The EMR Toolkit. Implementing electronic medical records in primary health care settings

Transcription

1 The EMR Toolkit Implementing electronic medical records in primary health care settings

2 Our mission is to help the people of Canada maintain and improve their health. Health Canada The opinions expressed in this document do not necessarily reflect the views of Health Canada. Contents may not be reproduced for commercial purposes, but any other reproduction, with acknowledgements, is encouraged. This publication may be provided in alternate formats upon request. For further information or to obtain additional copies, please contact: Publications Health Canada PL 0900C2 Ottawa, Ontario K1A 0K9 Tel.: (613) Fax: (613) This document is also available electronically (in PDF and HTML formats) at: Her Majesty the Queen in Right of Canada, 2006 Cat.: H21-274/2006E-PDF ISBN:

3 About the EMR Toolkit... 1 Table of Contents 1. Getting Started Selecting an EMR Preparing for Implementation Implementation & Maintenance Optimizing your EMR Canadian EMR Success Stories Appendices

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5 About the EMR Toolkit About the EMR Toolkit Contents What is the EMR Toolkit?... 2 Who developed it?... 3 Who is it intended for?... 3 In what formats is it available?... 4 For more information... 4 About the EMR Toolkit 1

6 About the EMR Toolkit What is the EMR Toolkit? support Canadian primary health care practices to adopt EMRs. Practices which are already using EMRs will find valuable information on EMR optimization and further benefits. The intent of the Toolkit is not just to support primary health care practices with selecting the hardware and software associated with implementing an EMR, but to help practices to get the most out of their EMR once it is in place. For instance, data quality, using the EMR to support clinical decision making, and using it to streamline workflow in the practice are key areas of potential benefit. The longer-term goal is to support primary health care renewal by encouraging the implementation of information technology in practice settings. EMRs have the potential to support information sharing among practice team members; improve quality and continuity of care (particularly with regard to chronic disease management); support planning and accountability activities; and improve clinical decision making tools. The Toolkit consists of three main elements: 1. A narrative step-by-step start-to-finish guide. An At a Glance summary is provided at the beginning of each chapter followed by the chapter details for each EMR project planning and implementation phase. 2. Practical tools and templates to assist with EMR project planning and implementation. Each chapter includes a listing of tools, templates, and further reading, a chapter Checklist, and space for user notes. The Checklists at the end of Chapters 1 through 5 provide the user with a mechanism for tracking progress during an EMR implementation project. Wherever possible, existing tools have been cited to avoid duplication and build on existing resources. Although some tools originated in individual provinces, they are applicable across jurisdictions and can be applied with little or no modification on a national basis. The tools are available as links in the online version of the Toolkit, and the hardcopy version provides information on how to obtain them. 3. Success Stories which provide examples of successful EMR implementation in Canada. Because it is a national-level resource, the Toolkit doesn t provide detailed information for each individual province or territory. However, it does provide contact information for each jurisdiction, and identifies questions you should be 2 About the EMR Toolkit

7 About the EMR Toolkit asking within your jurisdiction to determine what local support and resources may be available to assist with EMR adoption. Who developed it? The development of the Toolkit was overseen by Health Canada and funded through the Primary Health Care Transition Fund. A private sector consulting firm, Greymartin Consulting Inc., was selected through a competitive public tendering process to develop the Toolkit. Who is it intended for? It is intended for whoever is interested in implementing an EMR, across various primary health care practice models and settings. In some cases, a health care provider such as a physician may assume direct responsibility for implementation. In others, a group of providers may delegate the responsibility or hire a consultant for the purpose. Likewise, different types of practice models may have different priorities and considerations. Given the range of needs and interests, the Toolkit has been designed for flexibility and provides various layers of detail so that users may select the information which best meets their needs. A note on multi-disciplinary practice: The Toolkit is intended for a multi-disciplinary primary health care audience. However, many of the existing tools have been developed with physician audiences in mind. Some may be extrapolated to a multidisciplinary environment, but, as practice models increase in size and complexity, issues such as access to patient information between members of a practice team become more complex. EMR tools designed to incorporate new practice models are an important area for future development. The Toolkit identifies areas where there are considerations particularly relevant to multi-disciplinary settings. About the EMR Toolkit 3

8 About the EMR Toolkit In what formats is it available? You can access the Toolkit in several ways: Online interactive version at: Printable online PDF version: Hardcopy binder (available from Health Canada Publications): Publications Health Canada PL 0900C2 Ottawa, Ontario K1A 0K9 Tel.: (613) Fax: (613) The core text of the Toolkit is available in French and English. Where externallydeveloped tools are referenced, they are available in the language of origin. For more information EMR Toolkit: EMR Toolkit Project website: About the EMR Toolkit

9 Chapter 1 Getting Started Chapter 1 Getting Started Is it time for an EMR? Contents At a Glance What can an EMR do for a primary health care practice? What are the challenges to EMR implementation? Developing the IT business case: does my practice need an EMR? Conducting a needs assessment Conducting a readiness assessment Setting goals & priorities for EMR implementation Setting a budget Toward a technology-enabled practice Tools & Resources Tools Further reading Chapter 1 checklist User notes Chapter 1: Getting Started 5

10 Chapter 1 Getting Started At a Glance What can an EMR do for a primary health care practice? Before implementing an EMR system, you must consider whether its benefits justify the cost in computer hardware, software, and staff training. Potential benefits of using an electronic system to maintain patient records include: We wouldn t go back to paper there s nothing attractive about paper. We can do everything and more with an EMR. It will make life easier, but you do need to enter data and typing skills do help. - Dr. Tom Bailey 1. Improved quality of care by increasing the quality and quantity of information, reducing clinical errors, improving clinical practices and facilitating a consistent approach to managing clinical problems. 2. Reduced costs by helping prevent redundant tests, automatically generating reports and claims, enhancing office productivity, reducing patient risk, reducing legal exposure, and improving the security and availability of information. 3. Improved communication by improving the ability to share data with other health professionals and providing faster access to information. 4. Improved analysis of health data including simplifying the observation of trends in the health of individual patients and patient populations, enhancing the ability to analyze data to support management decision making, and enabling the demonstration of clinical competence for revalidation and certification purposes. This section provides tools to help develop a business case or value proposition to determine whether you need an EMR. It also provides tools and information to assist with budget development, assessing practice needs, developing goals, and determining readiness to embark on an EMR implementation project. It also provides a few ideas for easing into the concept of a technology assisted practice: practical online tools and resources that provide clinical value, and introduce users to the benefits of information technology in a primary health care practice setting. 6 Chapter 1: Getting Started

11 Chapter 1 Getting Started 1.1 What can an EMR do for a primary health care practice? Why would you go to the time, effort, and expense of implementing an EMR system? The value is not strictly financial. EMRs can help streamline current procedures and assist with reducing medical error, improving office efficiency, and improving documentation. They can also facilitate techniques, such as patient populations comparisons, which would be difficult using hardcopy-based record systems. The Canadian EMR Success Stories included in this Toolkit (see Chapter 6) provide real life examples of the benefits of EMRs in a variety of practice settings. Here is one clinic s story: Despite changing software products and vendors 3 times in four years, the clinic is now beginning to realize clinical benefit from the EMR product now in place for approximately 18 months. All staff are using the software, sharing data and patient care more effectively, and beginning to derive clinical value from the data in the system. For instance, new diabetes and asthma programs have been particularly successful as a result of decision support and data availability through the EMR: Patient registers have been developed for both programs. The EMR allows easy tracking of needed recall and management needs. Clinical guideline-based process measures (e.g., proportions of diabetes patients with at least one HbA1C in the past 3 months) can be tracked and changes can be monitored over time. For the asthma program, the nurse practitioner and respiratory technologist give full patient workups, as well as patient medical education and reviews, documented and shared through the EMR. The diabetes program includes a template-based one-hour initial assessment with the diabetic nurse and dietitian, all of which is captured in the shared patient record. All providers chart in the same system. With one system, data is not duplicated, and patients do not need to repeat histories. The providers (physician and non-physician) are beginning to look at their data, and to see the potential for improved patient health outcomes through evidence-based patient population management. - Taber Associate Medical Centre Chapter 1: Getting Started 7

12 Chapter 1 Getting Started Potential benefits gained from the implementation and use of an EMR may be summarized into four categories: 1. Quality of Care and Patient Safety Benefits. EMRs can improve the quality of patient care by: o Improving the quality of and access to patient information. o Reducing clinical errors. o Helping providers keep more complete records by addressing the need to record a greater quantity of information and by collecting information over time and between settings of care. o Ensuring that essential information (e.g., chronic conditions) is highlighted through the use of automated reminders (rule-based recall). o Giving decision support to practitioners. o Helping to improve clinical practices (e.g., providing templates and clinical guidelines to embed evidence-based practice in routine care). o Encouraging a consistent approach to the management of clinical problems. 2. Cost-of-Care Benefits. EMRs can reduce costs by: o o o o Reducing redundant tests and services due to unavailability of test results. Saving administration costs by generating reports automatically and electronically submitting claims. Enhancing productivity by reducing: The time spent searching for records or waiting for records already in use. Redundant data entry. The time needed to enter or review data. The time spent producing activity information, e.g., how is staff time measured, what activities are they engaged in? Reducing risks to the patient, and thus unnecessary costs of care, due to: Decisions that are delayed due to inability to find or access information. Repeating invasive tests and procedures. Adverse effects or interactions arising from drugs prescribed by practitioners unaware of the patient s full clinical situation. 8 Chapter 1: Getting Started

13 Chapter 1 Getting Started o o o Reducing legal exposure arising out of medical records that are inadequate, incomplete, or unable to be found when required. Reducing the likelihood of information going missing. Improving the security of information. 3. Communication Benefits. EMRs can improve communication by: o o o o o o Improving access to clinical information regarding patients. Providing faster access to pathology and radiology results. Improving the sharing of health information among primary health care providers. Improving the flow of information with secondary and tertiary care teams. Improving the legibility of notes. Providing patients with better access to their own records. 4. Analysis Benefits. EMRs can improve analysis of health-related data by: o o o Providing easier observation of trends and patterns in the health of a patient or patient group, making clinical audit, outcome assessment, and research easier. Enhancing the ability to analyze data to support management decision making. Enabling the demonstration of clinical competence for revalidation and certification purposes. 1.2 What are the challenges to EMR implementation? Converting a practice to an electronic record system is not a trivial exercise and requires careful thought and planning. Some potential difficulties to be considered in establishing an EMR include: The financial cost of new computers, network infrastructure, and software procurement and training. The temporary loss of staff productivity, and/or income while they become familiar with the new system. The fear of change, and fear of the obsolescence some staff will not feel comfortable being asked to work in a different way. The conversion of existing hardcopy records. The change fatigue associated with large projects, which may or may not have a clear benefit to the end-users. Chapter 1: Getting Started 9

14 Chapter 1 Getting Started Lack of buy-in from all practice team members: complex political environments and diverging opinions about goals and priorities can impede an EMR project s success. NOTE: Additional material discussing the advantages, benefits 1, and challenges 2 of adopting an EMR (from Dr. Nikki Shaw s Computerization and Going Paperless in Canadian Primary Care) can be found on the EMR Toolkit website ( 1.3 Developing the IT business case: does my practice need an EMR? To develop the business case (the rationale for implementing an EMR system), review the Building an IT Business Case 3 user guide, from OntarioMD, which includes an IT Business Case Template 4. The guide and template can help you identify key decision-making factors, document the results of your discussions on implementing IT, and clarify reasoning behind decisions you make. The American Academy of Family Physicians provides a cost/benefit worksheet 5 that can also be useful in developing a business case. NOTE: Although these tools were developed for individual jurisdictions, they are applicable to other providers and in other jurisdictions with little or no modification. The same is true of all tools cited in the Toolkit. Some jurisdictions (e.g., provincial/territorial government or regional health authority), may offer support programs for EMR selection and implementation. The Contacts section (see Appendices) identifies regional contacts for each province and territory and includes a list of questions to ask within your jurisdiction. 1.4 Conducting a needs assessment Key to the business case are the reasons you feel an EMR will benefit the practice. A needs analysis will help determine how an EMR may affect the practice and whether the expense and time spent changing to an EMR are justified. OntarioMD provides a series of practice needs-analysis templates 6 for core business and clinical processes. The templates suggest itemizing each work area within the practice, identifying what works well, what doesn t work well, identifying potential areas for improvement based on the analysis, and the impact changes in those areas may have on the practice (e.g., improved efficiency, improved patient health outcomes). All primary health care practice processes (from patient registration, scheduling, and file/records management, to clinical encounter capture, recall, reporting, referrals and communicating with other providers on your team), can be considered as potential areas that may benefit from the implementation of technology or a change in how any current technology is used. 10 Chapter 1: Getting Started

15 Chapter 1 Getting Started In a paper-based practice, in addition to considering how you do things now, consider some of the benefits specific to an automated practice: for instance - streamlined capabilities related to automated rule-based recall, appointment reminders, trend analysis of lab results for particular patients or for patient groups over time, alerts for out-of-range results, and drug recalls or contraindications, the ability to develop and manage patient registers for patients with particular risk factors such as diabetes or hypertension, and the ability to self-audit your practice team s success in meeting clinical guideline-based measures for processes of care. Combined with the readiness assessment tools in the Conducting a Readiness Assessment section, the process of developing a needs assessment will help the entire practice team to determine the value, benefit, challenges, and opportunities associated with EMR implementation, for their specific practice setting. 1.5 Conducting a readiness assessment Also key to the business case is determining whether members of the practice have the necessary skills and level of dedication to the change to make the move to an EMR feasible. Conduct a readiness assessment to determine: Provider commitment. Staff commitment. Understanding of system management requirements. Need and willingness to acquire computer literacy skills. Impact of automation on job roles and workflow. Alberta s POSP has an automation readiness assessment questionnaire 7. For larger facilities (e.g., large practices of 30+ providers), consider the Readiness Assessment for Large Practices 8, developed by the Info-Tech Research Group. 1.6 Setting goals & priorities for EMR implementation Consider the results of your needs analysis and practice assessments, and consult with other members of your practice team to identify the goals of the EMR implementation. Consider setting short (<6 month), medium (6-12 month), and long (>12 month) term goals, with measurable targets to help assess your progress toward those goals. Goals need to be realistic and attainable, as well as taking into account the current and future infrastructure for the clinic. For instance, have a good understanding of the current paper system, and how the clinical and administrative Chapter 1: Getting Started 11

16 Chapter 1 Getting Started staff interact with it, in order to better set goals related to the EMR implementation 9. It is important that all members of the practice team (clinical and administrative) are involved in setting practice goals in order to ensure that every area of the practice can capitalize on the benefits of the EMR. The following fictional scenario may help to stimulate goal-setting within your primary health care environment. Scenario: The practice has noticed that because they don t have a great on call coverage model for weekends and after hours, their patients are often visiting emergency rooms, or the walk-in clinic down the street for minor ailments and injuries, rather than waiting to see one of the clinic physicians. Even if the patients see one of the practice physicians on call, the physician does not have access to the patient s data from off-site. The practice wants to set up a shared call group for all physicians in the practice, so doctors can cover each other on weekends and after hours the EMR would help by making all patients records for all doctors in the practice available no matter who was on call. Practice Goal: Improved on call coverage for better continuity of care for their patients. How the EMR will help: Better access to patient data for all providers in the practice, whether on- or off-site, and whether the patient is theirs, or another provider s in the practice. 1.7 Setting a budget The physicians and the nurse had been using the EMR for about 10 years. When the PHC Coordinator was hired to integrate patient care and services across the whole health centre, one goal of the project was to expand EMR use to the whole clinical team. - Central Interior Native Health Services Set a budget for the whole project. This includes not just the initial cost of the EMR software, but the total project cost, including initial and ongoing costs such as those outlined here. Potential initial cost areas: o EMR software, hardware, operating systems. o Network infrastructure, including Internet access. o Office productivity software such as Microsoft Word and Excel, and e- mail applications. o Training. 12 Chapter 1: Getting Started

17 Chapter 1 Getting Started o o o Renovations to ensure exam rooms can support computer equipment, and to install network cabling and power supply upgrades where required. Staff costs for time dedicated to the EMR project and for lost productivity or light days scheduled to enable training and implementation. For some health care providers this will mean lost revenue (e.g., fee-for-service physicians participating in project planning meetings are not generating income by seeing patients). Project management costs for large clinics in particular, it may be worthwhile to hire a project manager to deal with the day-to-day details of the EMR project. This investment may pay for itself by shortening the overall project time, and reducing the time investment of other providers and clinic staff, since the project manager will be dedicated to the EMR implementation project, rather than attempting to fit in the work off the corner of his or her desk. Potential ongoing cost areas: o o o o Product support for the EMR software, hardware, and network. Maintenance are upgrades included in the initial EMR costs? EMR software, office productivity software, hardware, operating system and network maintenance likely require annual subscription costs, and potentially also replacement costs every few years (e.g., 3-5 years). Product enhancements some should be included in the upfront price of the software and hardware, but many will require additional expense through service agreements or service level agreements with the vendor(s). Subscription costs for services such as: Internet access Clinical decision support and data services such as drug formularies or other clinical reference tools. o o Training as new EMR software functionality is made available. Staff time to learn new features and to participate in training. For many health care providers, budgeting for an IT project like EMR implementation is difficult in the early planning stages. This is largely due to lack of familiarity with IT project requirements and difficulty estimating the amount of time that will be required by practice staff to support the project. Many practices will find it helpful to shortlist a few potentially appropriate EMR products, and talk with vendors and users in similar clinic/practice settings, to obtain approximate Chapter 1: Getting Started 13

