By Barbara E. Arnold, MBA, RHIT, APR
How do you launch a new electronic health record (EHR) in a healthcare organization with over 60,000 employees in four distinct geographical locations while also merging the health information management services (HIMS) departments from these four sites into one unified and uniform enterprise service—and continuing to put the needs of 1.3 million patients from 50 states and 136 countries first throughout the process.
Two Mayo Clinic HIMS leaders—Julie Hable, MBA, RHIA, operations manager, HIMS, based in Eau Claire, WI, and Jill DeBoef, RHIT, operations manager, HIMS, based in Rochester, MN—shared how their teams managed up, down, and across organizational lines to manage this critical transformation in culture and strategy over a two-year period.
Mayo Clinic is a nonprofit healthcare organization focused on clinical practice, education, and research. Mayo Clinic has four main sites: major campuses in Rochester, MN; Jacksonville, FL; and Scottsdale and Phoenix, AZ; and the Mayo Clinic Health System, which has 67 locations in Iowa, Minnesota, and Wisconsin.
Preparing for the HIMS Convergence
Commitment to teamwork and putting the needs of the patient first drove the vision behind the multi-year project to create “one patient record” across Mayo Clinic. For example, if a patient resided in Minnesota and snow-birded during the winter in Arizona and Florida, the goal was to have one rather than three separate medical records exist for that patient. Mayo Clinic patient care would be supported by a single instance, converged electronic health record/revenue cycle management system.
“The HIMS Convergence, which became effective January 1, 2018, was a bit painful as we moved from a ‘site’ to an ‘enterprise’ team,” Hable said. “Site employees were used to meeting face-to-face with leaders at each site. Now the head of HIMS was located in Florida, and the main way to communicate became the phone or Skype.”
With multiple states involved, substantial work was needed to successfully make the change. “Hundreds of job titles and job descriptions were standardized,” Hable said. “All sites divided work differently, and state laws also governed our work—for example, in Minnesota, medical records need to be kept forever, while in Wisconsin, seven to 10 years is the typical retention.”
Leadership met regularly to determine the best way to converge. Rather than have duplicative functions in each geographical location, three service lines were created:
- Documentation Services
- Projects and Systems Support
Operations covered the areas of record content management, release of information, chart completion compliance and evaluation, and regulatory/policy HIMS management. Coding falls under revenue cycle rather than under HIMS.
The new enterprise HIMS called for standardized workflow across Mayo Clinic. The team looked to technology to support this process, adding systems such as Epic EHR, OnBase enterprise content and process management software, and RightFax automated fax software.
Staff not only had to adjust to changes in operational policies and procedures as the new structure was implemented, they also had to adjust to cultural changes. Each site had its own culture for celebrating achievements, reinforcing their team culture, and recognizing staff. With the change to working in an enterprise system, teams had to find different ways to build and support that sense of unity among their teams.
“Staff lost a sense of identifying with a site,” DeBoef said. “For example, Florida staff would no longer be working solely on Florida patient medical records; they would also work on files from sites in Arizona, Iowa, Minnesota, and Wisconsin.
“Staff also changed from working in several service areas—[revenue cycle management], ROI, and CCE—to just one service section,” she continued. “So now rather than working on a variety of tasks, a staff member would scan and only scan for 40 hours a week. This also meant changes in leadership and who staff reported to.”
Leaders made a commitment to support staff during the transition. One of the most effective methods of support was the implementation of regular huddles. This brought the new teams together regularly and gave leaders frequent opportunities to explain changes and allow staff to share questions and concerns. In addition to the huddles, there were also all-staff meetings and regular one-on-one meetings between staff and supervisors to help them develop trusting relationships, especially in cases where staff now reported to a new supervisor.
This system has helped to ensure staff understand the need for the changes and have developed a culture that best supports the needs of their new teams.
Implementing the New EHR
The project to implement the new EHR was named the Plummer Project for Mayo Clinic physician Henry Plummer, MD, who introduced the concept of an integrated medical record at Mayo Clinic in 1907. The unified medical record continues today in an electronic record format.
