Understanding the Role of Physician-Focused At-The-Elbow Support During EMR Go-LiveLearnings from a mid-sized hospital Epic EMR Implementation.

The electronic medical record (EMR) Go-Live has become a regular occurrence across health systems, hospitals and clinics as they adopt new and updated EMR systems in order to meet meaningful use requirements. A success-ful Go-Live results in minimal productivity loss over the short term and sets an institution up for successful EMR adoption over the long term. An unsuccessful Go-Live can result in greater than planned productivity losses and, in serious cases, significant opposition to the EMR by the physician community. As a result, EMR Implementation teams focus heavily on maintaining provider engagement throughout the planning and immediate Go-Live stages.

At-the-elbow support has become a crucial component of all Go-Lives as a tool to maintain provider engagement and limit productivity losses. This report assesses the role of physician-focused at-the-elbow support provided during a mid-sized hospital’s Epic EMR Go-Live.

Contents

Data Collection .................................................... 1

Results .................................................................. 2

Number of Support Events ..................................2

Support Events by Day of Week ..........................2

Night Coverage ........................................................2

Duration of Support Events .................................3

Support Event Resolution .....................................3

Non-Physician Support Events ............................4

Support Events by Department ..........................4

Support Events by Request Topic .......................5

Discussion ............................................................ 5

Defining Effective At-The-Elbow Support ..........5

Insights for Go-Live Planning ...............................6

Integrating with the Hospital EMR Implementation Team ...........................................6

Managing the Variability of a Go-Live ................6

Conclusions ......................................................... 6

“I consider Essia Health part of my critical support network for Go-Lives” Health System Regional CMIO

Data Collection

A mid-sized hospital (~75 beds) that is part of a top 10 national healthcare system implemented Epic EMR as part of a health system-wide roll-out. Essia Health’s EMR Specialists provided at-the-elbow Go-Live support for the health system across multiple sites. Essia Health was the only contracted onsite support for the full 6 weeks of the Go-Live period and the only night shift and weekend support after the first weekend.

EMR Specialists collected data on every healthcare pro-vider ‘support event’ (SE) during the 6 week period of the EMR Go-Live.

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outpatient procedures or other appointments scheduled. Weekend support was largely restricted to the emergency department, obstetrics and inpatient units.

However, the Go-Live started at 2am on a Saturday morning and the initial two days demanded considerable at-the-elbow support as displayed in Chart 3.

Chart 1 highlights a decreasing number of SEs as the Go-Live progressed through each week to week 5. This trend was anticipated and Essia Health implemented a ‘taper’ to provide optimal coverage for the customer’s investment. The decline in SEs reflects physicians’ improved under-standing of the EMR system and, as a result, requiring less support. However, in the last week of the Go-Live there was a ‘bump’ in support events, as physicians sought to resolve any remaining issues while at-the-elbow support was still available.

Support Events by Day of Week

Chart 2 indicates that the amount of support required on weekends was significantly less than weekdays. Hospital volumes are lower on weekends as there are no

Results

Number of Support EventsOver the 6 weeks of the Go-Live there were 1292 report-ed support events (SEs), where Essia Health’s EMR Spe-cialists provided at-the-elbow support to the hospital’s healthcare providers. Providers include any member of the medical staff (ie MDs, DOs, PAs, NPs, CNMs, Residents and Medical Students).

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Typical At-The-Elbow Support Taper

• Weeks1and2:fullcoverage • Weeks3and4:50%coverage • Weeks5and6:25%coverage

Thetaperinat-the-elbowsupportensures coverageremainsappropriateforthe anticipatedvolumeofphysicianrequests.

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Night CoverageOver the 6 week period approximately 17% of SEs oc-curred during night shifts (18:00-06:00), a total of 221 SEs. This highlights the need to have appropriate at-the-elbow coverage during nights to ensure requests get resolved effectively. In addition, experience has demonstrated night shifts require more experienced EMR Specialists to handle the breadth, complexity and occasional ‘emergen-cy’ nature of the physician issues that arise.

