Jonathan Siff, MD, MBA, FACEP MetroHealth Medical Center Discuss some basic definitions List benefits of electronic records systems and reasons for getting one Discuss types of systems in broad terms Learn about the selection process and why the ED needs to be involved Understand post selection tasks Understand how the new system is likely to impact the ED Each of these objectives could be a multi-hour lecture We will touch on some major points under each topic There is a lot of help available if you are willing Specialty organizations Friends and colleagues Consultants
Practicing Emergency Physician 13 years of experience implementing, training, customizing, programming and surviving electronic medical records Currently System Director of Clinical Informatics Also the ED associate operations director, ED billing director and compliance officer So we are all speaking the same language EHR vs EMR Electronic Health Record Electronic Medical Record Some nuanced differences but we ll pretend they mean the same thing EHR will be used through out the talk Emergency Department Information System EDIS System that focuses on the ED functions of an EHR
Enterprise system An EHR that addresses all the needs of an organization may have modules to address specific areas such as the ED Best of Breed system A system focused on one area which has demonstrated excellence in that field Sometimes term used to just mean a vendor focused on just one clinical area (does one thing and does it well) Patient care benefits Safety Computerized Physician Order Entry (CPOE) Decision support Legible and immediately available notes No lost charts Multiple users can access chart at once Immediate access to past charts and data Connection to Health Information Exchanges (HIE) or Regional Health Information Organizations (RHIOs) Operational benefits Streamlined workflows Structured data for reporting Increased productivity and throughput???? Revenue advantages Cost savings? Better documentation leading to higher billings Better reporting
Keeping up with the competition Meaningful use requirements and incentives Federal Penalties, coming soon! State incentives / penalties Insurer / payor requirements Patient safety and quality initiatives Long term savings from increased efficiency and reduction of overhead They are making us How do I get started? Who needs to be involved? What impact can I expect on operations and finances? First and most important
Patient arrival Patient tracking Location Course Triage CPOE Results review Longitudinal data review Discharge management Overview of the department for managers Clinical documentation Problem lists Medication lists Notes Access to prior documentation Reporting MUST BE EASY TO USE Selection Vendor / System not yet selected Installation/Implementation System selected but not being used for live patient care yet Go live is the final piece of this phase Post-Implementation Changing vendors Using an EHR but getting a new one Get an ED Physician Champion Tech comfortable, not necessarily a geek A good teacher, respected by peers Fully knowledgeable about workflows and how your ED functions Get him / her on all related committees This is a big job, plan to pay for it Get nursing and front end staff involved early Start an ED EHR steering committee
Your workflows will likely have to change This is not necessarily a bad thing Use the opportunity to improve You cant fit the square peg in the round hole A huge decision that will impact your practice for years to come it s a business decision, not an IT decision! Talk to everyone you know who is using a system Discuss everything from finances, to training needs to would they use the same vendor again It is best if a clinician leads the process
Be sure the system has all the key features for the ED Be skeptical of that is coming in the next version ) Don t fall in love with a demonstration Make site visits and see the product in action Never buy a system you have not seen in the wild Vendor certification and financial stability Factor hardware, training, lost productivity and ongoing optimization into Return on investment (ROI) and Total cost of ownership (TCO) Advantages Usually single purpose more mature Generally maintain ED specific materials (ordersets, pathways) better than enterprise More focused on ED needs since you are often their only market Disadvantages Lack of integration with other hospital systems Loss of easy ability to integrate data across continuum of care How many ED s is the vendor installed in? Can I go visit them? What is the average time from go live to full productivity recovery? How many de-installs does the vendor have have and why? Can the product do all the key ED functions? Will it interface with legacy and other systems? What ED issues will an EDIS address? Will productivity losses be compensated?
