INTEGRATING QUITLINE E-REFERRALS INTO EXISTING ELECTRONIC HEALTH RECORDS: OKLAHOMA S EXPERIENCE AND CHALLENGES
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1 INTEGRATING QUITLINE E-REFERRALS INTO EXISTING ELECTRONIC HEALTH RECORDS: OKLAHOMA S EXPERIENCE AND CHALLENGES 2015 NAQC Conference 2015 The Future of Quitlines Joy L Leuthard, MS, LSWA, Mgr., Health Improvement Initiatives, OHA Eric Finley, MPH, Tobacco Treatment Systems Coordinator, OHA Jesse Anderson, Director, Ancillary Services - Health Systems Chickasaw Nation Medical Center An Initiative of the Oklahoma Hospital Association
2 Objectives Identify differences among diverse healthcare systems & EHRs Greater understanding of system integration from the clinical informatics perspective Increase understanding of the benefits and challenges of integrating e-referrals into EHRs Discuss the need for national EHR and e-referral standards to facilitate widespread integration of clinical tobacco treatment: - e-referrals and existing EHRs - the need for new EHR systems to include this as a standard.
3 Partnerships & Collaboration Oklahoma State Health Department - Office of the Tribal Liaison - Center for the Advancement of Wellness Oklahoma Tobacco Research Center - Oklahoma Tobacco Helpline University of Oklahoma - College of Public Health Oklahoma Tobacco Settlement Endowment Trust
4 Hospitals Helping Patients Quit Sustainable system changes embedded in hospital o Clinical process evidence-based o EHRs treatment, including e-referral to Helpline Comprehensive system changes tobacco-free culture: o o o o Policy driven Tobacco-free properties Patient treatment - inpatient - outpatient - family centered Employee treatment
5 Hospitals Helping Patients Quit Initiative of the Oklahoma Hospital Association Launched in 2009, serving OHA hospital members Funding Okla. Tobacco Settlement Endowment Trust (MSA $$) INTEGRIS Health first system-wide implementation - fax referrals October hospitals / 20+ clinics
6 Hospitals Helping Patients Quit 37 hospitals engaged / 2 health systems Integris / Mercy First tribal implementation - Chickasaw Nation Medical Center 13 hospitals in process for implementation includes one other tribal and one IHS hospital Began with Helpline fax referrals / moving to e-referrals
7 Oklahoma Provider Helpline Referrals All HHPQ proactive Helpline provider referrals Oct 2010 June ,327 Overall acceptance rate 38% Hospitals and their affiliated clinics accounted for 49% of all provider fax/e-referrals in June 2015 E-Referrals began in November 2014 Chickasaw Nation Total e-referrals mid-nov 2014 June ,008 Acceptance rate 26.4%
8 Helpline e-referrals Three hospitals / systems implementing bi-directional e-referrals - three different EHR s : - Chickasaw Nation Medical Center - RPMS - Mercy - Epic - first Oklahoma bi-directional e-referral system! - first Oklahoma multi-hospital and clinic system implementing bi-directional e-referral system. - Duncan Regional Hospital - Meditech - single regional rural hospital - clinic sites in Duncan
9 Helpline e-referral Three hospitals in various stages of clinical implementation and e-referral development : Lawton Indian Hospital Indian Health Service - RPMS - SW Oklahoma St. Anthony Hospital (2 hospitals + clinics) - Epic - OKC metro area W.W. Hastings Hospital Cerner - Cherokee Nation, NE OK
10 Two Health Systems of e-referral Development
11 Chickasaw Nation Medical Center Governor Bill Anoatubby Judy Goforth Parker, DNP Administrator Division of Health
12 Chickasaw Nation Medical Center Under the direction of Heather Summers, Under Secretary of the Health Department 1 Hospital 53 licensed beds - Acute care - Women s health - Emergency department - 3,100 admissions each year Outpatient clinics in Ada, Ardmore, Tishomingo - Primary care and Diabetes Care Center
13 Chickasaw Nation Medical Center Electronic Health Record (EHR) RPMS - Resource and Patient Management System - Used in all CNMC hospitals and clinics - Used by IHS facilities nationwide - Changes to EHR RPMS have potential to be expanded to all IHS facilities regionally and nationally
