1 A P P L I C A T I O N S A W H I T E P A P E R S E R I E S WITH FEDERAL LED E-HEALTH INITIATIVES, THERE IS A FLURRY OF ACTIVITIES IN THE EHR SPACE. HOWEVER, FROM A PROVIDER PERSPECTIVE, SELECTING A BEST-OF-BREED SOLUTION IS JUST HALF THE JOB. IT IS THE ACTUAL DEPLOYMENT OF THE SYSTEM ON-SITE AND ENSURING PROVIDER ACCEPTANCE OF THE SAME WHICH MAKES OR BREAKS SUCCESS. Electronic Health Records Overcoming Challenges in Deployment and End-user Adoption
2 STRATEGY LEADS TO SOLID FOUNDATION WHAT IS AN EHR? PROVIDER MATURITY IN ADOPTING EHR/EMRS WHAT ARE THE ISSUES IN IMPLEMENTATION? SYNTEL S PRESCRIPTION FOR PAIN FREE EHR IMPLEMENTATION A BIG BANG OR A PHASED APPROACH TO IMPLEMENTATION? CONCLUSION REFERENCES ABOUT SYNTEL Electronic Health Records In April 2004, President Bush called for widespread adoption of interoperable Electronic Health Records (EHRs) within ten years and established the position of National Coordinator for Health Information Technology (ONC). One year later, the American Health Information Community (AHIC) was formed to help advance efforts to accomplish this vision. The Community is a federally-chartered advisory committee and provides input and recommendations on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way. Recent changes to Stark law provisions (2006 amendment) are seen as a regulatory move encouraging widespread dissemination and adoption of EHR systems. One key focus area is to bring the individual physicians (or group practices) within the EHR spectrum of hospital-based providers to provide a continuum of care from the primary to the tertiary level S Y N T E L, I N C.
3 The EHR attempts to promote a more holistic view of patient records where continuum of care is the key aspect. 1. STRATEGY LEADS TO SOLID FOUNDATION With federal led e-health initiatives, there is a flurry of activities in the EHR space. However, from a provider perspective, selecting a best-of-breed solution is just half the job. It is the actual deployment of the system on-site and ensuring provider acceptance of the same which makes or mars the IT project. A stunning presales demo on a small amount of artificial data may not provide the same results when implemented on-site and one is left to deal with a large amount non-standardized clinical data. The deployment of healthcare solutions requires an in-depth understanding of departments specific needs and workflows. No two healthcare settings will have the same workflow; hence any healthcare IT solution must involve a great deal of customization to suit particular needs. Prior to implementing an EHR solution, a strategy planning exercise should be undertaken that examines issues such as: Scope of the implemented solution How to bridge the gap between what is available and what is needed End-user concerns with adopting IT systems and how to overcome them Steps involved in implementation How to achieve rapid deployment 2. WHAT IS AN EHR? The healthcare space is rife with literature on terminologies pointing to electronic patient data capture. The terms EMR (Electronic Medical Record), EHR (Electronic Health Record), CPR (Computerized Patient Record) 1 and others are often used interchangeably. In fact, there is no universally adopted definition distinguishing one from another. However, most references adhere to the 2003 Institute of Medicine (IOM) Letter Report in Key Capabilities of an Electronic Health Record System 2, where the EHR is defined as including: Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual Immediate electronic access to person- and population-level information by authorized, and only authorized users Provision of knowledge and decisionsupport that enhance the quality, safety and efficiency of patient care Support of efficient processes for health care delivery Simply put, EMRs refer to all patient related data traditionally captured in the medical case file within a single provider setting. EHR refers to a collection of a patient s health information gathered across his/her lifespan. The EHR is not restricted to interactions with a provider alone, but takes into account interactions across the healthcare system ranging from payers, regulatory bodies, registries as well as devices outside the provider setting. The EHR attempts to promote a more holistic view of patient records where continuum of care is the key aspect, allowing access to medical information by multiple stakeholders. An EHR can be a system of multiple systems or an enterprise wide solution spanning a range of functions and departments. In the course of this paper, the term EHR broadly refers to: A system of systems approach, providing an integrated view of electronic health data of a patient with diverse systems feeding data at one place A system that provides a continuum of care which includes integration between various care delivery organizations, providers and external systems
