When our hospital's board of directors approved our request for an electronic medical records system, we all let out a collective sigh of relief. We were amazed that our long, hard battle convincing others that we truly needed to advance our surgical services department was over and we had won.

Win? Just what did we win? Our big prize was a year of hard work to get this wonderful system up and running. (Note to self: Be careful what you wish for, because you just might get it!) We're still a ways away from enjoying the tangible benefits of electronic medical records: improved nursing documentation, efficient workflow and rapid access to actionable data. Those are the big payoffs. In the meantime, there's much behind-the-scenes work to be done to be sure we have all the people and pieces in place.

Time to roll up our sleeves
Never think that once you've signed the contract with the EMR vendor that you can sit back and relax. You must track every item and task that impacts the implementation. You must have weekly meetings to make sure everything is on track or the project will take on a mind of its own. This pre-planning and tracking is one of the most crucial phases of the implementation and I, as the main driver, must have my hands, eyes and ears on every task and phase as we move forward.

Where to begin? Once the holidays passed, we were in waiting mode. After about 2 weeks of no contact, I texted the sales rep:

"Contract signed and the rep goes AWOL?"
He replied instantly to assure me that things were happening. The company was working internally to make the transition from the sales team to the implementation and support team. This would take about 2 weeks and we scheduled an introduction call with the sales rep and the project management team. On the hospital's end, we began to build our implementation team. We have the clinical leaders, IT staff, OR staff, materials management staff and surgical services management all on board.

Planning the work and working the plan
Before we met with our new project manager from the EMR company, we held 6 internal meetings to review what a workflow analysis was and how we needed to use this tool to document what we do every day. This is a very important step in preparing for implementation, because many of the things we do now are "workarounds" in our older system. We have paper and electronic documentation along with lists, phone calls and other non-value-added tasks that we must evaluate. If the new system provides what is promised, we can eliminate many of these daily processes. The last thing you want to do is move one bad process into your new system and maintain that bad process.

The other items that needed work were the dictionary in our old system. We have always been limited by the number of character spaces in our old system, so item descriptions said, for example, "SU 633 VI4" when it meant "Suture, vicryl 4-0 SH, 663." We also have items on our materials side with the description entered by a non-clinical person. Most clinical people would not even recognize the item. So the first step is to determine how we are entering all of our descriptions (noun, type, size, catalog number). We had another meeting to set up with the materials management staff and clinical staff. This is the time to make sure our dictionaries are clean before placing them in the new system.

Where to put the servers?
While working on these items, I decided to contact our IT director to check if our servers had been ordered and to find out when they would be installed. Thank goodness I checked: The purchase order had not been submitted for the servers, so I had to push that forward. The worst news was we didn't have a location to place the stack servers. This would include building a new server room and at least a 6-week delay. Not a game-breaker, but certainly not good news either.

We had our introduction call the first week in February and planned our first site visit from the project team the first week in March. All of this is pending our servers being installed and ready to use. We validated what we are working on with the EMR project manager. Our site visit will last a week and we will begin training at that time.

Train along the way
There are many methods of implementation for EMRs. One way is to plan and design completely and then install and train. A better way is to move through the system and build on pre-designed content, training and implementing as you test each section. This way you can find out what works and what doesn't work as you move forward. It also keeps the design, planning and training close together so your staff is focused on a few sections at a time. You gain a more effective design in relation to your patient flow and better training and retention.