Critical Success Factors in Establishing the Electronic Health Record: the Experience of St. Michael's Hospital, Canada

John Wegener and Anna Jane Woodman


This presentation will provide insight into planning, implementing, and managing the transition of a health records department, moving from an overburdened and inefficient paper environment toward an automated electronic setting. This success story will look at how staff, work processes, and technologies were adapted to provide quality real-time information, despite challenges such as increasing expectations and scarce capital resources.


St. Michael's Hospital is a Catholic academic healthcare provider, fully affiliated with the University of Toronto and committed to innovative patient care, teaching, and research. Established in 1892 by the Sisters of St. Joseph to care for the sick and poor, St. Michael's Hospital remains dedicated to treating all with respect, compassion, and dignity. St. Michael's operates 600 beds and manages more than:

  • 25,000 inpatient visits
  • 55,000 ER visits
  • 34,000 day surgery
  • 500,000 ambulatory visits yearly  

Until 1998, when there was a Provincial mandate to merge with a similar size hospital, there had been little investment in information management and technology. This was due in part to debt repayment that financially strapped the hospital. Residents and students from the University of Toronto expected St. Michael's to provide the same level of technological tools as the peer hospitals where they rotated. The hospital needed to address these academic demands and provide an information management solution for clinicians to enhance the quality of care. The year 1998 was very important; a new strategic plan recognized information management and technology as key enablers in achieving the hospital's vision of being internationally recognized as the finest academic healthcare provider in Canada. Out of the five-year strategic plan emerged two important principles:

  1. Reliable infrastructure on which to build patient care systems
  2. Provide our clinicians with an integrated patient care management system to support compassionate and practice-based care

Since the merger with Wellesley Central Hospital four years ago, the Health Record Department at St. Michael's Hospital has undergone an immense transformation. St. Michael's Health Records Department has a mandate to deliver accurate and timely patient information for the provision of quality care, education, research, and administrative decision making. The Health Records Department is the caretaker of the physical record and is preparing to accept the responsibility of caretaker for the electronic health record (EHR). As an integral part of the infrastructure to launch the EHR, we have met this mandate by developing staff capacity, realigning processes, renovating the physical environment, and implementing new systems in support of the hospital's strategic plan.

Critical Success Factors in Moving to the Electronic Health Record

Developing Staff Capacity

  • How to manage culture changes
  • Meeting future departmental needs by providing education and other opportunities for career development  
  • Measuring staff and customer satisfaction

Developing a committed and qualified team is the single most important factor in any successful organization and is a crucial component in preparing for the EHR. More than three years passed from the announcement of the merger until the Health Record staff moved into one facility and began working as a unified team. During this time frame, maintaining morale as staff wondered how they would personally be affected was a challenge for all hospital management. The Human Resources Department worked with management, created toolboxes, and formed numerous workgroups to support team building, cross-site training sessions, and departmental integration.

Another layer of complexity was added to this challenge. The Wellesley Health Record Department had unionized staff, and St. Michael's Health Record Department was non-union. This was a familiar situation in many areas of the organization. A vote was held in 2000, and the union was decertified, again requiring management to be very sensitive to the feeling of loss by the Wellesley staff.

Over the next two years, through renovations, process and system changes, the staff morale level could easily be compared to a roller coaster ride. This was a very challenging period for the staff. In discussing the magnitude of change, one can envisage the tenuousness of a successful outcome.

The definitive action that finally created the successful team was a promise that the staff would be provided the tools to do their job and feel a sense of accomplishment and pride in their work. These tools were a new work space, best practice processes, new software applications, and improved educational opportunities. The promise was kept.

One venue to prepare the staff for changing roles, as the EHR is implemented, is a partnering with George Brown College to provide an abridged health record technician course to our clerical staff. The core components of this course were very similar to the accredited program; medical terminology, anatomy, ICD-10 coding, and technology applications. Many of the staff had not enrolled in educational sessions since high school, and through completion of this program, a true sense of accomplishment was realized. The professional staff is sent to yearly coding seminars and quality utilization meetings. All staff is encouraged to further their education, and the hospital provides a comprehensive tuition assistance program.

The last staff satisfaction survey was polled within a month of outsourcing transcription, and the department scored only 48 percent favorable.   These poor results were expected, and the next survey should indicate a marked turnaround in staff satisfaction, based on the direct correlation of staff satisfaction to customer satisfaction. One of our major customers, physicians, responded to a satisfaction survey in spring 2004, resulting in improved satisfaction rates of 85 percent.

Realigning Processes

  • How to plan and execute sustainable process changes
  • Process improvement methodology
  • Measuring the changes  

The first critical process change brought about by the merger was the consolidation of the paper chart between the two hospitals. An important factor in the physical merge of the Wellesley and St. Michael's hospital charts was both sites had the same Accounts Receivable/Admission, Discharge, Transfer (AR/ADT) system. This common encounter allowed for easier conversion and integration of the medical record numbers, patient demographics, and visit history. The transport of 130,000 active records from Wellesley, re-numbering charts, combining 116,000 duplicate records, and performing chart management processes while maintaining business as normal, was a daunting task. Due to the sheer number of duplicate paper charts, a decision was made to electronically merge the records while physically merging only active records. This decision kept costs, resources, and time frames within a manageable level.

