Successfully implementing an electronic medical record (EMR) system requires, among other things, starting from scratch with a clean system, without importing databases from older systems in a misguided attempt to save time.

That’s one of the lessons that Scott Soefje, PharmD, MBA, BCOP, the associate director of oncology pharmacy services at Smilow Cancer Hospital at Yale-New Haven Hospital (YNHH), in Connecticut, learned as YNHH went through the challenging process of implementing an EMR system that went live Feb. 1, 2013.

Dr. Soefje was one of the team leaders during the implementation and also helped guide a second EMR rollout that went live last June at a sister hospital, the Hospital of Saint Raphael. (The hospitals have since combined into one location.) He shared some insights gleaned from both rollouts with attendees of the Hematology/Oncology Pharmacy Association’s (HOPA) fall conference in Chicago.

To ensure successful implementation, he reiterated that the system has to be clean from the beginning (Table 1). “You can’t be importing databases from an old system and try to make it work,” he said. “We imported a database from another hospital and tried to modify it to save time, and when we launched in February, we found that we just didn’t get to everything we needed to [address]. There was a lot of disconnect between the systems.

Table 1. Start With a Clean EMR System
Databases Drive EMR
  • Duplicate, mislabeled, misnamed drugs create chaos
  • Interfaces rely on the database message
  • Many subsystems rely on the drug database
Standardize and Simplify
  • Especially important with chemotherapy treatment plans
  • Question everything
  • Don’t accept “that’s the way we have always done it”
  • Push for a standard way of approaching everything
  • Don’t have two when one will work
  • Demand consistency
Testing, Testing, Testing
  • EMR is a technology tool that requires the proper infrastructure
  • Make sure the pieces fit together
  • Test interface systems
  • Test dispensing systems
  • Test chemotherapy plans
  • Test it again
  • Follow a drug order from start to finish
  • Test it all again
Leadership Drives Change
  • Three components of change: people, process, technology
  • This change will take longer and cost more than you expect
  • Change is more than the EMR; focus on patient-centered care
  • Change is hard; expect resistance
  • Embrace the change; leaders must be the champion
EMR, electronic medical record
Source: Scott Soefje, PharmD, MBA, BCOP

“So in June, with the second implementation, we started with a clean slate and went through each drug line-by-line to make sure everything was accurate, and that launch went perfectly,” as opposed to the first, which “definitely hit some road bumps,” Dr. Soefje said.
There were, he noted, “tens of thousands of lines that had to be edited. There were two people who spent the better part of two months doing it. But it was worth it. We are still cleaning up databases from our first launch. In contrast, the database from the June implementation is pretty much clean right now.”

Keep It Simple
Also critical is the need to standardize and simplify. “This is particularly important with chemotherapy treatment plans. You can’t have multiple treatment [regimens] individualized for each doctor. It makes your system messy and difficult to manage. It’s not worth it.”

For both implementations, the YNHH team sat down with doctors, grouped by their treatment specialties into teams, and worked together to agree “on what should and shouldn’t be in the standardized treatment plans,” Dr. Soefje said. “We got to the point where we realized that as we simplified, things got easier and easier to work with, and we believe it will ultimately save money.”

YNHH also discovered, he said, that the EMR system “will pull from the drug database into the treatment plan, but it only does it one time. So if the drug database changes, the treatment plan has to be relinked to the drug again to make the plan work.” A related lesson learned: YNHH had to test all its interface systems to ensure that each drug routed correctly to all its systems, including Pyxis, billing etc., Dr. Soefje added.

The first implementation showed that despite pre-study expectations to the contrary, workflow was significantly affected, in part because differences in how care is delivered in varying hospital areas were not fully appreciated. For example, “you have to make sure that the EMR system provider understands that inpatient and outpatient treatments are different. They function differently, the workflow is different and so you have to walk the EMR provider through the system so they understand that,” Dr. Soefje stressed.

Change management, he added, is also critical. “It requires leadership all the way from the top down through the department heads to drive the change. We kept reminding our people that these changes were being done to improve patient care. As we kept pushing that, even though change was hard, people more willingly began to accept it.”