18 Chapter 1 Getting Started cost estimates based on their experience. These high level estimates can be used to guide the budgeting process....tom helped lobby the group to If your jurisdiction has an EMR support cost-share in the adoption of an program, the program support staff may be EMR. Approximately 10 of the able to provide advice and cost range physicians combined forces to costshare the purchase and support of estimates related to budgeting for your practice type. Note that costs and hardware and software for the complexity of the budget process will vary EMR. - Dr. Tom Bailey based on the size, composition, and needs of the practice. The goal setting exercise you and your practice team engage in will help to tailor your requirements to assist vendors with providing initial estimates for you. Some vendors may be reluctant to provide high level estimates to assist you with budget setting due to a fear that the estimate will bind them to that estimated cost. The Selecting an EMR chapter provides more information on defining your detailed practice requirements and developing a request for proposals (RFP) to obtain detailed (and binding) estimates from vendors. See the OntarioMD IT Budget Template 10 and the EMR cost comparison tools in the Selecting an EMR chapter for more information on budgeting, refining your practice requirements, and evaluating vendors. 1.8 Toward a technology-enabled practice At this point, you should have a good sense of how and when you would like to implement an EMR. If you are ready to implement an EMR, you may prefer to proceed directly to Chapter 2, Selecting an EMR. If you are still not sure about a full EMR implementation, you may want to consider some bridging strategies to introduce technology within the practice, and to move gradually toward full EMR implementation. There are a number of practical alternatives which will begin to ease you and your colleagues into the concept of a technology-enabled practice; many practical computer-based tools and resources are available that add clinical value, and that introduce users to the benefits of information technology in a primary health care practice setting. The examples provided in Toward a Technology-Enabled Practice an Introduction 11 are only some of the ways that a primary health care practice can begin to use technology to support patient care; anything you can do to strengthen or enhance the use of technology in clinical practice can help to improve your readiness for EMR implementation. If you decide to undertake activities to technology-enable the practice, remember to re-evaluate your EMR readiness on a regular basis you might be ready sooner than you think. 14 Chapter 1: Getting Started

19 Chapter 1 Getting Started Tools & Resources Chapter 1: Getting Started 15

20 Chapter 1 Getting Started All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: Tools References are available in the language of the author. 1 Benefits of adopting an EMR Reproduced with permission from Computerization and Going Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by Radcliffe Publishing, Challenges of adopting an EMR Reproduced with permission from Computerization and Going Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by Radcliffe Publishing, Building an IT Business Case User Guide A guide to building an IT business case describes the process for developing a business case and shows how to clarify objectives and make the right IT decisions for a group practice (from OntarioMD). 4 IT Business Case Template An IT business case template and sample from the Building an IT Business Case document provides a mechanism for summarizing EMR project Goals, Objectives, Needs, Options, Impacts, Budget, Decision, and Implementation (from OntarioMD). 5 Cost/Benefit Worksheet A Microsoft Excel spreadsheet for calculating a Cost/Benefit summary for EMR implementation (from the American Academy of Family Physicians). 16 Chapter 1: Getting Started

21 Chapter 1 Getting Started 6 Practice Needs Analysis Templates lysis%20v1.0.doc A series of templates for documenting and evaluating how a practice handles tasks and workflow (from OntarioMD). 7 Automation Readiness Assessment Questionnaire A checklist of questions to consider when implementing an EMR each of the topics posed in the checklist should be addressed before proceeding (from Alberta s POSP). 8 Readiness Assessment for Large Practices A readiness assessment worksheet that provides users with an overview of their organization s ability to successfully adopt an electronic medical record (EMR) solution. Includes an outcome interpretation section at the end of the document (from the Infotech Research Group). 9 Records Management A guide to help healthcare providers identify their goals and objectives for moving from paper-based to electronic medical records (from OntarioMD). 10 IT Budget Template A Microsoft Excel spreadsheet with a completed IT Budget example and a blank IT Budget template (from OntarioMD). 11 Toward a Technology-Enabled Practice an Introduction Enabled_Practice.doc An overview of the benefits of incremental IT adoption in primary health care practices. Includes a selection of electronic tools and resources to improve clinical care and practice efficiency (from Greymartin Consulting). Chapter 1: Getting Started 17

22 Chapter 1 Getting Started 1.10 Further reading 50 Reasons to Buy an EMR: Why it s Time to Purchase an Electronic Health Record System: An EMR Primer: Selecting an EMR with Confidence: Establishing a Business Case (White Paper): pdf Getting an EMR up and Running: EMR Lessons in Small Practices: EMR: Return on Investment: Economics of EMRs in large practices: ementingemroutpatient.pdf DOQ-IT Business Case: Chapter 1 checklist Checklist for Getting Started Have you discussed implementing an EMR with all practice staff? Does everyone understand the benefits of an EMR to the practice? Are all staff committed to adopting an EMR? Is there consensus on goals and priorities for your EMR? Have you looked into any regional and provincial programs, policies, and standards which may affect your decisions (e.g., budget or choice of EMR vendor)? Have you established your budget? 18 Chapter 1: Getting Started

23 Chapter 1 Getting Started 1.12 User notes Chapter 1: Getting Started 19

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25 Chapter 2 Selecting an EMR Chapter 2 Selecting an EMR How do you decide? Contents At a Glance Gathering your requirements Researching EMR software & vendors Evaluating vendors & EMR systems Developing a contract with your vendor(s) Tools & Resources Tools Further reading Chapter 2 checklist User notes Chapter 2: Selecting an EMR 21

26 Chapter 2 Selecting an EMR At a Glance Choosing the right EMR system for a primary health care practice requires careful consideration. Important steps to consider as part of the selection process are to: 1. Assess the practice s needs: consider software functionality, data standards, system interoperability, infrastructure requirements, and legislative and policy standards. Develop a detailed requirements list to help define the Scope of Work for the project....some of the EMR vendors did not respond when the clinic requested information, or responded several weeks after the request. The clinic used this as an indicator of service levels they could expect postimplementation. - Haig Clinic 2. Research available EMR systems and vendors: determine if your jurisdiction has a pre-approved vendor list; develop checklists & questionnaires to assist with product comparison; and, prepare a Request for Proposals (RFP). 3. Create a list of vendor selection criteria, and evaluate the vendors and software: review responses to the RFP; schedule demonstrations; check references; and, use proven tools/templates for assessing and consistently comparing vendors. 4. Develop contracts with the chosen vendors: include or use the Scope of Work document; establish responsibilities and timelines; include initial and ongoing training and support requirements; identify data (chart) conversion requirements; and, finalize acceptance criteria. 22 Chapter 2: Selecting an EMR

27 Chapter 2 Selecting an EMR 2.1 Gathering your requirements There are five basic areas of requirements to consider when developing the list of practice requirements: 1. Software functionality how does the EMR software handle different workflow and data flow requirements such as billing, scheduling, clinical charting, prescription writing, referrals, recall, reminders, etc.? 2. Data standards how is data captured, e.g., a mix of codified and free-text? What coding systems are used e.g., ICD, SNOMED, ICPC, DSM? 3. System interoperability does it communicate with other systems as required (e.g., lab, hospital, billing systems, provincial or regional registries such as pharmacy, chronic disease management, or public health registries)? 4. Technical infrastructure how does it provide for security, multi-user access, multiple user roles, remote access, database options, client-server or application service provider (ASP), etc.? 5. Legislative and policy standards how does it provide for privacy, medicolegal data retention and audit requirements, etc.? Based on the practice goals and priorities (developed in the Getting Started chapter), and any EMR requirements specific to your jurisdiction, work with your practice team to develop a list of key EMR requirements 1 for the practice. Some considerations when developing this list are described below. Jurisdiction-specific requirements Your jurisdiction, e.g., provincial Ministry of Health or regional health authority, may have standards or requirements in any or all of the five areas outlined above (see the Appendices for a list of regional contacts). The list of questions to consider when contacting your jurisdiction (see Appendices) can assist you to determine what, if any, support or resources are available to help the practice with EMR planning and implementation. Practice-based requirements In addition to any jurisdiction-specific standards and the practice s specific goals, defining practice requirements should include consideration of characteristics that make it unique. Some sample questions for consideration are: Is the practice multi-disciplinary? What types of providers are part of your team? What unique requirements, if any, does this introduce, e.g., does the software support care plans? How much work do you need to do with your practice team to be sure that everyone s needs are addressed? e.g., clinically? administratively? Do all members of your team use the same clinical coding Chapter 2: Selecting an EMR 23

28 Chapter 2 Selecting an EMR standards? Do different members of the team have different billing requirements or administrative reporting requirements? Is the practice in a single clinic location or are providers in multiple locations? Do you require access from more than one location? e.g., clinic, office, home, hospital, etc.? How will the EMR software support these needs? How will these needs affect your hardware and network choices? If the practice is rural, is there highspeed Internet access available? Will this limit your choice of vendors between ASP (Internet based) and local (on-site) solutions? If your jurisdiction offers EMR support or standards, do they have recommendations for how best to obtain Internet access? What specific interoperability requirements do you have with other systems for instance, local labs, clinics, hospitals, provincial and regional public health/disease registries, private and public billing systems? Your jurisdiction may have developed interoperability standards for some systems, but not necessarily for all. Does the practice have any specific reporting requirements to the Ministry or other organizations, related to monitoring patient health outcomes, for specific patient populations, or for provider self-audit? 2.2 Researching EMR software & vendors The clinic had been functioning as a co-located multi-disciplinary, partially EMR-enabled group for approximately 10 years. However, their experience in the past two years demonstrates their evolution to providing integrated, interdisciplinary, team-based patient care, fully supported by a shared EMR. - Central Interior Native Health Services Be sure to check if your jurisdiction has developed a prequalified vendor list, and whether or not selecting a vendor from this list is mandatory. Also determine if they are able to provide any additional support (or perhaps even funding) to assist you with making a selection and planning the implementation. The Regional contacts section lists additional questions (see Appendices) to ask your jurisdiction. Whether your region has a prequalified vendor list or not, consider developing a vendor checklist 2 to help identify specific needs (goals) that the EMR software must address this will help with selecting the correct EMR and vendor for your practice, based on the overall practice goals and objectives set in the previous chapter. A checklist will help you to consistently compare different vendors software and its ability to meet your predefined practice goals and requirements. This is much more effective than comparing vendors based on their marketing 24 Chapter 2: Selecting an EMR

29 Chapter 2 Selecting an EMR materials, and can form the basis on which to compare responses to a formal Request for Proposals (RFP). The purpose of a RFP is to document requirements and expectations (e.g., functionality, support, training, interoperability, price, timing constraints, and vendor reputation), so that vendors can respond in a standardized way that makes it easier to compare the responses. Whether or not there is a prequalified vendor list for your jurisdiction, you may want to formalize the selection process through a RFP, to provide a standard set of requirements to the vendors, and to request a standard format for their responses. This will help to improve consistency in the material received from vendors and to ensure that it is possible for the practice team to fairly and equitably review and evaluate vendor responses. Ask your regional contacts (see Appendices) if they have a RFP template 3 for use. If not, consider modifying an existing template to meet the practice s requirements. 2.3 Evaluating vendors & EMR systems Key considerations when reviewing and comparing vendor responses and products are: Review the RFP responses and weigh them against your requirements and practice goals. Schedule vendor demonstrations, and use a uniform test script 4 and question list 5 (tailored to reflect the practice s needs and objectives) to determine if vendors meet your requirements. Conduct site visits to other practices where the vendors EMRs are in use. Be sure to ask if the clinicians or administrators at the site have any vested interest in the vendor product beyond a client relationship e.g., are they shareholders or resellers of the product? Check references and assess the vendors reputations. Ascertain whether local training and support resources are available. Determine if the vendors are offering EMR software only, or full package solutions that include the EMR software, hardware, office productivity software, networking, installation, training, etc. Determine if the vendors software complies with jurisdiction-specific standards, programs, and policies. Chapter 2: Selecting an EMR 25

30 Chapter 2 Selecting an EMR Compare costs using a standard template based on all factors, e.g., initial and ongoing costs, training, support, enhancements, and scope. Do not focus on upfront costs alone. Alberta s POSP has a Buyer s Guide template 6 and worksheet 7 for comparing vendor costs and total costs of ownership. OntarioMD provides a template for assessing products and vendors 8, with a number of supporting tools linked from within the document. The American Doctors Office Quality IT (DOQ-IT) initiative also provides an EMR Cost Comparison Template 9 which offers a number of blank spreadsheet templates users can complete on their own. 2.4 Developing a contract with your vendor(s) Based on the practice s goals and priorities, negotiate the contracts with your vendor(s). Note that there may be more than one contract required if the EMR software vendor does not manage the hardware and network components as well as the EMR software itself. The two major stages of contract planning are: 1. Documenting the Scope of Work This stage determines exactly what is to be accomplished by the completion of the contract. OntarioMD has an example of a Scope of Work document 10, highlighting areas of consideration and levels of detail to consider when entering into a contract for an EMR. 2. Negotiating the contract This stage is arguably the most important in implementing an EMR system. An improperly negotiated and worded contract could cost the practice severely in both time and money. OntarioMD has a Contract Negotiations 11 document which can serve as a guideline to writing an effective contract with your vendor. Key Scope of Work and contract considerations include: Tying payments to vendor and system delivery and performance. Establishing systems management responsibilities such as maintenance, software and hardware enhancements i.e., who (you or the vendor) is responsible for what aspects of maintaining and upgrading the system. Ongoing training is written into the practice s service level agreement (contract) with their vendor. CINHS now applies a super-user approach, where staff members train other staff. - Central Interior Native Health Services 26 Chapter 2: Selecting an EMR

31 Chapter 2 Selecting an EMR Determining the location (on-site or at the vendor s facility), availability of, and access to, support. Also ensure that escalation procedures (i.e., the process for taking a technical issue through increasingly sophisticated levels of analysis and correction) are documented. Setting the level of training to be supplied by the vendor, both initial and ongoing. Setting responsibilities for and levels of data conversion and migration from existing systems, e.g., how are different data field types handled by the vendor (will free-text data be imported, or just structured data)? If data cannot be imported from your current system, your health region or Ministry of Health may offer a conversion service. In either case, ensure that the conversion requirements are documented as part of the Scope of Work. Finalizing acceptance criteria, i.e., for the acceptance testing stage (see the Implementation & Maintenance chapter) what will be considered acceptable standards of timeliness for system installation, record conversion, levels of accuracy of hardcopy-to-electronic record conversion, etc. Making sure interoperability requirements for new and existing systems, e.g., lab, hospital information systems, billing systems are met. Having an exit strategy for non-performance. Having a lawyer review the contract. This is critical, as a poorly written contract could expose the practice to legal action as well as unnecessary financial cost. Chapter 2: Selecting an EMR 27

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33 Chapter 2 Selecting an EMR Tools & Resources Chapter 2: Selecting an EMR 29

34 Chapter 2 Selecting an EMR All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: Tools References are available in the language of the author. 1 Key EMR Requirements A list of key components in an electronic medical record (from emrupdate.com). 2 Vendor Checklist oals%20list%20rev% doc A tool to help clinics outline the goals that will guide them in selecting a vendor. The goals are separated into four categories that represent four aspects of an EMR: functionality, usability, practicality, and reputation (from DOQ-IT Doctor s Office Quality Information Technology). 3 RFP Template gename=medqic%2fmqtools%2ftooltemplate&c=mqtools A Request for Proposals (RFP) template requires some editing to reflect Canadian requirements e.g., the template has a section for HIPAA compliance (from DOQ-IT Doctor s Office Quality Information Technology). 4 Vendor Test Script An example of a test script that can be used to compare vendor products using a uniform assessment tool. The example script provides a sequence for the demonstration based on a patient s encounter it covers clinical and administrative processes along with workflow from arrival to departure (from OntarioMD). 5 Question list for vendors gename=medqic%2fmqtools%2ftooltemplate&c=mqtools A questionnaire for healthcare providers to administer to potential 30 Chapter 2: Selecting an EMR

35 Chapter 2 Selecting an EMR EMR vendors (from DOQ-IT Doctor s Office Quality Information Technology). 6 Buyer s Guide Template A Microsoft Word template for comparing vendor offerings using a number of criteria (hardware, software, support, operational costs, etc.) - should be used in conjunction with the Buyer s Guide Worksheet (from Alberta s POSP). 7 Buyer s Guide Worksheet A Microsoft Excel worksheet of detailed cost breakdown categories covering workstations, servers, EMR software, common fixed, and additional assumed costs. The worksheet calculates total costs for each vendor and presents a tabular and graphic summary for all vendors (from Alberta s POSP). 8 Assessing products and vendors A four-step guide to evaluating IT products, vendors and services to find the ones that best meet a practice s needs (from OntarioMD). 9 EMR Cost Comparison Template A Microsoft Excel spreadsheet for comparing EMR vendor offerings (hardware, software, and support). Includes instructions, a completed sample worksheet, and a number of ready to use worksheets (from DOQ-IT Doctor s Office Quality Information Technology). 10 Scope of Work document A guide to developing a Scope of Work document that identifies tasks and activities associated with a successful IT implementation. Intended to be used in concert with the selected IT vendor(s), to document what tasks need to be addressed, who is addressing them, and if they were completed (from OntarioMD). Chapter 2: Selecting an EMR 31

36 Chapter 2 Selecting an EMR 11 Contract Negotiations A general guide to contract negotiations intended to cover the main topics and concepts associated with most contracts. The guide provides tips to help negotiate the best contracts with EMR software, hardware, and network installation vendors (from OntarioMD). 2.6 Further reading Guide to Buying GP Software Packages: Choosing a Systems Provider: IT Vendor Checklist: Request for Proposals (page 19): Contract Checklist (page 24): EMR Requirements: EMR Functional Requirements: Chapter 2 checklist Checklist for Selecting an EMR Have you established the requirements for your EMR (based on the practice goals and priorities)? Have you found out if there are any prequalified vendors in your jurisdiction? Is there any support available from your jurisdiction to help with vendor selection or system procurement? Are you eligible for support? Does your selected vendor meet all of the practice goals, priorities, and business requirements? If not, how do they propose to meet them? Is training covered within your contract with the vendor? Is it for the EMR only or does it include basic computer skills? Have you had a lawyer review the contract? 32 Chapter 2: Selecting an EMR