A continuum of activities after a vendor has been selected culminating in Go Live Three key areas People Strategy Technology Don t underestimate culture Adapted in part from: Adler KG. How to successfully navigate your EHR implementation. Family Practice Management. 2007 Feb;14(2):33-39. Technology Issues Process/Use Issues IS/IT Staff End Users 24
Champion Project manager Get ALL the stakeholders involved Set expectations and goals Must be measurable Must be realistic This is a long term project Fix team / people issues before the implementation Plan and plan some more Develop experts Redesign workflows You WILL have to change how you do things and who does what The new EHR workflow may not always be quicker or more efficient but may have other gains Populating the new system with old data Interfaces How computers talk to each other Content build Very important Must be ED specific Get vendor model content and modify ED specific order sets and preference lists for ordering Third party vendors do exist and can be very helpful
Inadequate training almost guarantees dissatisfaction or failure Develop clear policies around what training is required You are going to have to incentivize staff to go or they wont go Training should be: Role specific Within 1-2 weeks of go live Provide an opportunity to play in safe environment to practice Types of go live Big Bang Pilot Phased implementation I favor phased in the ED Not a Monday and not during high volume seasons (flu, Trauma) Get plenty of support Super users Vendor on site and / or consultants 24/7 from IS and staff empowered to authorize and properly document change Installing an EHR is a workflow and people project that happens to involve computers BUT That does not mean the technology is not critically important There are a number of key considerations
Infrastructure Must be fast enough to handle 3-4 times what you expect to use Hardware Many options a whole talk Consider cost, size, placement Mobile devices Non-computer devices (think tablets) Bring your own device Availability of information Be sure its easy for providers to find what they need in a logical place in their workflow Testing systems and maintenance Disaster recovery Tools for planned and unplanned downtimes Tools + Configuration + Use = Outcome
Lack of time and workload enough resources Productivity losses Will the system be easy to use and built for MY job? Impact on patient provider interactions Motivation to use the system why me? How will I..? Don t skimp on the initial resources you devote to implementation Post go-live you need to maintain resources Keep your super users engaged and help them stay up to date on system changes The leaders of this initiative MUST be clinical users
Downtime is when the EHR is not functioning either at all or in part. ED is most impacted by this Develop processes for: Complete downtimes Downtime of external systems that impact the EHR Explain the impact of downtime to all stakeholders outside of the ED Users must be trained on downtime procedures Expect a 20 to 40% loss in the first few weeks. Experiences 2.3 to 2.6 patient per hour to 1.5 pph productivity circled the drain Aaaaah Up staff as much as possible Wide range of new steady states In most implementations throughput does eventually improve Consider scribes Improved throughput Better patients per hour Higher provider satisfaction Can start anytime but best if with go live of documentation May reduce the number of docs sitting around hours after their shift charting and grumbling In productivity incentivized groups have a plan to address decreases before go live
Everything you do is now time stamped It is clear who owns every note and every set of vitals in the system Encourage staff to correctly time their entries It is very easy to tell if someone changes something so beware Beware cloned notes or identical documentation Pay particular attention to the teaching workflow The EHR is a great magnifier Shows your strengths and flaws Use this information to your advantage to improve processes Take a no blame, no embarrassment approach to what you learn
Culture eats strategy for breakfast An EHR is a complex social project that involves computers Have you ever met an ER doctor or nurse who likes change? Providers may see the EHR as a threat to their independence and autonomy Listen to the squeaky wheel they often have valuable input Get all stakeholders involved Leadership needs to be visible at go live Solicit input from your loudest squeaky wheel providers Communicate with staff Feed them during go live Reward milestones early on Say Thank you The project is not over Ongoing training and optimization are essential You will need to continue to devote resources to the EHR Super users Staff on hospital committees Updating content
Utilize your vendors user group forums and on line resources Try to avoid redundant processes If more than one user does a function it results in duplication of effort and potential conflicts in the record Ex. Medication reconciliation Critical results and re-reads need to be addressed in the digital world I usually find sticking with the pre-ehr process is the best You can never do enough training and you need to keep training because the system keeps changing Monitor your processes and inspect what you expect your users to do Never be afraid to admit something does not work and make it better And Don t Panic!
Jonathan Siff, MD, MBA, FACEP jsiff@metrohealth.org