1. Roadmap to Success in a Rural Local Health Department
Deb McCullough DNP, RN, FNP
Gordon Mattimoe RN, MSN, FNP
6/5/2013

2. Advantages Disadvantages
Improved patient safety and efficiency (immediate access to up-to-date patient information in the office or remote access).1
Require back-up systems to prevent data loss, user computer skills, can delete information inadvertently if record is not locked, requires extensive training.2
Improved office efficiency (multiple staff can access the record simultaneously, no lost time searching for or retrieving records, only staff with access rights can view the record, legible record, and promotes a more consistent and thorough approach to documentation).1
EHRs are not standardized, more difficult to use than paper records, implementation decreases productivity and disrupts workflow (in the beginning).2
Potential financial benefits (clear, timely, legible documentation).2
Cost. EHR benefits society and payers not providers, physician resistance.2,3
Cultural resistance and inertia; vendor product immaturity, legal and regulatory benefits; and required infrastructure and lack of standards.3
Review advantages and disadvantages of the EHR vs paper. ADVANTAGES – Improved patient safety and efficiency (immediate access to up-to-date patient information in the office or remote access).1 Improved office efficiency (multiple staff can access the record simultaneously, no lost time searching for or retrieving records, only staff with access rights can view the record, legible record, and promotes a more consistent and thorough approach to documentation).1 Potential financial benefits (clear, timely, legible documentation).2
DISADVANTAGES -Require back-up systems to prevent data loss, user computer skills, can delete information inadvertently if record is not locked, requires extensive training.2 EHRs are not standardized, more difficult to use than paper records, implementation decreases productivity and disrupts workflow (in the beginning).2 Cost. EHR benefits society and payers not providers, physician resistance.2,3 Cultural resistance and inertia; vendor product immaturity, legal and regulatory benefits; and required infrastructure and lack of standards.3

3. Steps to Select EHR conducted a needs assessment Staff Health services
FTEs: 2 FNPs, 3 RNs, and 5 clerical
Contract: MD, 2 NPs
Health services
Public health
Primary health care
Family planning
Immunizations
STD/HIV/TB
PROVIDERS: The LHD has three providers (a physician 16 hours per month and two full-time nurse practitioners), three Registered Nurses (RN), and six support staff. Contract NPs – 1 as needed and 1 weekly for family planning services
SERVICES: public health services to all county residents and a variety of personal health services to low-income county residents. Personal health services consist of primary health care, family planning, immunizations, tuberculosis, and sexually transmitted infections/HIV services.

4. Steps to Select EHR Funding sources Billing Special needs County
DSHS grants
Medicaid/CHIP/WHP/Medicare
Billing
Electronic immunization, family planning, Medicare
Special needs
communicate with DSHS when possible
immunization inventory, billing, and upload to ImmTrac
FUNDING: The County provides the majority of the LHD’s funding. Other payment sources include grant funding from the Texas Department of State Health Services (DSHS), and reimbursement from Medicaid, Women’s Health Program, Children’s Health Insurance Program (CHIP), and Medicare.
BILLING: LHD electronically bills family planning and Medicare services. The LHD submitted immunization information electronically using the Texas Wide Integration Client Encounter System (TWICES) a DSHS computer program.
SPECIAL NEEDS: As a public health clinic the LHD had special needs. These needs required the LHD’s EHR to communicate and report to DSHS when possible, to maintain an immunization inventory, and to upload the immunization data to ImmTrac. The LHD’s reporting requirements change annually or with grant funding; therefore, the EHRs flexibility with creating documentation and reports, and retrieving data is an important consideration.

5. Who is an Eligible Professional under the Medicare EHR Incentive Program?
Eligible professionals under the Medicare EHR Incentive Program include:
Doctor of medicine or osteopathy
Doctor of dental surgery or dental medicine
Doctor of podiatry
Doctor of optometry
Chiropractor
ACHD is potentially eligible for the Medicare incentives providing the contracted physician gives consent and approval to access these incentives. MD is contract and if he gave us the ability to access the Medicare incentive program he could not do it at his own clinic,