37 Chapter 2 Selecting an EMR 2.8 User notes Chapter 2: Selecting an EMR 33

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39 Chapter 3 Preparing for Implementation Chapter 3 Preparing for Implementation Getting ready Contents At a Glance Identify your IT project lead(s) Develop a plan & assign responsibility for tasks Build & maintain the team How will the EMR change the practice s workflow? Staff training What new policies & procedures do you need to consider? Tools & Resources Tools Further reading Chapter 3 checklist User notes Chapter 3: Preparing for Implementation 35

40 Chapter 3 Preparing for Implementation At a Glance Installing a new system may require profound changes to the way the practice operates, so making a smooth transition is dependent on careful planning. Before implementing these changes, you should: 1. Assign clinical and administrative project leads who will be in charge of coordinating the EMR project including planning, implementation, and training. The planning team should comprise representatives from each clinical and administrative group in the practice (e.g., physicians, multidisciplinary providers, and administrative and managerial staff). 2. Develop a detailed plan. Decide who in the practice is to be responsible for which tasks, such as project management, timelines, communicating with the vendors, defining and building consensus on priorities for EMR requirements, data entry, report generation, etc. 3. Build the team. Foster ownership of the EMR project with all members of the practice setting each member should own the change and understand why and how the EMR initiative will be an improvement. 4. Identify and understand workflow impacts associated with the EMR how will it change job roles and responsibilities for clinical and administrative staff? For patients? How can the EMR help to streamline workflow? 5. Accommodate the time and expense of training staff in the use of the EMR system. This may include some staff acquiring basic computer skills. Training on the EMR software was scheduled to occur in small groups (3 physicians per group), over a 3 day period for each group. Day 1: morning training, afternoon office visits using the software for each physician; Day 2/3: IT/training support on site, physicians using the software while seeing patients. Most Day 3 on site IT support was not required. - Group Health Centre 6. Familiarize yourself with any requirements for policies and procedures related to the EMR implementation. Identify any legal ramifications of using an electronic records system. Discard old policies where appropriate, and develop new ones. Consider privacy, security and system management implications (e.g., software and hardware maintenance, disaster recovery planning, and record archiving requirements). 36 Chapter 3: Preparing for Implementation

41 Chapter 3 Preparing for Implementation 3.1 Identify your IT project lead(s) Before the actual implementation of a new system begins, make sure you designate both a clinical and an administrative lead, or champion, in the practice. A champion can be defined as a peer with special interest in, or skills related to the EMR implementation. Ideally, champions are opinion leaders within the practice, who have the respect of their peers and who can communicate with and influence the practice staff and clinicians to reach consensus on decisions related to the EMR rollout. The champions will be instrumental in coordinating and ensuring ongoing progress through all the EMR project s phases. In small clinics, they may also have the role of project manager to coordinate the details of the EMR implementation project. In larger clinics, or for larger EMR projects, a dedicated project manager should be designated who will work closely with the champions to communicate with the rest of the practice team. Whether a champion or a professional project manager is identified as the project lead, the lead s key role is to ensure that the necessary project tasks and activities are identified, assigned, and completed in a timely manner. A large component of this role is communication with other members of the practice team, to ensure that the goals for the EMR project, and the practice s specific EMR requirements are well documented, communicated, and that the team has Dr. Tom Bailey is the IT lead for his four-physician practice in 2001, he helped lobby the group and several other physicians in the same medical building, to cost-share in the adoption of an EMR. Dr. Tom Bailey reached consensus on priorities, objectives and expectations for the EMR implementation project. 3.2 Develop a plan & assign responsibility for tasks The plan (also known as a project plan, or workplan) is a key tool in managing team expectations about the project. It is designed to document all project steps (tasks), their order, timelines, any dependencies between tasks, and the key individual who will be responsible for ensuring the task is completed, i.e., who will do what and when. Writing up the plan, with the help of the whole team, will help ensure no implementation details are missed. Along with the practice s clinical and administrative staff, the EMR vendor is a core member of the planning team. In most cases the vendor will be responsible for the majority of the implementation and training, and can offer recommendations Chapter 3: Preparing for Implementation 37

42 Chapter 3 Preparing for Implementation about approaches to going-live, chart conversion, data coding and quality standards and policies, and numerous other topics. The plan also serves as a useful communication tool to ensure all members of the team are informed about project steps and timelines, and have common expectations about the results and implications of each project stage. For instance, be sure that all members of the team are aware of the implications to their day-today workflow at each project stage renovations, for instance, may be very disruptive, and may require the clinic to close or reduce hours for a limited time. The following are examples of methods and resources to assist with developing the detailed plan: Alberta s POSP uses a Kick-off Meeting template 1 in their discussions with practices to develop the initial plan for a project. The template provides an overview of project tasks/components, and identifies the group responsible for their completion (clinic, vendor, or POSP change management support team). This high level template can be used as a starting point for more detailed workplan development. BC s Primary Health Care Branch supplies an EMR implementation workplan 2 template to practices and health regions looking at EMR implementation. It identifies the tasks associated with the project in enough detail to be able to establish project timelines and assign work areas to specific individuals. The template can be tailored to meet a practice s specific requirements. OntarioMD s Project Planning and Implementation Guide 3 provides an overview of critical project areas to document in the plan, and a sample layout for the project plan. The project planning overview section 4 of the OntarioMD website links to their full suite of planning tools and guides. The planning process will help to identify and schedule any site and staff preparations necessary for the project s success. For example: Are renovations necessary? Is there space in each patient exam room for a computer and monitor? Do you need to lay network cable or are different hardware and network options desirable (e.g., wireless tablets). What staff training is required? Basic computer skills, or just specific training in the selected EMR system? What go live implementation approach will you use? How will you install, test, and begin using the EMR? For instance, does a phased or Big Bang implementation approach make sense for the practice? Visit the DOQ-IT website to view their summary of EMR implementation options Incremental vs. Big Bang: Comparing Approaches 5. This slide encapsulates the pros and cons of each approach, along with considerations which may impact the 38 Chapter 3: Preparing for Implementation

43 Chapter 3 Preparing for Implementation option chosen. For instance, larger practices, without complete consensus about the EMR project, or with complex politics, may consider an incremental approach. Small practices with strong leadership (champions) and good buyin from the whole team may have success with the Big Bang approach. The CMA s manual, A Physician s Guide to Implementing Electronic Medical Records 6, also describes implementation approach options. What special training or implementation requirements are there for each different provider type in the practice? Does your project planning process include representatives from all clinical groups? For instance, if your practice team is growing or introducing new multi-disciplinary providers, have you worked with all provider groups to be sure their training and implementation requirements are addressed? How will you maintain communications among multi-disciplinary practice members throughout the planning and implementation process? Weekly project meetings for all team members are effective for keeping communication open and current, and ensuring any issues are identified early in the process. 3.3 Build & maintain the team Change management for the initial EMR implementation was through a shotgun approach. That is, as of day one of the implementation (Sep10/2000) we re using the EMR. Software and process workflows training and orientation were completed in advance of the go live date, but the clinic physicians and staff did not know how it would impact patient flow until they were living it. - Taber Associate Medical Centre Establishing an environment of mutual trust and respect is the foundational principle for building and maintaining a successful team. This relies on effective communication among all team members, including clinicians, administrators, practice support staff, vendors, and regional support staff. It requires a mutual understanding that everyone s opinions and ideas are valued. Each team member must own the change and understand why the change will be an improvement. All affected stakeholders must feel part of the project and agree to the project process and goals. Establishing ground rules for team meetings and communication is a technique to build mutual respect and trust. Some key resources and tips are: The National Health Service (NHS) Working with groups 7 document. Chapter 3: Preparing for Implementation 39

44 Chapter 3 Preparing for Implementation Team building exercises. The Introduction to Team Building 8 site contains many tools and techniques for identifying personality types, strengthening group relationships, and team building exercises. The NHS Improvement Leaders Guides 9 offer practical advice and tools for implementing and sustaining improvements in health care settings. The Guides home page 9 and the specific guides on human aspects of change 10 and working with groups 11 may also be useful. 3.4 How will the EMR change the practice s workflow? Implementing an EMR may have significant effects on how the practice functions, and on the roles and responsibilities of individual staff members. Considerations include: Anticipating and accommodating workflow changes in the practice. Using process mapping and building on your Needs Assessment (completed in the Getting Started phase) to determine how the EMR will change the practice and how different functional areas might be streamlined. OntarioMD s template for Practice Workflow Redesign 12 is a tool to help identify areas of improvement in each of the main functional areas of a practice. The NHS provides an overview of process mapping 13. Assessing the potential impact of a process on patients and patient outcomes. Consider how the patient experience may change as a result of the EMR once the anticipated impact is understood, consider implementing a communications strategy to update patients on how the practice will change as a result of the EMR, and how their care will benefit (e.g., faster prescription renewals, automated recall for required tests and preventive screening, better tracking of chronic disease data such as trends in blood pressure and A1C for diabetes patients, etc.). Determining how implementing an EMR will affect clinical and patient flow, how information and data move within, into, and out of the practice, and how workload flows. Considering how staff roles and responsibilities may be impacted as a result of the EMR, and how staff may need to assume, stop, or change roles or job functions. Note that all staff may not be prepared to change! There may be attrition if staff do not feel that they have input to the planning process or if they do not have access to (or interest in) the training to upgrade skills to support their new roles. The initial output of a process mapping exercise is an overview of how things are done today. When a process map is accurately completed, with all members of 40 Chapter 3: Preparing for Implementation

45 Chapter 3 Preparing for Implementation the practice team contributing their understanding of the process, the actual process often differs significantly from the way individuals on the team assume or understand it to occur. The resulting map of the actual current state is ideal for identifying potential areas for improvement where current processes are complex, requiring many steps or interactions among different individuals, there are often opportunities to streamline the what and the how of each process step. When looking for areas to improve, focus on what each function (each step in the process) is, not on who does it. Then ascertain what the best set of skills is to carry out the function. This may result in significant redistribution of work among members of the team (see Redesigning roles 14 ) in order to implement the streamlined processes in the day-to-day practice workflow. This process and workflow redesign to support the EMR may result in the identification of new training or staffing needs. Ensure any new training requirements are added to the training plan developed later in this section. Prior to the EMR, runners responsible for delivering paper charts to their destinations were a large proportion of the administrative staff. It was expected that the EMR would significantly reduce the number of runners required. Although this was true, the runners all upgraded to become scanners and transcriptionists this demonstrates successful role changes for staff as a result of the EMR workflow redesign, but also created increased staff costs for the higher skill jobs. - Group Health Centre 3.5 Staff training Assess and include current and ongoing training requirements in the training plan. Use a simple matrix or a User Skills Template 15 to assess current skills and to identify the types of training each user will require. Some users may require training in basic computer skills and desktop software as well as in the specific EMR application. Training in data privacy, security, networking, and Internet use may also be required. The University of Maryland University College provides a free online Basic Computer Skills tutorial 16 for Microsoft Windows. From the user skills template, develop a detailed training plan. Ensure the contract with your EMR vendor addresses, at a minimum: Initial EMR training to familiarize users with the administrative and clinical aspects of the EMR software. Additional post-implementation training to ensure all users are comfortable with using the software on a day-to-day basis. Initial training is often overwhelming for users and only a portion of the information shared in the Chapter 3: Preparing for Implementation 41

46 Chapter 3 Preparing for Implementation training sessions is retained. Followup training should start within one to two weeks after implementation and continue until all users are fully trained and comfortable with the EMR. Advanced training, once users are familiar with the software, to allow them to utilize more advanced clinical decision-support features such as custom or rule-based recall and alerts, self-audit for patient populations, reporting features, etc. Training to help integrate the EMR with practice workflow, and to change practice workflow where necessary to make the most of the EMR. Training for updates and enhancements to the EMR software as they become available. In addition to specific training in the EMR software, determine if the EMR vendor provides other training. For instance, they may offer basic computer skills training or training in other critical areas such as: Data backup and recovery, including validation of backups to ensure they are working correctly. Basic hardware and network maintenance and troubleshooting, including protocols for when and whom to call for help. Basic computer skills. Software learning opportunities are part of the weekly all staff team meetings. Ideas for process improvements, workflow changes, EMR enhancements, software tips/tricks and training are often exchanged. This gives all users the opportunity to learn from their peers, as well as reinforcing good data entry and coding practices. - Central Interior Native Health Services If your EMR vendor does not provide these training services you will need to go to other sources. For the EMR application, focus on building super users among your practice team. Clinical and administrative users who have a good basic understanding of computers should be considered as potential super users and as candidates to receive additional training in the EMR software so they can provide technical support to other users. It will save time, and potentially money, if problems can be resolved in-house, without needing to call the vendor s help desk for every issue. Plan for each user s training time. Schedule dedicated training time and light workloads for all members of the practice team during the training period and during system implementation. This will give users the time to familiarize 42 Chapter 3: Preparing for Implementation

47 Chapter 3 Preparing for Implementation themselves with new concepts and tools without the pressure of a full workload. Adequate, planned training time increases the likelihood that the new tools will be accepted and continue to be used in a sustainable way once workloads are back to normal higher levels. For larger practices, a longer term training strategy may also be of use. Microsoft provides a series of training articles and templates 17 to help with budgeting and developing a business case for ongoing training. 3.6 What new policies & procedures do you need to consider? Introducing an EMR forces many changes at many levels of a practice. This provides an excellent opportunity to develop new policies and to review current policies and procedures in various areas of the practice. Incorporate the specific legislative and jurisdictional standards in place for your jurisdiction when developing these policies. Your regional primary health care support resources, local professional associations, or regulatory bodies may have additional templates or recommendations in these areas. Some areas specifically affected by the introduction of an EMR are: Privacy: In the context of an EMR, privacy refers to the concept of information privacy the right of an individual to have knowledge of and control over the information about them. Maintaining adequate privacy of sensitive patient information requires privacy, confidentiality and security measures in a practice. o To establish privacy policy, review the Canadian Medical Association (CMA) Privacy Wizard 18. CMA members can log in and walk through a step-by-step tool which will assess current privacy practices and recommend areas for improvement. It will also produce a customized privacy policy document for physicians to post in their offices. o Vancouver Coastal Health Authority s Privacy Toolkit 19 builds on the CMA Privacy Wizard. It provides an overview of the contents of the CMA Privacy Wizard (particularly useful for non-cma members), and introduces privacy and security concepts and legislative considerations in Canada (particularly BC). It also provides practical tips for implementing a privacy policy in a primary health care practice. Security: Security refers to the technical considerations (rather than the policy considerations) of maintaining privacy, confidentiality, and the integrity and accuracy of sensitive patient information. Review the following resources for samples of security policies, and guidelines for consideration when developing policies appropriate for the practice: o Suggested Clinic Privacy & Security Guidelines v (Nova Scotia). Chapter 3: Preparing for Implementation 43

48 Chapter 3 Preparing for Implementation o o PHIM-002 Conditions of Appropriate Use V1.0.doc 21 (Nova Scotia) OntarioMD s Security and Deployment Guidelines 22 and Information Management Guidelines 23 contain templates and tips regarding data privacy and security policy development. Confidentiality Agreements: Confidentiality refers to the concept of restricted (authorized) access to information only authorized individuals are permitted to access information, and they are allowed to access information only to the extent required to support their job. o A confidentiality agreement is a binding agreement to document staff commitment to maintaining the confidentiality of the patient information in their care. It provides legal recourse for the patient and employer if confidentiality is breached. Every staff person in the practice should sign a similar agreement and be aware of the implications if they break the agreement. o Confidentiality agreements may vary based on the requirements of local privacy legislation or health care policy. Your local or regional professional association or regulatory body may have samples specific to your jurisdiction or practice environment. OntarioMD s Developing a Practice and Risk Management Manual 24 contains a sample confidentiality agreement. Systems Management: Systems management is about understanding how you are going to support and maintain your information technology operations on a daily basis. For instance, how will you deal with capacity planning (how much electronic storage do you need for all your records), business continuity (what happens if your EMR crashes), disaster recovery (what if there is a fire, flood, or other major damage to the practice), service level agreements (who do you call when something breaks), etc. Several guidelines exist to assist with developing policies in the practice: o Systems Management Guidelines (OntarioMD) 25. o Systems Management Guidelines (POSP) 26. o Developing a Practice and Risk Management Manual and the Practice and Risk Management Overview (OntarioMD) 27. Medico-legal requirements: Responsibilities for records retention schedules will not be affected by the implementation of an EMR. However, you will need to ensure you adopt policies for appropriate archiving and deletion of records. Also keep in mind the long term electronic storage implications of archived charts. For instance, the need for validity testing of archived material to ensure it is retrievable, and how much storage capacity, its accessibility and durability, are required to meet immediate and longer term needs. 44 Chapter 3: Preparing for Implementation

49 Chapter 3 Preparing for Implementation Tools & Resources Chapter 3: Preparing for Implementation 45

50 Chapter 3 Preparing for Implementation All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: Tools References are available in the language of the author. 1 Kick-off Meeting Template A high-level summary of the activities involved in preparing for an EMR and getting prices and demos. Includes a matrix to assist in defining what needs to be done, when it needs to be done and by whom (from Alberta s POSP). 2 EMR Implementation Workplan A Microsoft Project template to assist primary health care sites with planning for an EMR implementation. Has some specific references to BC funding models but provides a framework for a project plan to document, organize, and schedule an EMR implementation (from the BC Primary Health Care Branch). 3 Project Planning and Implementation Guide A guide that highlights key components for successfully implementing IT within a medical practice. It contains information to help build and manage an IT project plan (from OntarioMD). 4 Project Planning Overview The OntarioMD Transition Support Program s Project Planning section helps identify and document the timing and interdependencies of implementation activities and includes Guides, Tools, Forms, and Group Activities (from OntarioMD). 5 Incremental vs. Big Bang: Comparing Approaches =multipart%2foctet-stream&blobheadername1=content- Disposition&blobheadervalue1=attachment%3Bfilename%3DEHR+I mplementation+options.pdf&blobkey=id&blobtable=mungoblobs& 46 Chapter 3: Preparing for Implementation

