Managing EHR Implementations: Layered, Multi tasked Activities that Require Management of Culture, Departments, and Vendors Carolyn P. Hartley, MLA Stanley Nachimson
Core Questions What has to be done? Who has to do it? How much will it cost? What is the foundation? Layers? Copyright 2010, Physicians EHR 2
Very High Level Tiers Start Here Copyright 2010, Physicians EHR 3
Interdependencies Interdependencies typically folded into workflow that best fits the software Developer. Copyright 2010, Physicians EHR 4
Transition from Process Aware Copyright 2010, Physicians EHR 5
Interdependencies: a Gordian knot Culture Planning, Workflow EHR Data Migration Billing/PMS Interfaces EHR Vendor System Without challenge, we have nothing to keep us from going back to sleep. King Midas Snoopy Copyright 2010, Physicians EHR 6
Eight I s I s of an EHR Yellow = Vendor ; Red = You ; Orange = You & Vendor July 2010, Oncology Issues Copyright 2010, Physicians EHR 7
Project Manager: Qualities Organized, persistent about documentation and results management Clinical first; IT second (preferred, easier than IT to Clinical) Communication skills that invite and measure consensus building in multiple formats Risk manager, anticipating fires before they occur Hold team accountable to complete tasks Prioritize and reprioritize daily Respected / trusted by management Copyright 2010, Physicians EHR 8
Guiding Documents Your RFP Your budget Vendor s Proposal responding to your RFP Vendor s Contract Licensing, terms & conditions Documented updates Documented notes from status meetings Emails, training manual Copyright 2010, Physicians EHR 9
Ideal Project Manager Copyright 2010, Physicians EHR 10
Interdependencies (Eight Is of an EHR) 1) Introspection Culture/ workflow Departments /workflow 2) Investment Budget, Vendor Selection 3) Interdependencies Project Manager, Contracts, Timelines, scope of work 4) Infrastructure Networks, hardware, 3 rd party software, security/privacy 5) Interfaces Labs, PM EHR, Payers if new PM system, HIE 6) Implementation Customize databases, clinical decisions Big Bang vs. Tiered 7) Installation & Training Hardware, software, interfaces all installed prior to training Go Live with onsite support 8) Issues Resolution Copyright 2010, Physicians EHR 11
1) Introspection Preparedness Assessment Operational Organizational Technical Data Management Clinical Processes Allow time to assess cultural issues Workflow assessments include interdepartmental AND clinical Visit types, documentation capture Check in to check out, through billing and remittance posting Copyright 2010, Physicians EHR 12
Why Readiness? MDs Purchase 100% of EHR; use 10% Strategy is built on your Assessment Data Entry Copyright 2010, Physicians EHR 13
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2) Protect Your Investment Seek selection guidance get beyond the stalemate of reviewing EHRs Site visits are essential. Legal counsel and/or reference best practices from HITRC Collaborative RECs participate in Vendor Selection and Management Community of Practice (CoP) Law of Supply/Demand applies to EHRs as well. Copyright 2010, Physicians EHR 16
3) Interdependencies Selection Go Live is not a linear process Manage interdependencies with weekly status meetings Representative from each department Director of nursing Lead physician Pharmacist / Lab Technician Administrator/Finance Information technology Document and post: Action Items, Decisions Copyright 2010, Physicians EHR 17
4: Manage Infrastructure Needs IT Project Management (Out Source or In House) HIPAA Security Software selection, installation (EHR and 3 rd party) Workstation installs: Clinical & Admin Inventory User access (authorized, Minimum Necessary Rule, and safeguard against unauthorized) Network Server, wireless network (Wires & Pliers) Wireless HVAC Copyright 2010, Physicians EHR 18
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5. Common Interfaces E Prescribing Reference Labs Hospital Systems Billing/Charge/Clearing Houses Imaging Centers Healthcare Information Exchanges RHIO, LHIO Hospital Systems Internal Systems and Equipment Copyright 2010, Physicians EHR 20
Project Management Status of Interfaces Interface Developed Tested Approved by Production Faxing FN, JL Scanning FN, JL Centricity ADT/Scheduler in EHR to Centricity Orchard BioReference Quest WebCam (Remotescan license) AM Barcoding MF Copyright 2010, Physicians EHR 21
Semantic Interoperability Semantic Interoperability for Better Health and Safer Healthcare ICD 9, ICD 10 CPT / HCPCS LOINC SNOWMED CT First Databank Copyright 2010, Physicians EHR 22
Healthcare Standards Healthcare Information Technology HHS http://healthit.hhs.gov Health Level 7 (HL7) http://www.hl7.org Digital Imaging and Communications in Medicine (DICOM) http://medical.nema.org Copyright 2010, Physicians EHR 23
Meaningful Use, Plan: HIE Where does data come from? Hospitals Labs Imaging Pathology Referring physicians Status of HIEs in your state/region will include Patients Copyright 2010, Physicians EHR 24
Where to get Interfaces Your EHR Software Vendor Interface Companies Hardware Vendors Copyright 2010, Physicians EHR 25
6) Implementation, Data Migration Project Management Team Physician Implementation Core Team Your Project Manager EHR Vendor Project Manager Selection Hardware Inventory Workflow Interfaces Security P&P Super Users Internal Train All Dept Customization Team Database Protocols Regimens Build database Install EHR Train Super Users Interfaces Test Production Copyright 2010, Physicians EHR 26
