Like much of healthcare, electronic health record go-lives have had to pivot virtually in the wake of COVID-19—shifting more tasks to remote workers and away from in-person support.
Epic Systems Corp., Cerner Corp. and Meditech in recent weeks have completed go-lives of their EHR software virtually, without their employees on-site at a hospital. Some aspects of virtual go-lives could become common practice—even as states begin to reopen—as companies continue to figure out a new normal.
"It has us all stepping back and thinking: 'I think we can move to this virtual space. I think we can do this,' " said Vince Vickers, healthcare technology leader at consulting firm KPMG.
Under normal circumstances, healthcare software companies send dozens of their employees to hospitals to provide technology support and help troubleshoot problems when a new EHR is installed. They're often on site for a week or longer. But as COVID-19 has swept across the U.S., hospitals and technology companies have had to adjust that process to preserve social distancing measures.
That was the case for Macon Community Hospital, a 25-bed critical-access hospital in Lafayette, Tenn. The hospital had signed a contract with Cerner for a new EHR in spring 2019, long before the first COVID-19 case had been reported. It was on-track to activate the Cerner software in late March, undergoing training and testing of the system early this year.
Then, in February, Cerner told Macon Community it had suspended travel for its employees due to increasing COVID-19 cases across the country.
Cerner offered to postpone the hospital's go-live, but the hospital's leadership said that wouldn't work.
"We had already canceled our contract with our previous vendor," said Scott Tongate, Macon Community's chief financial officer. "We had a hard date of March 30, 2020, to go live."
So, the hospital shifted its go-live virtual, with Cerner support entirely working off-site. It required more planning, testing and training ahead of the go-live to ensure hospital staff were familiar with the new EHR. It also meant setting up new processes, so that off-site Cerner employees could troubleshoot and help with work-flow issues.
Macon Community's two-person IT team was on-site on the date of the go-live to provide in-person support as needed. Cerner's off-site employees were available 24/7 via phone calls and video conferencing for the following week, in an effort to replace at-the-elbow support that Cerner staff typically provide clinicians in the field.
Macon Community marked the first time Cerner had performed a virtual EHR go-live.
Many of Cerner's planned EHR activations will be postponed to later this year or early next year, said Mitchell Clark, president of CommunityWorks, Cerner's cloud-based delivery model designed for community and critical-access hospitals.
"We've evaluated a couple of other clients to do a virtual conversion," Clark said. "We came to the decision that no, that wasn't the right thing to go do."
Macon Community was able to complete a virtual go-live because its IT team was engaged and knowledgeable about the Cerner EHR system and had completed adequate system testing, Clark said. Not all hospital customers checked those boxes.
"It's all dependent on the client," he said.
Organizations that were more than halfway done with an implementation often move forward with activating their software, even if the go-live is virtual, said Sue Atkinson, a principal with the Chartis Group, a healthcare advisory firm that's unrelated to Macon Community's go-live.
Those moving forward with go-lives have "made such a huge investment at that point," said Atkinson, a leader in the Chartis Group's informatics and technology practice. "The cost and the time lost would be too significant." In her experience, organizations that aren't as far along have been more likely to defer their go-live, in the hopes of waiting until the pandemic subsides.
Valley Children's Healthcare based in Madera, Calif., also opted to move forward with a virtual go-live. It had been using seven different EHR systems across its children's hospital, pediatric primary-care practices and specialty-care centers, and in 2018 had struck an agreement with Epic to transition to a single EHR.
Valley Children's successfully went live on that EHR in late April.
There were a handful of employees from consulting firms Valley Children's worked with on-site, but many fewer than a typical go-live. Some analysts and project managers from Optimum Healthcare IT, the primary consulting firm Valley Children's worked with for the project, had been sent to the health system weeks before travel restrictions had been put in place.
Valley Children's officials decided it was particularly important to move to one EHR in anticipation of a possible second COVID-19 surge later this year, as a single health record system could help to streamline sharing patient information across Valley Children's and with nearby healthcare facilities also on Epic EHRs.
In the weeks leading up to activating the new EHR, Optimum hosted virtual training sessions for clinicians, including webinars and one-on-one meetings.