6. Who is an Eligible Professional under the Medicaid EHR Incentive Program?
Eligible professionals under the Medicaid EHR Incentive Program include:
Physicians (primarily doctors of medicine and doctors of osteopathy)
Nurse practitioner
Certified nurse-midwife
Dentist
Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant.
To qualify for an incentive payment under the Medicaid EHR Incentive Program, an eligible professional must meet one of the following criteria:
Have a minimum 30% Medicaid patient volume*
Have a minimum 20% Medicaid patient volume, and is a pediatrician*
Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals
* Children's Health Insurance Program (CHIP) patients do not count toward the Medicaid patient volume criteria.
Not eligible for Medicaid because we are not an FQHC or Rural health Center, and our patient volume was not 30% Medicaid. We see the uninsured poor. CMS designed the incentives for clinics providing services to “paying customers,” specifically Medicare and Medicaid. Even though we are not eligible for the financial incentives, attaining meaningful use is important to improving patient quality and outcomes. Some benefits of achieving meaningful use include reduction in medication errors, increased availability of records and data, CDS, refill automation, electronic medication reconciliation, and e-prescribing.

7. Steps to Select EHR Workflow analysis Organizations’ current structure
Paper appointment, medical record, and billing
Workflow progression
Patient flow
Documented patient and staff activities from check-in to check-out
Changed clinic set-up and processes
The LHD had a paper appointment and medical record system. The LHD received paper copies of lab, x-ray, and diagnostic test results. Providers either called prescriptions to the pharmacist or hand wrote the prescription. When choosing an EHR, it is essential to determine if the EHR system has the capacity to manage the clinic’s administrative and clinical workflow. Workflow is “what happens as a result of workforce members following an established path to reach a common outcome.” 8 p.39

8. ACHD Workflow Analysis
The workflow analysis consisted of determining the organization’s current structure, evaluating the LHD’s workflow progression, documenting the patient and staff activities from check-in to checkout, and creating a patient flow diagram. The workflow diagram served as a visual tool to illustrate the inefficiencies in the processes. In response the stakeholders provided feedback and formulated a plan to improve the overall quality of care in the clinic. Staff resistance to change is common8 and as expected some staff criticized and resisted the changes. Obtaining staff buy-in is important to successful EHR implementation and use. A key way to ensure buy-in is to involve staff in the EHR selection and implementation process.8

9. Workflow Analysis with EHR
The workflow redesign process essentially addresses who, what, where, and when of the critical clinical and administrative processes that change in a transition from paper record to an EHR.8 The LHD and HIT REC staff conducted additional workflow analyses and determined EHR documentation and reporting requirements. Ultimately, the assessment provided leadership with evidence of how the LHD could potentially streamline care in the clinic through process redesign and EHR implementation. The assessment also identified opportunity to potentially decrease the LHD’s employee full-time equivalent (FTE) needs.

10. Steps to Select EHR Hosted (Cloud computing) vs onsite system
ease of use;
immediate availability of software updates; reduced start-up expenses;
vendor provided system redundancy, back-up, privacy and security;7 and the LHDs limited IT support and expertise.
The limitations of a hosted EHR system
Internet connectivity and potential downtime
ACHD does not have IT on-site. Andrews County has one IT person for all County departments, therefore we could not manage an onsite system. BENEFITS of a hosted EHR include: ease of use; immediate availability of software updates; reduced start-up expenses; vendor provided system redundancy, back-up, privacy and security;7 and the LHDs limited IT support and expertise. LIMITATIONS of a hosted EHR system are Internet connectivity and potential downtime. LHD has a T1-line, which should decrease Internet connection issues.

11. Steps to Select EHR
Evaluated multiple vendors for meeting meaningful use and national certification regulatory requirements
Evaluated multiple vendors for meeting meaningful use and national certification regulatory requirements

12. Staff Expectations Decrease medication errors
Provide a better mechanism for updating the medication list
Eliminate physician’s handwriting issues
Reminders to patients per patient preference for preventive/ follow up care
Improve preventive care services provided and compliance with clinical guidelines
Meet national EHR goals
Meet meaningful use and clinical decision support (CDS) criteria
Reduce administrative and reporting burden
Retrieve files and sort medical records
Gather and help analyze data
Improve prescription process, patient safety, and workflow management
Conduct clinical quality improvement (QI) research
Provide clinical decision support (CDS)
Enhance practice management (integrate scheduling, billing, and coding)
To prepare for EHR selection ACHD determined staff expectations from the EHR. Improve documentation of current medication list and prescription process, and decrease error, eliminate MD handwriting issues, patient reminders for appointments, use CDS to improve care, decrease administrative reporting burden (visit type counts), access to medical record, data analysis, QI data, and improve practice management with integrated scheduling, billing and coding.

