Electronic Health Reporter

Guest post by Calvin Chock, vice president, product management and engineering, McKesson Specialty Health.

Shifting from one electronic health record (EHR) system to another can be a highly disruptive and anxiety-filled process for a health system. Often, among the largest obstacles encountered is the need to migrate legacy EHR data between the old and new EHR systems. But a good understanding of this data migration process — and a strong technology vendor relationship — can help overcome this challenge and lead to a successful EHR transition.

There can be many reasons for a health system to transition between EHR systems. The original EHR system could be missing key features, or it might have reached its end-of-life, or perhaps it is not certified to meet evolving meaningful use requirements. The old EHR may not have kept up with new population management requirements on health systems, such as the need for more support for value-based care models. Whatever the reason, all health systems will want to find a solution that not only meets their projected operational and patient care needs, but which also minimizes disruption to the health system during the transition.

Conceptually, most EHRs capture the same types of information. However, when early (and still market-dominant) EHRs were first introduced, there were very few mature medical content standards, even for important categories of medical content, like diagnoses, lab results, medications and allergies. As a result, many of these early systems created their own proprietary terminology. When current standards (as incorporated into Unified Medical Language System – UMLS) began to coalesce, these early EHR systems typically struggled to migrate to the new terminology standards. Often this resulted in vast corpuses of legacy/non-standard historical patient chart data remaining in the EHR. Understanding and mapping this blend of standard and proprietary legacy data, for the purpose of coalescing each patient’s history into a new EHR, can be a tremendous challenge.  Trying to fully automate this mapping process with a high level of accuracy and with larger patient volumes is a still greater challenge.

To give a specific example of this mapping problem, an older EHR may have a patient listed as having a “seafood allergy.” In meaningful use certified EHRs today, that “seafood allergy” description as such might not exist; that patient’s allergy entry would need to be accurately translated & codified into a new standardized term, perhaps referencing a either a specific shellfish allergy, or perhaps for any number of non-shellfish seafood allergies. Trying to faithfully automate terminology mapping decisions like this when there isn’t enough information to make an accurate determination can be nearly impossible. Yet not properly translating and mapping this allergy means the new EHR cannot properly use this information to trigger important patient safety system alerts (e.g., a drug-allergy interaction alert). Further, without accurate translation & coding, the new EHR will not be able to properly transfer this important part of a patient’s record to another healthcare system, like a patient portal, a clinical decision support service, an HIE, or another EHR.

In my experience, it is possible to identify three types of data migrations.

The first type of migration involves shifting to a newer version of the same product, perhaps running on a new technology platform. This type of data migration will typically allow the most comprehensive transfer of data with the least amount of disruption.

Another type of migration involves switching to a new EHR from another vendor, but with the aid of a cooperating & generally supportive EHR vendor. Although migration from one vendor’s EHR system to another’s is more complicated, if the original EHR’s vendor is willing to share information about their data structure and ontology with the new vendor, it will typically ensure access to a larger subset of key data elements are and more reliable data mapping.  Look for established migration pathways, since EHR-to-EHR migration processes often improve each time they occur. This class of migration is often suggested by an older EHR vendor when they decide to sunset or end-of-life an EHR product.

Finally, the most difficult type of migration, involves a move to an EHR with very limited inter-vendor cooperation. This also happens to be the most common type of migration, especially when a health system chooses to migrate to an EHR vendor’s competitor’s EHR. The vendor of the current EMH system is often not willing to share more than the legally-required level of information, so the new vendor must rely on either a proprietary data extract or a batch of patient CCDA files (CCDA is an export format for patient summary data, which all EHR vendors must supply.). In either case, these patient data extracts will then need to be manually loaded, reviewed, and electronically (or manually!) reconciled for every patient chart.

Health systems planning this third type of migration should allot many additional months to work with the new vendor’s IT staff as they determine how to transform and load the old EHR’s patient data. Further, the health system must be aware that the transition will require a much higher investment of staff time for the data to be cleaned up and reconciled. This type of transition can take months or even years to complete.

If upgrading to a newer version of a current is not a viable option, a health system should follow these general guidelines for a successful transition to a new system:

1. Find an experienced vendor partner.

In addition to finding an EHR system that meets your health system’s operational/functional needs, try to find a vendor partner with experience migrating data from your current EHR vendor.

