Electronic health record implementation: how to reduce the possible negative impacts

This paper presents a methodology for implementing action plans to mitigate the negative impacts of Electronic Health Record (EHR) adoption, demonstrating that effective governance and multidisciplinary execution significantly resolve implementation issues and increase project success rates.

The Gist

Imagine a hospital is like a massive, bustling city. For years, the doctors, nurses, and staff have been running this city using a mix of paper maps, handwritten notes, and old-school radio communication. It works, but it's messy, slow, and prone to errors.

Now, the city decides to upgrade to a "Smart City" operating system: an Electronic Health Record (EHR). This is a giant digital brain that connects everyone, tracks every patient, and automates tasks. Sounds great, right?

But here's the problem: You can't just flip a switch and expect a whole city to instantly adapt. If you force everyone to use a new GPS system overnight without training, people will get lost, traffic will gridlock, and accidents will happen. In the hospital, this "traffic jam" is called a negative impact.

This paper is essentially a survival guide written by the team at Hospital Israelita Albert Einstein in Brazil. They didn't just install the new system; they built a safety net to catch the inevitable problems before they became disasters.

Here is how they did it, broken down into simple concepts:

1. The "Pre-Flight" Inspection (Before the Launch)

Before they turned the new system on (a moment called "Go Live"), they didn't just guess what might go wrong. They gathered a "Dream Team" of 38 experts—doctors, nurses, pharmacists, and even the billing staff.

Think of this like a car crash test. Before the car hits the wall, they simulate every possible crash.

• They asked: "If a doctor tries to prescribe a drug, will the screen confuse them?"
• They asked: "Will the nurses have to click 50 times just to check a patient's temperature?"
• They asked: "Will the billing department get lost in the new filing system?"

They found 264 potential "crashes" (negative impacts).

2. The "Fix-It" Toolkit (The Action Plans)

Once they knew what could go wrong, they didn't panic. They created 389 specific action plans to fix these issues. They used five main tools in their toolkit:

• The Training Manual (50% of the fixes): Most problems were solved by teaching people how to use the new system. It's like giving everyone a driving lesson before letting them on the highway.
• The Boss's Pep Talk (28% of the fixes): They prepared the managers (the "team captains") to lead their groups through the change. If the captain is calm and confident, the team is too.
• The Customization (17% of the fixes): Sometimes the software was too rigid. They went back to the software company (Cerner) and said, "This button is in the wrong place for our doctors; can we move it?" or "Can we change the process so it fits our culture?"
• The Communication (5% of the fixes): They used forums and workshops to talk openly about fears and questions.
• The Process Change (8% of the fixes): Sometimes, the people had to change their habits, not the software. They tweaked how a task was done to make it fit the new digital world.

3. The Launch Day (Go Live)

When they finally flipped the switch in October 2016, they were ready.

• Before the switch: They had already fixed about 19% of the potential problems (51 out of 264). They had already changed the workflows and fixed the software bugs.
• During the switch: The remaining 81% of the problems popped up. But because they had their "Fix-It Toolkit" ready, they didn't freeze. They immediately deployed their action plans.

4. The After-Action Report (6 Months Later)

Six months after the launch, they checked the results.

• Of the problems that actually happened, 80.5% were successfully managed.
• The team considered their plans "effective" or "partially effective" in the vast majority of cases.

The Big Lesson

The paper concludes that technology is easy; people are hard.

If you just buy the most expensive software and install it, you will likely fail (the paper notes that over 50% of these projects fail). Success comes from Change Management.

Think of it like moving into a new house:

• The Software is the new house.
• The Implementation is the moving day.
• The Action Plans are the packing tape, the labels, and the instruction manual on how to assemble the furniture.

If you just dump all your furniture in the middle of the new house (the software) and expect to live there comfortably, you'll trip over boxes for months. But if you plan where the beds go, label the boxes, and teach your family how to use the new thermostat, the transition is smooth.

In short: This study proves that if you listen to your staff, anticipate the headaches, and have a plan to fix them before they happen, you can successfully navigate the chaotic journey of digital transformation.

