millennium EHR platform for implementation because it offered an all-encompassing solution that would span CAMH’s emergency department, inpatient and outpatient clinics. In addition, the vendor was interested in gaining more expertise in mental health systems.
“We’ve been developing dynamic documentation to capture data in areas where there are a number of contributors to a health record,” said Jim Shave, president of Cerner Canada. “The CAMH project helped us advance that system.”
Cerner staff worked in conjunction with CAMH staff on the project, but MacArthur says most of the implementation team was comprised of in-house staff. “Over the course of the 20 months for the technical implementation, about 150 clinicians were involved in design, testing or coaching their peers at various points in the project. We also had a dedicated project team of about 100 people, mostly comprised of CAMH staff, but we also had some people from Cerner and Deloitte. ”
The team also implemented a separate data warehouse in parallel, so staff would be able to start using and analyzing the data immediately. “We take all the data out of Cerner, as well as other systems, and we put it in the data warehouse to aggregate it and generate reporting with Microsoft Business Intelligence. Our decision was to centralize all of reporting into our iManage tool, which is a single portal for all reporting, be it clinical, HR, or financial data.”
MacArthur says there have been almost no technical hiccups since the system was implemented last year. “Our biggest challenges were around the management of the logistics on the critical go-live date. We were fortunate to receive support from other Cerner hospitals in the Toronto area. You really need just-in-time training with the big bang approach so the learning is still fresh, so most of it was completed in the six weeks prior to the go-live date.”
However, the team has had to tweak some of the documentation templates since the implementation. “It was hard to anticipate precisely how much of our clinical documentation should be contained in discrete data fields versus free-form narrative documentation. We may have erred too much on one side or the other in our data capture, so we’ve been fine-tuning that.”
With electronic data, clinicians can now see patterns and correlations they couldn’t before. For example, there are links between physical and mental health, but clinicians didn’t have hard data to crunch to determine how to improve care. “In the past, medical histories were noted in charts, but because we’re capturing that information now as very discrete data elements, we’re able to generate alerts to physicians. The system is showing us that over 90 percent of our patients are coming in with medical diagnoses, which is more than we expected.”
CAMH’s systems are now connected to a number of external entities, including its local family health team, the Ontario Lab Information System, the regional health record project, ConnectingGTA, and others. “We’ve been a viewing site only until now, but in the coming year, we’ll be contributing data to ConnectingGTA. And now that our discharge summaries are electronic, we can send them to any GP within 24 hours.”
With a wealth of data to slice and dice, CAMH can see where there are gaps. “Because we can now report more accurately on our patient population, we’re starting to see where we’re not doing a good job of collecting complete data on our patients and where we need to focus more effort. For example, getting a complete picture of how patients are arriving to us and capturing the referral sources, so that we’ll know which organizations are most important for us to collaborate with.”
CAMH will continue to build up its systems in the coming years, says MacArthur. “We’re planning to expand our analytics platform so we can drive more quality-of-care advances. And we’ll be focusing on integrating research with clinical care, and implementing our clinical-trial functionality in the future. For example, we’re involved in collaboration with Trillium and Sick Kids called the Medical Psychiatry Alliance that will look at news ways of integrating mental and physical health care.”
Shave says CAMH’s success with its big bang implementation is already inspiring other Canadian hospitals to follow suit. “The next major implementation we’re doing is at a community hospital in Cornwall that’s also opted for a big bang implementation to reduce costs.”
Big bang implementations have already been making a big comeback in the U.S. in recent years, and there are good reasons for this, says Shave. “It’s really hard to take an incremental approach with a partly automated system while parts of the system are still based on paper. That piecemeal approach to automation introduces broken workflows and inconvenient or really difficult workarounds. Those horror stories in the media occurred in the past when the technologies and processes weren’t sophisticated enough for big IT projects. The market wasn’t ready for that level of collaboration and coordination. But all these elements have evolved today.”