Another positive aspect of the chart merge was a request for proposal (RFP) process to manage the increased requirements for off-site chart storage. This assisted in the temporary removal and storage of active charts during the move from Wellesley hospital and renovations to the Health Record Department. Much of the renumbering, merging, and loose report filing was outsourced to our storage vendor during these two pivotal periods.

Process redesign was strategically and tactically important at this phase of planning and implementation, to ensure departmental renovations and workflow aligned for best practice processes. As the renovations began, a management team was training on Six Sigma, a statistical methodology for measuring defects in a process or product. Four   tactical projects were undertaken resulting in major improvements to Health Record core processes.

  • Reduction of loose report backlog and improved filing turnaround time (TAT)
  • Improved chart completion practices and the reduction of incomplete charts
  • Improved chart fulfillment rates for ambulatory patient visits
  • Improved cost per weighted cases through changes to coding workflow

The projects began in April of 2000, and by August of that year, major measurable improvements had been achieved. Many of the gains were sustainable; however, it wasn't until all core processes had been addressed and new system applications implemented that best practice was achieved.

Of growing concern to the organization and to our referring physician community was the TAT for transcribed reports. A variety of solutions were investigated over a three- year period to improve productivity, but without success. Finally, when we realized transcription was not a core process effectively performed in-house, we moved to outsourcing this function. The outsourcing decision based on service level agreements has achieved best practice for TAT and quality when aligned with our in-house applications to manage report editing, authentication, and distribution. A few issues arose due to the outsourcing decision, and important lessons were learned from this experience.

  • Staff morale was negatively affected, and trust between management and staff was strained.
  • There was a large backlog of reports in the hospital dictation/transcription system at conversion time, and elimination took more time than originally anticipated.
  • Due to the backlog, the transcriptionists were kept on after the initial layoff date and during this time, productivity and morale remained low.
  • A smooth distribution process for transcribed paper reports took a number of months to implement.

In retrospect, elimination of the backlog should have transpired prior to layoffs. The transcriptionists should have left their jobs within days of layoff notice. A report distribution process should have been implemented in conjunction with the dictation/transcription deployment.

The full improvement cycle was co-dependent on new system applications; however, all reports were transcribed and available in the hospital electronic database for viewing within 24 hours of dictation, and stat reports were available in two hours or less. This was a tremendous accomplishment from the six- to eight-week turnaround time experienced prior to outsourcing and taking into consideration volumes increased by 29 per cent in the first contracted year.

The success of the outsourced transcription work lead to a re-assessment of the departmental core process for better overall information management. We determined that best practice could be achieved for patient care, research, and education by internally managing:

  • Chart management: report filing, chart retrieval and filing
  • Qualitative and quantitative chart completion
  • Release of information
  • Coding and abstracting
  • Data quality

This lead to further quality changes between 2002 and early 2003 where inpatient chart flow improved with the nursing units accepting full responsibility for chart assembly order. Monitoring of the assembled product, including creation of incident reports for patient documents filed on the incorrect chart, was implemented. Chart completion practices were improved and suspension policies' were passed through the Medical Advisory Committee, improving timeliness for clinical documentation and coding.

Renovating the Physical Environment

  • Remodeling the physical environment for optimal workflow  
  • Renovations and the production line
  • Decommissioning the satellite area

Planning appropriate workflow space in a Health Record Department is similar to creating an assembly line. The configuration of workstations and space for chart holding areas should align with the chart processing steps, allowing for reduced chart filing/retrieval time. The technical and physician chart completion areas need to be designed for quiet concentration. Of utmost importance is adequate space to accommodate the active charts so filing can be performed quickly and accurately. Another consideration in the planning of a health record department is security of patient information while allowing access to the department for hospital employees, physicians, and external parties in a 24/7 operation. All of these considerations became part of the renovation planning process.

A challenge in renovating the entire department was the need to move staff, processes, and product to a temporary location. The temporary location was less than optimal, so for a number of months, the staff faced extra challenges in meeting the needs of the organization. However, the performance contracts with the off-site storage vendor allowed for time-sensitive assistance to the staff in managing chart availability for patient care and research. As detailed earlier, the outsourced vendor performed chart cover re-numbering, combining physical duplicate records, purging inactive records, and responding immediately to urgent chart requests.

When the renovations were completed and the ribbon cut, the staff had new ergonomic workstations equipped with upgraded computers and enough storage space to house most of the active charts. There was a satellite department that stored the overflow of active records where a skeleton staff performed all chart management functions. By the beginning of 2003, the chart storage vendor was asked to perform another purge and this time, the satellite area was decommissioned as a work area and is used only for older chart storage. All staff and departmental functions were finally consolidated into one area and the last phase of change began.

System Planning and Implementation

The critical success factor to consider in implementing new systems is remembering that successful applications require successful processes to realize optimal collection and generation of information.