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Chart 4 shows 78% of support events were 20 minutes or less, with an approximately equal number of queries in the 1-5mins, 6-10mins and 11-20mins ranges. Quick resolution of these relatively straightforward high volume requests is critical to ensure minimal disruption to work-flows and maintenance of overall productivity. If every small request brought the care process to a halt, provider frustration would soar and productivity would plummet.During the course of the Go-Live there were 281 support events that lasted longer than 20 minutes, with 56 that lasted longer than an hour. Assuming the duration of a SE can be used as an indicator of complexity, it highlights the range of request complexity that at-the-elbow support needs to be able to address. EMR Specialists must be able to adapt between physician requests that can be resolved in a matter of minutes to much more complex requests that require several hours to resolve.

SEs were longer during night shifts, with an average dura-tion of 29 minutes. EMR Specialist feedback suggests this is because: 1) more time was available to work through the provider’s request and 2) there was time to explore more advanced functionality.

The duration of SEs varied as the Go-Live progressed. Chart 5 illustrates a decrease in SE duration over the course of the first 4 weeks of Go-live; however, there was a sharp increase in SE duration during week 5. This reflects a shift in the type of provider requests from basic ‘How do I do X?’ requests to more involved ‘Is there a more efficient way of doing Y?’. This shift in the focus of physician support suggests two general points:

Duration of Support EventsThe duration of SEs ranged from a couple of minutes to over 2 hours. The average duration of SEs was 20 min-utes.

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1. Up until week 5, providers are learning and adjusting to a ‘basic-level’ of interaction with the EMR system. At week 5, a level of comfort is reached where providers are confident enough to ask about more advanced functionality and processes.

2. Providers need to have access to EMR Specialist support over an extended period to reach higher levels of competency with the EMR system. If adequate support is not provided it can take longer for physicians to reach an appropriate level of system adoption.

In week 6 there was a sharp decrease in the duration of SE events, almost halving from the week 5 figure. This sug-gests a lower level of request complexity. In the last week of coverage physicians wanted to resolve all their out-standing queries, which resulted in an increased volume of relatively simple requests.

The fact that this ‘flurry’ of more basic requests occurred in week 6, supports the two general points raised above; many providers were still at a relatively basic-level of com-petency with the new system at week 6 of the Go-Live.

Support Event ResolutionOver the course of the Go-Live 92% of SEs were resolved at-the-elbow, 1186 in total. Chart 6 illustrates a slightly lower SE resolution rate in week 1 at 90%, this is offset by a high transfer rate to IT. This is typical of the first week of Go-Live as technical software issues get ironed out. The resolution rate was 93% or higher for weeks 2 through 6.

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Chart 7 demonstrates the resolution rate did not sig-nificantly change depending on the time spent working though the request. This is an important insight that speaks to the need for effective at-the-elbow support. If, for example, the high resolution rate was achieved for shorter SEs, but the resolution rate decreased signifi-cantly for longer SEs, it would suggest the provider’s time was wasted working through a SE for 30mins only for the request to be transferred or not resolved or transferred (NROT). Similarly, it is beneficial to the physician that an EMR Specialist can work through a more complicated re-quest for 45 minutes and reach a satisfactory resolution. This enables the physician to continue with their work and not be distracted by an IT ticket that would take a much longer time to reach a point of resolution.

Support Event Resolution Rate by Week

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70 (5%) SEs were transferred to IT. Effective Go-Live sup-port streamlines communication between care providers and technical IT staff. The Essia Health EMR Specialist communicates the issue to the Essia Health staffed Pro-vider Engagement Center for review and then onto the IT

Central Command Center. There are 2 key advantages to this communication approach: 1) it ensures providers are not engaging directly with technical IT staff and 2) all issues are delivered to IT with an appropriate level of urgency and accuracy.

The remainder of SEs were NROT. These were typically requests made by physicians that could not be resolved, but also did not need to be referred to IT. Most commonly they were software feature requests that fell outside of the scope of the build. It is important that these type of requests get handled appropriately so they do not damp-en the physician’s belief and confidence in the system.

