Improving Safety, Quality & Efficiency with an Ambulatory EMR: Can it be done?

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1 Improving Safety, Quality & Efficiency with an Ambulatory EMR: Can it be done? Paula Spencer, PMP, CPHIMS Deborah Burgett, RN, MSHA DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Objectives Explore the success characteristics of an ambulatory care clinic EMR implementation Explore strategies for leadership support and physician engagement Explore the ROI metrics used in a successful ambulatory care clinic EMR implementation

3 About VCU Medical Center Only academic medical center in Central Virginia Referral Center for the state and Mid-Atlantic Fiscal Year 2011: 865 Licensed Beds 33,664 admissions to 40 inpatient units 553,549 outpatient visits to 80 clinics 84,291 admissions to Level 1 Emergency Department MCV Physicians 600-physician, faculty group practice Virginia Premier Health Plan 110,000 member Medicaid HMO

4 Our EMR Journey Converted to Cerner EMR in 2004 Main focus on inpatient Outpatient Results retrieval Hybrid medical records Formal outpatient transition began October 2009

5 Motivating Factors Patient safety Workflow improvements Financial incentives Care integration

6 Success Factors Project management Formalized governance Clinician involvement Communications plan

7 Communications Plan Stakeholder identification Executive Business and Administration Clinic Leadership End User Information dissemination Internal and external Formal and informal

8 Implementation Guidebook Communication tool Artifact of the planning process Serves as a map for each implementation Enables repeatable processes

9 Feedback Loop = Adoption MD to MD support Implementation Team offers support Leadership gives feedback to resistant providers Metrics published, given to leadership

10 Focus Areas Automation Standardization Adoption Patient Care Clinical Outcomes Improvement

11 Scope In Scope Workflow standardization eprescribing Provider/Clinician Documentation Dictation Health Maintenance CPOE Patient Portal Out of Scope Records room transition Electronic billing Bedside medical device integration Reduced sign-on CPOE

12 Standardization Medication List Allergy List Problem List Social History mpage Specialty View Patient Level Data Data Presentation Clinical Documentation Provider Documentation iview PowerNote Dictation

13 Standardization Medication List Allergy List Problem List Social History mpage Specialty View Patient Level Data Data Presentation PowerForms Clinical Documentation Provider Documentation Scanned written notes iview PowerNote Dictation

14 Workflow How important is workflow to the implementation of an electronic record? Why not just tell everyone they have to use the computer? Why spend all these resources assessing and documenting workflow?

15 Workflow Documentation Document existing workflow in representative clinics very valuable exercise Create future workflow possibilities great process Present final product to leadership

16 Assessments Hardware Assessment Have an institutional decision on computer deployment EMR Integration Assessment Training and support needs, change expectation Documentation Assessment Correlate with workflow

17 Education and Training Evaluation of needs Web-based training useful (Step 1) At-the-elbow support (Step 2) Must mandate training and track results Dedicated time for training Next steps Intermediate training Advanced training

18 Education and Support CTS team roles Support go lives Identify issues Start intermediate training MD to MD Support

19 Implementation Decisions How many times should we go back to a clinic to implement new workflow or technology? Two distinct implementations, with different focuses What are resource constraints which influence these decisions? What are the hard and fast timelines we have to meet? Meaningful Use Project budget/timelines

20 Phased Implementation Electronic Prescribing / Messaging Learned a tremendous amount about change Provider Documentation Leadership, standardize Clinical Documentation Involve users in decisions

21 Perfect is the enemy of good Establish a hard and fast stop date for changes Tools will not be perfect or meet everyone s needs all the time Using the tools can provide better feedback for later developments Software and regulations are constantly changing Difficult for team and users Post implementation reviews

22 Go-live Strategies Reduce volume? Advantage: More time for training Disadvantage: Reduced repetition Absolutes on Day 1 No new charts Nothing added to an existing paper chart Flexibilities on Day 1 Printing of a patient summary Use of a scratch pad

23 How do you move the critical information from paper to electronic documentation? How do I find my stuff in these folders? What will happen to the current paper charts? I NEED my paper charts! Where is my stuff?!?

24 Physician Adoption Importance of leadership Physician involvement from the start Planning, workflow and design meetings Volume reduction Productivity Engagement vs. listening

25 Adoption Metrics Depart summary completion Front desk adoption Smoking history Nurse adoption Allergy list Nurse adoption Problem list Provider and nurse adoption

26 Pic of report card Meaningful Use Provider Scorecard

27 Actual Ambulatory EHR Project Expenditures MIPPA Incentives (calendar year) Meaningful Use Program Expenditures Meaningful Use Incentives (Medicare EP = 374) Meaningful Use Incentives (Medicaid EP = 160) Financial ROI FY2010 FY2011 FY2012+ ($756,000) ($1,589,000) $153,000 $100,000 $75,000 ($1,125,000 avoided penalty) ($900,000) ($4,500,000) $15,870,000 $10,136,000 Total Expected ROI $18,589,000 *Does not include: future conversion of records rooms to revenue generating space; eliminated paper chart costs; additional revenue generated due to improved documentation

28 Average Time Difference (minutes) Visit Throughput Reg / Checkout MD Time RN Time Days Post Go-Live

29 Summary Patient Safety Patient Satisfaction Next project Remaining clinics Ambulatory procedure areas Enhancements

30 Contact Info Paula Spencer Deborah Burgett Susan Wolver

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