The Health Record Department had automated chart location, release of information, and coding/abstracting systems. The systems, however, were based on old technology, providing little functionality, and even less reporting capabilities. After a review of the hospital strategic plan, an RFP with detailed functional specifications was sent to four vendors. One important requirement of the RFP was vendor assurance that their applications would run on Citrix appliances. The hospital was moving toward a rollout of this hardware as a cost-effective solution to increased workstations throughout the organization. The Citrix solution also reduces possible introduction of virus infected floppy disks or CDs on the departmental desktops.

The successful proposal to supply Health Record systems was submitted by SoftMed, and a contract was negotiated to provide a full suite of applications to be installed during a six month period, with the first application to go-live on April 1, 2003.

Abstracting Application

We installed an abstracting module to accommodate ICD-10 conventions and interfaced it to the ADT system, creating an abstract on admission. Additionally, the product would be interfaced to a 3M encoder and grouper application. The implementation was a first for SoftMed in dealing with the ICD -10 conventions and the Canadian DAD (Discharge Abstract Database) and NACRS (National Ambulatory Care Reporting System) Ministry mandated reporting requirements.

Challenges that occurred during the implementation were:

  • The go-live occurred during SARS, and the staff was trained on this new application via the Web. The application is user friendly and intuitive, so there was little impact in not having the vendor on site.
  • The fiscal year starts April 1 and coding in the new application began on target; however, CIHI issued new errata for over 1000 codes on April 19, and all charts from the live date had to be re-coded.
  • The encoder product did not have the new values installed for a number of months, and another less efficient code finder product had to be utilized.

Despite all the issues, the actual system implementation, product training, and acceptance went very well.

Subsequent to the benefits realized from this implementation, another positive improvement has been achieved through the partnership with SoftMed. In October of 2003, the Ontario Ministry of Health mandated coding of Haemodialysis visits. A pilot assessing impacts of this mandate determined it would require a staffing complement of 1.4 FTEs processing the 33,000 yearly visits. The vendor has provided an electronic hard coded enhancement to the abstract, enabling auto-coding of these visits. This solution resulted in the cost avoidance of 1.4 FTEs, and closing the month's visits is completed in five minutes.

Chart Management Applications

The next suite of products implemented was chart management, comprised of chart locator, chart reserve, and chart completion. A decision was made not to bring conversion data from the legacy systems into the new applications. This meant that until a history developed over time in the new systems, searching in the legacy systems continued for a limited time period. This created extra work for the staff; however, corrupt data was not imported to the new databases. Within six months, the legacy data was rarely accessed.

The implementation issue of not having an on-site vendor for building the systems or reviewing process continued due to SARS. The applications are intuitive, and the staff built and tested the applications with conference call support and dial-in system access.

The only outstanding issue with this product range is the full utilization of Chart Reserve, which will not occur until an interface is developed with our new enterprise-wide scheduling application. Until this phase is complete, fulfillment rates are measured manually; however, processes are not affected, and we maintain the target of 99 percent chart fulfillment.

Release of Information Application

The release of information application was installed concurrently with the chart management applications. Conversion of data was not considered a viable option, requiring manual input of all outstanding requests. During the build and testing phase of this product, approximately one month of outstanding requests were incomplete. Three months after go-live, backlogs were measured in hours and the successful elimination of backlogs has increased revenues by 16 percent over budget.

Transcription Application

The last system application installed as part of the planned six-month implementation was ChartScript. This application provided a solution to manage the format and distribution of the reports received from the outsourced transcription vendor. There is an interface from ChartScript to the clinical repository where the reports are viewed online. Print or fax distribution of reports is also managed through this software and enables report distribution within 48 hours or less.

The entire suite of products was implemented on time and budget due to the vendors well defined implementation plans and documentation and a dedicated implementation team. An additional product enhancement for documentation authentication has been added to this product package and has been well received by the physician community.


The department has achieved measurable positive outcomes in all core processes, and the statistical trends indicate the outcomes are sustainable with effective utilization of departmental resources.

  • Staffing--due to departmental changes, a budget reduction of 8 FTEs has been achieved through attrition and reduction in casual hours.
  • Abstracting--due to process changes and system implementation, cost savings for the last fiscal year is reduced by 45 percent.
  • Auto-coding of Haemodialysis patients realized a cost avoidance of 1.4 FTEs.
  • Reduced coding submission turnaround time from 90 to 20 working days.
  • Transcribed reports--savings of 67% on paper costs.
  • Reduced transcribed report turn around time to 24 hours.
  • Release of information--last fiscal year a 16 percent increase in revenues was realized.
  • Data quality--achieved reconciliation of statistical data between Registration, Health Records, Finance, and Decision Support departments on a monthly basis through improved collection and reporting of information.


In moving to an electronic health record, it is imperative that information management and technology:

  1. Support a culture of respect that is fostered between staff and management.
  2. The core processes are well defined and have been reviewed and optimized.
  3. A culture of learning and innovation are evident in vision and in practice.
  4. Outcomes are measurable.

Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004