4 Aspirin Causing Headaches? Consider the scenario of aspirin prescriptions from a Neurologist and Cardiologist point of view. Aspirin prevents platelet aggregation, thereby increasing the bleeding risk in the case of a hemorrhagic stroke patient. Therefore, this drug is routinely prescribed by cardiologists to prevent a recurrence of a myocardial infarction (heart attack). However, a neurologist might wish to have a trigger alert for this drug which might prove extremely irritating to the cardiologist who regularly prescribes it. This example illustrates the level of complexity in customizing the system. PATIENT JOURNEY EHR MODULES ELECTRONIC HEALTH RECORD SPECTRUM VISIT TO CLINIC MPI/REGISTRATION PATIENT CENSUS PATIENT LIST SCHEDULING BILLING/CLAIMS ALL STAGES CDSS/CMV PORTALS REGISTRIES & REGULATORY BODIES PAYERS DIFFERENT PROVIDERS DISEASE MANAGEMENT MOBILE HEALTH PLATFORM As in the definition, an EHR system receives inputs from multiple applications catering to departmental or functional areas. We have attempted to map these functional areas with a patient journey so as provide an end-to-end overview of an EHR. 3. PROVIDER MATURITY IN ADOPTING EHR/EMRS Organizations are at different maturity levels in terms of EMR adoption. A study by Health Information and Management Systems Society (HIMSS) 3 indicated seven stages in achieving a full-fledged EHR where Stage Zero indicates some clinical automation may be present, but all three of the major ancillary department systems (laboratory, pharmacy, and radiology) are not implemented. In this same study, Stage Seven indicates an ideal provider setting which has a paperless EMR environment where clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a regional health network (i.e., other hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients). Statistics from the study reveal that the majority of U.S. hospitals (almost 40%) are in the early stages (Stage 0 and 1) of EMR adoption. Most others are at a reasonable maturity level (Stages 2, 3 and 4). However, less than one percent of hospitals have achieved Stages 5 and 6 and not even one hospital in the HIMSS analytics database is at Stage 7. Beyond cost, successive generations of solutions come with a battery of complex functionalities which are REFERRED TO HOSPITAL REFERRAL DOCUMENTATION ADT CARE PLANS/CHARGE CAPTURE EVALUATION & SPECIALTY CARE RESULT MANAGEMENT PACS/DICOM PHARMACY OPERATION SUITE CARDIOLOGY SUITE CONSULTED BY PHYSICIAN ENCOUNTER-DRIVEN CLINICAL DOCUMENTATION HISTORY, PROBLEMS EXAMINATION NOTES ASSESSMENTS, VITALS TASK LIST ORDER PLACING CPOE LABS, RADIOLOGY DRUGS (E-PRESCRIBED) NURSING OTHER (BLOOD, ETC.) extremely challenging to implement. One study suggests that the more advanced the application in terms of functionality, the greater are the perceived net benefits. Unfortunately, the degree of EMR adoption by physicians appears to be inversely related to functionality. 4. WHAT ARE THE ISSUES IN IMPLEMENTATION? There are various factors which can have an impact on a successful implementation. The outlined figure to the right provides an overview of these. DOMAIN FACTORS Lack of a common vocabulary Healthcare solutions deal with a variety of medical vocabulary. Some segments of this problem have been addressed in the form of International Classification of Diseases (ICD), Diagnosis Related Groups (DRG), or drug codes. However, confusion still exists in some key areas, including: Lab test result formats are defined by Logical Observation Identifiers Names and Codes (LOINC). However, there are no standardized codes for orderable lab tests National Drug Codes (NDC) specifies drug codes of only dispensable prescriptions There is no dictionary of terms for orderable radiology investigations Process variation between hospitals No solution can be replicated directly from one
