Electronic Medical Records: Implementation and Beyond

Transcription

1 Electronic Medical Records: Implementation and Beyond William M. Keane, MD Chief Medical Officer, Jefferson University Physicians Bruce A. Metz, PhD Chief Information Officer, Thomas Jefferson University John Ogunkeye Executive Director & VP, Jefferson University Physicians

2 Agenda I. Jefferson University Physicians Background II. EMR Project Overview III. Keys Steps and Critical Success Factors A. Project Organization and Governance B. Clinical Transformation C. Physician Adoption D. System Roll-out IV. Primary Challenges and Lessons Learned To-date V. Q&A

3 Jefferson University Physicians Background aka: A clinical enterprise that supports the academic mission of Thomas Jefferson University, a leading academic medical center in Philadelphia, PA Responsible for patient care Work closely with Thomas Jefferson University Hospital, our partner hospital 485 Faculty in 17 Clinical Departments 230,000 Active Patients 412,000 Ambulatory Encounters $220 Million in Revenue FY 07 Activity 25,000 Admissions to Primary Hospital 16,600 TJUH Surgical Cases at Primary Hospital Activities (22 hospitals & 44 Ambulatory Sites)

4 Jefferson University Physicians Background Complex Operations Multiple sites Challenging External Environment

5 Jefferson University Physicians Background History of Fragmented Care Integrated practice profile and whole system approach not matched by integrated clinical information systems Patient A Patient A Inpatient Stay Patient A Y Patient A Ancillary Service Islands of information

6 Jefferson University Physicians Background Institutional Goals Patient Centric Environment Preferred Employer Patient, Physician and Staff Satisfaction Fiscal Stability Patient Mandate Develop a plan to ensure that our patients experience in our clinical enterprise is operationally excellent from their first contact with Jefferson, across our sites and settings and continuing after/between episodes of care. Jefferson Clinical Planning Patient Experience Committee September, 2005

7 Context for a EMR Strategy Quality is a Strategic Priority for Unmanaged Care Delivery Process Managed Care Delivery Process Manual Environment + Informed Patient = Patient/Physician/Staff Disaffection Heightened Regulatory Environment + Waning Patient Satisfaction = Greater Exposure for Risk and Liability Market Reputation + Increased Competition = Threat to Business Model B u s I n e s s P r o c e s s R e e n g I n e e r I n g Enhance Patient Care Delivery Processes Patient Centric Care Meet Organizational Goals Respond to External Imperatives

8 Long-term Vision: Phased Integration of the Islands of Information Other Jefferson Patient A Volunteer Other Jefferson Patient A Volunteer Ancillary Group Jefferson Patient A Volunteer & Other TJUH Ancillary Service TJUH Inpatient TJUH Inpatient TJUH Ancillary Service TJUH

9 Long-term Vision: A Wired Jefferson Physicians Able to Access Any Chart, Anytime, Anywhere Physician at Home Broadband Router with Firewall and VPN Internet CCR Data TJUH Patient Demographics Patient Insurance Medications Allergies Health Maintenance Alerts Lab Results Dictated Reports Vital Signs D and CPT codes Wireless Access Point Personal Computer Volunteer Faculty EMR/PM Application Wireless Access Point Personal Computer A EMR/PM Application B Wireless Access Point Personal Computer

10 Strategic Business Drivers EMR Strategy Development Began in 2003 Improve Workflow Efficiency Eliminate Medical Errors Improve Patient Satisfaction Improve Faculty/Staff Satisfaction Improve Community Image Improve Patient Safety and the Quality of Care for Patients Standardize Patient Care Delivery Process Enable Instant Access to Information EMR System Selection in 2005; Project Kickoff in 2006

11 Summary of EMR Benefits Adverse Drug Events Prevention 15% Transcription Savings Chart Pull Savings 5% 5% 13% Decreased Billing Errors 14% Increased Billing Capture Drug Savings 29% Lab Savings 4% Radiology Savings 15% Source: Partners Health Care experience based on 2500 patients and providers. Cost and Benefit Analysis for electronic medical records in primary care. The American Journal of Medicine 2003;114:

