Ambulatory EMR Implementation at Texas Children s Hospital. GE Healthcare User Summit September 23, 2004

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1 Ambulatory EMR Implementation at Texas Children s Hospital GE Healthcare User Summit September 23,

2 About TCH Texas Children s Hospital (TCH) is the largest pediatric hospital in the U.S., with licensing for 715 beds. TCH is affiliated with Baylor College of Medicine and serves as its primary pediatric training site. The medical staff consists of 1,600+ primarycare, specialist and sub-specialist physicians, as well as dentists. TCH covers more than 40 pediatric medical and surgical subspecialty areas. More than 1 million patients have been cared for since the hospital opened in West Tower Inpatient Care 2

3 Clinical Care Center - Outpatient Clinical Care Center Texas Children s Clinical Care Center is a 17-story, 810,000-square-foot outpatient facility housing approximately 55 ambulatory clinics. The Center is designed to incorporate clinical information systems from family waiting areas to exam rooms. The Center includes 8 operating rooms, 25 postanesthesia care unit beds, and a dedicated child-life preoperative teaching room. The Texas Children s Cancer Center has grown to include 25 areas for outpatient chemotherapy, 12 exam rooms, a satellite pharmacy, activity areas and centralized team stations. 3

4 TCH IDS 2004 Q2 Statistics Inpatient Admissions 21,727 Total Patient Days 202,653 Surgeries 20,491 Transplant Cases 37 Emergency Center Visits 80,374 DI/Radiology Exams 144,925 Lab Tests 1,453,926 Med. Doses 2,410,983 Respiratory Care RX 813,968 Outpatient Visits 638,194 TCPA (owned practices) Patient Encounters 938,586 Health Center Patient Encounters 60,260 Home Health Visits 25,002 TCH IDS Employees: 6,000 TCH EMR Distinctives Broad access to patients medical records across clinics, units, buildings, and different metropolitan regions Deep access to patient information from many disciplines & specialties, and to custom documentation tools Coordination and management of implementation by information services, operations, medical records, and medical staff 4

5 TCH 2004 Q2 EMR Vital Signs 4+ years of implementation began in October clinics live on one database 300+ physician users 3,000+ user accounts 300,000+ unique patient charts 3,000,000++ chart documents Ambulatory Clinics Adolescent Medicine Allergy & Immunology Autism Spectrum Disorder Blue Bird Neurology Bone Marrow Transplant Brachial Plexus Bridges Program Child Protective Health Clinic for Attention Problems Critical Care Craniofacial Dental Dermatology Developmental Pediatrics Eating Disorders Feeding Disorders Fetal Surgery Center Fracture Gastroenterology/Nutrition General Medicine General Pediatrics - Academic Genetics/Metabolic Gynecology Hand Surgery Infectious Disease Neonatal Follow-up Neonatology Graduate Neurofibromatosis Neurosurgery Ophthalmology Orthodontics Orthopedics/Scoliosis Pain Clinic Pediatric Surgery Physical Medicine Plastic Surgery Prader Willi Pulmonary Medicine Psychiatry/Psychopharmacology Rheumatology Renal Skeletal Dysplasia Retrovirology Rett Center/Epilepsy Sleep Disorders Spasticity Clinic Spina Bifida Sports Medicine Super Kids Mobile Clinic Texas Children s Cancer Center Urology 5

6 Health Centers Clear Lake Health Center Sugar Land Health Center Cy Fair Health Center Woodlands Health Center Memorial Health Center Ancillary Services Audiology Ostomy/Wound Care Child Life Physical Therapy Dietitians Pulmonary Diagnostic Lab EC Child Abuse Phresis Learning Support Center Respiratory Therapy Neurophysiology Social Services Nutrition Support Speech Language & Learning Occupational Therapy Wellness Center EMR Environment 6

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10 Clinic Implementation Team EMR Systems Analyst EMR Systems Educator Clinic staff physician Clinic nurse Resident/Fellow Clinic Manager Clinic Assistant Director Medical Record Assistant Director Ancillary staff: clinical assistant, respiratory therapist, social worker, et al 10