5 provider setting to another without extensive customization. There are also variations between what is the right flow even within a provider. One needs to evaluate which aspects are required and which ones are to be made redundant. Disagreement regarding the protocols to be followed On medical aspects of care, opinions can vary between what should be the standardized set of protocols to be established. Some examples are: Follow generic drug names or trade names for medicines Standardized therapy protocols for assessment forms or order templates Level of Clinical Decision Support to provide (which alert is supportive & which is intrusive) Policy on defining scope of decision support intervention (whether to allow alert overrides, customizing of order sets, etc.) An interesting scenario in this regard is the challenge in customizing an ordering solution for a neurology and a cardiology provider. SYSTEM FACTORS The lack of interfaces between the physician practice and the data systems of external clinical labs, radiologists, and other specialists at the time of EHR implementation is considered a significant drawback for IT solutions. Healthcare providers are grappling with solutions needing interoperable EHR systems. How to link disparate sets of data with a common identifier as well as view these at a single place is the current focus of healthcare IT solutions. The multiple interfaces should present a coherent picture without diluting the accuracy and quality of data displayed. END-USER FACTORS One of the most critical end-user groups are the physicians. Hence, to overcome physician resistance it is important to understand their concerns with EHRs. Physician factors can range from accessibility to a personal resistance to change. These issues can be grouped into two broad areas: IT applications use a. Effort required while abstracting data for migration to new solution b. Ability to access data anywhere (portals and handheld units could be the solution) c. Presenting the right information in the right context d. Formulating descriptive clinical summaries e. Problems in easy data entry f. Comfort with adopting newer technologies Negative perception of IT systems a. Ambiguity of benefits derived from newer solutions b. Resistance to change process Although there are no composite solutions to all these issues, a thorough evaluation of various EHR applications from a usability perspective (keeping in mind the physician issues with using IT applications) would help resolve some of these issues. A good way to communicate the positive impact on processes would be to document pre & post implementation metrics. This provides a dual advantage of familiarizing the processes prior to implementation and secondly provides benchmark data for comparison. Physician resistance to change stems from the lack of clarity regarding what changes take place to work-flows and how these would impact productivity. In this case, strong clinical leadership and motivation by clinician champions is critical to tide over the change resistance. Implementation teams also need to gear up to promote an environment where change is welcome. Physicians need to be prepared to change some of the traditional ways of data capture, as systems force documentation which were earlier verbally managed. The other end-user factors range from the lack of having a thorough training plan to addressing the challenge of maintaining dual work-flows till users stabilize. Training should target specific concerns rather than generic sessions. Implementation teams should realistically identify the learning curve and time to return to baseline productivity. There would be a dip in productivity initially for which a plan has to be framed to manage it rather than being overwhelmed by it. 5. SYNTEL S PRESCRIPTION FOR PAIN FREE EHR IMPLEMENTATION The EHR implementation process starts long before the physical deployment of the application on-site. The implementation plan needs to be thought out even before selecting a vendor. The Electronic Physician Guidelines for Implementing a Paperless Practice provides an PHYSICIAN CONCERNS WITH EHRs DATA MIGRATION AND ABSTRACTION LIMITED ACCESSIBILITY INFORMATION DELUGE DESCRIPTIVE CLINICAL SUMMARY DATA ENTRY AMBIGUITY OF BENEFITS COMFORT WITH TECHNOLOGY RESISTANCE TO CHANGE Any negative perception of any of the key aspects of the EHR mental model as perceived by an end user can mar a successful implementation plan. IMPORTANT FACTORS IN EHR IMPLEMENTATION DOMAIN FACTORS LACK OF COMMON VOCABULARY PROCESS VARIATION BETWEEN PROVIDER SETTINGS DISAGREEMENT ON STANDARD PROTOCOLS OR POLICIES SYSTEM FACTORS LACK OF WORKING INTERFACES MULTIPLE VARIED SOLUTIONS TO BE INTERFACED QUALITY OF DATA DISPLAYED END-USER FACTORS PHYSICIAN DISCOMFORT TRAINING MAINTAINING DUAL WORKFLOWS