51 Chapter 3 Preparing for Implementation blobwhere= A model demonstrating pros and cons of phased and big bang approaches to EMR rollout. Identifies key factors to consider when choosing an approach (from DOQ-IT Doctor s Office Quality Information Technology). 6 A Physician s Guide to Implementing Electronic Medical Records Available through the CMA website Requires CMA membership (from the Canadian Medical Association). 7 Working with groups ement Leaders Guides NEW/1/1. General Improvement Skills/1.3 WG - Working with groups.pdf A guide to effective group management techniques for project and department leaders (from the United Kingdom National Health Service). 8 Introduction to Team Building An introduction to team building includes resources, exercises, and activities (from 9 Improvement Leaders Guides The%20Guides.aspx A portal to a library of basic tools and techniques for general quality improvement skills, process and systems thinking, and personal and organizational development (from the British National Health Service). 10 Human Aspects of Change ement%20leaders%20guides%20%20new/1/3.%20personal%20and %20Organisational%20Development/3.1%20HD%20- %20Managing%20the%20human%20dimensions%20of%20change. pdf A guide written by experienced Improvement Leaders involved in healthcare improvement. Focuses on change management supports Chapter 3: Preparing for Implementation 47

52 Chapter 3 Preparing for Implementation to empower, enable, and engage project team members. Includes the models and frameworks that helped the authors while working with a wide variety of people in healthcare (from the British National Health Service). 11 Working with groups ement Leaders Guides NEW/1/1. General Improvement Skills/1.3 WG - Working with groups.pdf A guide to effective group management techniques for project and department leaders (from the British National Health Service). 12 Practice workflow redesign A series of templates (for group practices) designed to help determine how current procedures will change with a new or enhanced clinical management system, what new processes will be needed, and how the changes in the practice will affect staff, physicians and patients (from OntarioMD). 13 Overview of process mapping A process mapping overview intended to help practice teams in determining where to start making improvements that will have the biggest impact for patients and staff (from the British National Health Service). 14 Redesigning roles ement%20leaders%20guides%20%20new/1/3.%20personal%20and %20Organisational%20Development/3.2%20RR%20- %20Redesigning%20roles.pdf A guide written for individuals involved in improvement who feel that current roles are restrictive, hinder service improvements or don t recognize and use the abilities of staff. Includes tips and advice for the inexperienced, as well as for those with responsibility for workforce planning, staff development and training, recruitment and retention (from the United Kingdom National Health Service). 15 User skills template 48 Chapter 3: Preparing for Implementation

53 Chapter 3 Preparing for Implementation A Microsoft Excel spreadsheet for recording user skill levels and determining training needs (from Greymartin Consulting). 16 Basic Computer Skills Tutorial A hands on tutorial to assist novice-intermediate users in familiarizing themselves with the Microsoft Windows environment and building baseline knowledge and skills (from University of Maryland University College). 17 Microsoft training articles and templates A series of demos, articles, and templates to assist with development of a training plan (from Microsoft Corporation). 18 CMA Privacy Wizard A Privacy Wizard to help create a patient privacy notice, privacy policy for the office, and a self-assessment of privacy practices and suggestions for enhancement. Requires CMA membership to access (from the Canadian Medical Association). 19 Privacy Toolkit for Primary Health Care Practices V1.3.pps A Microsoft PowerPoint tool designed to help primary health care practices identify and address privacy and security issues expands on the CMA privacy wizard (from the Vancouver Coastal Health Authority). 20 Clinic Privacy and Security Guidelines delines_v1.1.doc Suggested privacy and security guidelines intended to assist clinics in reducing the risk to confidential patient information (from the Nova Scotia Primary Healthcare Information Management Program). 21 Conditions of Appropriate Use Chapter 3: Preparing for Implementation 49

54 Chapter 3 Preparing for Implementation 002_Conditions_of_Appropriate _Use_V1.0.doc A sample document identifying a number of security areas that should be considered when implementing an EMR remote access, , internet access, password security, etc. (from the Nova Scotia Primary Healthcare Information Management Program). 22 Security and Deployment Guidelines A privacy and risk management tool that provides guidelines for installing and configuring information technology systems and assists the user to ensure that the privacy of patient information is protected whenever the new information technology is used (from OntarioMD). 23 Information Management Guidelines A guide to developing and maintaining policies and procedures that assure privacy, security and business continuity (from OntarioMD). 24 Developing a Practice and Risk Management Manual A framework for developing a policy manual the templates and samples in the guide help groups set up a manual and can be used as is, or modified to suit particular requirements (from OntarioMD). 25 System Management Guidelines OntarioMD A tool to help IT professionals to manage and maintain systems and ensure system continuity and security (from OntarioMD). 26 System Management Guidelines POSP A guide to systems management principles and key content areas intended for end-users (from Alberta s POSP). 27 Practice and Risk Management Overview 50 Chapter 3: Preparing for Implementation

55 Chapter 3 Preparing for Implementation A guide to elevate awareness regarding the implementation of IT and the implications it has on the way group practices ensure the continued privacy, confidentiality, safety and security of patient and practice information (from OntarioMD). 3.8 Further reading Business Process Mapping: Questions to ask your staff (Computerization and Going Paperless in Canadian Primary Care): Process Mapping a Health Care Supply Chain: CATION_PG1/DEL_POLICY_PAPER_PG1/PROCESS-MAPPING-PAPER-GHC.pdf PRIMIS Case Study: Understanding Firewalls (tutorial): n.pdf What to do When the Power Goes Out: 26 weeks to using computers in GP and Nurse consultations: Chapter 3 checklist Checklist for Preparing for Implementation Do you have a clinical lead and an administrative lead for the project? Have you appointed a project manager? Does one of the leads have the time and skills to do this, or do you need to hire a consultant? Have you worked with your team to create a project plan, with tasks, timelines, and a named individual responsible for each task? Is everyone in agreement with this plan, including the vendor? Have you worked with your team to complete a process map for the practice and identify areas for improvement, e.g., where the EMR software will change how you work, where staff have different roles, where information and data flow differently? Chapter 3: Preparing for Implementation 51

56 Chapter 3 Preparing for Implementation Have you determined the training requirements for each member of the practice? Do some need to acquire basic computer skills as well as training in the EMR software? Have you identified potential super users in the clinical and administrative areas who can help other users become familiar with the software and troubleshoot issues? Have you scheduled dedicated training time and lighter workloads for staff during training and implementation? Have you developed privacy and security policies for the practice? Do all staff understand the policies? Are patients aware of the policies? Have you established system management guidelines and a disaster recovery plan for the practice? Have you worked out implementation details with your vendors? 52 Chapter 3: Preparing for Implementation

57 Chapter 3 Preparing for Implementation 3.10 User notes Chapter 3: Preparing for Implementation 53

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59 Chapter 4 Implementation & Maintenance Chapter 4 Implementation & Maintenance Going Live Contents At a Glance EMR system installation & training Data conversion Acceptance testing System & software user guides Accessing support services Data entry, quality, & reporting implementing best practices Maintaining your EMR Tools & Resources Tools Further reading Chapter 4 checklist User notes Chapter 4: Implementation & Maintenance 55

60 Chapter 4 Implementation & Maintenance At a Glance The Implementation & Maintenance phase acts on the components of the EMR project plan (developed while Preparing for Implementation ) that address implementation: installing the EMR, converting data from existing paper and electronic systems, completing user training as defined in the training plan, testing the EMR and new procedures and policies in the practice, and signing off based on the acceptance criteria established with your vendor. Implementing and beginning to use and maintain the EMR involves: 1. Installing any necessary hardware and software. This may include renovations to your offices to install network cables etc. 2. Completing user training to ensure all clinical and administrative users have the necessary skills to start managing patient charts electronically. 3. Converting existing patient chart data (as little as necessary) to the new system s format and establishing a timeline for all staff to have completed their conversions....three EMR products were tried and discarded before the current product s implementation. This led to significant practice disruption, cost, and staff turnovers, but has resulted in the implementation of an EMR which meets the clinic s needs. - Taber Associate Medical Centre 4. Acceptance Testing to sign off on the installation to be sure all aspects of the EMR software, hardware and network meet the requirements outlined in the Scope of Work (in the vendor contract). 5. Obtaining and maintaining all hardware and software documentation (electronically or on paper), and ensuring there is a means to keep the documentation current. 6. Establishing software/hardware support procedures for obtaining assistance with the system, i.e., do you have an in-house expert available and at what point do you contact the vendor for help? 7. Establishing best practices for data coding and data entry, for consistent, high quality data to support clinical decision making. Practical analysis (datamining) of the data in the EMR can improve the derived value of the EMR, by improving patient care processes (which can lead to better patient safety and health outcomes) and practice efficiency. 8. Establishing and testing procedures for system backup, data recovery, and system maintenance. 56 Chapter 4: Implementation & Maintenance

61 Chapter 4 Implementation & Maintenance 4.1 EMR system installation & training Installation of hardware and network equipment is the most disruptive component of an EMR implementation. Try to schedule this work so it occurs outside regular office hours. If construction is required to install new network cables, this should be done first, since it often requires wall and ceiling repair and new paint. Initial training for all clinical and administrative users is normally undertaken as soon as installation is complete. All clinical and administrative users should have the necessary skills to start using the EMR. Further training is undertaken as documented in the training plan (see Preparing for Implementation ). 4.2 Data conversion Data from the existing practice environment may need to be moved to the new EMR. The key question is how much (or how little) data do you need? ; the key principle is don t convert any more than necessary. A good heuristic on which to base data conversion requirements is to consider the new EMR as volume 2 of a patient s paper chart once volume 2 is started with any essential information copied from volume 1, how often do you (really) go back to look at volume 1? Despite lack of consensus on the best method of converting data, there is general agreement on what paper chart data is essential. These include: Patient demographics. Allergies. Medications. Active problems. Recent significant diagnostic and lab results. Significant personal and family histories. Once you ve determined the minimum amount of data requiring transfer into the new EMR, there are several common approaches for converting the data: 1. Paper to Electronic: Have each provider enter a few records outside office hours, until all charts are entered, or to save time, only enter the frequently seen and high risk Ad hoc back-data entry is manageable (when a patient has an office visit, or the day before), and there s no unnecessary work generated from entering data for patients who do not return to the practice. Dr. Tom Bailey Chapter 4: Implementation & Maintenance 57

62 Chapter 4 Implementation & Maintenance patients, e.g., those with chronic conditions and/or multiple comorbidities. Enter the rest of the charts as the patients come into the office. Enter data for patients only as they come into the office. This approach has the advantage of avoiding unnecessary work associated with entering data for patients who never return to the practice but tends to prolong the conversion process and thus possibly delay achieving the maximum usefulness of the EMR. 2. Electronic to Electronic your previous systems (e.g., billing and scheduling software, or another EMR) may allow patient demographic data and clinical data to be extracted in a format suitable for import to your new EMR. If this data cannot be imported from your current system, your health region or Ministry of Health may offer a conversion service. In either case, ensure that the conversion requirements are documented as part of the vendor s Scope of Work. Providers in the practice may find that a different model works best for each of them. Whichever model is chosen, come to agreement with your practice team on a definite time limit for all providers to have completed their chart migrations. Review the Canadian EMR Success Stories (see Chapter 6) for further examples of several Canadian providers experiences and advice regarding data conversion during their EMR implementations. 4.3 Acceptance testing The clinic ran the old and new EMRs in parallel for 18 months, in order to permit staff to migrate patient charts as patients came into the clinic. Staff attempted to keep both systems up to date, but found this extremely difficult, and would recommend a clean cutover to remove (archive) the patient from the old system, as soon as the patient is entered in the new system. - Haig Clinic Acceptance testing is about ensuring the system functions in the practice setting as defined in the Scope of Work. It requires a formal, binding agreement by both the vendor and the practice that the criteria outlined in the Scope of Work have been met. Once completed, the project passes from the implementation phase to the operational. The EMR vendor s role then evolves to providing post-implementation operational support and the service level agreement for support and maintenance comes into effect. 58 Chapter 4: Implementation & Maintenance

63 Chapter 4 Implementation & Maintenance As part of your training, and as part of the go live process, test each and every new procedure related to the EMR hardware, software, and networking in your own practice environment. For instance, test components such as the following (this is a sample list which would be developed in more detail in your actual Test Criteria): Logging in, changing passwords, locking workstations, adding and removing new users from the system. All aspects of EMR functionality including prescription writing, referral letters, intra-office messaging, reporting and recall functions, etc. System-to-system interoperability including all agreed upon electronic data imports and exports, e.g.: o Billing for private and public payers. o Lab results, medications, and diagnostic data from external sources. o E-prescribing. o Diagnostic order entry. o Data feeds and reporting to and from other provincial and regional systems, e.g., hospital information systems, registries (immunizations, chronic disease management, cancer, etc.). Note: Interoperability is also addressed in Chapter 5 Optimizing your EMR, under the Data sharing & interoperability section. Internet access and from every workstation and every user account. Printing from every workstation and every user account. Also test label printing (if relevant). Access to office productivity tools, e.g., word processing and spreadsheet programs, clinical reference tools, etc. for all users who need them. Backup and recovery. Verify that the process works as it should and that data restored from a backup is useable. Archiving of patient charts when a patient leaves the practice. Remote Access. If remote access is provided to permit users to access the EMR system from off-site (e.g., at home or in another clinic location), ensure that it works as planned and that all security protocols are installed and activated. Wireless network security. If a wireless network is used, ensure security is properly enabled and that unauthorized devices (computers, messaging devices (e.g., Blackberry, Palm), etc.) cannot view or access the network traffic. Chapter 4: Implementation & Maintenance 59

64 Chapter 4 Implementation & Maintenance OntarioMD provides a template for implementation acceptance testing 1. This template can be customized to suit a practice s goals and requirements. 4.4 System & software user guides Ensure that the vendors supply good user manuals for both the hardware and software, in either printed or electronic form (preferably both). User guides for the EMR and any desktop applications (e.g., Microsoft Office ), and basic hardware and networking troubleshooting guides are invaluable to new users and to super users supporting others in the practice. 4.5 Accessing support services Ensure that all staff members are aware of what to do when they have technical problems. For instance, under what circumstances should a user call the vendor s help line or customer support centre? The practice should consider developing a simple policy for users on a day-to-day basis, such as the following: If you have trouble with your EMR, follow these three steps in order: 1. Use the help file: examine the user guides to try to resolve the issue on your own. 2. Consult the on-site super user or other IT support, if available. 3. Contact the vendor s support desk. More detailed support policies and procedures should be documented as part of the service level agreement with your vendors. Service level agreements and the documented escalation procedures can be very general or extremely detailed, but should outline criteria and timelines for support and system performance issues. In addition to outlining basic support procedures, the agreement should also address the steps to be taken in the event of a system failure, response times for routine and ad hoc queries, and response times for problem resolution (network down, machine failure, etc.). 4.6 Data entry, quality, & reporting implementing best practices The largest value in using an EMR is not in the data you enter, but in the information you can retrieve to help improve patient care. Effective EMR use relies on a sound understanding of a few quality principles and core concepts about data: 60 Chapter 4: Implementation & Maintenance

65 Chapter 4 Implementation & Maintenance Data types and management The data collected may be in either or both plain text or structured formats. OntarioMD s Records Management Guide 2 is a short, content-rich guide that introduces the concepts of data types, principles of data capture, quality, storage and archiving, and data conversion approaches, including key tips on deciding whether to scan data into the EMR. Data mining and reports Data collected is useful only if it can be retrieved in an efficient manner. Similarly, meaningful reports can be generated only if the data is accurate and complete. Understanding data mining and reporting principles helps set the stage for continuous improvement in the practice. Implementing effective clinical decision support at the point of care and managing patient populations (e.g., recalls and alerts, self-audit) is not possible without good quality data. See the Canadian EMR Success Stories (Chapter 6) for examples of quick wins with data mining to improve patient care and see the chapter Optimizing your EMR for more details on technology-enabled quality improvement and best practices. Key principles of data quality and coding are: Team members have recognized the criticality of good data coding and data entry practices. E.g., one physician did not code diagnostic data (ICD9) well. Now that the practice is using the EMR to generate comparative reports over time, and the reports are often discussed at the weekly meetings, the physician has seen the impact of poor coding practices on the data, and is working to improve coding habits. The team has also standardized the way all disciplines encode diagnoses for alcohol overuse, and is working on standardized coding for other high priority diagnoses. - Central Interior Native Health Services Data quality The GIGO principle: If you put garbage in, you will get garbage out. In health informatics, definitions of quality data generally refer to data with the following characteristics: it is accurate, complete, relevant, up to date, and accessible when and where it is needed. Consistent data entry and coding practices help to generate quality data, and to ensure that the data in the EMR will be useful. Without quality data, your ability to use your EMR data to self-audit is impaired and the GIGO principle rules. Self-auditing is particularly useful in ensuring best practices are followed for patient populations with specific health risks, chronic conditions, or comorbidities. For instance, managing diabetes and cardiovascular care is easier if you can consistently identify all Chapter 4: Implementation & Maintenance 61

66 Chapter 4 Implementation & Maintenance patients in the practice with the conditions, or at risk due to particular characteristics. If inconsistent coding practices are applied, or the data is incomplete, you may miss portions of your patient population when attempting to implement recall programs (e.g., for A1C monitoring, or influenza vaccines for high risk populations). Dr. Nikki Shaw s, Computerization and Going Paperless in Canadian Primary Health Care (Chapter 11) 3 provides an overview of data quality and a sample of the benefits gained by mining your EMR data to improve patient health outcomes. Data entry Agree on a common approach to data entry and coding among all members of the practice and ensure that all members of the practice team follow this approach. Data entry best practices rely on consistency and codified data. Aspects of data entry include: o o o o o Data coding and quality standards are set with input from all members of the team: clerical (scanners, stenos, billing staff), and clinical staff (physicians and nurses). - Haig Clinic What to record? How much detail? What do you need to know to support patient care? How to record it? Structured data, such as standard templates, terminology and dictionaries, and code sets are strongly recommended rather than free text data entry. However, free text is still valuable for letter writing, referrals, and some clinical notes. Who is to record it Direct data entry (the clinician, at the point of care) or indirect data entry (a medical office assistant or transcriptionist)? When is it to be recorded During the patient encounter or afterward? What codes should be used How will the practice team agree on common terminology and code sets for all patients in the practice? For problem lists? For medication lists? Dr. Nikki Shaw s, Computerization and Going Paperless in Canadian Primary Care (Chapter 10) 4 provides an overview of data entry guidelines and tips. To scan or not to scan Records are still being created in many formats such as fax, hardcopy, and non-standardized electronic message formats. Integrating these records into an EMR system can be a complex and time consuming process. A common solution is to scan paper documents into the EMR. Scanning creates an electronic image of the original document which is linked to the patient record. However, this image will not add clinical value to the EMR unless a user (e.g., a 62 Chapter 4: Implementation & Maintenance