Non-Physician Support EventsIn this setting the at-the-elbow support was focused on physicians. Interestingly, approximately 23% of SEs were for non-physician care providers and in most cases nurs-es (17%). Others included physician assistants, therapists and pharmacists. The support provided to non-physi-cian care providers typically related to a task in the EMR system that directly impacted an attending physician. For example, if a physician enters an order for a medication, and the attending nurse needs assistance viewing the order, providing support to the nurse helps complete that action, which directly benefits the physician. Such non-physician support is key to maintaining productivity during Go-Live.

Support Events by DepartmentSEs occurred in 21 hospital departments which included one category termed ‘Other’. Five of these departments accounted for over 63% of all SEs, as listed in Chart 8. Surgery in particular required considerable focus from EMR Specialists. Typically, surgeons only work at a hospital on the days they are operating. As a result they have less time to familiarize themselves with the new EMR system, both during the pre Go-Live training period and over the 6 weeks of Go-Live. This is consistent with a general correlation between time spent on an EMR system and competency with that EMR system. The Hospitalist/Inter-nal Medicine accounted for a large number of SEs due to the number of physicians working in this department. Whereas the 24/7 nature of the Emergency Department (ED) contributed the high volume of physician requests.The duration of SE showed some variation by department with the ED and Endoscopy having notably shorter aver-age SE durations. The ED data can be explained by the fast-paced nature of the department, whereas the specific nature of the endoscopy procedure narrows the Endosco-pist’s level of interaction with the EMR, which contributed to shorter SEs.

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These five main departments had an SE resolution rate ranging from 91% for Obstetrics to 96% for Surgery.

Support Event by Top 5 Departments

Chart 8

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Overall, the resolution rate was consistent across most request topics. Notable areas where more SEs were trans-ferred were: existing IT tickets (62% transferred), Round-ing (25% transferred), Account Login (17% transferred), Hardware (16% transferred) and Lab Results/Vitals (13% transferred).

Average SE duration showed some variation by request topic. Topics with shorter durations were Hardware (13mins), Printing (10mins) and Dictation (11mins). Only two areas had significantly longer SE durations; Workflow Questions as mentioned above (30mins) and Surgery (38mins). The remaining request topics nearly all fell with-in the 15-25 minutes range.

Discussion

Defining Effective At-The-Elbow SupportEffective physician support during EMR Go-Live is consid-ered fundamental to ensuring a successful implementa-tion. This report highlights the large volume of physician requests that arise during a Go-Live: 796 in the first 2 weeks for a ~75 bed hospital. Without an efficient support process, requests would remain either unresolved or directed to IT. Unresolved requests lead to provider frus-tration and disrupt the ‘rhythm’ of care. If many requests were directed to IT, it would significantly impact the IT department’s ability to focus on high priority technical software issues.

What does effective at-the-elbow support mean? It is not enough to simply have support available to physicians. If the support is not resolving the significant majority of physician requests in a timely fashion, the Go-Live would still be disrupted. With the knowledge that the Go-Live in this study was executed very successfully, it suggests a SE resolution rate of >92% and an average SE duration of <20minutes is an appropriate benchmark for at-the-elbow support effectiveness.

This data highlights the breadth of physician requests that at-the-elbow support must handle. To be effective, sup-port must have the flexibility and expertise to handle the short 2 minute physician requests as well as much longer requests that require in excess of 60 minutes to resolve.

Insights for Go-Live PlanningThe data from this hospital Go-Live gives insights for planning a Go-Live and preparing training for providers. Knowing that 5 topics account for approximately 44% of SEs and that 5 hospital departments account for approx-imately 63% of SEs helps to focus training content on key topics and prioritize training for key departments. The data indicates the importance of providing effective night

Some departments had significantly longer SE durations than the overall trend. Oncology was the longest with an average SE duration of 63 minutes. Orthopedics and Ra-diology were also long at 35mins and 34mins respectively. Anesthesia and Cardiology had lower SE resolution rates at 80% and 70% respectively. The requests that were transferred from these two departments accounted for nearly a quarter of all issues that were transferred to IT.