6 THE SIX-STEP DEPLOYMENT PLAN 1 ASSESSMENT PHASE JOINT IT TEAM FORMED DEFINE SCOPE WORK-FLOW ASSESSMENT ELIMINATE REDUNDANCIES GAPS ANALYSIS GAP ASSESSMENT DOCUMENT GENERATED 2 GAP RESOLUTION ADDRESS GAPS (SIGN-OFF) INTERFACING NEEDS ADDRESSED NEW FEATURES ADDED BENCHMARK DATA COLLECTED 3 APPLICATION CONFIGURATION DATA INTEGRATION CONFIGURE RELEVANT CLINICAL META DATA INTERNAL TESTING DOCUMENTATION UPDATED CHANGE MANAGEMENT & COMMUNICATION PLAN 4 INSTALLATION PILOT IMPLEMENTATION PHYSICALLY DEPLOY APPLICATION KITS ON-SITE DATA MIGRATION 5 TRAINING TRAINING SUPER-USERS CLINICIAN CHAMPIONS PHASE WISE END USER TRAINING GO-LIVE 6 SUPPORT ADDRESS NEW CR S DUAL WORKFLOW HAND-HOLDING ON-GOING SUPPORT IMPROVEMENT ANALYSIS EHR mental model 4 which lists the following as primary criteria to be considered before finalizing an EHR solution: Usability Specificity Workflow Deployability Scalability Syntel has developed a structured best practice roadmap that addresses these criteria and provides an implementation plan to deploy EHRs. ASSESSMENT PHASE The key objectives of this phase are to understand the current situation and develop a plan to implement EHR successfully within the organization. A joint implementation team is formed in this phase to conduct a detailed organizational assessment. The team includes clinician users, management representatives, other departmental users, vendor partner, and internal IT support team partner. The assessment executed by the team defines the scope of the project in terms of the functions and departments to be supported. A detailed work-flow analysis of the scoped functions is also performed to understand gaps and redundancies. Any gaps identified are analyzed on a cost-benefit perspective to determine if the feature is essential in the final solution. In this phase, the team also develops the implementation plan with implementation milestones and deliverables for a clear roadmap and role clarity for team partners. GAP RESOLUTION AND READINESS PHASE In this phase, gaps identified in the Assessment Phase and deemed essential are closed. This may involve developing enhancements or features supporting the solution design. In addition, readiness activities are undertaken. This includes addressing interface requirements as identified in the scope, such as developing and testing HL7 messaging brokers or other interfacing solutions for data exchange. Simultaneously, pre-implementation benchmark data for comparison is collected to provide useful inputs in determining the impact the solution has had in improving efficiency. APPLICATION CONFIGURATION PHASE This phase begins with validating the integrity of data onto the new solution. The relevant functional data sets are mapped between the legacy and new applications and tools are developed to assist in transferring this data across to the new database. Relevant clinical and other data dealing with forms, templates, alerts, drug and laboratory order sets, specific reference terminologies used with the hospital, user profile mapping, and other requirements are configured into the system. The solution undergoes rigorous internal testing to determine the correctness of the data migration and configuration. End-user functional testing is also executed in this phase to confirm the flow s clinical correctness. This phase also involves detailed documentation of solution features as well as training templates for support. The implementation team will develop a change management plan addressing which users and departments to target, the most effective mode of communication and how to overcome change resistance. INSTALLATION PHASE In this phase, the network, hardware and application infrastructure is physically installed on-site and detailed data migration process is carried out. Prior to this phase, Syntel works with the customer to evaluate which department should be the first to launch the new system. TRAINING PHASE Training includes super-user training which would then help in training other users in phases. Carefully identifying a clinician champion at this juncture promotes the physician acceptance within the doctor network. Based on user comfort and stability of the application, a go-live date is set. SUPPORT PHASE This phase involves addressing any new change requests due to unforeseen essential customization. The department maintains dual work-flows in parallel for a period of time to take care of any contingencies as well as to gain end-user confidence in the system. A period of handholding by the joint support team is determined which later moves into an on-going support phase. Post stabilization, one can analyze efficiencies by comparing current data with pre-implementation benchmark data.