67 Chapter 4 Implementation & Maintenance scanning clerk, Medical Office Assistant (MOA), or clinician) takes the time to index the picture by manually inputting key clinical data about the document (description of the test, results, values, etc.), and attaching that to the patient record along with the image. Use caution scanning! If you cannot derive structured data which will allow you to use the scanned document in a data query or report, it will have little value in the EMR. See the Canadian EMR Success Stories (Chapter 6) and Going Paperless in Canadian Primary Health Care, pages for more details. 4.7 Maintaining your EMR Staying current with user training, system maintenance, and upgrades ensures that the EMR will be more likely to continue to meet your needs. These items should be addressed as part of your service level agreements with vendors. Alberta s POSP has released a series of documents addressing system and data management on an ongoing basis (see Further Reading for this chapter). They identify the core content areas for service level agreements, and provide suggestions for best practices related to data management, archiving, disaster recovery planning, and related systems management activities. More system maintenance, backup, archiving, and security principles are discussed in Preparing for Implementation, under the section on What new policies and procedures do you need to consider. Chapter 4: Implementation & Maintenance 63

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69 Chapter 4 Implementation & Maintenance Tools & Resources Chapter 4: Implementation & Maintenance 65

70 Chapter 4 Implementation & Maintenance All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: Tools References are available in the language of the author. 1 Implementation Acceptance Testing A guide to help verify that all components in the Scope of Work are completed and working the way they were designed and contracted to work (from OntarioMD). 2 Records Management Guide A guide to identifying the goals and objectives for moving from paper-based to electronic medical records. Describes the different types of data that can exist in an electronic medical record and explains the implications of using different data types includes templates (from OntarioMD). 3 Overview of data quality and a sample of the benefits gained Reproduced with permission from Computerization and Going Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by Radcliffe Publishing, Overview of data entry guidelines Reproduced with permission from Computerization and Going Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by Radcliffe Publishing, Deriving structured data and adding clinical value. Reproduced with permission from Computerization and Going Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by Radcliffe Publishing, Chapter 4: Implementation & Maintenance

71 Chapter 4 Implementation & Maintenance 4.9 Further reading Kick-off Meeting Project Checklist (POSP facilitated): CMA A Physician s Guide to Implementing Electronic Medical Records: Critical Care for Your Electronic Data: System Management Guidelines: System Management Guidelines Custodian s Summary: Chapter 4 checklist Checklist for Implementation & Maintenance Have all users received training per the training plan? Is the EMR installed per the Scope of Work requirements? Is the electronic-to-electronic data conversion/migration complete? Is paper-to-electronic data conversion underway? Have a strategy and timelines been developed and have all members of the practice team agreed to them? Have the acceptance criteria as defined in the contract with the vendor (based on the Scope of Work) been met, signed off, and have you moved to an operational support agreement with your vendor? Have you verified that your backup processes are working correctly and verified the data? Have you been following your system management plan to ensure all desktops, servers, and related peripherals (e.g., printers) are up to date with their operating systems, security patches, antivirus and application software? Are you aware of planned upgrades to your EMR software? Have you agreed with your team on criteria for deciding whether to and when to implement them? Chapter 4: Implementation & Maintenance 67

72 Chapter 4 Implementation & Maintenance 4.11 User notes 68 Chapter 4: Implementation & Maintenance

73 Chapter 5 Optimizing your EMR Chapter 5 Optimizing your EMR Practice efficiency & ongoing improvement Contents At a Glance Post-implementation reviews (PIRs): evaluating the EMR Data sharing & interoperability Quality improvement (QI) Looking ahead Tools & Resources Tools Further reading Chapter 5 checklist User notes Chapter 5: Optimizing your EMR 69

74 Chapter 5 Optimizing your EMR At a Glance Realizing and maintaining the optimal benefits of an EMR requires measuring how the system has changed the practice and regular re-evaluation of the system. 1. Regular practice assessments (e.g., post-implementation reviews and reassessments of the practice s needs) help to determine: the impact of the EMR; whether it s meeting the practice s requirements; opportunities for improvement; and ways to measure the impact of new changes within the practice. 2. System-to-system interoperability (e.g., for electronic receipt of lab results, e-prescribing, and exchanging patient data between EMRs) is the next generation of value for primary health care providers with EMRs. EMRs open the door to trying other Without good interoperability, changes in our practice. For scanning and manual data entry instance, we ve implemented costs and the lack of consistently advanced access scheduling, and structured data formats between could not have tracked 3rd next systems undermine the value of an available appointments without EMR it limits a health care the EMR. - Dr. Paul Murray provider s ability to intelligently mine the data for clinical decision support and proactive care planning. 3. A practical quality improvement approach can help practices to identify short and long term goals, and to test ways to use the EMR to meet them. 70 Chapter 5: Optimizing your EMR

75 Chapter 5 Optimizing your EMR 5.1 Post-implementation reviews (PIRs): evaluating the EMR Both the practice s needs and the EMR system may change over time, so regular evaluation and re-evaluation of the system, practice goals, and priorities will help to ensure you continue to get the most from the EMR. The purpose of a post-implementation review is to assess the degree to which the practice s goals and requirements have been met and thus assess the value of the EMR. PIRs are not intended to be one time events. They provide an opportunity to assess what works, what doesn t, and to determine the best means to address any outstanding issues. The first review should be held within one month of becoming fully operational. All members of the project team should be included: the practice team, vendors, and any health region support staff who participated. The same meeting ground rules (see NHS Working with groups 1 ) as you used during project planning should apply. PIRs can and should be conducted regularly, e.g., 1, 3, 6, and 12 months postimplementation, and every 6-12 months subsequently. Regular review and reassessment of the EMR, and its fit with the practice goals and objectives, will help you continue to maximize the value from your investment in the technology. Sample questions for consideration in a PIR include: Was the EMR implemented on time? Was it on budget? Does it meet your needs, as documented in the Scope of Work and the contract with the vendor(s)? Did the Scope of Work and vendor contract(s), as written, effectively document the clinic s requirements? Does the EMR meet staff s expectations? If not, why not? Are all health care providers and administrative staff using the EMR? If not, why not? Are all health care providers and administrative staff using all features of the software which are relevant to their jobs? Are all paper charts archived? If not, what timeframe has been set to complete this work? Are health care providers coding problem lists consistently? Have standards been set for the level of detail to capture for data entry/data coding? Chapter 5: Optimizing your EMR 71

76 Chapter 5 Optimizing your EMR Has the EMR improved patient care? If so, how? Has the EMR improved patient safety? If so, how? Does the EMR save any time for health care providers? If so, how: o o o o o o o o o Charting? Billing? Prescription writing/renewal? Referrals/letter writing? Assessing lab results? (e.g., out of range values? trends over time?) Monitoring rule-based recall/guideline-based care processes e.g., how many diabetes patients have had their A1C measured within the past 3-6 months? Identifying high risk patient populations (e.g., patients eligible for/requiring annual flu vaccines)? Drug recall? Other areas? Does the EMR save any time for administrative staff? If so, how: o Billing? o Scheduling? o Referrals? o Patient recall? o Other areas? Is additional training required for any health care providers or staff? The results from a PIR research project 2 have been compiled in a formal study. The results demonstrate the increasing value of an EMR over time. 5.2 Data sharing & interoperability To maximize the utility of your EMR, you need to be able to share data with other providers participating in the care of your patients, with other health care facilities (e.g., labs, hospitals, pharmacies, public health organizations), with government agencies (e.g., billing), and with patients themselves. All patient data is not available in a single information system, and health care providers are situated in many different practice settings, facilities and 72 Chapter 5: Optimizing your EMR

77 Chapter 5 Optimizing your EMR organizations, all of which use different information systems or none at all, relying on paper-based charting. Consequently, sharing patient data, and, more basically, obtaining a complete view of a patient s health record, usually requires system-to-system interoperability. Interoperability relies on the development and implementation of standard data definitions (for data format and content) and information exchange infrastructure (e.g., system architecture), to allow different systems to communicate with one another. In jurisdictions with EMR standards or vendor accreditation programs, the interoperability requirements for EMR vendors are often predefined. In early EMR planning stages, this may help to identify a short-list of vendors who are prequalified to meet your interoperability requirements. Standards for facilitating data sharing are under development at all levels (national, provincial, and regional). Investment in the national electronic health record and ehealth is escalating, and the emphasis on vendor compliance with interoperability standards is increasing. This is a rapidly changing and evolving environment in order to be positioned to maximize the interoperability of your EMR, confirm if your jurisdiction (region, province or territory) has established any formal or informal interoperability standards which may influence your EMR choice (see Appendices for regional contacts, and a list of related questions to ask your jurisdiction). Also, engage in regular discussions with your EMR vendor, and your jurisdiction, to see what new opportunities for improved patient care may arise through new interoperability standards. 5.3 Quality improvement (QI) Quality improvement relies on good data. An EMR can support improved patient care and practice management by enabling measurement of improvement through high-quality data. The Assessing your Practice: Green Book 3 provides guidelines to assist practices to collect quality data and information. Maximizing the benefits of an EMR requires strict adherence to rules regarding the types and amount of data collected and how it is maintained. This set of best practices is crucial to providing consistent levels of patient care. The American Academy of Family Physicians provides Tips on Patient Centred Care 4 to help practices to use the EMR to improve clinical workflow and patientprovider communication. These tips provide an introduction to quality improvement that can help a practice to maximize the benefits of the EMR. Chapter 5: Optimizing your EMR 73

78 Chapter 5 Optimizing your EMR An EMR should provide a means to improve your ability to deliver good patient care, in addition to improving practice efficiency. However, without a means to measure change, it is difficult to determine if a change such as EMR implementation has led to an improvement. The Institute for Healthcare Improvement (IHI) provides a simple, practical quality improvement model to help a practice to set goals, and measure progress toward those goals. The steps in the IHI s Model for Improvement 5 are: Set the aim. Establish the measures. Validate the measures with the team. Test the changes. Spread and sustain the changes. This model provides a customizable framework to help a practice to assess its success in meeting its goals (e.g., EMR project goals set during the Getting Started phase of the EMR project). It can help with measurement of general practice efficiency, workflow, improvements in processes of care and patient health outcomes....practice physicians are actively engaged in implementing the Institute for Healthcare Improvement s Model for Improvement to improve health outcomes for patients with chronic conditions. This has led to patient register development for high risk patients, active rule-based recall to insure clinical guidelines are met, and overall, more proactive care planning. - Taber Associate Medical Centre Taber Associate Medical Centre (see inset), and the Vancouver Coastal Health Authority (VCHA) have actively implemented the Model for Improvement to assist with primary health care clinical practice improvement and efficiencies. To assist practices, VCHA provides a set of sample measures 6, including core indicators, sample data collection processes, and an overview of QI basics 7 to effect office practice redesign. Regardless of whether a practice is interested in applying a formal methodology to measure change, or just interested in working together more effectively to provide the best patient care possible, there are three general questions to address with your practice team to effect continuous clinical practice improvement: What are we trying to accomplish? This is intended to help focus your team s effort on a specific goal. Use evidence, data, and what s important to team members and patients, to define goals and set priorities for addressing them as a team (practice). 74 Chapter 5: Optimizing your EMR

79 Chapter 5 Optimizing your EMR How will we know that a change is an improvement? Quantitative measures (data) are necessary to answer this question. Teams should work together to establish and agree on measures to assess the impact of a change. When assessing whether a specific change actually leads to an improvement, ensure it is not concurrently causing problems in another part of the system. What change can we make that will result in an improvement? All improvement requires change but not all changes result in improvement. To meet the goals, it is necessary to identify and implement the changes that are most likely to result in improvement. Ideas for change can come from many sources including scientific evidence, creative or critical thinking, observations, insights, and hunches. These questions offer a practical and easy to way to implement and measure quality improvement in a practice. They are applicable to any practice situation where you want to determine how to improve health care delivery standards, and whether or not a change in methods (such as beginning to use an EMR) has led to an improvement in patient outcomes or practice efficiency. 5.4 Looking ahead In conclusion, implementing an EMR isn t just a one time deal both the practice and the EMR will continue to evolve over time. Along with that evolution you will identify new priorities, goals, and opportunities for each. As a part of this continuing process, you will want to stay up to date with your vendor(s) what new services, products, or features are being introduced; and with your jurisdiction (region, province, territory) what new standards for interoperability, EMR support programs or training opportunities are available. EMR implementation can be a difficult and complex multi-disciplinary effort that can stretch an organization's skills and capacity for change. The process is a continuous learning experience that will be challenging, occasionally stressful, and ultimately, offers the potential for significant clinical and practice value. Seeing the systematic benefits of an EMR in improving patient care is a gratifying experience that will make the effort of the EMR implementation project worthwhile. Good luck realizing your EMR goals! Chapter 5: Optimizing your EMR 75

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81 Chapter 5 Optimizing your EMR Tools & Resources Chapter 5: Optimizing your EMR 77

82 Chapter 5 Optimizing your EMR All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: Tools References are available in the language of the author. 1 Working with groups ement Leaders Guides NEW/1/1. General Improvement Skills/1.3 WG - Working with groups.pdf A guide to effective group management techniques for project and department leaders (from the British National Health Service). 2 Post-Implementation Review Research Project A compilation of the findings of a formal PIR results research project which demonstrate the increasing value of an EMR over time (from the Centre for Evaluation of Medicines McMaster University). 3 Assessing Your Practice: The Green Book A guide to assist practices in collecting information and data. An organized, locally adaptable method to identify opportunities which can lead to significant improvements in patient care, outcomes, and staff work life (from via the Vancouver Coastal Health Authority). 4 EHRs in the Exam Room: Tips on Patient Centred Care 10 tips for conducting EHR-enhanced exams to improve doctorpatient communication using EHRs. Recommendations come from either study subjects or the authors observations as investigators (from the American Academy of Family Physicians). 5 The Model for Improvement wtoimprove/ A model for accelerating improvement not meant to replace change models that organizations may already be using, but rather 78 Chapter 5: Optimizing your EMR

83 Chapter 5 Optimizing your EMR to accelerate improvement (from the Institute for Healthcare Improvement). 6 Sample Measures for Improvement in Primary Health Care ction_processes.pdf A list of core indicators, data collection processes, tools and targets being used to effect positive change and effective office practice redesign (from the Vancouver Coastal Health Authority). 7 QI Basics for Chronic Disease Management A discussion paper on the basics of quality improvement in chronic disease management. Prepared by Dr. Chris Rauscher (from the Vancouver Coastal Health Authority). 5.6 Further reading Cost and Quality Benefits of EMRs Case Study: Computerized Registries in Chronic Disease Care: nicdisease.pdf Improving Chronic Care: Institute for Healthcare Improvement: The Case for Improvement: Improvement Methods and Tools: NHS Improvement Leaders Guide: Measuring for Improvement: 20Leaders%20Guides%20%20NEW/1/2.%20Process%20and%20Systems%20T hinking/2.1%20mi%20-%20measurement%20for%20improvement.pdf Chapter 5: Optimizing your EMR 79

84 Chapter 5 Optimizing your EMR 5.7 Chapter 5 checklist Checklist for Optimizing your EMR Have you completed the post-implementation review? What works and what doesn t? Are all users using the EMR? If not, why not? Now that you ve been using the EMR for a while, what else can it do for you? Are you using it to its fullest? Is additional or refresher training required to ensure all users are comfortable with the system? Is everyone using the same data coding and quality standards? If not, why not? Have you implemented any patient recall programs or clinically-indicated alerts? 80 Chapter 5: Optimizing your EMR

85 Chapter 5 Optimizing your EMR 5.8 User notes Chapter 5: Optimizing your EMR 81

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87 Canadian EMR Success Stories Chapter 6 Canadian EMR Success Stories Contents At a Glance Dr. Tom Bailey, Victoria, BC Taber Associate Medical Centre, Taber, AB Central Interior Native Health Services, Prince George, BC Group Health Centre, Sault Ste. Marie ON Haig Clinic, Lethbridge, AB Canadian EMR Success Stories 83

88 Canadian EMR Success Stories At a Glance The following Success Stories relate the experiences of 5 real-life cases and champions of the electronic medical record. They demonstrate the value of EMRs in various multi-disciplinary primary health care settings and the impact EMRs can have on health outcomes and provider satisfaction. The Stories demonstrate a variety of: PHC governance models. Provider remuneration models. Funding sources for IT implementation. EMR implementation models. Practice sizes. EMR implementation needs. Change management lessons learned. These Success Stories have been documented as of January # Name Description 1 Dr. Tom Bailey Victoria, BC A small (4 physician) fee-for-service practice, colocated with several other practices. The unaffiliated practices cost-shared in the adoption of the EMR and in its ongoing maintenance. The practice also participates in a provincial pilot of an electronic medical summary (e-ms) to exchange electronic referral information with specialists. [ more on page 87] 84 Canadian EMR Success Stories

