Electronic Medical Records (EMR) in academic medical centers often have additional complexity to them due to structural and organizational differences. Often the hospital operates independent of the medical school such as the physicians often work for the medical school, while the nurses and other ancillary departments work for the hospital. Such differences require special consideration when making changes to an EMR. The case study concerns an academic medical center where there are two ways to access the EMR. One methodology is to use a clinical computer on clinical floors within the hospital. A second methodology is the use of Citrix servers to access the EMR. Due to organizational differences, the EMR users access the system via two separate sets of Citrix servers. The hospital’s support staff controls one set of Citrix servers and the academic support staff controls the other set. Physicians and mid-level providers utilize the academic Citrix servers, but nursing and other ancillary departments use the hospital’s Citrix servers. With the servers controlled by separate teams, careful coordination is needed to ensure uniformity across the servers for a consistent user experience.
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Over the past few weeks, the acute care EMR team worked with their in-house developers, John and Jason, to design and create a new module to improve clinical workflow in the electronic medical record. The hospital of the academic medical center owned the acute care EMR; therefore the EMR IT staff were hospital employees. The clinicians who tested and reviewed the module believed it offered increased efficiency to the workflow for the organization. Further, the new module also excited the Clinical Analytics Team because the module provided additional data for rich data analysis to improve patient care and generate regulatory reports with greater ease.
The EMR team, excited by the acceptance and overall enthusiasm around the new module contacted the hospital’s Information Systems Support team (IS Support) to inquire the necessary steps required to place the module into production. The manager of IS Support, Mike, said it required an installation into the SQL database and an installation to all the hospital clinical PCs and Citrix servers. He further explained the physician group had a separate set of Citrix servers managed by a different team that would also need to install the module. Mike estimated it would take a week for each of these tasks to be done, though he believed each respective team could do them simultaneously. Therefore, Mike told the EMR team in two weeks the module would be in place and could be used in the EMR. In addition, Mike volunteered to create work requisitions for the install and coordinate between the various support teams for both the hospital and academic Citrix servers. The EMR team communicated a three-week timeline to the clinicians in the hospital, which included the academic physicians, just as an additional precaution.
Three days prior to the installation of the module by the support teams, Mike e-mailed John to explain the EMR was having production problems that needed to be fixed prior to introducing a new module. Therefore, Mike recommended the install be pushed back two days; however, this still allowed the EMR team to meet their go-live deadline for the clinicians. John verbally communicated this information to several key members in the EMR team. Everyone agreed they could still meet the intended deadline.
On Sunday, three days later, Jason tested the module on the hospital’s clinical PCs and Citrix servers. He also noticed the support team still had not made the appropriate changes to the database and that the Citrix servers did not yet have the module. Thus, he sent an e-mail to John and Mike explaining he noticed the discrepancy in the Citrix servers. Mike responded he would look into it tomorrow. Mike included other IS Support members were on the response e-mail, however, the e-mail did not include any EMR IT staff.
At 8:30 AM on Tuesday, John just sat down to an off campus meeting. He was excited since he knew the module would go-live soon, support just needed to make sure it was installed on all the correct PCs and servers prior. He decided to check his e-mail before the meeting began. He saw three new e-mails with the subject simply “Call me!” from Betsy, an EMR team member. John immediately excused himself from the room and called her. Betsy explained she had placed the link to the new module into the EMR this morning and clinicians excitedly began using it. However, the clinicians reported they were unable to use the module from the Citrix servers and were very upset. Julie, the manager of the EMR team, was very upset because the team was losing user credibility, especially since the EMR had production problems last week.
John could not believe it. What had gone wrong? He immediately called Julie to discuss the current status. Julie explained they had taken the link out of production so it would not negatively impact the clinicians until they could resolve the problem. She then explained that she had just spoken with Mike and who claimed he never realized there was a specific go-live date. He also claimed he did not realize he should have installed the module on the Citrix servers at the same time as the clinical PCs. Mike further stated he had not yet contacted the academic Citrix server support group.