12 Return on Investment Benchmarks Hard Dollar Benefits Capture lost charges Reduce defensive down coding Reduce claims denials and delays Increase preventive and management services Reduce transcription Stretch Dollar Benefits Industry 1 1% - 5% revenue gain 5% - 11% revenue gain day A/R speedup 5% revenue gain $5k - $15k/yr costs cut ROI Analysis 1% revenue gain 1% revenue gain day A/R speedup Not included in analysis $6,404k/yr costs cut Increase physician productivity Staff efficiency Reduced chart pulls Reduce cost of paper chart materials Reduce costs of chart storage and archiving 0% - 15% revenue gain 0% - 15% cost reduction $5/pull or $6k/yr/MD $1-5/pt or $1k/yr/MD $1k/yr per physician Not included in analysis 7% cost reduction $2.59/pull or $3,617/yr/MD $ /pt 0 1 Mark Leavitt, Medical Director of HIMSS, 2005 DOQ-IT Presentation

13 EMR Project Review: Implementation Plan Key Components Implementation budgeted at approximately $18.0M Wave 1: Organizational and System Readiness Wave 2: Implementation of TouchWorks Modules and Supporting Interfaces Wave 3: Go Live and Roll-Out Transition to Steady State 36 Month Period

14 Implementation Timeline MONTH MILESTONE OCT 1 NOV 2 DEC 3 JAN 4 FEB 5 MAR 6 APR 7 MAY 8 JUN 9 JUL 10 AUG 11 SEP 12 OCT 13 NOV 14 DEC 15 JAN 16 FEB 17 MAR 18 APR 19 MAY 20 JUNE 21 JULY 22 AUG 23 SEP 24 OCT 25 NOV 26 AUG.. 35 SEP 36 Change Management and Communication WAVE 1 Process Redesign and Standardization Project Organization and Mobilization Project Team Space Acquisition Hardware Procurement and Installation of Network (Server side) Client Device Procurement and Rollout WAVE 2 Introduction to Touchworks Training and Interface Training Future State Design and Documentation (Best ) Design and Develop Full EMR and Interfaces Interface Delivery and Remediation Note Design and Development Integrated Testing, Fit Gap Analysis and Rapid Redesign Steering Committee Sign-off Simulation WAVE 3 Deliver Alpha Site Rollout Beta Site General Rollout Rollout Closeout

15 Critical Planning Items Project Definition Not an Information Technology Project Cultural Transformation leveraging technology Workflow Redesign Training, Behavior Decision Making Quick turnaround on decisions Financial implications Integration with current leadership making structure Minimize redundancy Focus on what is in the best interest of the patient Time Commitment Physicians Dedicated effort» Compensation/Incentive Administrators (all levels) Specialty lead Incentive

16 Critical Success Factors Strong Executive Sponsorship Effective Governance Extensive Change Management (Clinical Transformation) Deep Physician Involvement Tight Project Management (Tasks and Budget) Comprehensive Training, Support and Communication All tied together by a structured, strategic approach

17 Project Organization and Governance SELECT COMMITTEE OF THE BOARD EECUTIVE SPONSOR Management Committee PHYSICIAN ADVISORY GROUP PROJECT EECUTIVE COUNCIL VENDOR OVERSIGHT COMMITTEE PMO Q/A RISK MANAGEMENT PROJECT DIRECTOR BUDGET PMO PROJECT COORD PROJECT STEERING COMMITTEE COMMUNICATIONS INFRASTRUCTURE TEAM DESIGN & BUILD TEAM CLINICAL ADVISORY TEAM GO-LIVE TEAM CLINICAL TRANSFORMATION GROUP

18 Project Organization and Governance (continued) EMR TASK FORCE OF THE BOARD EECUTIVE SPONSOR Project Accountability Pods Communication Flow Management Committee Clinical Departments PROJECT SPONSORS Medical Specialties Primary Care Surgical Specialties Hospital Based PHYSICIAN ADVISORY GROUP PROJECT EECUTIVE COUNCIL VENDOR ADVISORY COMMITTEE Phys Lead (3) Admin. Lead (2) Phys. Lead (2) Admin. Lead (1) Phys. Lead (3) Admin. Lead (1) Phys. Lead (2) Admin. Lead (1) Q/A RISK MANAGEMENT PROJECT DIRECTOR BUDGET TEAM PMO PROJECT COORD PROJECT STEERING COMMITTEE COMMUNICATIONS PMO Communication Flow IT TEAM DESIGN & BUILD TEAM CLINICAL ADVISORY TEAM CLINICAL TRANS TEAM TESTING TEAM OTHER TEAMS

19 Project Guiding Principles Quality Principle Patient Safety Patient Services Patient Satisfaction Evaluation and Demonstration of Quality Decision Making EMR Adoption Description A primary driver for decisions regarding the EMR will be to ensure the delivery of quality patient care. A primary driver for all decisions regarding the EMR will be to ensure safe patient care. Available functionality will be leveraged to enhance the patient experience with. Patient satisfaction is a primary focus of. The EMR will be designed and implemented in a fashion that permits ongoing evaluation and standardization of quality of care rendered by each provider. Decisions regarding the EMR will be made within the governance structure that supports both enterprise-wide and multispecialty perspectives, while sustaining the academic and research missions of the University. The decision process will be transparent and have clearly delineated lines of communication. The EMR will be universally adopted and will be used as designed.