2. Focus on your staff workflows.

The new EHR will not do everything the same way as the old EHR. Your goal is to ensure new EHR vendor understands and supports the various workflows in your health system: billing, scheduling, pharmacist, physicians, etc. Ensure the new system can load enough data from your old system that the impact to your staff’s workflows will be tolerable.

3. Create an internal implementation team with a blended skill set.

The best EHR transitions occur in health systems that assemble an internal team with members representing all disciplines & workflows within the organization. This transition team will typically:

• Be led by a strong project manager, who will ensure the transition is moving according to plan;
• Contain a team of “super users” from within your health system, who will be instrumental in training and a technical team to provide guidance on hardware needs and re-establishing interfaces with existing third party systems (e.g. practice management systems, lab systems, PACs systems and patient portals).
• Have good communication paths with the old and new EHR vendors

4. Change one system at a time.

It’s common for health systems to also change a practice management systems (PMS) when changing EHR systems. In these situations, it’s often helpful to stagger the transitions, and implement the PM system first, followed by the EHR system only after users are comfortable and ready to take on more change. This allows time for staff to assimilate to one system before overloading them with too many new workflows & systems to learn.

5. Be prepared to devote significant staff time.

Migrating data is a huge job. Data that automatically maps must be verified. Data that does not map cleanly needs to be manually reviewed; decisions must be made on what to do with such data. A strong recommendation is to have a health system decrease patient loads and increases staffing during the first few weeks after going live with a new EHR. This will enable enough time for a thorough review of migrated data, and leave an appropriate amount of time for users to learn the new EHR. Even well-planned and executed migrations require a period of transition, not least for staff to learn how to use a new system and implement new workflows. Nightly chart preparation is highly recommended; expect existing typically chart prep times to increase until all the EHR data is fully migrated, for all currently active patients.

6. Be patient.

Physicians and staff want to treat patients, and not learn new systems. Needless to say, with a new EHR, there will be a lot to learn, and even some new workflows to adapt to.  There will always be push back, anxiety and frustration by users during the initial installation of a new EHR.  The phrase “. . . but this is how we’ve always done things” will be heard many times. It’s just a fact that the first several weeks or months of learning a new system will inevitably make staff less efficient at treating patients; the potential for unintended mistakes can be high. Healthcare systems should set expectations properly and plan for an overall decrease in revenue and efficiency during this transition period.  Having easy access to several “power users” to reinforce training and double check work will shorten the initial efficiency ramp-up period with the new EHR. Also, constantly reassure your users that they will eventually become experts again at some point:  medical professionals often rely on projecting an aura of competence to patients, and they rarely appreciate new EHR systems interfering with that critical sense of control and capability.

7. Make training a priority.

Some health systems find it challenging to convince all physicians and staff to attend training sessions for the new system. But training must be mandatory for a successful migration. Providing extra training for one or more “power users” of the new EHR, and then placing those users at each location prior to go-live, can help decrease anxiety levels by giving staff a go to person for questions. Try to leave these “power users” with reduced duties during the transition period, so they can be fully available to answer staff questions.

8. Schedule regular communication with new EHR vendor.

Have a daily meeting with the new EHR vendor and transition team during the first two to three weeks after go-live, to cover any issues and questions that arise. Regular communication can reduce the duration of issues and shorten the adoption transition period. Maintain a communication path to the old EHR vendor as well, if at all possible.

9. Measure revenue.

Perform a weekly or monthly financial reconciliation, as a measure of success. EHR technology issues, staff training issues, or workflow issues that might not be apparent at first will show up in the bottom line. Conversely, some often-voiced user frustrations may not have any immediate revenue impact, and instead can be due simply to difficulty adjusting to the new EHR; such adjustment pains may eventually fade, either on their own or with additional training. Frequently, measuring revenue is a good early indicator of whether the new EHR adoption is successful, or if there are major workflow problems brewing.

10. Minimize time using multiple EHR systems.

Any ambiguity about which EHR is the “system of record” for patient data can lead to fatal patient safety errors and serious financial repercussions. Properly planned data migrations should ideally contain a “go-live” date, after which the new EHR will be the “system of record”, and the old EHR system will be used only in “read-only” or “historical reference” mode.

Modern EHR systems can greatly enhance a health system’s ability to deliver quality patient care. A strong vendor partner, diligent preparation, and selecting a system with a robust migration process can minimize disruption in a health system.