Enterprise EMR implementations are long and complicated, usually taking place over the course of a few years. Though vendors provide project management staff to work onsite during implementations, some hospitals choose to augment, or even forego that talent in favor of a consulting firm. Others rely more on their in-house staff. For EMR implementations, does staffing come down to cost, experience, or a mix of both?

Most agree that when it comes to implementation staffing, there is no such thing as one size fits all and that the most important factor is the system itself. According to Vince Ciotti, principal with Santa Fe, N.M.-based HIS Professionals, the EMR selection should determine subsequent staffing selection. There are many pitfalls in this first step, not the least of which is staffing for the RFP itself, he says. “Most hospitals get seduced by a giant consulting firm that leads them down the rosy path of the biggest possible implementation.”

Guide to Need for “Consultant” Implementation Assistance, by Vendor Size

Ciotti says that if the same consulting firm is hired for both the RFP and the implementation itself, it can lead to a serious conflict of interest as the firm may push for a larger and more costly system than is necessary.

At Wheeling Hospital in Wheeling, W.Va., David Rapp, CIO and vice president, supply chain, decided to forego a consulting firm for his EMR RFP, and spent a year digging through the weeds with an in-house comprehensive vendor analysis (he ended up selecting Eclipsys). “We didn't use a consulting firm for the RFP,” he says. “We didn't want to be in the position of saying, ‘The high-powered consultant said it was a good choice.'”

That was a smart move, according to Ciotti, who says that consulting firms have a quota just like vendors. “They aren't your partner,” he says. “Hospitals have to be very suspicious of consultants and vendors equally. They're both in league to suck money out of the hospitals - that's how they make a profit.”

His advice? If using a consulting firm to help select an enterprise EMR, use a separate consulting firm for implementation.

At Wheeling, Rapp kept staffing front and center in contract negotiations with Eclipsys. “We pushed very hard for that - to meet and review candidates,” he says. “We wanted them to be seasoned veterans, and that was part of the negotiation.”

Project staff salaries can also be part of those contract negotiations. Neal Ganguly, vice president and CIO at Freehold, N.J.-based CentraState Healthcare System, says there were two staffing elements in the negotiated price of his Siemens (Malvern, Pa.) Soarian EMR. The first was selecting vendor project staff as part of the standard application, and the second was for additional Siemens staff he might need in the future for an order build or on a tight deadline. Ganguly says he negotiated a discounted rate upfront for the additional personnel.

Savvy CIOs know that implementation staff provided by the vendor can make or break a project. Ciotti suggests hospitals insist on meeting the implementation team before any contract is signed. His advice is to tell the vendor: “I'm not signing a multimillion dollar contract for people I can't meet.”

Most agree the quality of vendor staffing varies enormously. “Many vendors recruit at college campuses and train on the job - sometimes they're upfront about it, and sometimes they're not,” says Terri Steinberg, M.D., CMIO of Christiana Care Health system in Wilmington, Del. “Vendors tend to send their best resources to their best customers.” For smaller hospitals, that can be a problem.

Even with the best upfront negotiations for quality vendor staff, a consulting firm is often needed to assist in the implementation. Ciotti says that although it will cost millions, when it comes to high-end systems, using a consulting firm like Accenture or Perot is a must. Vendors simply do not have enough project managers on staff for a large EMR rollout, he says. However, when it comes to a smaller scale, things are quite different. “You should never waste a dime on consultants for the low-end EMRs; it just interferes and slows things down.”

Small systems aside, most say a balanced EMR approach involves using some combination of a vendor, a consultant and in-house staff. Steinberg says she uses project staff from multiple consulting companies. “I'd recommend a combination of somebody who has a window into the mothership from the vendor, combined with really good resources from the consulting side. There's no project that has sufficient time or resources to succeed using anyone who's less than excellent - and how many excellent resources does any consulting company have at any given time?” And it's not the company name that Steinberg says she cares about, only the person they send. “You should be looking for people, not companies.”

Finally, smart CIOs know that some of the expertise will come from within the hospital. Sometimes, that means reorganizing the department and creating new titles, which is what happened at Wheeling. Rapp says he was against using consultants. “They want to keep themselves employed and keep enough problems around so they can come back.” Now six months into Phase I of the Eclipsys implementation, Rapp has created a clinical informatics department, hiring 14 people internally to complement the vendor staffing. “We decided we were going to staff this with seasoned, highly effective results-oriented people, and went out looking for the smart nurse managers on the floor.”

Rapp says he had one stipulation for all internal staff joining the project team: they had to spend one day per period working in a clinical role. Otherwise, he feared they might forget the clinicians' experience and would revert to an “us versus them” perspective.

Another strategy Rapp found for keeping the internal implementation staff motivated was bonuses based on reactions from floor end-users.

The internal implementation staff at CentraState had an even larger role for a different reason: Soarian was so new at the time that Ganguly says there simply wasn't a big enough pool of experienced consultants. In addition to using Siemens' implementation staff, part of his overall strategy was to use internal interdisciplinary teams, including 40 to 50 clinicians. “You've got to have ownership,” he says. “If you have external people, they disappear and then you don't have a body of knowledge to build on.”

That post-implementation staffing is something savvy CIOs keep front and center. Ganguly says the core people on the project became like his own employees. In fact, the lead member, though still a Siemens employee, is with him today. “We became a key partner for Siemens and I felt it would make a lot of sense for her to come on board with us,” he says.” I convinced everyone it was in our mutual best interest.”

That is the rare exception, however, as many vendors discourage this type of migration, and some expressly forbid it.

“You have to make sure you build knowledge transfer into the project plan,” says Steinberg. “You may be hiring an analyst to do the build, but if the design is done by your own people, it's a natural transfer.” In the end, she says, the critical success factor is treating all implementation staff as part of the same team. “If you can go around the table and figure out who is working for whom, you've failed.”