7 6. A BIG BANG OR A PHASED APPROACH TO IMPLEMENTATION? There is an enormous debate on whether to go in for a BIG BANG approach in implementation or to go for a slower PHASE WISE implementation of EHRs. Opinions widely differ on the two topics. Syntel s perspective on the issue is that there is no one size fits all answer for this dilemma. An organization must analyze many factors to determine the best approach including size of the practice, complexity of the solution, alignment to existing workflow, function of end-user, structure of data entry, workload and time available for pre-training. A phased implementation approach will provide a slow ramp-up of knowledge base without taxing users ability to grasp the new processes and adapt to change. Typically, complex multi-departmental clinical solutions should follow the phased approach while smaller physicians or group practice with customized solutions could be successful with a Big Bang approach. The Big Bang approach also removes the necessity to maintain dual workflows simultaneously. 7. CONCLUSION Deploying a healthcare solution presents a unique set of challenges pertaining to the domain, solution, as well as the physician and the end-user. The solution s acceptance by the end-user, in particular the physician, is critical to the success of the deployment. A good deployment plan anticipates and accommodates issues arising out of the deployment process. Quite often it s the ambiguity of benefits and the inertia to change which mar the deployment process. Choosing a reliable partner who understands the domain and can support providers through the deployment process would take away the pain associated with implementation. References 1 Dave Garret & Mike Davis, EMRs and EHRs, Healthcare Informatics online, October Key Capabilities of an Electronic Health Record System, Letter Report from the Institute of Medicine 3 The EMR Adoption Model, HIMSS Analytics in benchmarking reports 4 The EHR mental model: The big picture, The electronic physician: guidelines for implementing a paperless practice BIG-BANG VS PHASED IMPLEMENTATION FACTORS TO CONSIDER Size of practice Complexity of the solution Alignment to existing workflows Function of end-user Time available for pre-training Work-load Interfaces Structure of Data entry BIG-BANG APPROACH Individual physician or smaller group practice of single specialty Simple features with less of memory-driven UI High degree of customization Administrative or clerical More Moderate volume Single departmental or simple interface Pre-configured fixed templates PHASED IMPLEMENTATION Large number of multi-specialty physicians Complex decision support solutions with multiple features Standard product needing modification of workflows (more gaps) Clinical or nursing related profile Less High volume Complex interdepartmental solutions Descriptive or gradually evolving data
8 aboutsyntel: Syntel provides custom outsourcing solutions to Global 2000 corporations. Founded in 1980, Syntel s portfolio of services includes BPO, complex application development, management, product engineering, and enterprise application integration services, as well as e-business development and integration, wireless solutions, data warehousing, CRM, and ERP. Recognized by customers to be Small enough to listen, Big enough to deliver. for our responsiveness and ability to build collaborative partnerships, Syntel is known for solutions that deliver sustainable business advantage. Our mission is to create new opportunities for customers by harnessing the passion, talent and innovation of Syntel employees worldwide. We do this by leveraging dedicated vertical and service Centers of Excellence along with its flexible Global Delivery Model to deliver solutions that drive innovation, improve quality and reduce costs. Syntel s global approach also makes a significant and positive impact on speed-to-market, budgets, and quality. We deploy a custom delivery model that is a seamless extension of your organization to fit your business goals and a proprietary knowledge transfer methodology to guarantee knowledge continuity. SYNTEL 525 E. Big Beaver, Third Floor Troy, MI phone v i s i t S y n t e l s w e b s i t e a t w w w. s y n t e l i n c. c o m