UAB HEALTH SYSTEM AMBULATORY EHR IMPLEMENTATION

UAB HEALTH SYSTEM AMBULATORY EHR IMPLEMENTATION

Richard Rosenthal, MD Associate Chief of Staff Ambulatory Services Associate Professor of Medicine Department of Medicine Endocrinology

Agenda About UAB Health System EHR Vision and Guiding Principles Project Scope and Approach Benefits and Measures Keys to Provider Adoption Page 3

UAB Health System University Hospital As the cornerstone of UAB Health System, University Hospital is a Teaching Medical Center and Alabama s First Nursing Magnet Hospital Alabama s only Level 1 Trauma Center 1,157 Beds 72,000 Admissions 77,500 ED Visits 1,141 Active Medical Staff Ambulatory Clinics Over 1.1 million ambulatory visits and procedures performed each year in 135 Ambulatory Clinics The Kirklin Clinic houses over 33 specialties under one roof Page 4

Vision One Clinical Chart Standardize on a single system as the source of truth Enter data once, use many times, avoid data duplication between systems Consistent, system-wide decision support and alerting Redesign processes and workflow to maximize information system use Page 5

Cerner Implementation began in 2003 Surgery UED Radiology Pathology Background Inpatient EHR went live in 2008 CPOE and Results Reporting Nursing and Physician Documentation Pharmacy with Pyxis Integration PowerChart Maternity and Fetalink BMDI with positive patient ID Device integration rollout for: Physiologic monitors for ICUs Ventilator integration for ICUs Page 6

Improve Quality and Safety Improve Communication Ensure Continuity of Care Facilitate Research Extract Data Improve Efficiency Meet Regulations Ambulatory EHR Project Objectives Page 7

Project Scope Ambulatory EHR roll-out to multiple clinic locations to replace manual systems: Schedule View Orders with ABN Alerts Documentation Message Center E-Prescribe MPages Single Document Scanning Page 8

Implementation Approach Practice Similarity / Location Proximity Wave 1 May 16, 2011 Wave 2 Aug 2, 2011 Wave 3 Jan 27, 2012 Wave 4 April 30, 2012 Wave 5 July 30, 2012 Primary Care, OB/GYN Ancillary Areas Medical Services Cardiology Oncology Surgical Services Specialized Clinics Specialization / Content Practice Similarity Workflow Content Location Proximity Reception/Pods Shared Staff Specialization Unique focus of care Content Varying coverage per specialty Volume Balanced across Waves Page 9

Standardization vs. Customization Balance Documentation and Orders Existing vs. New Hospital vs. Clinic Dictation, Dragon, Structured Data Access Standard devices to support Access from variety of devices and places Page 10

Project Structure Regular updates to: HSF Executive Committee HSIS Executive Committee Physician Faculty Meetings Clinical Practice Committees Executive Administrators TKC Nurse Council TKC Directors MSO Parallel Projects PowerInsight isite/pacs Replacement Board Executive Sponsors Clinical Advisory Group/Surgery Committee Project Management Office - PMO Parallel Projects: Transition Team Project Teams (~25 teams aligned with functionality) Page 11

Physician Participation High level physician and staff participation throughout all project phases: Design, Build, Testing, Training, Rollout Physician Leadership support and input for: Standardization in process and system design Timely decisions to stay on target and on budget Physician Champions Facilitate overall change management for the clinic Page 12

Physician Participation Physician Content Leads Drive development and standardization of system content with input from colleagues Contribute to clinical process improvement and content development in conjunction with colleagues and administrators Test and approve design and build Be an advocate for change during Go-Live Page 13

Keys to Physician Acceptance of the EHR Education Organization Assistance Implementation Optimization Page 14

Mission: Clinical Advisory Group Lead Clinical Process Redesign Help Define High-Level Policies/Procedures Forum for feedback and peer review, liaisons to other committees Review and approve variances from standardized content Address and resolve clinical implementation issues in a timely manner Learn the IMPACT system s workflows and limitations Page 15

Clinical Adoption Approach Feet on the ground in every clinic to understand current workflows Introductory workshops to familiarize clinics with a generic future state In depth follow up sessions to prepare clinics individually for implementation Customize documentation to bolster adoption Simulation Center to review device options in a clinic setting Provider driven pre-load decisions Administrators and providers involved in transition planning Coordinated workflow practice sessions with individual clinics prior to go-live Page 16