The Plummer Project schedule and implementation were intense by any project management standards. In late 2016 and early 2017, preparation and system upgrades took place at Mayo Clinic Health System in Minnesota and Wisconsin. Staff training took place six weeks prior to the go-live dates, and staff worked the weekend to gain comfort and experience before the actual go-live day. The first go-live was Mayo Clinic Health System sites in Wisconsin in July 2017, followed by Mayo Clinic Health System sites in Minnesota in November 2017. Next up was the Mayo Clinic campus in Rochester, MN, in May 2018. The campuses in Arizona and Florida went live in October 2018.
Keeping the directive behind the vision for the project—the needs of the patient come first— front and center was important. The patient portal layout was one area where this messaging could be included. Once implemented, the patient portal headline read, “Patient Online Services…An easier way to a healthier you,” and encouraged patients to, “See your records and results as fast as your clinician does,” plus “Manage your appointments,” and “Handle your bills,” whether at the business office or home on a computer or from a smart phone or a tablet.
Effective communication is critical to the success of any complex project. The communication strategy for the team at Mayo Clinic included a dedicated intranet site, newsletters, internal publications, emails, and presentations to various audiences. Command centers were set up for each go-live and staffed by Mayo Clinic leaders, the project team, and site-based leadership. Designated super-users assisted staff on the floor.
Another key component to the project’s success was effective training, which was provided in person before each go-live date. Quick-reference guides were provided to users. And the super-users were available along with the core team. Staff preparing for an upcoming go-live participated in a current go-live and huddles were held daily. A focus on teambuilding was also important.
“Maintaining staff morale and satisfaction during this time was incredibly challenging of course,” DeBoef said. “Food…potlucks were a great team-builder as were go-live survival kits, which encouraged team members to be flexible and would include a package of Life Savers, for example.”
“With each implementation, our team learned something, and we got better with each go-live,” shared Hable.
“Everything went very, very quickly,” added DeBoef. “And toward the end, we would joke that we went through 20 years of change in two years.”
Going through this project drove home that communication with staff regarding changes to workflows and future expectations for skills is essential. Likewise, communication with clinicians regarding how to send documents to HIMS is necessary. All types of communication—written, verbal, audio, video, one-way, and two-way—must be used.
When it comes to the go-lives, the team learned it is important to train early and often. Some effective practices included:
- Use the weekend before the go-live day to allow staff to get comfortable before the Monday rush.
- Test all devices and check access to the EHR.
- Implement a system for submitting tickets.
- Identify a designated point person with a chain of command for questions and fixes.
There’s no way around it—go-lives are stressful. The team learned that go-live leaders need to manage up so there are no surprises. Go-live leaders also need to be role models for the team, including following the dress code and working the same hours as staff. It’s a good idea to have a one-on-one meeting if a leader is struggling. Display grace under pressure, and know that answering questions may take a team.
It also helps to reduce anxiety by providing as much practice and at-the-elbow support as possible. Project leaders should remind those involved about the vision; for the Mayo Clinic team, that mean reminding everyone that they were working toward putting the needs of the patient first. It’s important to plan for multiple learning styles in training. Turnover, including retirements, is to be expected. Finally, be mindful of those chosen as super-users—the Mayo Clinic team found that floor staff who communicate well and are change agents are typically the best choices.
The Change Continues
With such fundamental changes over the past several years, change is a way of life in HIMS. By the time the most recent system upgrade started on June 1, 2019, others were already scheduled beyond it to keep up with technology. HIMS convergence will continue as staff becomes more familiar with the Epic EHR, as well as any changes in release of information and optical character recognition technology. In addition, HIMS is also moving toward full-time telework including tele-leaders and tele-training.
“Change is now routine in HIMS each and every day,” Hable said.
**Editor’s Note: Views expressed in this article are those of the author alone and do not necessarily reflect the opinion of AHIMA.