13. Steps to Select EHR Involved staff in EHR selection and implementation
EHR demonstrations
3 online ( WTHIT REC)
I onsite demonstration (LHD with eCW)

14. Successful EHR Implementation
People skills (leadership, communication, and training)
Articulate vision
Actively involve staff and MD in pre- implementation planning phase
Example of non-participation in EHR selection
People skills (leadership, communication, and training) are essential to successful EHR implementation.12 Requires a clear vision of the goal and ability to express the vision skillfully.13 from the frontline staff to the County Judge and Commissioners (for funding). ACHD staff and physician were involved in the project’s pre-implementation planning phase because project success requires stakeholders to support and comprehend the project plan.10 Gordon will provide example of the impact of non-participation in the process.

15. Organizing Framework Step 1: learn basics of EHR
Step 2: conduct workflow analysis, compare paper and EHR processes, identify EHR champions
Step 3: determine appropriate EHR based on budget and work flow needs, purchase EHR.
Step 4: implementation phase – changing from paper to electronic

16. Implementation Steps
Formed a team to complete the 15-week pre-implementation tasks
Recruited based on job descriptions and potential contribution to the team
Met weekly answering these questions
What did we accomplish?
What are the next steps?
List things to do?
What went well?
What didn’t work?
Team determined criteria for successful EHR implementation
After EHR selection, the director formed a core EHR team to focus on the tasks of the final 15-week pre-implementation period. Recruited team members based on their current job descriptions and potential contributions to the team.10,17 Team members signed a meeting participation agreement, reviewed the project vision, identified team member talents, defined roles and responsibilities, and developed clear goals with timelines and responsible persons. The team met at least weekly for 15 weeks answering the questions: What did we accomplish? What are the next steps? List things to do? What went well? And what didn’t work?

17. ACHD Criteria for Successful Implementation
Live with an EHR by October 1, 2011.
Eliminates paper charting and generates minimal paper forms to add to the EHR.
Uses the EHR to its best capacity as determined by reassessing and streamlining workflow processes.
Meets the Stage 1 meaningful use criteria by November, 2012.
January 22, 2013.
Live with an EHR by October 1, met
Eliminates paper charting and generates minimal paper forms to add to the EHR – achieved. Lab and diagnostic tests are faxed into the machine. Most consents are electronic. Can only sign one signature per consent so child consents are completed and scanned in to EHR.
Uses the EHR to its best capacity as determined by reassessing and streamlining workflow processes – worked hard to achieve this.
Meets the Stage 1 meaningful use criteria by November, No but did so on January 22, 2013.

18. Meaningful Use Certificate

19. Implementation Steps Reviewed equipment and technical requirements
Workflow needs and space requirements
Computer on wheels in each clinic room, staff can face patient, or use computer where needed in the clinic
In the 15 week pre-implementation period, the team reviewed equipment and technical requirements, workflow needs and space requirements ( ACHD staff decided to have computer on wheels in each clinic room, so the staff could face the patient during the visit, (staff reported not liking visits with providers with EHRs because they were always looking at the providers back) and use computer where needed in the clinic).

20. Implementation Steps
Reviewed processes, conducted workflow analyses, and established redesign strategies.
For example, to avoid transitioning ACHD’s dysfunctional Medicaid Texas Health Steps (THS) paper process to an electronic format, the staff redesigned and streamlined the documentation.
In July 2011, stakeholders from ACHD and Texas Department of State Health Services (DSHS) met to review Texas Health Steps (THS) forms and documentation requirements. Prior to EHR, ACHD staff completed 20 forms during an initial THS visit. ACHD seized the opportunity to redesign and streamline THS documentation in the EHR to avoid transitioning a dysfunctional paper process to electronic format.

21. Staff Training Attended Crossroads Conference 2011
Meaningful use, patient safety,
, e-Prescribing, medication reconciliation, and CPOE
4 day vendor training
Demonstrations and hands-on practice time for front office, RN, provider, and billing staff.
End of day meeting to address clinic policy questions and identify how-to questions
eCW assigned ACHD a strategic account manager and access to online chat for how- to-questions
CPOE = computerized provider order entry.