Dr. Soefje added another point worth stressing: “This process never stops. There is continued implementation and a continuing need for change management even after the system is up and running successfully.”

Even at Start-up, Keep Maintenance Top-of-Mind
In another presentation, Joseph Bubalo, PharmD, BCPS, BCOP, an oncology clinical pharmacy specialist at the Oregon Health & Science University (OHSU), in Portland, described how OHSU included an ongoing maintenance program in the start-up building process for its EMR system, which went live in 2009 (Table 2). To ensure that maintenance would be successful, he said, OHSU employed two full-time equivalent (FTE) technicians to support the module in OHSU’s EMR system dedicated to oncology when it went live. Today, OHSU still has one FTE on staff for support.

Table 2. Tips for EMR System Implementation
The Build-up At Start-up Ongoing Maintenance
Regimen eligibility Common regimens (adult vs. pediatric) New standards of care New drugs Salvage regimens Rare diseases Drug shortage management
Specialty regimens Bone marrow transplants Intraperitoneal drugs Research protocols Transarterial Non-oncology antineoplastics and chemotherapy in the OR ED methotrexate Desensitization protocols
Supportive care Antiemetics Hydration Integrated labs and levels Leucovorin rescue Standard of care changes Formulary changes Bar coding/NDC support
Special practices Dose rounding Regimen validation Inpatient/outpatient differences Pharmacy-managed supportive care Oncology clinics Specialty regimens
ED, emergency department; OR, operating room
Source: Joseph Bubalo, PharmD, BCOP

“There is always going to be maintenance in these systems,” Dr. Bubalo noted, “so you have to have dedicated people to maintain the system. It won’t maintain itself.”

The implementation team also decided during the build process to standardize supportive care such as fluids and hydration, lab data, safety parameters and hypersensitivity management. “At the onset, you get the system going and you’re taking care of patients,” he said. “But once you’re taking care of patients, things happen. The standard of care changes. New drugs are approved. Chemo regimens that you weren’t expecting to use become important. You have a rare disease to treat. [There are] drug shortages. We tried to build the system at start-up in a way that would make maintaining it easier.”

To manage changes in supportive treatments, OHSU created “order groups” that helped streamline the start-up of their new EMR system. “Any time a specific chemo drug is used and there is a special supportive care treatment like calcium and magnesium infusions, those are automatically added to the order set as a group,” Dr. Bubalo said. “So if the time comes to modify them, we can just change the group (add to it or delete it) and it automatically changes the chemo drug order.

“The maintenance team can run a report to see which order records are going to be affected by a drug shortage or a change to a new product. That gives us a list of the regimens that need to be changed. And once you have that list, it’s just a matter of making sure you have adequate staff to make those changes.”

The OHSU team uses a similar process for swapping drugs in or out of the system as generic drugs come on and off the market, when a branded drug becomes generic and when a drug shortage occurs. As part of maintenance, OHSU developed an electronic alert that tells physicians a drug is in short supply and directs them to approved alternative regimens. “That was not something we anticipated we would have to do when we went live,” Dr. Bubalo said, adding that when the drug comes off shortage, the system directs physicians back to the original regimen.

OHSU has dedicated personnel to make sure bar codes and National Drug Code numbers are updated daily. “Every time there is a new generic drug, we have to make sure that the codes are updated. Otherwise the system will not recognize the code. We also update our in-house coding system for compounds that we create.”

For busy times, OHSU uses flexible times or quiet times on regular shifts to add more help as needed to make changes in care plans.
To optimize the system, Dr. Bubalo said that after the EMR system had been live for about a year, the maintenance team went back and started finding and identifying “exceptions,” such as other uses for cancer drugs that hadn’t been anticipated at start-up, and putting them into the EMR. “We ended up making a set of orders for the most common uses of cancer drugs in noncancer situations,” he said. The oncology pharmacists, he noted, became the “consultants to make sure that the noncancer uses of cancer drugs were safe for the patients.”

Dr. Bubalo ended by reemphasizing that changes in the EMR system will affect workflow. “You have to realize that’s going to happen and plan for it.”