89 Canadian EMR Success Stories # Name Description 2 Taber Associate Medical Centre Taber, AB The clinic is a multi-disciplinary health care centre in a small community in rural Alberta, with 20+ staff, including 9 physicians, 2 nurse practitioners, 2 respiratory technicians, a diabetes educator, and an on-site lab drawing station. After 3 failed EMR implementation projects, the practice is now successfully running an EMR for all providers. Funded by POSP, the clinic focused on finding software that met their particular clinic s requirements, and selected a vendor with an excellent reputation for user support both during, and post-implementation. [ more on page 92] 3 Central Interior Native Health Services Prince George, BC 4 Group Health Centre Sault Ste. Marie, ON This multi-disciplinary, non-fee-for-service health care centre provides full-spectrum care, primarily to the First Nations community in downtown Prince George. The EMR has been used by physicians, clinic nurse, and medical support staff for more than 10 years, but only recently have the other clinical team members begun using it (e.g., the social worker, aboriginal health worker, and alcohol and drug worker). The clinic hired a primary health care coordinator to integrate and coordinate services across the clinic IT integration, to share a common patient record, was a key goal of the initiative. [ more on page 98] Group Health Centre (GHC) implemented an EMR for all providers of their large multi-disciplinary primary health care centre. The EMR was implemented in 1997 and provides a totally paperless environment for over 70,000 patients and more than 240 providers (including 64 physicians and 180+ other health care providers). Providers can access the EMR within the centre and remotely. GHC is a multidisciplinary, multi-site, multi-specialty not-for-profit organization funded through a combination of capitation and fee-for-service funding. There was no external funding or support for the EMR implementation. The EMR is integral to coordinated Canadian EMR Success Stories 85

90 Canadian EMR Success Stories # Name Description patient care, and to supporting GHC s research mandate: to support dynamic, evidence-based medical research in primary health care. [ more on page 103] 5 Haig Clinic Lethbridge, AB The Haig Clinic has been operating for more than 60 years and has more than 100,000 patient charts. With 15 physicians and 9-10 nurses, the clinic is an example of how a fee-for-service (FFS) practice can optimize its workflow processes, supported by an EMR, to begin to integrate multi-disciplinary care within the clinic s (physician-generated) FFS revenue. The clinic adopted its first EMR more than 17 years ago and recently used the POSP funding to upgrade to a full-function clinical charting and decisionsupport-enabled EMR. The practice ran parallel EMRs for 1.5 years during the conversion to their current EMR. Their lessons learned highlight the difficulty of keeping two completely separate (unintegrated) systems up to date during the transition period. [ more on page 109] 86 Canadian EMR Success Stories

91 Canadian EMR Success Stories Dr. Tom Bailey Victoria, BC Description Dr. Tom Bailey is the IT lead for his four physician, fee-for-service practice. The practice also has a part-time chronic disease nurse (1 day/week), funded by the local health authority. Tom s practice is located in a medical building in a suburb of Victoria. The medical building is home to seven offices totaling approximately 16 physicians, as well as a private x-ray facility, pharmacy, and after-hours clinic. In 2001, Tom helped lobby the group to cost-share in the adoption of an EMR. Approximately 10 of the physicians combined forces to cost-share the purchase and support of hardware and software for the EMR each office maintains its own (separate) patient chart database on the shared infrastructure. The practices are otherwise unaffiliated. The practice is also participating in a provincial pilot demonstrating the value of an electronic medical summary (e-ms). The e-ms is an interoperability standard that permits secure electronic exchange of patient medical summary information, between information systems (e.g. EMRs), to support referrals, emergency and oncall patient encounters. The practice is piloting the referral/consult e-ms component with a local specialist office, their EMR vendor, and the Vancouver Island Health Authority (VIHA). The e-ms project is now receiving international recognition for their work. Governance & Funding Why selected as a Success Story? Fee For Service (FFS). No external funding or support for the EMR implementation. Health Authority funding for a part-time chronic disease nurse. FFS physician in a small practice this scenario is representative of the majority of primary health care physician practice environments across Canada. The practice is a successful example of collaboration and cost-sharing on an EMR project among unaffiliated physicians. The practice has been integral to the development and piloting of the e-ms interoperability standard. Canadian EMR Success Stories 87

92 Canadian EMR Success Stories How is the EMR used? What needs does it address? The EMR offers full function clinical charting. Data not available electronically are scanned and linked to the patient chart. Lab results from private labs and the local hospital lab are electronically linked with the EMR. Some data (e.g., viral studies) from the BC Centre for Disease Control are also electronically linked to the EMR. The EMR was implemented to save time for the physicians and office staff, and to improve their data management capacity for patient care e.g., rulebased recall support, prescriptions, prescription renewals, consult notes and referral letters are much easier, Coumadin (blood thinner) management is much more efficient and safer for patients. As a result of the EMR, it is also much easier to share a patient s care with another physician in the office, and respond to questions from other providers (e.g., specialists, pharmacists). Physicians and the chronic disease management nurse access patient charts from both on- and off-site. The EMR securely sends and receives standardized e-ms data for referrals and consults, as part of the VIHA pilot between this GP office and a participating specialist office. The EMR is also used to securely transmit data to the provincial chronic disease management (CDM) quality improvement registry system (the CDM Toolkit), and is integrated with the provincial electronic billing system (Teleplan). Does it support multi-disciplinary teams? The clinic has part-time nursing support funded by VIHA. The nurse visits the clinic one day per week to see chronic disease patients, and to support the practice s involvement in a structured quality improvement Collaborative for diabetes, congestive heart failure and depression patient populations. Physicians and the nurse all use the system from both on-site and elsewhere. Why is this project a Success? There have been significant improvements in the providers ability to identify what we should be doing, e.g., through rule-based recall, customizable by patient, and for patient groups. Coumadin management is also much safer, so physicians are more likely to follow recommended guidelines the system graphs values, and records in/out of range information, as well as providing integrated billing from the same screen. 88 Canadian EMR Success Stories

93 Canadian EMR Success Stories Patients (and pharmacists) love the legibility of the prescriptions, and being able to see their data in graphic form for instance, demonstrating the impact of a drug over time (e.g., these are your blood pressure results for the past 12 months, and this is when you began taking this anti-hypertensive). There have been significant time savings for providers and efficiencies in dayto-day work processes e.g., long term prescription renewals, particularly for patients with multiple prescriptions; referral/consult letters; telephone followup with specialists and pharmacists often the MOAs and pharmacy assistant can address questions, without consuming more costly time of the physician and the pharmacist or specialist. The providers now look at their data, and it improves their ability to selfaudit. The e-ms pilot provides better integration of data between EMRs in different practice settings. This increases the clinical value of the EMR by making the patient data available at the location and point in time that it s needed, to the provider who needs it, as well as decreasing scanning staff time and costs. How is/was change management addressed? EMR Implementation Once all physicians had agreed to invest in an EMR, they worked together to review and assess potential EMR vendor products. This gave all physicians the opportunity to engage in the decision making process and come to agreement on the product best suited to their needs. Note that the nurse was not part of the practice at this time. The physicians wanted a company with a large enough user base to feel comfortable that the company would not be going out of business next month. They chose the product that best suited their office workflow. All physicians and office staff committed significant extra time to the implementation over approximately 3 months. MOAs were compensated for their overtime. Over that period, the group found it essential to maintain their focus on the long-term benefit of the EMR the whole team endured significant stress and numerous server support/maintenance issues which created upheaval. To minimize upfront data conversion work, an ad hoc on demand approach to chart conversion was used, to enter patient data into the EMR once the patient booked an appointment. This eliminated the need for unnecessary work for patients who did not return to the practice (e.g., those who died or moved). This approach also helped ensure that data that was most frequently used was also most likely to be available. Canadian EMR Success Stories 89

94 Canadian EMR Success Stories The practice estimates that the initial 3 months of the implementation required longer days for all staff to learn the software and enter data, followed by 3 months of the same length days (relative to paper), and now, the physicians have shorter days as a result of the EMR some of the physicians are using the saved time to see more patients; others leave the office earlier. e-ms Implementation The practice s participation in the provincial e-ms initiative has involved iterative work with the vendors and the physicians and MOAs in the practice to develop the look and feel and functionality of the EMR software interfaces, and associated work processes for sending and receiving e-ms referral and consult data electronically. This cooperative, iterative approach has ensured that the project addresses physician and MOA requirements, with an eye to its scalability provincially once the pilot is complete. Post-Implementation Since the small practice could not afford a full time, on site IT support resource, server support often ended up as the job of the techie docs. This was not a sustainable model, so the practice moved to an ASP model for the same EMR product, hosted off site. This has improved system performance overall and the users access from outside the office. The same IT company is providing the ASP solution, so the impact of the change is minimized the users and the IT resource have continued their working relationship. There have been some challenges to the ASP, such as performance degradation, but these are being resolved. What are the Lessons Learned from the initiative? Dr. Tom Bailey s practice offers the following comments for others considering EMR implementation. Lesson Learned We wouldn t go back to paper there s nothing attractive about paper. We can do everything and more with an EMR. It will make life easier, but you do need to enter data and typing skills do help. Transferability to Other Projects? This is the gain data entry is the pain. Remember that the pain tends to lessen over time. 90 Canadian EMR Success Stories

95 Canadian EMR Success Stories Lesson Learned Ad hoc back-data entry is manageable (when a patient has an office visit, or the day before), and there s no unnecessary work generated from entering data for patients who do not return to the practice. Scanning is old school the next wave of EMR implementers should have better interoperability e.g., specialist consults, all hospital data. From a business case perspective, the benefit from an EMR is much greater the less scanning you need to do. IT (hardware, software, Internet costs, support staff) is an everyday cost of doing business. We each pay a share of the ongoing system maintenance costs. Transferability to Other Projects? There are many approaches to converting paper-based charts to electronic. The goal of all should be to minimize the amount of effort required to make the EMR useful - to meet your ongoing clinical and record-keeping requirements. Not every piece of paper in the chart needs conversion. Not all charts need conversion. Determine if your preferred vendor builds to current interoperability standards relevant to your jurisdiction i.e., make sure that any health authority, Ministry, or other organization s systems standards are met by the vendor. Primary health care practices considering implementing an EMR must plan for the ongoing cost of IT support hardware, software, network costs, and support staff, and build the costs into their operating budgets. What are the next steps for this Success Story? Tom s practice is continuing its pilot of the e-ms project, and their involvement in the chronic disease management collaborative. They expect to see continued improvements in provider satisfaction and patient health outcomes as a result of better access to, integration of, and sharing of patient data through their EMR. Canadian EMR Success Stories 91

96 Canadian EMR Success Stories Description Taber Associate Medical Centre Taber, AB Located in southern Alberta, the Taber clinic is a multi-disciplinary healthcare centre that serves a catchment population of approximately 16,000 people (8,000 in Taber). The clinic team is composed of 9 physicians, 2 nurse practitioners, 4 RNs, 2 LPNs, 3 receptionists, 3 billing/secretarial staff, and 8 medical assistants (lay physician assistants). The region also provides a diabetes educator, respiratory technologists, 2 x-ray technicians, and an on-site lab drawing station. The clinic began their EMR journey in 2000 and over the course of the next 4 years went through 3 failed implementations, each with different EMR products and vendors. They are now on their 4th implementation (for the past 18 months). The Clinic Manager is a member of the Alberta Vendor Conformance and Usability Requirements (VCUR) focus groups which define provincial standards for EMR functionality and interoperability. The clinic s current EMR product selection was based on three main criteria: Functionality. Ease of use. Willingness of the vendor to work with the clinic to improve the system. The clinic and vendor have established a good working relationship and continue to plan, pilot, and implement enhancements which improve the software. Governance & Funding Why selected as a Success Story? Alberta PHC Network clinic includes some funding for multidisciplinary programs and services. Blended Capitation & FFS payment system based on geographic roster. Currently funded under Alberta s Physician Office System Program (POSP). The practice physicians are actively engaged in implementing the Institute for Healthcare Improvement s Model for Improvement to improve health outcomes for patients with chronic 92 Canadian EMR Success Stories

97 Canadian EMR Success Stories conditions. This has relied extensively on development and maintenance of patient registers, active rule-based recall of patients, and improved proactive care planning among all providers on the team, all of which have been enhanced by the ability to mine data from an EMR. The practice is an example of perseverance leading to success three (3) EMR products were tried and discarded before the current product s implementation. This led to significant practice disruption, cost, and staff turnovers, but has resulted in the implementation of an EMR with which the clinic is now satisfied. The clinic has a continuing strong relationship with the EMR vendor and is looking forward to being able to capitalize on the data mining and decision support capacity of the software. How is the EMR used? What needs does it address? The EMR offers full-function clinical charting. Data not available electronically are scanned and linked to the patient chart. The EMR meets Alberta s POSP functionality and interoperability requirements. This means that as regional systems are enhanced or implemented which offer clinical data integration services (e.g. lab results reporting, diagnostic images, order entry, etc), the EMR will be able to accept these data and link them directly to the patient chart. The first of these services is the planned rollout of electronic lab results data from the regional labs, scheduled for April Regional labs represent virtually 100% of external lab results for this clinic. The clinic is using the EMR to manage patient registers for high risk patient populations and for high prevalence chronic conditions. This is enabling more proactive diabetes management, and improves the clinic s capacity to monitor and provide guideline-directed care. Canadian EMR Success Stories 93

98 Canadian EMR Success Stories Does it support multi-disciplinary teams? All clinical staff (physicians, nurses, nurse practitioner, respiratory technologist) have access to the EMR both on-site and off-site. Physicians are the primary health care providers for all patients in the clinic, but may delegate care to another provider as appropriate. For instance, a patient may be triaged to a non-physician provider, or the nurse practitioner may see a patient first, and not send the patient to the physician. Shared care is fully supported through the EMR. One of the nurses has developed a very successful process for managing INRs in concert with the physicians. Coumadin (blood thinner) results are tracked in the EMR, and the nurse adjusts doses if results are within certain tolerances. If outside of the tolerances, the physician is consulted. Why is this project a Success? Despite changing software products and vendors 3 times in four years, the clinic is now beginning to realize clinical benefit from the EMR product now in place for approximately 18 months. All staff are using the software, sharing data and patient care more effectively, and beginning to derive clinical value from the data in the system. For instance, new diabetes and asthma programs have been particularly successful as a result of decision support and data availability through the EMR: Patient registers have been developed for both programs. The EMR allows easy tracking of needed recall and management needs. Clinical guideline-based process measures (e.g. proportions of diabetes patients with at least one HbA1C in the past 3 months) can be tracked and changes can be monitored over time. For the asthma program, the nurse practitioner and respiratory technologist give full patient workups, as well as patient medical education and reviews, documented and shared through the EMR. The diabetes program includes a template-based one hour initial assessment with the diabetic nurse and dietitian, all of which is captured in the shared patient record. All providers chart in the same system and update the physicians regularly. With one system, data is not duplicated, and patients do not need to repeat histories. The providers (physician and non-physician) are beginning to look at their data, and to see the potential for improved patient health outcomes through evidencebased patient population management. 94 Canadian EMR Success Stories

99 Canadian EMR Success Stories How is/was change management addressed? EMR Implementation Change management for the initial EMR implementation was through a shotgun approach. That is as of day one of the implementation (Sept. 10, 2000) we re using the EMR. Software and process workflows training and orientation were completed in advance of the go live date, but the clinic physicians and staff did not know how it would affect patient flow until they were living it. No backfile conversion was done. Patient demographics were imported from the old billing/scheduling system. The decision not to convert any paper chart data was based on physician consensus: I only look at the last couple of visits anyway, so I ll look at the paper chart if I need to. The approach was successful. As of 3 months post-implementation, very few patient charts were being pulled. 12 months later, none. Post-Implementation Now that the clinic has been operational with their EMR for approximately 18 months, the clinic s emphasis is shifting to data quality and process and outcomes of care improvement. For instance: Working on getting the providers to data mine and update their patient problem lists with standard terms. Trying to make better use of recall system and task management software features. Trying to get the EMR to do proper evaluations of a patient e.g., if diabetes is on a patient s problem list, provide alerts about A1C recall windows, etc. within the system. They can identify which patients have which problems, and have templates for clinical guidelines in place, but still have to manually order tests etc. Working on PAP and mammogram recalls. Through regular weekly community rounds meetings of all providers, they are working on building consistency across providers in how they use the system. A key item on the meeting agendas is to discuss how they can do things better. Canadian EMR Success Stories 95

100 Canadian EMR Success Stories What are the Lessons Learned from the initiative? The Taber Clinic offers the following comments for others considering EMR implementation. Lesson Learned There is no cookie cutter way. Now, all but two of the clinic physicians type their own notes: one physician has a nurse input notes from his handwritten notes and another uses dictation. Several physicians needed to learn how to type. One physician had such illegible handwriting, but now types and has the best notes of the group. We scan everything that comes into the clinic from external sources. Without interoperability, scanning is an unfortunate necessity that requires approximately.5fte. Transferability to Other Projects? User personalities and practice styles impact each individual s preferred means to input data throughout the conversion process and on an ongoing basis. Flexibility in approaches will improve user acceptance, and comfort levels with the process. Set deadlines for converting to the EMR, but for success, you must let each physician/clinician user choose their own way to start inputting data and using the EMR as the main charting tool. Regional integration initiatives will reduce scanning requirements by improving data sharing and interoperability across disparate systems. When selecting an EMR, determine if your preferred vendor builds to current interoperability standards relevant to your jurisdiction (if they exist) i.e., make sure that any health authority, Ministry, or other organization s systems standards are met by the vendor. 96 Canadian EMR Success Stories

101 Canadian EMR Success Stories What are the next steps for this Success Story? Alberta s Regional Shared Health Information Program (RSHIP) is going live with linkages to electronic lab results in April The clinic is eagerly awaiting this functionality. Electronic receipt of these results is expected to save the Taber Clinic approximately 40% of the time they currently invest in scanning reports received at the clinic. In addition, the clinic is continuing to work with the EMR vendor to develop and refine templates for management of specific conditions: hypertension, heart health (prevention and cardiac care), and INR management. The clinic is also continuing to encourage all the physicians and clinical staff to standardize problem lists (for data quality control), and to data mine to improve decision support capacity and the ability to analyze trends in data for individuals and groups of patients. Canadian EMR Success Stories 97