22. Lessons Learned
Encourage and promote continual improvement and workflow redesign

23. PDSA Cycle Act Plan Do Study Carry out the plan
Summarize what was learned
Change or test
Determine what changes are to be made
Act
Plan Do
Study
PDSA Cycle: Three fundamental questions. 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in Improvement? Revisited process at least 25 times

24. Clinical Decision Support (CDS)
Systems provide tools to deliver intelligently filtered, appropriately timed, and actionable information to patients or clinicians.
CDS/Stage 2 meaningful use. Measure 1: Implement five clinical decision support interventions related to four or more clinical quality measures at
Is a process for enhancing health related decisions and actions with pertinent, organized clinical knowledge, and patient information to improve health and healthcare delivery.
Information recipients can include patients, clinicians, and others involved in patient care delivery; information delivered can include general clinical knowledge and guidance, intelligently processed patient data, or a mixture of both; and
Information delivery formats can be drawn from a rick palette of options that includes data and order entry facilitators, filtered data displays, reference information, alerts, and others
HIMSS, 2011, Improving outcomes with clinical decision support; an implementer’s guide

25. Promote Continual Improvement
Immunizations
Didn’t understand how all the components (EHR, billing, inventory) worked together.
Prior to the EHR, multiple staff conducted tasks within ACHD’s immunization program. Billing occurred magically in TWICES the DSHS program for documenting immunizations and tracking immunization inventory. Except to Texas Health Step vaccines . The assistant administrator billed the well child visit immunizations on paper using codes the clinic staff didn’t know.. The front office staff pulled the record and made demographic changes, the nurses documented vaccines provided on paper and in TWICES (double work), inventory report was ran at the end of the clinic day and the nurse counted the vaccines to ensure the report to actual on-hand vaccines matched So when we went to the EHR the staff didn’t understand how these items occurred on paper so we didn’t get it into the EHR correctly for billing to automatically occur.

26. Inventory and Billing
The first step in changing the clinical and administrative activities from paper to electronic is setting up the immunization inventory, billing, and administrative functions.
In eClinical Works (eCW) the inventory set-up consists of naming the vaccine, adding CPT, CVX, and administration codes, vaccine dose, and national drug codes (NDC). ACHD named Tdap (child) and Tdap (adult) to help staff distinguish Texas Vaccine for Children (TVFC) from Adult Safety Net (ASN) vaccine.
- If the system includes a vaccine inventory add the lot numbers, manufacturer, expiration date, Vaccine Information Statement (VIS) date, dosage, lot type (government/private stock), and number of doses.
- How to accomplish the set-up varies for each EHR system. The authors’ recommend adding as much information as the system allows.
- Make sure you add all the information the system asks for. On this slide the information is used for the vaccine inventory and provider documentation.

27. Billing
Setting-up the vaccine billing consists of adding the vaccine charges and administration codes (90471 for the first vaccine and for additional vaccines). Add the TVFC vaccine Medicaid charges ($0.01 for each vaccine), the Medicare/private stock vaccine charges (Q2037 Influenza $20.00, Influenza High Dose $30.00, etc), and the administration charges (90471 $10.00, G0008 $10.00, etc.).

28. Inventory and Billing
The CPT code here is part of the billing and so is the administration code.

29. Order Sets
The clinical administrative function includes adding immunization consents, clinical decision support (CDS) vaccine alerts, and order sets to the EHR. Determine when and who will add the patient’s vaccine history to the EHR.
ORDER SETS decrease the time the nurse or provider spends adding medications, labs, diagnostic tests, appointments, and referrals.

30. CDS/Alerts
ACHD staff added multiple CDS/alerts to the system to decrease missed opportunities for vaccines and preventive health screenings.

31. Documentation in EHR
Screen Shot of documentation of the immunization in the EHR. Very easy to document vaccine administration and includes all of the Texas Vaccine for Children documentation requirements.