20 Project Guiding Principles (continued) Principle Care Collaboration Campus Collaboration Clinical Content Communications Operational Efficiency Economic Impact Go Live Productivity System Availability Description The EMR will support care collaboration across, TJUH and external organizations. Alignment of process and systems will promote the ideal patient experience and enable long term integration. Clinical information, using the Allscripts library content, will be defined and managed within the EMR governance. The EMR project requires a collaborative communication strategy supported by a communication team with representation from all stakeholder groups. The EMR will be designed to improve operational efficiency and promote patient safety and clinical excellence. The EMR implementation will maintain a financial focus and facilitate achievement of the ROI. productivity related to the EMR go live is expected to decrease transiently and there will be a plan to minimize its impact. The goal and commitment is to high system availability.

21 Project Branding

22 Organizational Transformation More than Technology Leveraging Technology Merging of technology and operational processes to achieve value and intelligence for clinical care delivery Transforming the Workforce Achieving change through communication, Governance/leadership, knowledge Management while focusing on organizational culture Sustainable Change Periodic Review of Metrics that Measure, Monitor Benefit Realization for Processes Organizational Transformation Clinical Process Optimization Standardization, efficiency and utilization optimization in care delivery and administrative process Physician Integration Provider engagement in the development, adoption, acceptance and accountability for care delivery processes Modified from Healthlink Approach to Process Redesign & Clinical Transformation

23 Clinical Transformation Initiative Healthlink/IBM served as Clinical Transformation (BPR) vendor Healthlink Engagement Results Part I Detailed current state analysis for representative practices: Otolaryngology Family Medicine Obstetrics and Gynecology Internal Medicine Cardiology Surgery Healthlink Engagement Results Part II Detailed Future State Design Based on Best s Scope included:» Appointment Scheduling» Orders» Patient Encounter documentation» Dictation» Prescription Renewals» Patient Intake» Medical Records» Charges

24 Clinical Transformation Initiative (continued) Road Map to the Future State Each practice will identify the gap between their current work flows and the desired future state workflows Clinical Analysts conduct focus group sessions with each practice to develop their future state road map. Clinical Analysts provide on-going oversight of the implementation of the road map(s) Future state planning is complete for: Family Medicine Otolaryngology Future state planning is in process for: Ob/Gyn Cardiology

25 Clinical Transformation Initiative: The Family Medicine Experience As part of the clinical transformation effort two practices were selected to pilot a hard copy medical records outsourcing solution Family Medicine and Otolaryngology. Otolaryngology has a very efficient medical records process Family Medicine was extremely challenged Family Medicine, by its nature, is a magnet for medical record documents. As a result they could no longer adequately manage their patient medical records. Working with the EMR Clinical Analysts, Operations and the EMR Project Director, the Family Medicine practice re-engineered their approach to medical records management including: Scanning of clinically medical record documents Abstracting medication lists and allergies and entering them into the pre live EMR system Outsourcing all of the medical records functions

26 Physician Adoption: Dealing with Change There is the ever-present issue of securing wide-spread physician adoption for an EMR implementation The EMR makes me look like I don t know what to do in front of my patients and colleagues. Don t tell me how to practice medicine! You don t understand how I do my job. You are shifting the work from the staff to me. My productivity will suffer and thus my compensation could be negatively impacted. This will adversely change my relationship with the patient. The organization gets all the benefit while I get more work. This is going take a lot more of my time.