14 Chickasaw Nation Medical Center OHA, OSDH Tribal Liaison met with CNMC to begin planning implementation of comprehensive tobacco treatment for patients July 2013 Key health providers formed the implementation work group Work group met regularly for 18 months EHR changes comprised the bulk of the group meetings Buy-in from all work group members
15 Chickasaw Nation Medical Center IT staff attended all meetings and interacted with Helpline vendor during development, testing, launch and post launch Strong support from Oklahoma Tobacco Helpline staff to facilitate troubleshooting and system streamline IT staff had both IT knowledge and clinical knowledge Team attitude can do Hospital launch Mid-November 2014 Clinical launch Jan March 2015
16 Mercy Health System Hospitals: 10-1 large urban hospital OKC: 380 licensed beds - 9 hospitals serving rural areas: 541 licensed beds - Acute Inpatient Discharges : 15,901 - Emergency Visits: 55,361 Outpatient Clinics: 65 - Outpatient Visits: 1,102,939 - Primary and specialty care
17 Mercy Health System EHR Epic 2014 Among the first health care organizations in the U.S. to have a comprehensive, integrated electronic medical record - over 7 years ago Utilized by all hospitals and clinics
18 Mercy Health System Conversation with OHA staff and leadership in the fall of 2011 Meetings with Mercy leadership (Oklahoma) continued over a few months OHA and Mercy entered into a contract beginning July 2012 to implement a comprehensive tobacco treatment system for all patients
19 Mercy Health System Contract included partial fiscal support for a full time Tobacco Treatment Coordinator to facilitate entire process Initial focus began on outpatient clinics with outpatient work group A comprehensive work group for inpatient and outpatient was also formed
20 Mercy Health System Meetings with 22 outpatient clinics provided information to OHA from physicians - if the protocol is not imbedded in the EHR, including Helpline referral, it won t happen Changes to EHR began in the fall of initial focus on outpatient clinics - changes would apply to all areas using the EHR - minor tweaks for inpatient EHR
21 Mercy Health System Process took 2 years due to complexity of the system and several delays - IT staff turnover due to corporate layoffs - unclear processes administratively - Coordinator staff turnover - - unclear oversight responsibilities OK vs Corporate led to delay in getting corporate IT involvement Launched 65 clinics Jan April 2015 Launched OKC hospital June 2015 Other hospitals launching over the next 6 mos
22 E-Referral Development Variability When Developing / Implementing e-referrals in Different Systems
23 E-Referral Development Chickasaw Nation Medical Center Mercy Health
24 EHR Modifications Health System /EHRs CNMC / RPMS MERCY / EPIC EHRs Function Modifications Required Tobacco Screening Alert for Counseling No No Medication Order Set 12/24 hr. Reassessment No Helpline e-referral
25 CNMC Embedded e-referral Screen
26 CNMC File Transfer Process CNMC Provider Provider sends referral Batches and manually encrypts flat file to quitline vendor Oklahoma Tobacco Helpline Vendor Manually decrypted batched file auto populates patient EHR CNMC Privacy Officer Encrypted outcomes flat file is sent back to health system
27 CNMC Drag & Drop e-referral CNMC Hospital Server Patient Referral Encrypted Batch File Patient Outcome Report Encrypted Batch File Helpline Server: Alere
28 Mercy File Transfer Process Mercy Provider HL7 formatted batch file is retrieved from EHR (order REF100) Encrypted flat file is sent to Quitline vendor Oklahoma Tobacco Helpline Vendor File is converted to HL7 interface; Auto populates patient EHR EPIC file conversion workaround (Nightly) Encrypted outcomes flat file is sent back to health system
29 Training and Project Launch Training Topic CNMC MERCY CEU Available Primary training style inpatient staff Primary training style outpatient staff Limited for Grand Rounds Classroom / live speaker Classroom / live speaker Majority of Trainings Electronic / PowerPoint with voiceover **Live speaker for RRT Electronic / PowerPoint with voiceover Primary training style M.D. s Grand Rounds / live speaker **With electronic option Electronic / PowerPoint with voiceover