32. Work Flow
Review workflow routinely to ensure consistency and no one added work-arounds to the process.

33. Workflow Interface with ImmTrac
EHR interface with the statewide immunization registry (ImmTrac) is not automatic.
For more information: trac/attestation.shtm
ACHD is waiting on eCW to set-up the interface.
ACHD is not interfaced with ImmTrac. EHR interface with the statewide immunization registry (ImmTrac) is not automatic.
For more information: ACHD is waiting on eCW to set-up the interface.

34. Reminder/Recall Schedule appointments for the next vaccine
Phone call reminders from the system
Enroll immunization only patients in the patient portal – sends an and provides access to immunization record
Form letters for appointment missed
For vaccine recall – easy to pull patients who received the vaccine
The Immunization Program Outreach Specialists schedule appointments for children to receive their next vaccine. The system provides phone call reminders and sends s to those with addresses in the system. ACHD staff strive to enroll immunization only patients in the patient portal – sends s and provides access to the child’s or adult immunization record 24/7. When I child misses the vaccine appointment, form letters from the EHR are sent to the parent. The EHR makes it easy to list the patients who received this lot number of vaccine if the need arises.

35. Lessons Learned
EHR facilitated and improved the immunization program’s administrative and clinical processes.
Workflow analysis with all staff increased understanding of the system and individual role within the program.
Adding the vaccine history to the EHR versus scanning records improved provider assessment of vaccine needs at all clinic visits.
Adding CDS influenza and tetanus alerts decreased adult vaccine missed opportunities.
- The EHR facilitated and improved the ACHD immunization program’s administrative and clinical processes.
Conducting workflow analysis with nurses, immunization, front office, and billing staff increased their understanding of the system and their individual role within the immunization program.
Adding the vaccine history to the EHR versus scanning records improved provider assessment of vaccine needs at all clinic visits.
Adding CDS influenza and tetanus alerts decreased adult vaccine missed opportunities.

36. Lessons Learned
Adding order sets decreased immunization documentation time.
Scheduling patients for follow-up vaccine visits aided in reminder and recall (phone calls prior to appointment and letters sent to no-shows).
Adding the vaccine record to the patient portal increased patient access to records.
Adding order sets benefited nurses and decreased immunization documentation time.
Scheduling patients for follow-up vaccine visits aided in reminder and recall (phone calls prior to appointment and letters sent to no-shows).
Adding the vaccine record to the patient portal increased patient access to records.

37. Diabetes Goal: To meet the diabetes standards of care.
a relevant point in patient care for the entire EHR reporting period. Absent of four quality measures related to an EP’s scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions.

38. Diabetes Minimum Practice Recommendations
Complete H&P
Initial visit and at clinician’s discretion
Diabetes Education
Medical Nutrition Therapy
Exercise Counseling

39. Diabetes Minimum Practice Recommendations
Psychosocial Counseling
Initial visit and at clinician’s discretion
Lifestyle/Behavior Changes Counseling
Smoking Cessation /Alcohol reduction
Weight/Height/BMI
Every visit BP
Foot Inspection
Visual inspection for skin and mail lesions, calluses, infection

40. Diabetes Minimum Practice Recommendations
Oral/Dental Inspection
Every visit
Growth and Development (Children)
Aspirin/Antiplatelet Prophylaxis
A1c2
Every 3-6 months
Kidney evaluation
Type 2: initial visit and annually
Dilated funduscopic eye exam

41. Diabetes Minimum Practice Recommendations
Oral/Dental Exam
Annually or as needed
Foot exam
Complete foot exam and neurologic assessment
Lipid Profile
Annually if at goal otherwise every 3 – 6 months
Immunizations
Influenza
Td Vaccine
Pneumococcal Vaccine
Childhood Immunizations
According to CDC

42. Order Set - Meds

43. Order Set
Diabetes order set include immunizations, labs, eye and dental exams. All evidence based interventions and many core measures. Mapping

44. CDS/Alerts

45. CDS/Alerts

46. Flow Sheet
Flow sheets provide longitudinal data. Aide

47. Lessons Learned Determine scanning policy
Scan enough of the chart to avoid pulling paper charts
Adopt standardized nomenclature to access and retrieve the scanned data quickly
Pre-EHR plan laborious and time consuming.
Final policy
HX, medication list, immunization record, past year of progress notes, and lab/x-ray reports
Adler recommends determining a scanning policy and “scanning enough of the chart so that you won’t need to pull paper charts for appointments.”14,p.36 The core team decided to scan the chart the day before the patient’s appointment, and adopted a standardized nomenclature to access and retrieve the scanned data quickly. The pre-determined scanning policy was too laborious and time extensive. ACHD modified the policy to include the history, medication list, immunization record, the most recent year of progress notes, and lab and x-ray reports.