The main concern ahead of the go-live was figuring out how to "virtualize" at-the-elbow support for clinicians, said Kevin Shimamoto, Valley Children's chief information officer. Epic's staff weren't the only ones off-site—most of the staff from Optimum and some of the health system's own "super users" were also remote.
"The main thing is communication," Shimamoto said. "How do we best answer questions? … Can you be 'at-the-elbow' without being at the elbow, if you will?"
Along with establishing connections between clinicians and off-site super users, the organizations also set up two command centers—one on-site with local IT staff from Valley Children's, and another with off-site workers—as well as twice-daily leadership huddles.
The command centers were up and running for two weeks following the go-live.
To replace the experience of having at-the-elbow support, staff from Optimum were able to remotely access a user's desktop and view their screen to talk them through problems. Optimum's staff were working remotely from their homes, but had a call schedule in place to maintain IT support 24/7.
The goal was to set up processes that were "just as easy as if I was standing down the hall from you, and you needed help, and you raised your hand to call me over to help you," said Rebecca Manne, Optimum's executive vice president of EHR implementation. On average, it took staff just 10 seconds to respond to requests for IT support, she said.
For employees stationed at the on-site command center, Valley Children's set up precautions like plexiglass dividers to reduce contact.
The EHR go-live at Valley Children's to some extent benefited from low patient volumes. The health system had been forced to reduce surgeries and close some pediatric clinics in late winter and early spring because of COVID-19, which meant some clinicians had more time to prepare and get familiar with the new EHR, Shimamoto said.
That's important to keep in mind when evaluating whether virtual go-lives could become mainstream after the pandemic subsides.
KPMG's Vickers, whose firm had no role in the Macon Community or Valley Children's go-lives, said all the virtual go-lives he's worked on and seen during the pandemic have been successful; that includes EHR activations, but also implementations of other software, like enterprise resource planning systems.
However, he cautioned hospital leaders against thinking all go-lives will be able to be completed virtually.
"It's exciting what we're seeing, and I'm absolutely pro moving towards more virtualization," Vickers said. But he stressed that for many organizations not in COVID-19 hot spots, patient volumes had dropped.
"You could argue it's actually the ideal time to cut over and move to new processes and a new system," he said.
While it's unlikely that companies will work completely off-site during a conversion, hybrid go-lives with both on-site and virtual support may become more common, according to EHR vendors and consultants.
Epic will likely integrate more remote work for software implementations in the future, said Dan Sullivan, the company's vice president of implementation services. But it doesn't intend to transition all go-lives virtual.
"There's certainly an efficiency with (working virtually) and a reduction in the overhead of travel," Sullivan said. "I think there's a big relationship component, and a communication component, that people appreciate when they can see people face-to-face as well. We'll likely see a mix of the activities."
Virtual go-lives have resulted in some cost savings for hospitals, since customers no longer need to cover costs of a company's employee travel and lodging expenses.
Those costs can add up. Clark said for a go-live similar to the one at Macon Community, Cerner would typically send between 25 and 40 employees for on-site support. Those workers could be more efficient at Cerner's office, since they don't need to spend hours traveling.
Cerner isn't planning to remove all on-site support for EHR go-lives. However, depending on a customer's level of experience, the company may start reducing the number of employees it sends to a hospital—setting up a smaller team of employees on-site, and bolstering their support with coverage from a set of remote workers.
"I think a lot of this will stick around," said Farrell Sanders, Cerner's senior vice president of consulting and support services. "Maybe a hybrid model will be what we're doing in the future. I don't think our aim is to do zero people on-site (for) go-lives, but rather to just be smart about it and make really efficient use of the people we have on site."
It could be more challenging to shift a go-live completely virtual for larger and more complex health systems that span multiple regions, according to Vickers. It could also be challenging to start a software conversion without travel, since being on-site can help companies develop a relationship with hospital customers and better understand their work flows.
Both Macon Community and Valley Children's had started implementation activities a year ago or more, with staff from EHR vendors and consulting firms visiting for on-site meetings, training and testing prior to the COVID-19 outbreak.
"Can we be as successful starting virtual?" Vickers said. "That's a TBD. That question still remains out there."