30 Training and Project Launch Training Topic CNMC MERCY Key training topics EHR s workflow FDA approved medications Tobacco related morbidity Clinical guideline / 5A s Motivational interviewing Quitline services & support EHR s workflow FDA approved medications Tobacco related morbidity Clinical guideline / 5A s Motivational interviewing Quitline services & support Project rollout Inpatient hospital (11/2014) Outpatient clinics ( 5/2015) Outpatient group 1 (2/2015) Outpatient group 2 (4/2015) Mercy OKC (6/2015) 9 Hospitals (pending)
31 Tips for Success
32 Tips for Success Key leadership support is essential Examples from CNMC Examples from Mercy Get the right players in place early OHA s getting started checklist CEO, CMO, CNO, Rx, RRT, CM, SW, IT, Security, OPD Examples from CNMC Identify, early, the organizational and decisionmaking processes / key personnel
33 Tips for Success Advocate for an FTE for large health systems Tobacco Treatment Coordinator at Mercy Consistent and accountable administrative leader Hands-on oversight & leader of meetings / momentum Shared EHR between hospital and outpatient clinics Selecting targets for success Obtain support from State Quitline Coordinator if available Examples of support provided by OTRC
34 Tips for Success Be flexible with health systems you work with When you ve worked with one health system, you ve worked with one health system A cookie cutter approach will not work must be tailored to each system Build the tobacco treatment system to meet the needs and resources of the health system Communication, communication, communication
35 Prepare for Hurtles / Barriers
36 Prepare for Hurtles / Barriers Interoperability between health system and Quitline CNMC EHR Workaround MERCY EHR Workaround
37 Prepare for Hurtles / Barriers Overcoming traditional view points of inpatient care and patient based wellness initiatives With heavy workloads tobacco treatment is often viewed as an add on Who will be responsible for added workload / shared responsibilities
38 Prepare for Hurtles / Barriers Communication Barriers Public Health Professionals and IT language Trust the Process IT/EHRs applications vs. staff communication within the health system Health system IT staff and Quitline vendor IT staff Large system has several IT with their own expertise
39 Prepare for Hurtles / Barriers Encourage health systems not to overlook important building blocks Early data collection Communications planning and public promotion Celebrate the victories often!
40 Key Benefits
41 Key Benefits Enjoyed Post Integration Positive unintended consequences Positive growth in staff relations and team dynamics Networking and new relationships A great sense of team accomplishment and efficacy Application of new skills to other treatment processes Motivational Interviewing
42 Key Benefits Enjoyed Post Integration Robust systems change process prepares health systems to meet national quality standards for patient based tobacco treatment For Example Joint Commission Meaningful Use
43 Key Benefits Helping Patients Quit Total ereferral 200 # Accept Service Mercy 24% CNMC 26%
44 The Clinical Informatics Perspective
45 Building the right team Information Technology System Administrators Computer Programmers Applications Support
46 Building the right team Clinical Informatics Medical Technologists Pharmacists Nurses Providers Rad Techs
47 Build a system to meet providers needs Usability Human Interface Workflow Driven Information Overload Feedback, Feedback, Feedback
48 Build a system to meet providers needs Collect Data EHR Governance, Applying Risk Management Tools to EMR
49 Piloting, Testing, and Maintenance of new EHR Application Infrastructure Workflow Driven Structured Data Capture Create Lines of Communication
50 Piloting, Testing, and Maintenance of new EHR Application Be a Physical Presence Feedback, Feedback, Feedback Lesson Learned, Communication
51 Need for National Standards Interoperability barriers Standardized elements within e-referral builds EHR s need to build standardized Tobacco treatment protocols and e-referral Mechanisms into their products following the Clinical Practice Guidelines
52 Questions?
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