1 Navigating the Electronic Medical Records (EMR) Terrain: A Guide for Emergency Departments A CEP America White Paper By Michael Aratow, MD Director of Medical Informatics, CEP America
2 Navigating the Electronic Medical Records (EMR) Terrain: A Guide for Emergency Departments By Michael Aratow, MD, Director of Medical Informatics, CEP America Introduction Electronic Medical Records (EMR) have long been touted for the ability to revolutionize healthcare and improve practice processes. But as widespread EMR adoption inches towards reality, providers and administrators have been plagued with regulatory bureaucracy, implementation barriers, and an overabundance of information that can make EMR selection confusing and difficult. CEP America recognizes the unique problems facing today s emergency departments when it comes to EMR implementation. The purpose of this white paper is to provide an overview of the current state of EMR, focusing on Emergency Department Information Systems (EDIS), including: Requirements and incentives for adoption and meaningful use by the Congress, the Department of Health and Human Services (HHS), and the Centers for Medicare and Medicaid Services (CMS); Selecting, implementing, and analyzing EDIS; A case study of EDIS success; and The future of EMR. CEP America is committed to equip its Physician Partners and hospital sites with the tools necessary to make the transition to EMR utilization as smooth as possible. This white paper is designed to serve as an introductory guide for physicians and administrators as EMR implementation becomes a reality. The Current State of EMR When Congress passed the American Recovery and Reinvestment Act of 2009 (ARRA), it allotted $22.6 billion to health information technology innovations. i This included two billion dollars towards the creation of the Office of the National Coordinator for Health Information Technology (ONC), with the remaining funds allotted for incentive payments to healthcare providers for EMR adoption. The passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 reiterated the government s desire for widespread EMR use. Borne out of these two pieces of legislation have been numerous regulations published by HHS and CMS describing how incentive payments will work, which providers and hospitals are eligible, and, most importantly, when Medicare providers will face monetary penalties for failure to meaningfully implement EMR. In early-2010, CMS released the first of several rules clarifying these points and
3 establishing the meaningful use criteria regulations that a provider s or hospital s EMR initiatives must meet in order to be eligible for the incentives offered by ARRA. ii The purpose of the criteria is to ensure that providers have some guidance for EMR implementation and outlines what national benchmarks they will be graded against. Although hospital-based physicians such as emergency physicians cannot qualify for an incentive payment on their own, they are counted towards a hospital s incentive payment they. iii Consequently, this paper will focus solely on hospital eligibility. At the start of 2011, CMS opened registration for hospitals wanting to participate in the first stage of meaningful use data collection and reimbursement. Hospitals choose whether they wish to qualify based on Medicare or Medicaid patients, and then register their EMR efforts with CMS through the Medicare & Medicaid EHR Incentive Program Registration and Attestation System. Incentive payments began as early as May 2011 and will steadily decline until 2015 when Medicare providers who have not taken the steps to implement EMR will face monetary penalties. Meeting the Meaningful Use Requirements To qualify for incentive payments and meet meaningful use requirements, a hospital must use a federally-certified EMR to record and measure data mandated by CMS. To be eligible, a hospital must meet fourteen core requirements, include five out of ten menu measures, and fifteen clinical quality measures. Emergency Department (ED) patients are included in a hospital s EMR attestation for computerized provider order entry (CPOE), as well as for the fifteen clinical quality measures. There are also two emergency department throughput metrics included in the clinical quality measures. To aid in the selection of a federally-certified EMR platform, the Office of the National Coordinator for Health Information Technology (ONC), has developed a certification program under which organizations can become accredited to test EMR systems and certify them as ONC-approved. There are currently six ONC-Authorized Testing and Certification Bodies (ATCBs). Only EMR systems approved by one of these organizations will meet the meaningful use requirements: Drummond Group, Inc. (DGI) Certification Commission for Health Information Technology (CCHIT) InfoGard Laboratories, Inc. SLI Global Solutions ICSA Labs Surescripts LLC ONC also offers a certified product list, which hospital administrators and providers can search for systems based on practice type and specific criteria they re looking to measure.