102 Canadian EMR Success Stories Central Interior Native Health Services Prince George, BC Description This multi-disciplinary, non-fee-for-service health care centre provides full-spectrum care, primarily to the First Nations community in downtown Prince George. The EMR has been used by physicians, clinic nurse, and medical support staff for more than 10 years, but only recently have the other clinical team members begun using it (e.g., the social worker, aboriginal health worker, and alcohol and drug worker). The clinic hired a primary health care coordinator to integrate and coordinate services across the clinic IT integration, to share a common patient record, was a key goal of the initiative. Governance & Funding Why selected as a Success Story? Northern Health Authority (NHA) funded organization, with non-fee-for-service physicians. Startup funding for the PHC Coordinator position was provided through the NHA s Primary Health Care Transition Fund (PHCTF) allotment. All EMR-related costs hardware, software, network support etc, are funded out of CINHS operational budget. The clinic had been functioning as a co-located multi-disciplinary, partially EMR-enabled group for approximately 10 years. However, their experience in the past two years demonstrates their evolution to providing integrated, interdisciplinary, teambased patient care, fully supported by a shared EMR. This change in management models demonstrates a team-based approach to engaging providers in ongoing quality improvement, and building improved care models through technology-enabled relationships with providers across several disciplines. 98 Canadian EMR Success Stories

103 Canadian EMR Success Stories How is the EMR used? What needs does it address? The EMR is used to support all clinical charting requirements for all health care provider disciplines at CINHS. It also supports billing and scheduling requirements for all disciplines and provides significant decision support and clinical template capability (discussed more in the section: Why is this project a Success ). The EMR project has encouraged team building activities within the clinic: o o Weekly clinical team meetings that include chart audit and clinical learning opportunities for the team members engaged in particular patients care. The clinical team meets in their private meeting room and conducts case reviews by projecting the electronic chart to a screen. The team can then add notes to the electronic chart, and document clinical recommendations as decisions are made for each patient. Software learning opportunities as part of the weekly team meetings. In addition to weekly clinical team meetings, there is a weekly all team (clinical and administrative staff) meeting, where ideas for process improvements, workflow changes, program development, and software tips/tricks and training are often exchanged. This gives all users the opportunity to learn from their peers, as well as reinforcing good data entry and coding practices. Team members have recognized the criticality of good data coding and data entry practices. E.g., one physician did not code diagnostic data (ICD9) well. Now that the practice is using the EMR to generate comparative reports over time, and the reports are often discussed at the weekly meetings, the physician has seen the impact of poor coding practices on the data, and is willing to try to improve coding habits. The team has also standardized the way all disciplines encode diagnoses for alcohol overuse, and is working on standardized coding for other high priority diagnoses. Does it support multi-disciplinary teams? All members of the health care team physicians and non-physician providers use the EMR for all patient charting requirements. Canadian EMR Success Stories 99

104 Canadian EMR Success Stories Why is this project a Success? This initiative was not viewed as an EMR project although the EMR has been integral to the Centre s goals CINHS main goal was to improve integration and coordination of service delivery. Improved information management through a shared patient record was an essential component enabled by the EMR. Ongoing team building and relationship building have created strong working relationships among all team members. Work on the relationships preceded the work on the EMR this has enabled a shift from the electronic charts being viewed as doctor s files to patient s files, which are managed by all members of the team through a common charting process. All providers (physicians and non-physicians) are engaged in using and recommending improvements to the software and related clinical processes. Proximity and responsiveness of the software vendor the EMR vendor is based locally and can (and does) provide personalized and responsive support and enhancements. Clinically, an emphasis on building locally-relevant clinical guideline-based templates into the software (e.g., Hepatitis C flowsheets and population-level reporting functions) has effectively addressed community-based health needs. How is/was change management addressed? EMR Implementation Relationship- and team-building among the providers and administrative staff has been instrumental to CINHS success. This has been enabled by: o o o o Foremost, an emphasis on clinical value and improvements to patient care through improved team-based collaboration use of the EMR is secondary. Strong ongoing collaboration and communication among the providers, administrative staff and vendor to identify requirements and develop solutions. Ongoing weekly clinical and whole team meetings together adding up to ½ day per week. These were originally viewed with some disdain, as a waste of time when we should be seeing patients, but now the whole team enthusiastically participates. Providing team members the time to change to see the benefits and begin to approach work differently. 100 Canadian EMR Success Stories

105 Canadian EMR Success Stories Extensive initial and ongoing software training was provided with the following features: o No maximum cap per user to recognize that all users training needs are different. Ongoing training is written into the practice s service level agreement (contract) with their vendor. o o CINHS now applies a super-user approach, where staff members train other staff. For instance, instead of paying for external training, the MOA recently trained the social work practicum student who joined the practice. Most training can be managed by the MOA, but peer training (e.g., physician to physician; nurse to nurse) is also used for some software components. Team meetings and strong team relationships have created an effective cross-learning environment all team members are comfortable asking questions, and sharing knowledge about the software (etc.) to help other team members. Post-Implementation The same key components of change management apply post-implementation: the practice has continued the weekly clinical and whole team meetings, and with no cap on the amount of training a user can receive, their clinic supports a continuous learning environment for all administrative and clinical EMR users. What are the Lessons Learned from the initiative? CINHS offers the following comments for others considering EMR implementation. Lesson Learned Address the fear Transferability to Other Projects? Successful EMR adoption in a multidisciplinary environment is about developing trust-based relationships among the team members, and providing the technology tools to support business flow not about changing business to fit how the technology works. The change management ( people and process ) components of an EMR implementation project must actively address initial and ongoing training Canadian EMR Success Stories 101

106 Canadian EMR Success Stories Lesson Learned Transferability to Other Projects? requirements, team building, and perhaps most importantly, ongoing clinical and administrative stakeholder engagement strategies. Opportunities for ongoing training are paramount. The technology enables CINHS to focus on quality improvement, data and longitudinal patient outcomes, not just individual providers discrete encounters with patients. However the output is only as good as the data we put in. All users need different amounts of time to feel comfortable with the software. Training requirements, access and availability should reflect that. Administrative users, and clinical users in administrative roles, need training in the reporting capacity of the software. Data coding and quality standards are critical to developing a complete and accurate view of a patient population. Success of the EMR implementation relies on clinical value and outcomes of the EMR initiative, not on the implementation of the technology itself. What are the next steps for this Success Story? Continuing to work with the vendor to develop an HIV flowsheet (template) to support guideline-directed multidisciplinary care. More training for the administrative users to improve their comfort level with the software s administrative reporting/decision support capacity. Ongoing team-building and communication among all members of the practice, and with the EMR vendor, as new training needs and clinic requirements are identified. 102 Canadian EMR Success Stories

107 Canadian EMR Success Stories Group Health Centre Sault Ste. Marie ON Description The Group Health Centre (GHC) implemented an EMR for all providers of their large multi-disciplinary primary health care centre. The EMR was implemented in 1997 and provides a totally paperless environment for over 70,000 patients and more than 240 providers (including 64 physicians and 180+ other health care providers). Providers can access the EMR within the centre and remotely. GHC is a multidisciplinary, multi-site, multi-specialty not-for-profit organization funded through a combination of capitation and fee-for-service funding. There was no external funding or support for the EMR implementation. The EMR is integral to coordinated patient care, and to supporting GHC s research mandate: to support dynamic, evidence-based medical research in primary care. Governance & Funding Why selected as a Success Story? Not-for-profit organization funded through capitationbased rostering (58,000+ patients), and FFS for nonrostered (20,000+) patients. Multi-disciplinary, multi-site, multi-specialty, with 64 physicians, 180 other health care providers. No external funding or support for the EMR implementation. GHC employs IT staff to support the network, hardware and desktop software. Physicians are not employees of GHC. Physicians are paid on a non-fee-for-service performance adjusted basis. Approximately 8 years of operational experience with the same EMR product in a large health care organization. GHC s organizational vision and goals recognize the criticality of an EMR: it is essential to have an integrated, legible, accessible chart, in order to be able to provide quality care, and to support data access for research. Significant organizational change to support and encourage use of IT for improving quality of care, make GHC a leader in EMR use and provider engagement in IT adoption. Canadian EMR Success Stories 103

108 Canadian EMR Success Stories How is the EMR used? What needs does it address? EMR vendor selection was a two year process including site visits. At the time, the clinic had approximately 44,000 paper charts, and approximately 100 full time equivalent health care providers (200 users over all). GHC s EMR needed to meet the following needs: o o o o o Fit with the existing information and communications technology (ICT) environment. Increase research support capacity. Permit rapid access to patient medical information across multiple providers and sites. Improve security of medical information. Segregate psychiatric specialties. Additional considerations included: o Physician acceptance levels ICT expertise. o o Financial there was an expectation that monetary savings would be realized by reducing the need for paper and reducing clerical runner staff ( paper-clip savings), and that providers would save time with charting. Archival significant space considerations associated with 44,000+ paper charts. The EMR has enabled GHC to deliver better health care, better outcomes and increased quality of life to patients. This tool has enhanced pro-active, quality patient care, and incorporated accountability mechanisms. Active programs in diabetes, congestive heart failure, anticoagulation, osteoporosis, immunization and mammography screening have been established and continue to show outstanding improvements. Disease site registries of hypertension, coronary artery disease and atrial fibrillation have been developed and implementation strategies are in the planning process. For instance: the Health Promotion Initiative for diabetes management has improved health outcome measures for all key indicators by 55% over an 18 month period. 104 Canadian EMR Success Stories

109 Canadian EMR Success Stories Does it support multi-disciplinary teams? All members of the health care team physicians (GPs, specialists), and nonphysician providers use the EMR for all patient charting requirements. Why is this project a Success? In eight years of use, the EMR has provided many benefits/opportunities in the promotion of health for patients. The EMR has expanded the scope and quality of medical care in the areas of: research; management of chronic diseases; truly collaborative medical practice; and diagnostic results management. The EMR has enhanced pro-active, quality patient care through incorporation of evidence-based best practice processes, and incorporated accountability mechanisms (e.g. audit logs). The organization has contributed to the body of knowledge for primary health care EMR adoption by documenting their experience, lessons learned, and recommendations to others contemplating this change. Key success factors include: o EMR acceptance and commitment at all levels. o Acknowledgement of the learning curve (steep new skills, new work processes require time). o Acknowledgement that information flow is paramount to good patient care, and that individualization improves acceptance. o Recognition that change management is an essential component. o Recognition that training and support are fundamental. o Realism in scope and expectations change must often be incremental due to cost, e.g., interfaces to other systems are costly, but essential for integration of disparate systems. o Collaboration and communication among the providers, administrative staff and vendor to identify requirements and develop solutions to build on the strengths of all parties. How is/was change management addressed? EMR Implementation There was a process of planning and training when the EMR was implemented in 1997 that addressed some of the change management issues. Training is offered as a continuous process. Canadian EMR Success Stories 105

110 Canadian EMR Success Stories A physician champion, Dr. Lewis O Brien, worked with the physicians to obtain buy-in by explaining the benefits of moving to an EMR. He was able to attain a unanimous vote for EMR adoption in advance of the decision. This rollout included significant network and building upgrades to permit installation of terminals in each exam room (e.g., the network cable was so heavy, the ceiling needed reinforcement). Health care providers were able to choose their own exam room layout to support the computer. This improved support, but increased cost due to the unstandardized approach. In two weeks over the summer of 1997, 240 users went live - all providers began using the EMR. Paper charts were still available, but as closed volumes. Providers saw patients throughout the go-live. Schedules were booked ½ hour light each day. The group decided that each physician would be responsible for entering patient data and archiving his/her own charts at the next visit for each patient. Training on the EMR software occurred in small groups (3 physicians per group), over a 3 day period for each group. Day 1: morning training, afternoon office visits using the software for each physician; Day 2/3: IT/training support on site, physicians using the software while seeing patients. Most Day 3 on site IT support was not required. Training followed a train the trainer, or super user approach to develop local experts who could assume responsibility for trouble shooting and training followup with users once the formal training was complete. Post-Implementation Adopting technology, and making the most use of it in a practice is an iterative process requiring regular attention and followup to continue making improvements. As a result, change management and user training are ongoing requirements. GHC s experience demonstrates that identifying physician, clinical and administrative champions early on in the process is essential to user buy in and success, but also that ongoing involvement of clinical champions assists with provider engagement in continuous improvement over time. For instance, champions can assist with identifying ways to optimize the use of the EMR through software enhancements, and improvements in clinical workflow. Continuous improvement over time leads to improved user acceptance and support. 106 Canadian EMR Success Stories

111 Canadian EMR Success Stories What are the Lessons Learned from the initiative? The Group Health Centre offers the following comments for others considering EMR implementation. Lesson Learned Just do it! You will never look back. A provider satisfaction survey 5 years post-implementation shows: 80% would not return to paper; it takes 1 year for users to be comfortable with the system. Data quality for research and longitudinal patient tracking programs depends on consistent, well-defined data entry for all provider types. Support for a mix of free text and codified data is essential. We assumed physicians would type their own notes. Most could not type, and this resulted in the need to increase transcription staff. Transferability to Other Projects? Adopting technology, and making the most use of it in the practice is an iterative process requiring regular attention and followup to continue making improvements: Acceptance at all levels of the organization - providers and administration - is required for success. Having a physician (or other health care provider) champion the EMR project will improve buyin with the clinical team. Change management and user training are ongoing requirements. Continuous improvement over time leads to improved user acceptance and support. Coding and data entry policies and standards for diverse health care provider types must be implemented to enable effective use of electronic data. Familiarization with technology and typing skills for health care providers would be valuable CME and medical school training to support EMR adoption. Canadian EMR Success Stories 107

112 Canadian EMR Success Stories Lesson Learned Paper-clip savings are not real. The business case for IT was built on eliminating runners and reducing paper costs. However, the runners all upgraded to become transcriptionists at higher rates. Time savings for charting (e.g., vendor estimates of 20 min per day) are NOT real. It likely takes more time/thought for transcription and data entry. However, getting data OUT of the system is much faster legible, in one place. Transferability to Other Projects? The benefit to patient health outcomes and provider satisfaction outweighs the cost (time, dollars, stress) of transition. Focusing on gains in clinical and administrative processes and outcomes is more realistic and a better business case than focusing on potential cost/time savings. What are the next steps for this Success Story? Continue using the EMR and IT to deliver better health care and achieve better outcomes for patients. Continue expansion of number of sites (now 14) and providers, and addition of several new disciplines. The local health unit (a separate organization) has now implemented the same EMR software. Among other collaborations, GHC and the health unit run joint flu clinics and immunization programs Patients expect providers in the two clinics to be able to share data. The GHC and the health unit are working with the vendor, and their policy groups to work through the privacy/patient consent considerations to assess the feasibility of establishing a regional patient record with provider-specific, role-based access. 108 Canadian EMR Success Stories

113 Canadian EMR Success Stories Haig Clinic, Lethbridge, AB Description Located in southern Alberta, in the Chinook Health Region, the Haig Clinic is a 15 physician clinic, and has been in operation for more than 60 years. To help manage the clinic s 100,000+ charts, the clinic adopted its first EMR approximately 17 years ago. In 2003, the Alberta Physician Office System Program (POSP) gave the clinic the opportunity for funding and support to upgrade to a new EMR vendor, and implement a full function, integrated EMR system. Upgrading to a POSP-compliant EMR offers the key benefit of being able to integrate clinical data from regional systems as they become available. For instance, electronic lab results soon to be made available (April 2006) through the Alberta Rural Shared Health Information Project (RSHIP), will eliminate the need to input lab results manually. This will save physicians and clerical staff time, and improve the clinic s decision support capacity patient data will be immediately available in the electronic patient chart, and it will be easier to identify patients for lab followup (e.g., if their results aren t back within 3 weeks of their clinic appointment) or for proactive recall programs. The clinic team is composed of 15 physicians, 9-10 nurses (approximately 2 nurses to every 3 physicians), and approximately 9.26 full time equivalent (FTE) administrative staff supporting the clinical operations of the clinic: 1.5 scanners, 3 full time stenos, 3 billing and payroll staff, 5 central bookers, 2 full time front desk clerks, and 1 referral booking clerk. The clinic s Assistant Manager acted as the project manager for the EMR implementation. To choose their EMR vendor from the POSP approved vendor list, the clinic s main criteria were: Vendor responsiveness at first contact some of the other EMR vendors did not respond when the clinic requested information, or responded several weeks after the request. The clinic used this as an indicator of service levels they could expect post-implementation. Testimonials and information from users of the same EMR, including feedback on both the clinical and practice management (billing and scheduling) system components. Canadian EMR Success Stories 109

114 Canadian EMR Success Stories Governance & Funding Why selected as a Success Story? 100% fee-for-service (FFS) clinic. The clinic s FFS billings also cover all nursing salaries. EMR is currently funded under Alberta s Physician Office System Program (POSP). If POSP is discontinued, all physicians have committed to contribute to the operational budget for the EMR system and IT infrastructure. Alberta PHC Network program clinic this will support setup and expansion of multi-disciplinary care teams, and clinical programs integrated with the health region. The practice ran parallel EMRs for 1.5 years during the conversion to their current EMR. This provides strong lessons learned about the difficulty of keeping two completely separate (unintegrated) systems up to date. This a strong example of how a FFS clinic can optimize its workflow processes, supported by an EMR, to begin to integrate multi-disciplinary care within the clinic s (physician-generated) FFS revenue. How is the EMR used? What needs does it address? The EMR offers full function clinical charting. Data not available electronically are scanned and linked to the patient chart. The EMR meets Alberta s POSP functionality and interoperability requirements. This means that as regional systems are enhanced or implemented which offer clinical data integration services (e.g. lab results reporting, diagnostic images, order entry, etc), the EMR will be able to accept these data and link them directly to the patient chart. The first of these services is the planned rollout of electronic lab results data from the regional labs, scheduled for April Regional labs represent virtually 100% of external lab results for this clinic. Even without full lab data integration, the time spent by data entry staff to scan and code paper-based lab results is more than compensated by the improvements in data quality and comprehensiveness. For instance, once paper-based lab results are entered, the clinic can followup with patients if 110 Canadian EMR Success Stories

