Leading from the future: leadership makes a difference during electronic health record implementation.

WHEN I STARTED working in the information technology (IT) department of a large metropolitan hospital in the mid-1980s, my job was to assist in the installation of computer applications for our nursing units. One of my first projects was computer-based order entry for health unit coordinators and nurses. The job was simple and the benefits clear-replace paper requisitions, eliminate the manual transfer of the requisition to the ancillary departments, and get rid of manual charge entry into the patient accounting system. We did this with a mainframe-based, self-developed computer system that automated order entry, printed the order in the ancillary departments, and transferred the charge for the order into the patient accounting system. There was no confusion about what the application did and what its benefits were. Everyone agreed that the computer-based system was better than the manual system-it reduced errors, improved throughput time for orders, and virtually eliminated lost charges. Much has changed over the last 25 years. Today we see a new level of clinical IT use that touches almost every aspect of the clinicians' workday and requires defined integration into clinical workflow. We are now implementing systems that support clinician care planning and documentation, provide best practice alerts and clinical reminders, document medication administration and positive patient identification using bar coding, and promote evidence-based practice with order sets. We have moved from simple system installation to complex system implementation and now need to tend to concerns about system utilization by clinicians. We talk about successful electronic health record (EHR) implementations with words like system adoption, workflow optimization, and enabling care transformation. Let's examine some of the reasons for this sea change and look at the role of leadership in facilitating successful EHR implementation. LEADING FROM THE FUTURE As discussed in the articles by Hood and Bernd and Fine, EHR implementations are challenging, complex, disruptive, and expensive. The authors point out that it is difficult to drive clinical transformation to achieve return on investment without paying very specific attention to it - and that is where leadership plays a key role. I couldn't agree more. So exactly what does "leading from the future" reference? As many leadership books explain, leadership begins with a clear vision of a goal, and effective leaders articulate the vision and inspire people to follow. But developing that clear vision in healthcare is getting harder. Until now, we've been able to use the past as an effective guide to plan the future, but we can no longer rely on what was successful in the past. Now as we develop the vision of what we want our healthcare organizations to be, we need to look to the future to see where we need to go. Bernd and Fine emphasize the importance of articulating a clear vision that serves as a rallying point for clinicians and can also be used in communications supporting the EHR implementation. This articulation is an important first step, but there are many other ways that leaders can use what they know about the future to build and support EHR project success. BUILDING THE PROJECT SUCCESS FACTORS Physicians and nurses love technology when it helps them in their patient care and supports their workflow processes. But they become frustrated with technology when it is slow, imperfect, takes more time, or generally does not fit into a workflow process. At times we can force the use of systems when we implement. For example, we can take away the paper, and physicians and nurses are forced to use the computer, as would be the case when eMAR (electronic medication administration record) is implemented and the paper MAR is eliminated. But we cannot force the technology adoption into workflow or the transformation of care, particularly if these are not inherent to the technology and process being implemented. …