Support Events by Request TopicAs might be expected, the most frequently used func-tionality in the EMR were the 3 major areas for provider requests: Orders, Discharge and Notes. These areas accounted for approximately 1/3 of all requests. Requests relating to General Workflow frequently arose; of note, these took on average 50% more time to resolve, reflect-ing a greater level of complexity. Generally, the majority of requests relating to these topics were resolvable, with resolution rates of 95% or higher.

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significant frustration. These high value sessions were a key success factor for the overall implementation.

Managing the Variability of a Go-LiveDue to the nature of physician rounding, practice man-agement and OR block time, there are are varying time and location requirements for provider support during the EMR Go-Live. Unlike clinical staff, physicians are not always present. Essia Health’s Onsite Manager coordi-nated all aspects of at-the-elbow support. This included adjusting staffing levels to meet the shifting demands of morning, afternoon and night coverage. The manager also closely monitored coverage requirements at the depart-mental level and coordinated staffing levels based on physician demand. This flexibility contributes to a smooth implementation and is harder to achieve with internal teams that have fixed hours and fixed responsibilities associated with specific hospital departments. In the plan-ning phase, a significant decline in the number of physi-cian requests over the 6 week period was anticipated. As a result, Essia Health implemented a ‘taper’ in the number of EMR Specialists to provide optimal coverage for the customer’s investment.

Conclusions

Prioritizing at-the-elbow support to ensure high physician engagement is a lynch-pin of successful Go-Lives. How-ever, it remains a challenge for hospitals executing EMR implementation projects to find the appropriate exper-tise to complete the role. The support must be readily accessible across all departments, able to provide expert end-user specific knowledge and flexible to work different shift times. In addition, the support staff must operate effectively within the multi-layered hospital team support-ing the Go-Live.

This study demonstrates how Essia Health’s EMR Spe-cialists were able to meet the needs of the hospital EMR implementation project team and deliver a 92% SE res-olution rate with a 20 minute average SE duration. Essia Health can provide this level of expertise by drawing upon its extensive experience supporting over 100 EMR Go-Lives, and delivering a highly reproducible level of quality service which it has proven across multiple healthcare facilities and EMR systems.

This overall hospital EMR Go-Live was delivered success-fully, consistent with the Go-Lives across the wider health system of which Essia Health was the Go-Live support partner of choice.

coverage as well as a flexible support team to appropri-ately cover weekends and the varying level of support required across the full 6 weeks.

Integrating with the Hospital EMR Implementation TeamA key requirement for externally-sourced at-the-elbow support is to integrate effectively with the multi-layered hospital EMR implementation project team, which typically consists of IT Analysts, Physician Clinical Champions, Train-ers, Clinical Informaticists and all of the healthcare work-ers participating in the Go-Live. Essia Health adopts its Zone Support Model to provide the best possible support to Physicians and to interface effectively between all of the layers of the implementation project team - see Figure 1.

The Zone Support Model allows more complex physician requests to be logged with the Provider Engagement Center (PEC) and draw upon additional Essia Health sup-port to get the issue resolved at-the-elbow. In addition, the model enables the Essia Health team to coordinate all communications between physicians, hospital de-partments and the implementation project team. This is crucial to developing an overall picture and understanding of EMR adoption by physicians in the first critical weeks of Go-Live.

During this Go-Live (and across the EMR roll-out for the whole health system), customized Tool Set-up, Order Sets and Documentation Templates were required for each physician. Due to the time commitment (typically 2 hours), conducting 1:1 physician customization sessions was not a responsibility of the hospital EMR implementation team. Essia Health held 1:1 EMR Optimization Labs for all physi-cians from 2 weeks prior and throughout the Go-Live pe-riod. Physicians need flexible, dedicated time to prepare their tools prior to Go-Live. Developing tools while taking care of patients is inefficient and can be cause for

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