Chart Selection for Prepping Existing patients Weekly Bi weekly Monthly Frequent Callers Chronic Diseases High risk diseases Copyright 2010, Physicians EHR 27
Index Charts for Consistency Applaud the Medical Record team that has already indexed the charts. Front to back choice, but make it consistent Demographics, including payer Vitals best if the system creates a trend line Current Medications Allergies (meds, food, environmental) Problem List Lab results Surgical history Past history Family medical history Copyright 2010, Physicians EHR 28
Discrete Data Entry 2011 2012 Core Objectives CPOE (eg. Lab values) erx (pharmacies) PQRI clinical measures Record & chart vitals Clinical decision support Demographics Problem list Active medications Check drug drug allergy Core Objectives Active allergies Check drug allergies Clinical summary to patients, e copy to patients Smoking status & Cessation Exchange ephi to patientauthorized entities Risk assessment & Security Copyright 2010, Physicians EHR 29
Scanning Strategy Scan Everything Recommended method 3 years ago, better for hospitals than practices Can be very costly Difficult to abstract data for reporting Takes up storage on server Scan Strategically Strongly advised now Scanning less expensive Resources data entry Much easier for data reporting Storage: Scan on demand, paper storage space Copyright 2010, Physicians EHR 30
Data Migration: Chart Prep Tab Data abstracted, entered Into patient s EHR record Scanning completed, physician initials chart pull up to three times Prepped EHR Scanned initial Pulled Retire Duplicates removed; contents in order (progress notes 1 st, problem list 2 nd, labs 3 rd, etc. Record is scanned; scanner initials Chart is retired; policy on Paper chart recalls Copyright 2010, Physicians EHR 31
Three Strategies for new PM system Migration between now & 2011 1. Implement PM system 60 days prior to EHR 2. Purchase integrated system, run parallel systems until A/R on old system is retired 3. Depending on readiness, hold off new PM system until after Stage 1 reporting NOTE: Integrated systems are not designed to be pulled apart Copyright 2010, Physicians EHR 32
7) Installation Initialize (Customize) Database Physician Decisions Somewhat Easy Create fax cover sheet Integrate patient demographics Assign user names & IDs Build pharmacy lists Build call message center user lists Populate physician letters Establish downtime procedures Build downtime cabinet More Difficult/Require Consensus Build list of referring MDs Determine exam defaults Determine rules for open charts Build nursing note macros Agree on clinical protocols Link consent & authorizations to procedures Rules for standing orders & revisions Governance for non-compliance Rules, best practices for data validation testing, Clinical policies & procedures Copyright 2010, Physicians EHR 33
8) Coordinate Go Live and Resolve Post Implementation Issues Approve database for Go Live Set travel schedule for Vendor PMs and Trainers 1 application specialist for every 2 ½users One traffic cop/patient problem solver Project Manager One super user for every 3 nurses/ma/lpns Inform patients (letter, signs in lobby) Dry Run 1 2 days prior to Go Live Food, drinks copyright 2010 Physicians EHR 34
EHR Vendor Technical Support What is your Vendor s Technical Support Offer? Level 1 (Basic help, triage calls) Is your computer plugged in? When did you last recharge your battery? Have you reset your monitor? Level 2 (Remote assistance Go to my PC) Problem resolved remotely EHR vendors may want to be the first point of contact Level 3 (Bugs, Enhancements) May require an onsite call Technical person bills at contracted rate Upgrades & maintenance Copyright 2010, Physicians EHR 35
Possible Vendor Implementation Problems Volume of work Shortened implementation timeline You don t understand our EHR Physician delays Interfaces not ready Physicians return to paper Reporting capabilities (*Certification onsite) Congress Lawsuits Copyright 2010, Physicians EHR 36
Return to Pre EHR Productivity* Develop on site technical support resources Create templates before and during implementation for documentation Enter past patient data before Go Live Set up interfaces with other data sources before Go Live Reorganize workflow to incorporate the EHR *Source: Fullerton, Cliff, MD, Aponte, Phil, MD; Hopkins III, Robert, MPH, PhD; Bragg, David, MD; and Ballard, David J., MD, MSPH, PhD. Lessons learned from pilot site implementation of an ambulatory electronic health record. Proc, Baylor University Medical Center, Vol 19, pp. 303 310 Copyright 2010, Physicians EHR 37
Summary Leverage findings in your assessment to build your implementation strategy. Each of the eight stages of implementation are interdependent. Your Project Manager must be able to manage multiple tracks. Implementation is a clinical activity that is supported by your IT dept. not the other way around. If you aren t sure where you are in the process, ask for help. Copyright 2010, Physicians EHR 38
Thank you! Carolyn Hartley, President, CEO Physicians EHR, Inc 919 637 0220 Carolyn@physiciansehr.com Stanley Nachimson, Principle Nachimson Advisors 410 935 7084 Nachimson_Advisors@verizon.net Copyright 2010, Physicians EHR 39