4 Selecting & Implementing the Right Emergency Department Information System Unlike many other healthcare settings, emergency departments function in such a way that seamless EMR system implementation is all the more necessary and all the more difficult. EDs are fast-paced environments that rely on quick patient turnaround, so an EDIS must integrate exceptionally well with an ED s operations and not impede workflow as providers learn to adapt to the new technology. iv EDIS adoption can be broken down into three major components: Selection Implementation Analysis Selection There are a few important questions hospital administrators and ED providers need to ask themselves when selecting an EDIS: What s the goal of adoption? Is there something the hospital is specifically trying to change about ED operations? What are the baseline functionalities that an EDIS system should perform? The selection process should be just as important and thorough as implementation. Selecting the appropriate EDIS system should follow the following steps: 1. Create a selection committee One of the biggest mistakes a hospital can make when seeking out an EDIS is doing so without input from those that will be using EDIS on a daily basis. A poorlyfunctioning EMR system, or one that doesn t align with the ED s culture, can lead to disastrous results reduced productivity, increased time-to-provider and turnaround time, decreased employee morale, and unsatisfied patients. In fact, a common complaint among ED physicians is that EDIS reduce the amount of face time they have with a patient and hinder their ability to see patients in an efficient manner. v Create a selection committee with members representing all providers in the ED working together towards identifying the needs of the ED that can be fulfilled by EDIS. An inclusive selection committee one that represents physicians, nurses, PA/NPs, IT, laboratory, radiology and hospital administration will be the first and foremost key to successful selection and implementation. vi 2. Determine functional requirements The selection committee should be the group that determines functional requirements and investigates EDIS options that meet the CMS meaningful use requirements.
5 Although CMS established baseline requirements that a hospital s EMR must meet in order to qualify for incentive payments, it s important that the selection committee consider how the ED currently functions and how EDIS could be used to improve operations. Among those system requirements that will be the most useful are: Registration and support for triage assessments Patient tracking and discharge instructions Clinical documentation Order Entry Resource tracking and management eprescribing capabilities Reporting capabilities The system requirements should also be influenced by what processes your ED is looking to improve. Collect and analyze data on documentation, patient flow, and discharge to see what practices can and should be labeled as high-priority action items for improvement. In fact, workflow analysis is another key to successful implementation. This entails documenting current workflow and how it can be modified to leverage EDIS capabilities for maximum gains in efficiency and productivity. This modified workflow is then carefully recorded and used in guiding implementation and training. 3. Compare options After the selection committee has defined the functional Most Utilized EDISs at CEP America Sites requirements, the real legwork 25% comes in as the committee searches for and identifies those 20% systems that meet the ED s 15% needs and CMS meaningful use requirements. Although the 10% ONC s online database of certified systems provides a 5% baseline list of options, there is 0% no real feedback on providers Cerner Allscripts Picis Meditech T system opinions of the systems. Independent monitoring group KLAS interviews healthcare providers and administrators from around the country, ranks and quantifies their input, and provides a free rating system and reviews of all
6 Implementation available EDISs on the market. Referencing KLAS reviews and those approved vendors on ONC s website should result in a short list of potential systems. If possible, contact ED colleagues at other hospitals to get their input, recommendations, and critiques of their respective systems. CEP America leadership also has extensive experience with EDIS implementation over half of all CEP America emergency departments currently used EDIS and can serve as a valuable resource in your search for an EDIS. 4. Evaluate and make a selection The selection committee should take all of the information gathered, narrow the possibilities down to two or three, and then contact the specific vendors for more information and product demonstrations. At this time, site visits should be conducted with the finalists. Site visits represent a unique opportunity to see the EDIS product operating in the real world. Vendors can supply references for such visits, but another valuable resource is CEP America or other colleagues who have similar systems installed in their organizations. Vendors offer references whose implementations have exceptional execution; it is also beneficial to observe sites outside of the vendors favorites to discover what, when and why implementations are not optimal. It is also important to conduct a cost-benefit analysis to determine the benefits of one system over another, as well as installation and maintenance costs associated with each system. Following product demonstrations and evaluation, the selection team should be ready to make a decision. After selecting an EDIS, it is important to decide how to implement the new system without disrupting ED operations. Some EDs choose a more gradual route to implementation start by utilizing only one or two of the system s features before expanding. Others may feel that the ED is equipped to handle training sessions with an on-site vendor educator followed by fullimplementation. The extent of training and implementation process really depends on the hospital and ED s culture. vii One of the most effective methods to ensure implementation success is utilizing the selection committee as the champions of EDIS. At the start of implementation, members of the selection committee are likely to be the providers most familiar with the system. Going forward, they should be the super users on the ground that are available to provide technical support to other providers when issues arise; as well as serve as cheerleaders for the system as it is being put into place. It should be expected that there will be members of the ED resistant to change, but putting resources in place to ease the transition and increase satisfaction are keys to success. The more work that goes into configuration of the EDIS before go live, the smoother the implementation will be. This involves creating documentation templates, ordering pathways that bundle laboratory and diagnostic imaging studies based upon chief complaint or diagnosis and other
7 time saving features of the EDIS selected. By a thoughtful approach to this task, new users will see gains over old processes almost immediately and have a better attitude towards the new system. Nothing alienates users more than when they feel abandoned trying to learn a new system. A crucial element of the EDIS go live strategy should be at the elbow support of all end users. Instant response to frustrated healthcare providers learning a new system who cannot control the flow of patients through their door is well appreciated and will lead to higher rates of compliance. Analysis Both before and after implementation takes place, it is important to gather and analyze data on ED operations to understand how the processes have been changed as a result of the EDIS. When the selection committee was defining functional requirements, the data collected and analyzed prior to implementation can serve as a baseline to compare how the new system is affecting productivity and patient care. Returning to the goals of adoption set during the selection process will provide baseline measures against which all new data can be compared. Ultimately, collaborating with providers and looking for ways to improve ED operations through the EDIS should be an ongoing goal. Monthly meetings to review data, implementation issues, and success stories will allow the EDIS to thrive and more fully-benefit the ED. Implementation is just the first step; successful utilization is what makes the system meaningful. EDIS Success: Rideout Memorial Hospital Rideout Memorial Hospital Marysville, CA Annual ED Visits: 56,300 ED Beds: 25 CEP America Staffed Since: 2004 Rideout Memorial Hospital began the task of implementing an EDIS in Hospital Administration knew implementation of Electronic Medical Records would be inevitable and we wanted to get ahead of the curve, recalls Rudy Zaragoza, MD, ED Medical Director at Rideout. As Rideout s administration began looking for systems that would be appropriate for hospital-wide use, the ED staff was aware of problems with some EMR and worked with hospital administration to find a system that was specifically designed for the ED.