Technical Summary

1. Problem Statement

The adoption of Electronic Health Records (EHR) in healthcare institutions is a critical component of digital transformation but is associated with high failure rates (often exceeding 50%) and significant operational disruptions. Key challenges include:

• Workflow Disruption: EHR implementation forces profound changes in daily clinical and administrative workflows, often clashing with established institutional cultures.
• User Resistance: Professionals (physicians, nurses, administrators) often resist new systems due to perceived increases in workload, loss of efficiency, and cultural mismatches (e.g., US-based software logic vs. Brazilian clinical practices).
• Reactive vs. Proactive Management: Many institutions attempt to mitigate issues only after they occur (post-Go Live), leading to financial losses and compromised patient safety. There is a lack of empirical data proving the effectiveness of proactive mitigation strategies.

2. Methodology

The study employed a retrospective, descriptive design analyzing the implementation of Cerner® Millennium (v2015.01.09) at Hospital Israelita Albert Einstein in São Paulo, Brazil.

• Setting: A 750-bed hospital complex with 15,000 employees and 8,000 physicians, covering inpatient, outpatient, and emergency care.
• Timeline: Project initiation (Jan 2014) to Go Live (Oct 2016), with a 6-month post-implementation evaluation period.
• Team Composition: A multidisciplinary team of 38 key users (physicians, nurses, biomedical professionals, therapists, pharmacists, and administrators) was hired exclusively for the project.
• Process:
  1. Impact Mapping: The team identified 264 potential negative impacts across all hospital sectors by analyzing workflows.
  2. Stratification: Impacts were categorized by severity (High, Medium, Low).
  3. Mitigation Planning: Based on project management literature, five specific action plans were developed to address impacts:
     • Training Focus Point (targeted training).
     • Alignment with Area Manager (preparing leadership).
     • Communication Plan (forums/workshops).
     • Tool Adaptation (customizing the software with the supplier).
     • Process Adaptation (changing institutional workflows to fit the tool).
  4. Execution & Evaluation: Plans were executed before and during Go Live. Six months post-implementation, key users assessed whether impacts occurred and if the mitigation plans were effective.

3. Key Contributions

• Proactive Mitigation Framework: The paper proposes a structured methodology for identifying and stratifying negative impacts before implementation, shifting from reactive damage control to proactive risk management.
• Differentiation of Strategies: It distinguishes between structural solutions (process/tool adaptation) required before Go Live and people-oriented solutions (training/management alignment) required during Go Live.
• Quantitative Validation: Unlike many qualitative case studies, this research provides quantitative data on the effectiveness of specific mitigation plans, validating that a combination of governance, multidisciplinary input, and strategic planning significantly reduces implementation friction.

4. Results

• Impact Resolution:
  • Pre-Go Live: 51 of the 264 identified impacts (19.3%) were resolved prior to Go Live using 52 action plans. These were primarily solved through structural changes: 65.4% via institutional process adaptation and 34.6% via tool customization.
  • During Go Live: The remaining 213 impacts were addressed using 337 action plans. The strategy shifted to people-centric actions: 58.5% focused on targeted training, and 32.3% on aligning area managers.
• Effectiveness Analysis (6 Months Post-Go Live):
  • Of the 213 anticipated impacts, 190 were confirmed to have occurred.
  • Success Rate: The mitigation plans were deemed effective in 61.57% of cases and partially effective in 18.94%.
  • Total Resolution: 80.51% of the confirmed negative impacts were successfully mitigated or resolved.
  • Ineffective: Only 19.47% of the plans were considered ineffective.
• Key Finding: The most successful pre-Go Live strategy involved modifying institutional processes to align with the software, whereas the most critical Go Live strategy was intensive, targeted training and manager alignment.

5. Significance

• Evidence-Based Change Management: The study provides empirical evidence that a multidisciplinary, proactive approach to EHR implementation significantly increases the likelihood of project success.
• Governance and Culture: It highlights that technical implementation is insufficient without strong corporate governance and a robust change management strategy that addresses the "people side" of technology adoption.
• Replicability: The methodology (impact mapping $\rightarrow$ stratification $\rightarrow$ tailored action plans) offers a replicable model for other healthcare institutions facing similar digital transformation challenges, particularly in environments where legacy workflows differ significantly from the software's native design.
• Resource Allocation: The findings suggest that resources should be heavily invested in pre-implementation process redesign to eliminate structural conflicts, while Go Live resources should focus on training and leadership engagement to manage user resistance.

Conclusion: The study concludes that effective governance, a multidisciplinary methodology, and well-executed action plans are critical determinants for the success of health technology projects. The ability to resolve 80.5% of negative impacts through this structured approach demonstrates that EHR implementation risks can be systematically managed rather than merely reacted to.