11 Pre-Implementation Assessment Prior to any implementation activities, a clinic readiness and needs assessment is completed The Clinic Chief, providers and clinic staff are interviewed to understand: Clinic characteristics & operating data Clinic processes Decision-making processes Potential issues A confidential White Paper is prepared for review by the Clinic Chief and the EMR Executive Steering Team Pre-Implementation Assessment Resources and Technology Skill level Medical Staff Support Staff Potential Issues Staff Implementation Expectations Expectations Potential Issues 11

12 Pre-Implementation Assessment Analysis/Summary of Findings Summary of Findings Overall Risk Level (Minimal, Moderate, High) Opportunities Implementation Recommendations What must be done for this clinic to ensure its success with the EMR? Example 1: Forms-based Real-time Transcription Pediatric Ophthalmology High throughput clinic Maintain or increase productivity New workflow was developed Tested with time-trials MD views custom encounter form in EMR MD dictates note with micro-cassette recorder Staff performs structured data entry into EMR while listening to micro-cassette MD reviews, edits and signs note in EMR 12

13 Example 2: Continuity of Care for Surgical Clinics Phase 1 EMR use for dictation of inpatient operative reports New work types for inpatient transcription Electronically edit/sign documents remotely Print copy for inpatient paper medical record Access to op reports via EMR enables Decreased transcription turn-around time Decreased time to send letters to referring MD Decreased time to submit claims to payors Example 3: Mental Health Providers HIPAA & state law compliance for PHI and psychotherapy notes Restricted document types in EMR Shared medication, problem and allergies lists for patient safety New document model supports Appropriate access for coordination of care Elimination of shadow records Chart access surveillance 13

14 Other Examples: Custom Clinical Development Inpatient & Outpatient Transcription H&Ps, Consult notes, Op notes, D/C summary Electronic Data Interfaces Inbound: Anatomic Pathology, Diagnostic Imaging, Lab Information System, Physical & Occupational therapy Outbound: City-State Immunization Registry Special Studies EEGs, EMGs, Sleep Studies 12-week Implementation Start-up activities Interview clinic staff; observe physician work processes; train to view & print; analyze workflows; determine data for pre-load; assess hardware requirements Week 1 Kick-off meetings Week 2 Identify flowsheets, custom problem & med lists Week 3 Identify needs for letters and handouts Week 4 Workflow for intake, vital signs and check-out Week 5 Workflow for Rx refills and phone notes Week 6 Workflow for office visits Week 7 Workflow for nursing visits Week 8 Workflow for office procedures Week 9 Workflow for letter and handouts Week 10 Workflow for downtime procedures Week 11 End user training Week 12 Go-Live 14

15 Operational Efficiency End paper chase with on-line access to clinic chart, relevant hospital documentation, reports, etc. Access critical inpatient & outpatient patient information in a timely manner Respond quickly to patient requests for information Respond quickly to request for services: refills, etc Specialists complete documentation and complete outside referring MD letter in timely manner Medical Record Department 25% reduction in medical record retrieval positions Redefinition of job descriptions and responsibilities Further changes as EMR reliance increases 15

16 Quality of Care Increase accuracy and legibility of documentation and prescriptions Prevent drug allergy and drug-drug interactions Improved adherence to evidence-based practice Improved reliability of chronic and preventive care Asthma action plans Diabetes care plans Health maintenance guidelines Improved coordination of care across specialties Combined many separate record locations Eliminated roadblocks to information sharing Simultaneous access across clinics Access in seconds vs minutes/hours Billing Compliance Billing Improved compliance with HHS E&M criteria for CPT coding of office visits More appropriate coding and billing for ambulatory services such as chemo infusion, post-operative care Billhold Reduction More efficient coding and claims submission Standardized documentation within clinics Access time reduced, coding speed increased Impact $1.9 million reduction attributable to EMR in 1 year $96,778 cost of capital return on reduction 16

17 EMR User Experience Survey For TCH Providers Representing 25 clinics using Logician in 2003 Q1 305 surveys administered 126 received completed 41% response rate 73% Good to excellent overall satisfaction For TCH Clinic Support Staff 145 surveys administered 142 received completed 98% response rate 94% Good to excellent overall satisfaction Question & Answer 17