8 The ED staff started by focusing on the selection process, both formally and informally. We talked with the CEP America Regional Director, as well as with other EDs that have implemented EDIS, reports Dr. Zaragoza. We also reviewed the KLAS report of the top-ranked systems and really identified what we didn t want in an EDIS. After reviewing and selecting their top three candidates, the ED chose EmPower for its focus on the physician interface as well as its promised ROI Time to Provider (mins) Pre EDIS 4.5 Post EDIS 1.8 Left Without Being Seen (%) As the selection shifted to implementation, Rideout s ED created a multi-disciplinary implementation committee to break down the day-to-day processes on paper and identify how the EDIS would improve patient flow in the department. Utilizing EmPower technical resources and CEP America s Practice Management Consultants, the ED chose to avoid a tiered-implementation and instead had the entire ED up-and-running on the new EDIS at the same time, with 100% physician and nurse computerized documentation, full computerized physician order entry (CPOE), and complete integration with other hospital systems, such as radiology and the lab. Beginning to end, the entire process took Rideout Memorial Hospital fourteen months. Since going live with EmPower at the end of 2009, they have seen extraordinary results. The ED now has improved access to data, which has resulted in improved operations and an increase in physician productivity. Time-to-provider (TTP) also dropped from an hour to 27 minutes and the Left Without Being Seen (LWBS) rate fell to 1.8%. Our success is really because the hospital administration allowed the ED to make the selection, emphasized Dr. Zaragoza. For anyone looking to implement an EDIS, it is important to get the department involved and choose a user-friendly system. Poor selection can cripple the ED, as well as hinder retention and recruiting. The Future of EMR Widespread implementation of EMR has been both heralded and decried by policymakers and providers alike. Many feel that the government s decision to require providers to utilize health IT or face penalties after 2015 is a standard many will be unable to meet; and one being enforced before the technology is capable of meeting the needs of today s healthcare system. Coupled with stories of decreased physician productivity as a result of inoperable EMR, forecasts of successful EMR adoption have been bleak. But with the new meaningful use requirements, providers have no choice but to discover, implement, and adapt.
9 Fortunately, as technology has evolved so have the interfaces designed for physicians to utilize it. The release of the ipad, as well as other tablets, and more advanced smart phones have resulted in EMR applications that can be purchased, downloaded and carried from patient to patient and the choices will likely increase. Having a portable device not only benefits the healthcare system as a whole, but ED providers in particular. But it will still take planning and provider buy-in for any EMR to be successfully adopted and implemented in the emergency department. i Department of Health and Human Services (HHS). Recovery Act-Funded Programs. January June 2011 <http://www.hhs.gov/recovery/programs/index.html#health>. ii Centers for Medicare & Medicaid Services. Electronic Health Record Incentive Program. Proposed Rule. Washington, DC: Federal Register, 13 January iii Centers for Medicare and Medicaid Services. "[EHR Incentive Program] Which Emergency Department patients should be included in the denominators of meaningful use measures." 24 March CMS Support. 3 June 2011 <https://questions.cms.hhs.gov/app/answers/detail/a_id/10126/~/%5behr-incentiveprogram%5d-which-emergency-department-patients-should-be-included>. iv EMR Consultant. "Emergency Medicine Specific EMR/EHR Softwar." June 2011 <http://www.emrconsultant.com/specialties/emergency-med-emr>. v Klauer, Kevin. "EMR: State of the Art or Digital Disaster." Emergency Physicians Monthly 13 April vi Wade, Christine. "Six Strategies to Secure Nursing Buy-in for an Emergency Department EHR." Becker's Hospital Review 09 February vii Wolfe, Richard. "Electronic Charting in the ED: Making it Work for All." Healthcare Informatics October 2010:
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