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Before an EHR, you must endure a 'paper cut'

March 1, 2006
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The hardest part about building an EHR is not choosing software—it's changing culture

Electronic health records (EHRs) have captured our industry's interest. Some organizations are fully electronic, more are partially so, and many, perhaps most, still are deciding when, how, and even if they can move to a paperless system.

Much has been written about how to pick a software product and/or vendor. Software functionality is of particular importance to us clinically and fiscally. However, we often assume that until a software decision is made, little can be done to take us to EHR nirvana. The good news is that plenty can be done to move an organization from paper to electronic systems before an EHR package is chosen. The bad news is that it is hard to do.

The product/vendor decision is an important one, to be sure. However, the difficulty of buying computers, installing software, and transitioning clinical and financial operations pales in comparison to the difficulty of changing the organization's culture. This transition is not about hardware and software. It is about changing people's hearts and minds to move from a paper-centric to a computer-centric organization. More specifically, this transition is about three interrelated organizational changes: technologic, clinical, and cultural.

Technologic change is the most obvious, and it occupies most of our time in this process, involving hardware, software, and telecommunications decisions. Oddly, despite how foreign these decisions might be for managers, they are also the easiest because they are so tangible. Except for the computer infrastructure's purchase and installation (PCs, servers, LAN, and WAN), many technologic changes must be delayed until the EHR purchase decision is made.

Clinical change is usually about work-flow decisions. Managers are forced to ask, “How will we practice differently with an EHR?” Astute managers realize an EHR's potential to do things better than with a paper record, but many are so preoccupied with the technology that the EHR's possibilities receive inadequate attention. Some believe (or are lobbied by their staff to believe) that the EHR is just an electronic version of their paper record, rather than a whole new way to provide and manage care.

Client flow through the organization can and should change with an EHR. Policies regarding how and who captures data will need to be revised. For example, will clients still complete paper forms at intake? If not, how will information be entered into the system? This is an area that can be partially addressed before the EHR implementation, but some of the work-flow issues will be bound by the software's and hardware's limitations.

Cultural change is arguably the hardest, but it can be addressed long before the organization's EHR “goes live.” In fact, these changes can begin at any time. If the organization is moving not just to implement an EHR but to become a computer-centric organization, then with few exceptions everyone and every process should be on a computer. This challenges the paper-centric view often ingrained in the culture of a behavioral health organization. Challenges to this expectation include “We've never done it this way before” to “It can't be done this way at all.”

It is more efficient to have all the work processes be electronic, not just the EHR's clinical transactions. For example, it makes little sense for a clinician to spend part of her day charting on a computer and the rest of the day responding to paper-driven processes, such as reading memos and completing paper forms for the human resources department. Since the organization will have invested in computers for staff, why not leverage them fully by automating all possible work processes? These non-EHR activities can be made computer-centric now and, in doing so, the organization's culture will begin to change, employees’ expectations will be modified, and “covert” testing and training on basic computer competencies can occur.

To change culture, employees must change their job expectations, and they must achieve a certain level of technical facility with computers. This is why this level of change is so difficult. It forces the organization to decide: (1) what level of computer competency it expects from employees, (2) how that competency will be measured, and (3) what personnel action will occur if an employee is deficient in these competencies. These are big decisions in any business's evolution, but by changing the work processes for all nonclinical activities, it will soon be clear which staff members are unable to make the transition.

An organization's culture is not readily apparent, but the behaviors in an organization directly reflect that culture. If the goal of transitioning early to computers is to reorient the organization's culture to one that thinks of electronic solutions and communications rather than paper, the following questions provide a window into just how much culture change has occurred:

  • Computers: Does everyone in the organization have a computer? If not, why not? It is rare that a potential vendor will use anything other than personal computers even for Web-enabled application service provider-based products. Placing computers in an employee's hands early in the process isn't likely to be a wasted investment, and it forces employees to think differently about how to get things done.

  • Internal communications: To what extent does the organization rely on paper products for communicating? For example, are memos sent and routed on paper rather than through e-mail and word-processing documents (such as those made in Microsoft Word)? Are budgets and other financial reports sent via paper or as Microsoft Excel attachments via e-mail?

  • Scheduling: Do staff (clinical and administrative) use “little black books” or other paper schedules for appointments, or do they use electronic schedulers such as Microsoft Outlook?