27 Physician Adoption Plan: Major Components Lead Project Conceptualization Planning committees led by physicians Physician Champions/Advocates Messiahs spreading the gospel Project Guiding Principles Signed off by physicians Decisions track to guiding principles Assign Physicians to Specialty Groups Clinical content Physician workflow design teams Computer device demonstrations Communicate, Communicate, Communicate

28 Physician Adoption Issues: Physician Roles Appointed a Physician Champion (50 % Effort) Reports to Medical Director (Executive Sponsor) plan covered effort associated direct and indirect costs) Housed in EMR Project Office Works shoulder to shoulder with Project Director Appointed 3 Physician Advocates (~10% Effort each) plan covered effort associated direct and indirect costs) Broad based specialty representation

29 Physician Adoption Issues: Physician Advocate Role Provides leadership, mentoring and guidance to colleagues Provides ongoing communication to peers and other staff Goals, objectives and project benefits Link between EMR project and other initiatives Serves as subject matter expert Current and future state, clinical workflows Serves on appropriate advisory groups Serves as a liaison to and from the practices, operations, project teams and the organization s leadership Serves as an active participant in clinical transformation activities and provides advice, recommendations and guidance

30 Physician Adoption Issues: Key Points to Consider Value - Do the physicians see the value of the EMR? Content - Is the clinical content of the system complete and useful? Functionality - Is the functionality of the application adequate? Navigation - How easy is it to navigate through the various screens? Transaction Efficiency How many clicks does it take to get to the required function/information? Individual Customization Does the application support individual customization easily? Intuitiveness/Thought Flow How closely does the flow of the screens and data match the way physicians can envision working? Functionality vs. Ease of Use When does the system functionality impede ease of use?

31 EMR Roll-out Schedule S O N D J F M A M J J A S O N D J F M A M J J A S O OTO Fam Med Anesthesia Radiology Pathology ED Rad Onc OB/GYN/JOGA JIMA/ Hematology Cardiology Surgery Neurology Neuro -Surgery Urology Endocrinology Pain Center Rheumatology Pulmonary Infectious Disease Nephrology Sleep Center Primary Care Rehab Dermatology Psych

32 EMR Roll-out Schedule (continued) Pre-live Milestones by 180 Days Out 120 Days Out 60 Days Out 14 Days Out 190 Days Out 130 Days Out 100 Days Out 30 Days Out 5 Days Out Hardware Selection Network Build out Scanning/ Abstracting Plan User Set Up Specific Build Out Interfaces Activated Super User Training End User Training Final Pre Go-Live Review Hardware Ordered Clinical Content Review, Edited and Approved Scanning and Abstracting, Commences End User Dictation/ Transcription Training Hardware Deployed Simulation Testing

33 Primary Challenges Going Forward Vendor Management and Software Stability High Availability IT Infrastructure Roll-out Support Implementation of New Workflows for the s Physician Acceptance Organizational Change and Communication

34 EMR Data Center Solution: An Architectural Overview of Major Components Fiber Optic Network DBSi to 401 Broad Linking to University Network and Co-lo 401 Broad St. Carrier Hotel TJU Co-Location Fail-Over Site Sungard Disaster Recovery Site Campus Fiber Network Ring DBSi Data Center Hosting Site Valley Forge, PA Internet Links Connecting TJU/H Center City Sites, Methodist, St. Agnes, 401 Broad St. (TJUH IS Projected Completion Date of 11/07) Backup DSL Links From Sites to Internet Dedicated Backup Link To TJU Co-Location Dedicated Data Circuits Connecting Campus Network To Remote s Off-Site s Connected by Remote T1 Circuits, Frame Relay, and Managed Ethernet TJU/TJUH Center City Campus Scott Data Center and Network Core Locally Connected s and Clinics Backup Internet Links

35 Key Lessons Learned (To-date) Important Keys to Success Leadership and institutional commitment matter Organizational culture is key Technical, social and organizational systems go hand in hand Physicians should drive the initiative Disruptive technologies can create positive change Building stakeholder trust and buy-in is vital Negotiate solid contracts with vendors Following these keys is not enough

36 Key Lessons Learned Expect the Unexpected Unchartered Waters Consultant Fit/Model Cannot Over Communicate Cannot Over Manage Physician Anxiety Loyalty Switch Economics

37 Key Lessons Learned Anticipate the issues and solve well in advance May need to modify plan to meet current reality Enlist a skilled, dedicated and experienced project team Do not forget staff in the process Even then Doing everything right can still disappoint. So. Be Flexible and Adaptable

38 Key Lessons Learned Expect Bumps along the Road Status of Technology Budgets People Vendors Physician Advocates

39 Key Lessons Learned Tips that can Help Sell process, not technology Secure commitment from physicians and staff to change how we currently do business Thoroughly plan and monitor progress Anticipate the issues and solve well in advance Tie decisions to project guiding principles

40 Q&A William M. Keane, MD Chief Medical Officer, Jefferson University Physicians Bruce A. Metz, PhD Chief Information Officer, Thomas Jefferson University John Ogunkeye Executive Director & VP, Jefferson University Physicians