48. Lessons Learned Decrease patient load post-implementation.
Some processes should model existing paper practices
1 per hour, took 2 hours for HX
Cumbersome EHR process
Paper HX provided structure
Resolved issue by arranging EHR format to replicate paper HX form
The core team decided to schedule one patient per hour, but the initial patient intake took two hours because of the cumbersome and time-consuming EHR history-taking format. Cumbersome processes encourage work arounds and decrease efficiency, safety, and consistency.13 ACHD’s paper history provided structure to the RN’s process for gathering information and prompted specific questions. The director resolved the issue by rearranging the format to replicate the paper history form and concluded some processes should model existing paper practices.

49. Lessons Learned
Repetitively encouraged staff to report EHR problems or write on a flip chart
6 months after implementation nurses identify EHR issues quickly and strive to redesign to improve efficiency
Eg, lab billing for in-house and referral lab
a billing issue arose because the medical secretary could not distinguish between in-house and referral lab ordering in the EHR to assign charges. The RN suggested the director change the lab names to include in-house; this resolved the issue.
eCW allows providers to use a standard form, existing templates, or create additional templates. The director created a template for sexually transmitted infection visits, and for conducting health risk assessments and preventive health education. Blood sugar and waist circumference were added to the vital signs section allowing the provider to view the results in the progress notes and decreasing time associated with adding a lab order. The family-planning nurse practitioner (NP) struggled with the EHR’s physical exam; a template was created and the NP’s patient load matches the pre-implementation numbers.

50. Lessons Learned
New users embrace the EHR more rapidly if it is easy to use and meets their needs
System flexibility is important
Created templates for Texas Health Step visits, family planning physical exam, STD visits, health risk assessment and preventive health education
Blood sugar and waist circumference added to the vital sign section
The EHR team lacked the system knowledge to pre-determine data entry details (who, what, when, and where). Registered nurses (RN) were charged with entering the history, problem, medication, and allergy lists into the EHR. ACHD scheduled one patient from every program and used the vendor educator to help resolve issues on the go-live day.
Didn’t work because the information in eCW wasn’t formated the same. Sometimes need to repeat the system into the EHR. eCW allows providers to use a standard form, existing templates, or create additional templates. The director created a template for sexually transmitted infection visits, and for conducting health risk assessments and preventive health education. Blood sugar and waist circumference were added to the vital signs section allowing the provider to view the results in the progress notes and decreasing time associated with adding a lab order. The family-planning nurse practitioner (NP) struggled with the EHR’s physical exam; a template was created and the NP’s patient load matches the pre-implementation numbers.

51. Lessons Learned Select a flexible electronic system, and
Ability to add component eg well child history, exam
Building DX codes
Treatment (ease of attaching the diagnostic code to lab or imaging, referrals)
Medication reconciliation (easy to list all the meds under correct diagnosis)

52. Lessons Learned
Pre-implementation policies not transferred to post implementation state
Staff adhered to how-to as learned in the vendor training, focused on technology and not their clinical expertise and knowledge
Observe staff using EHR and identify barriers, challenges, and mechanisms for improvement to avoid staff frustration, work-around and necessity to unlearn behaviors
Pre-implementation policies created by the team were not transferred to the post-implementation state. The novice to expert scale provides an explanation for the behavior. As novice EHR users, the staff had no experience and displayed rule-governed behaviors (limited and inflexible).20 The staff adhered to the how-to learned in the EHR vendor training and focused on the technology making them oblivious to their clinical expertise and knowledge. The author recommends observing staff perform the EHR processes and identifying barriers, challenges, and mechanisms for improvement frequently to avoid staff frustration, work arounds, and necessity to unlearn behaviors.

53. Lessons Learned
Interfaces require IT

54. Summary Successful EHR implementation and use involves:
gaining leadership, stakeholder, and end-user buy-in;
using a step-by-step process; and
matching the selected EHR’s capacity to the staffs’ perceived benefits.