Clinic Workflow with ARRA and Regulatory Requirements MAJOR WORKFLOW STEPS PROCESS STEPS Scheduling & Registration Schedule appointments in IDX Collect/update demographic information including preferred language and ethnicity Pre-cert in IDX ARRA Requirements Joint Commission Regulations Patient Check in Arrive patient in IDX Confirm patient information Collect patient pharmacy information Collect patient selfassessment form, if applicable Receive external records day of visit Print encounter forms Print HIPAA Acknowledgement as needed Patient Intake Record vital signs Height Weight Blood pressure Record Medication History Record Past Medical History Record Procedure History Record Family History Record Social History Record Allergies Record Cultural/Spiritual needs Record pain assessment Record Immunization history, if applicable Perform Point of Care tests Provider Assessment Complete Review of Systems and physical exam Document via Power Note Can use Dragon in narrative portion of template Review Health Maintenance Review Chronic Condition Management Update Problem List Record Diagnoses Place Orders eprescribe only print schedule drugs or if requested Care Delivery Administer in clinic meds Perform Point of Care Tests Perform In-clinic labs, if applicable Collect In-clinic specimen for delivery to Lab Perform/Document patient education Complete clinical tasks and document via PowerForms Dictate in Horizon only when absolutely necessary Discontinue using forms in Horizon Check out Schedule appointments Print Depart Summary Give Patient printed prescriptions if applicable Print Requisitions for external orders or non-live clinics Process External referrals Between Visit Care Manage Rx refills Manage phone triage Pull charts - transitional Schedule appointments Scan documents postvisit such as consents, external records Manage Results Generate result patient letters if applicable Generate other patient letters Perform MRP/ROI Discontinue reviewing results in Horizon; use Message Center Chart Prep Scan external records/results Pull charts - transitional Load patient information as determined by clinic Track orders Review documents in Horizon for non live clinics Check Meds in Horizon for non live clinics ARRA METRICS Demographics: Must enter 1-time on more than 50% of patients. This data requirement met through IDX updates Vital Signs: Must enter 1-time on more than 50% of patients Meds and Allergies: more than 80% of patients must have 1 medication and 1 allergy or indication n/a Enter 1-time the smoking status of more than 50% of all patients >12 yrs old Problem List and Diagnosis: Must enter 1 or indicate N/A for more than 80% of patients CPOE: More than 30% of patients with 1 medication in Med List must have at least one medication order entered through CPOE eprescribe: More than 40% of all permissible prescriptions must be transmitted electronically Patient Education: More than 10% of all patients are provided patient specific education resources Clinical Summary ROI - Release of (Depart Summary): Information: More Provided to than 10% of patients for more patients are than 50% of all provided timely office visits within electronic access 3 business days. to parts of their EHR upon request Provide an electronic copy of parts of their EHR for more than 50% of patients who make the request Page 17

Training Training and Practice Sessions Required providers to attend two 3-hour training sessions Required providers to spend 2 nd half of the Provider II class building order favorites and pre-completed PowerNotes Offered providers additional open house sessions for help with PowerNote templates and building favorites Staff required to attend full day of training In-clinic workflow practice sessions conducted prior to go-live to allow providers and staff to: Simulate workflow who will do what, when Place clinic-specific orders and complete documentation on test patients Test equipment Page 18

End User Go-Live Support Model One expert assigned to each provider schedule One front desk/back desk support person Go-Live Support Team leads to manager go-live support personnel and channel issues/updates Scanning/MRP floaters Command Center Fast track go-live support calls from normal helpdesk calls to a command center Command Center comprised of phone support, analyst support in one area to quickly triage calls Page 19

Users Group Meetings every 2 weeks Ongoing Clinic Optimization Physician Clinical Advisory Group monthly Expert Team rounding in Clinics to: Identify issues with system design and track to resolution Assess processes and evaluate roles & responsibilities to recommend workflow refinement Identify gaps in knowledge and provide additional training Develop Ongoing Training Strategy Page 20

Evaluate, understand and redesign clinic workflow Identify opportunities to repurpose staff Provide a Simulation Center to evaluate device needs Lessons Learned Address preload plan early What will be preloaded? Who will do the preload prior to go-live? Who will assume chart prep responsibilities long term? Understand the impact of a foreign scheduling system on Referrals to other clinics Future visits and future order tracking Appropriately set expectations around creating outbound charges to an external billing system Avoid introducing new policy at go-live Page 21

Over 135 HSF Clinics LIVE on IMPACT Ambulatory Total Users 3466 Page 22

Physician to Patient Visit Ratios for Waves 1-4 Wave 1 Wave 2 Wave 3 Wave 4 Page 23

Wave 5 Provider to Visits Ratio thru 10 days Day1 Day2 Day3 Day4 Day5 Day6 Day7 Day9 Day9 Day10 Providers 2012 93 117 101 113 81 102 107 100 118 77 Providers 2011 65 75 80 81 57 67 76 80 79 59 Patients Arrived 2012 577 728 753 701 453 767 688 686 827 470 Baseline Arrived 2011 606 631 642 710 429 695 673 716 733 457 Arrived Pts. per Provider 6.2 6.2 7.5 6.2 5.6 7.5 6.4 6.9 7.0 6.1 Baseline Arrived Pts per Provider 9.3 8.4 8.0 8.8 7.5 10.4 8.9 9.0 9.3 7.7 % Provider Days in Clinic - Current to Prior Year 143.1% 156.0% 126.3% 139.5% 142.1% 152.2% 140.8% 125.0% 149.4% 130.5% % Pts. Arrived Current to Prior Year 95.2% 115.4% 117.3% 98.7% 105.6% 110.4% 102.2% 95.8% 112.8% 102.8% % Arrived Pts. per Provider to Previous Year 66.5% 74.0% 92.9% 70.8% 74.3% 72.5% 72.6% 76.6% 75.5% 78.8% Total arrived patients to provider ratio is 21% below previous year after 10 days Page 24

We chose quantitative measures for key objectives Improve quality and safety of care Comply with regulations Improve overall efficiency Qualify for ARRA incentives Improve patient and provider satisfaction Health maintenance screening Drug interaction and allergy checking % delinquent charts % signed orders Transcription costs (see projections in next slide) Forms costs Medical necessity write-offs Meet MU Stage 1 requirements Patient satisfaction with care experience Provider satisfaction Page 25

We chose qualitative measures for the rest Improve communication across the organization Satisfaction with Message Center Ensure continuity of care across settings Common clinical data repository Provide data extraction and reporting PowerInsight Facilitate research More data More reliable data Codified data Page 26

Electronic Documentation vs. Transcription 95.8% Savings 92.7% Savings 93.4% Savings 93.0 Savings 85.0% Savings 5.9 % Dictation Actual 1 st Year 7.3 % Dictation Actual; 1 st year 6.6 % Dictation Annualized 7.0 % Dictation Annualized 15.0% Dictation Annualized (Conservative Estimate) Average 92% Projected Annual Savings Page 27

1 Week Road to Productivity 6 Weeks 3 Months 6 Months 1 Year Page 28

Questions Page 29