115 Canadian EMR Success Stories lab test results are not received within a couple of weeks of the patient s appointment, to ensure that the patient did go for the tests. The clinic is also beginning to look at their EMR data to identify priority patient populations, and to begin to develop processes for organized, structured patient followup (e.g., rule-based recall). Does it support multi-disciplinary teams? All staff (physicians, nurses, support staff) have access to the EMR. Physicians are currently the primary health care providers for all patients in the clinic. The clinic is using the EMR to support shared care (multi-disciplinary care), through preliminary workups managed by the nurse, prior to the patient seeing their physician. Shared care is fully supported through the EMR. Through the Alberta Primary Health Care Network program, the clinic is looking at ways to expand the role of nursing staff to assume broader responsibilities for patient care. For instance: o o A patient may be triaged to a non-physician provider, or the nurse may see a patient first, and not send the patient to the physician. The EMR represents the complete shared patient record for all providers. Health region staff supporting clinical specialty programs (e.g., the diabetes lipid clinic, mental health programs) have access to the clinic EMR for patients participating in the programs. In the future, patient care for targeted populations may be supported by data linkages between the clinic EMR and the health region s specialty program clinic systems. Why is this project a Success? All providers chart in the same system. With one system, data is not duplicated, and every provider has access to the full patient record as required to provide optimal care. The clinic is starting to look at population data for priority patient groups, to target specific clinical-guideline based programs toward improving their care (e.g., developing and managing a register of heart condition patients). Data standards and comparability across all health care providers in the clinic (particularly the 15 physicians) are much higher. The EMR vendor worked with the clinic s physicians and staff to customize data templates, and to set standards for how data should be entered. It took only 6 weeks to standardize all lab results data entry and existing historic data. Canadian EMR Success Stories 111

116 Canadian EMR Success Stories How is/was change management addressed? EMR Implementation The clinic scheduled on-site meeting time with the POSP change management support team. The POSP team helped the clinic to redefine workflow to optimize use of the EMR. This resulted in cost savings for the clinic by identifying what processes could be streamlined (and how), to promote patient, staff, and information flow through the practice. In a single building, the clinic consists of 4 nursing stations, each with 3-4 physicians per station. The size of the clinic contributed to the size of the learning experience for all staff. Some physicians, particular older members of the clinic team took a while to get rolling. The clinic engaged in an incremental approach to migrating to the new EMR. Over 6 to 8 months, all users began using the system fully. Not all functions were started for all users at the same time. A subset of physicians was the first group to begin using the software. Not all physicians started immediately, some began by using most of the EMR functions, and some with lab only (lab signoffs and electronic memos). Post-Implementation The clinic ran the old and new EMRs in parallel for 18 months, in order to permit staff to migrate patient charts as patients came into the clinic, and to support the gradual migration of staff from one system to the next (at their own pace). Staff attempted to keep both systems up to date, but found this extremely difficult, and would recommend a clean cutover to remove (archive) the patient from the old system, as soon as the patient is entered in the new system. Work is also ongoing to ensure consistent and complete standards for data quality with respect to data entry and coding. This will enable more comprehensive use of the EMR for clinical decision support, and population-level analysis, e.g., for groups of high risk patients. Data coding and quality standards are set with input from all members of the team: clerical (scanners, stenos, billing staff), and clinical staff (physicians and nurses). 112 Canadian EMR Success Stories

117 Canadian EMR Success Stories What are the Lessons Learned from the initiative? The Haig Clinic offers the following comments for others considering EMR implementation. Lesson Learned There are no significant time savings for using an EMR, and initially, time will be lost. The benefits of an EMR are in improved readability of patient records: this equates to better records. Doctors dictate better notes than they scribble on paper, which means more and better information is available in the patient chart. Conversion of all incoming paper to coded or structured data formats makes it much easier to access specialist consult notes etc. (as a result of OCR and image scanning). There s a higher workload for stenographers, as a result, but much more complete and usable data. Physicians would not go back to paper. Transferability to Other Projects? Budget for the time cost associated with EMR implementation. This cost is relevant to all staff physicians, other clinicians, office staff, and sometimes patients as well. Health care provider learning curves, and the downtime associated with changing workflow and clinical and office processes take time. Better data improves the patient record, both in terms of auditability (accountability), and the opportunity for improved decision support from better access to clinical data. Office staff can retrain to develop or enhance scanning and coding skills to accompany transcription skills. The physician learning curve is big, but not insurmountable. How to navigate the software is the most frequently recurring issue. Once mastered, there are significant gains in: Prescribing legibility, reduced error rates, reduced duplication, fewer pharmacist call backs to Canadian EMR Success Stories 113

118 Canadian EMR Success Stories Lesson Learned Transferability to Other Projects? the practice. Researchability of the data. Office efficiency e.g., electronic memos and notes in the EMR, rather than sticky notes on charts and desks. Standardization for data input - e.g., better data consistency and comparability resulting from standardization of how to code and enter lab results ; how to setup clinical templates for management of specific conditions standards improve guideline-based care delivery. What are the next steps for this Success Story? The clinic is starting to use the EMR data to look at specific patient populations, to begin to identify priorities for how the team should be spending their time; i.e., in organized, structured programs for patient followup. Top priorities for the clinic include: Anything to do with chronic care and being able to keep closer tabs on those patients, for instance: o The clinic has recently established and is managing a heart disease patient register, and would like to start to use the EMR s capacity to support clinical guideline-directed recall. o The clinic has joined Alberta s Primary Health Care Network Program and is piloting a couple of new chronic care programs which expand the multidisciplinary scope of practice in the clinic. One physician is working with the Chinook Health Region s Diabetes Lipid Clinic, and his experience is influencing other clinic physicians to join. The EMR supports data sharing between the physician and the health region clinical staff, and enables proactive patient recall for the physician s diabetes patients in the program. Alberta s Regional Shared Health Information Program (RSHIP) is going live with linkages to electronic lab results in April The clinic is eagerly 114 Canadian EMR Success Stories

119 Canadian EMR Success Stories awaiting this functionality, in order to eliminate the dirty heaps of manual scanning and data entry currently required to input lab data to the EMR. Canadian EMR Success Stories 115

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121 Appendices Appendices Contents Regional Contacts & Programs Questions to consider when contacting your jurisdiction Checklists List of Acronyms Acknowledgements Appendices 117

122 Appendices Regional Contacts & Programs This section provides contact information for various jurisdictions and organizations with interest or involvement in EMR implementations. These contacts include: Provincial/Territorial ministries of health. For each jurisdiction (where they exist) o Health regions. o EMR support program links. o Privacy information sources. Regional chapters of the medical and nursing associations (e.g. local CMA and CNA chapters). The Canadian Healthcare Information Technology Trade Association (CHITTA) - the Canadian EMR vendor association: Alberta Alberta Health and Wellness: Alberta Health Regions: Physician Office System Program: Primary Care Initiative: Office of the Information and Privacy Commissioner of Alberta: Alberta Medical Association: Alberta Association of Registered Nurses: British Columbia British Columbia Ministry of Health: &navId=NAV_ID_province British Columbia Health Authorities: British Columbia Office of Primary Health Care: Appendices

123 Appendices Office of the Information and Privacy Commissioner: British Columbia Medical Association: Registered Nurses Association of British Columbia: Manitoba Manitoba Health: Manitoba Health Authorities: Manitoba Health Primary Health Care: Personal Health Information Act: Manitoba Medical Association: College of Registered Nurses of Manitoba: New Brunswick New Brunswick Department of Health: Regional Health Authorities: Personal Health Information Act: Protection of Personal Information Act: New Brunswick Medical Society: Nurses Association of New Brunswick / Association des infirmières et infirmiers du Nouveau-Brunswick: Newfoundland and Labrador Newfoundland and Labrador Department of Health and Community Services: Health Authorities: %20Authorities.pdf Access to Information and Protection of Privacy Act: Privacy Act: Appendices 119

124 Appendices Newfoundland and Labrador Medical Association: Association of Registered Nurses of Newfoundland and Labrador: Northwest Territories Northwest Territories Health and Social Services: Health and Social Services Authorities: Northwest Territories Medical Association: Northwest Territories Registered Nurses Association: Nova Scotia Nova Scotia Department of Health: Nova Scotia Health Links (includes Health Authorities): Department of Health Primary Health Care: Freedom of Information and Protection of Privacy Act: Doctors Nova Scotia: Registered Nurses Association of Nova Scotia: Nunavut Nunavut Department of Health and Social Services: Regional Health Contacts: Ontario Ontario Ministry of Health and long-term Care: Health and Long Term Care Primary Care: OntarioMD Transition Support Program: Appendices

125 Appendices Consultation on Privacy Protection: Ontario Medical Association: Registered Nurses Association of Ontario: Nurse Practitioners Association of Ontario: Prince Edward Island Prince Edward Island Ministry of Health and Social Services: Prince Edward Island Ministry of Health and Social Services Primary Health Care: Freedom of Information and Protection of Privacy Act: Medical Society of Prince Edward Island: Association of Registered Nurses of Prince Edward Island: 17 Pownal Street Charlottetown, Prince Edward Island C1A 3V7 Tel: Fax: Quebec Santé et Services sociaux Québec: Régions: Association médicale du Québec: Ordre des infirmières et infirmiers du Québec: Saskatchewan Saskatchewan Health: Regional Health Authorities: Saskatchewan Health - Primary Health Care: Health Information Protection Act: Appendices 121

126 Appendices Saskatchewan Medical Association: Saskatchewan Registered Nurses Association: Yukon Territory Yukon Health and Social Services: Yukon Medical Association: Yukon Registered Nurses Association th Avenue Whitehorse, Yukon Y1A 3T3 Phone: Fax: [email protected] 122 Appendices

127 Appendices Questions to consider when contacting your jurisdiction When contacting your health region or ministry of health, the following questions may help to determine what (if any) support is available to assist with selecting and implementing an EMR for your primary health care practice. Question Comments SECTION A 1. Is there an EMR support program for my jurisdiction (if yes, go to Section B)? 2. Is there any funding available to support EMR implementation? 3. Are there recommended or certified vendors for my jurisdiction? 4. Are there any guidelines for EMR products e.g. for compatibility with billing systems or other functionalities? 5. Is change management support available to help plan and execute a successful implementation? Appendices 123

128 Appendices Question Comments 6. Are there any training programs or workshops which would be helpful? 7. Other questions? SECTION B: For jurisdictions with EMR Support Programs 1. How do I contact the program? 2. What are the eligibility requirements? 3. Does it provide funding for startup costs? What about ongoing support? 4. Does it provide a list of prequalified or certified EMR vendors? 124 Appendices

129 Appendices Question Comments 5. Does it provide guidelines for EMR products? e.g., for compatibility with billing systems or other functionalities? 6. Is there change management support available to help me through the process? 7. Is there project management support available? 8. Are there any training programs or workshops which would be helpful? OTHER QUESTIONS Appendices 125

130 Appendices Question Comments 126 Appendices

131 Appendices Checklists Chapter 1 Checklist Checklist for Getting Started Have you discussed implementing an EMR with all practice staff? Does everyone understand the benefits of an EMR to the practice? Are all staff committed to adopting an EMR? Is there consensus on goals and priorities for your EMR? Have you looked into any regional and provincial programs, policies, and standards which may affect your decisions (e.g., budget or choice of EMR vendor)? Have you established your budget? Appendices 127

132 Appendices Chapter 2 Checklist Checklist for Selecting an EMR Have you established the requirements for your EMR (based on the practice goals and priorities)? Have you found out if there are any prequalified vendors in your jurisdiction? Is there any support available from your jurisdiction to help with vendor selection or system procurement? Are you eligible for support? Does your selected vendor meet all of the practice goals, priorities, and business requirements? If not, how do they propose to meet them? Is training covered within your contract with the vendor? Is it for the EMR only or does it include basic computer skills? Have you had a lawyer review the contract? 128 Appendices

133 Appendices Chapter 3 Checklist Checklist for Preparing for Implementation Do you have a clinical lead and an administrative lead for the project? Have you appointed a project manager? Does one of the leads have the time and skills to do this, or do you need to hire a consultant? Have you worked with your team to create a project plan, with tasks, timelines, and a named individual responsible for each task? Is everyone in agreement with this plan, including the vendor? Have you worked with your team to complete a process map for the practice and identify areas for improvement, e.g. where the EMR software will change how you work, where staff have different roles, where information and data flow differently? Have you determined the training requirements for each member of the practice? Do some need to acquire basic computer skills as well as training in the EMR software? Have you identified potential super users in the clinical and administrative areas who can help other users become familiar with the software and troubleshoot issues? Have you scheduled dedicated training time and lighter workloads for staff during training and implementation? Have you developed privacy and security policies for the practice? Do all staff understand the policies? Are patients aware of the policies? Have you established system management guidelines and a disaster recovery plan for the practice? Have you worked out implementation details with your vendors? Appendices 129

134 Appendices Chapter 4 Checklist Checklist for Implementation & Maintenance Have all users received training per the training plan? Is the EMR installed as per the Scope of Work requirements? Is the electronic-to-electronic data conversion and migration complete? Is paper-to-electronic data conversion underway? Have a strategy and timelines been developed and have all members of the practice team agreed to them? Have the acceptance criteria, as defined in the contract with the vendor (based on the Scope of Work), been met, signed off, and have you moved to an operational support agreement with your vendor? Have you verified that your backup processes are working correctly and verified the data? Have you been following your system management plan to ensure all desktops, servers, and related peripherals (e.g., printers) are up to date with their operating systems, security patches, anti-virus and application software? Are you aware of planned upgrades to your EMR software? Have you agreed with your team on criteria for deciding whether to and when to implement them? 130 Appendices

135 Appendices Chapter 5 Checklist Checklist for Optimizing your EMR Have you completed the post-implementation review? What works and what doesn t? Are all users using the EMR? If not, why not? Now that you ve been using the EMR for a while, what else can it do for you? Are you using it to its fullest? Is additional or refresher training required to ensure all users are comfortable with the system? Is everyone using the same data coding and quality standards? If not, why not? Have you implemented any patient recall programs or clinically-indicated alerts? Appendices 131

136 Appendices List of Acronyms TERM AAFP ASP CDM CINHS CMA CME CNA DOQ-IT DSM EHR EMR e-ms FFS FTE GHC GIGO GP ICD ICPC ICT IHI INR ISP IT LPN MOA DEFINITION American Academy of Family Physicians Application Service Provider Chronic Disease Management Central Interior Native Health Services Canadian Medical Association Continuing Medical Education Canadian Nurses Association Doctor s Office Quality Information Technology Diagnostic and Statistical Manual of Mental Disorders Electronic health record Electronic medical record Electronic Medical Summary Fee-For-Service Full Time Equivalent Group Health Centre Garbage In, Garbage Out General Practitioner International Classification of Diseases International Classification of Primary Care Information and Communications Technology Institute for Healthcare Improvement International Normalized Ratio Internet Service Provider Information Technology Licensed Practical Nurse Medical Office Assistant 132 Appendices

137 Appendices TERM DEFINITION NHA Northern Health Authority NHS The United Kingdom National Health Service OCR Optical Character Recognition PHC Primary Health Care PIR Post-implementation Review POSP The Alberta Physician Office System Program QI Quality Improvement RFP Request for Proposals RN Registered Nurse SLA Service Level Agreement SNOMED Systematized Nomenclature of Human Medicine VCHA Vancouver Coastal Health Authority VIHA Vancouver Island Health Authority Appendices 133

138 Appendices Acknowledgements Health Canada gratefully acknowledges the support of the following individuals and organizations in the preparation of the EMR Toolkit: Steering Committee: the project benefited at all stages from the advice of a Steering Committee composed of representatives of: o British Columbia Ministry of Health o Alberta Health and Wellness o Manitoba Health o Nova Scotia Department of Health o Winnipeg Regional Health Authority o Canadian Medical Association o Canadian Pharmacists Association o Canadian Nursing Informatics Association o College of Family Physicians of Canada o Canada Health Infoway o Group Health Centre, Sault Ste. Marie Formative evaluation participants: development of the Toolkit was informed by formative evaluation activities at several stages. This included the input of an informal Working Group, as well as formal evaluation sessions in Victoria (May 2006) and Toronto (June 2006). Also, support for the formative evaluation activities is gratefully acknowledged from: o British Columbia College of Physicians and Surgeons, for the generous loan of its portable computer lab; and o Canada Health Infoway, for the engagement of its medical advisory group members, and provision of meeting space for the Toronto session. Wherever possible, the EMR Toolkit linked with existing publicly available tools for EMR implementation. Two existing jurisdiction-specific programs, Alberta s POSP program, and OntarioMD, were particularly valuable sources for content, and many of their tools may be used with little or no modification across Canada. Other major sources for content include: o Vancouver Coastal Health Authority o National Health Service (UK) 134 Appendices

139 Appendices o American Academy of Family Physicians (AAFP) o Doctor s Office Quality - Information Technology (DOQ-IT) program Special thanks to: o Dr. Nicola Shaw for granting permission to reproduce material from Computerization And Going Paperless in Canadian Primary Care. o Dr. Alan Brookstone for feedback and raising awareness of the EMR Toolkit through publication on the CanadianEMR website. The EMR Toolkit initiative was funded through the Primary Health Care Transition Fund. For more information on the PHCTF, please visit its website at: EMR Toolkit Working Group Special thanks to the following people for their participation on the EMR Toolkit Working Group: Landis Esposito Dr. Bill Cavers Julie Latreille Dr. Sandra Lee Dr. Jim Thorsteinson Stephanie Crichton George Fettes Liza Kallstrom Tim Smith Maureen Detwiller Ed Hunt Dr. Diamond Kassum Marlene Chapellaz Michael Hurka Dr. Andy Swan Dr. Norman Yee Joseph Mendez Dr. Karim Keshavjee Sylvia Robinson Dr. Morgan Price Amanda Sinclair Judy Huska Roberta Vyse Dr. James Lai Dr. Tobias Gelber G.W. Roy David Sookaveiff Appendices 135