COACH

HIMagine IT without HIMLower Mainland Health Information Management

March 2015: Breaking Down Barriers-Getting IT Done

Yoel Robens-Paradise, MPAExecutive Director, Lower Mainland Health Information Managementyparadise@providencehealth.bc.ca

Presentation Outline

1. Lower Mainland Consolidation2. HIM Overview3. HIM Evolution4. Breaking Barriers: HIM view on selected

topics

A few questions to ponder:1. What is your understanding of HIM’s role as it

relates to Health Authority’s Electronic Health Records?

2. When people say, “IT is an enabler…projects should be clinically or business driven”, what does that look like in practical terms?

Lower Mainland Consolidation• Lower Mainland Consolidation is an innovative approach to improve value

for money through cross-health authority amalgamation in select non-clinical and clinical support areas.

• The health organizations and the MoH launched the initiative in August of 2009 setting the goal to achieve a total of $100 million in cost savings.

• One organization assumes accountability for each consolidated service across the Lower Mainland. The consolidated department provides quality service to all participating organizations based on a service agreement; and achieves specific cost savings targets.

Consolidated service– Biomedical Engineering PHC Chris Buck– Business Initiatives & Support Services VCH David Handley– Facilities Management FH Peter Goldthorpe– Health Emergency Management FH John Lavery– Health Information Management PHC Yoel Robens-Paradise– IMITS PHSA Barry Rivelis– Integrated Protection Services FH Jeffery Young– Interpreting Services PHSA Suzanne Barclay– Medical Imaging VCH Sue Avery– Pathology & Laboratory Medicine PHSA John Andruschak– Pharmacy Service FH Michele Babich

LM HIM• Fraser Health, Providence Health Care, Provincial

Health Services, Vancouver Coastal Health

• 1,300 Staff across 35 sites

• Primary services include Registration, Health Records Services, Transcription and Coding

• $65 Million Budget

Care Levels– Acute Inpatient & Outpatient– Emergency – Surgical Day Care– Residential Care– Primary Care

Health Information Management Landscape

Registration/Admitting Patient Care Intake, Client Identity and Encounter MgmtData Guidelines

Health Records Management•Access to and Provision of Information ( Paper, Scanned, Electronic)

•Assembly and Scanning Services•Record Completion (QA)•Release of Information•Clinical Forms Mgmt•Legal Record Stewardship

Care DeliveryPaper/Electronic

Record

Transcription ServicesStandardization of Dictated Reports

Coding and Abstracting

Budgeting Bed Allocation ResearchService Planning Education Performance MeasurementUtilization Mgmt

HIM Operations HIM Stewardship

• Standardize IM policies• Advance data quality• Support interoperability• Improve Information quality•access & confidentiality• Information design and capture• Content mgmt• Info analysis and use• Client identity and encounter mgmt

HIM services by the numbers…• Registration processes approximately 15,000 visits daily

across the Lower Mainland health authorities.

• Lower Mainland Health Information Management ROI Departments receive and respond to more than 230,000 requests per year.

• Transcription Services processes approximately 18,500 dictated minutes (averaging 5,300 reports) a day.

• HIM Coders review over 260,000 surgical and inpatient cases annually to assign diagnostic and procedure codes.

The times are a changing..

Changes in Technology, Business Processes, Clinical Practices, Organizational Structures…etc. WHERE IS HIM HEADED?

HIM Record Management & Registration Business Evolution

Release of Information

Quality Assurance

Forms Management

Record Storage

Form Design, Chart Tracking, Chart Release, Legal Record Certification, Destruction Certificate

Registration/AdmittingScheduling

Health InformationExchange/Report Distribution,Access Model (portal support)

EHR Data QualityElectronic Signature Mgmt

Enterprise Content Mgmt, Form Ontology

EHR Record RetentionDelegated Stewardship forElectronic Legal Record in thecreation, distribution, Scanning,Record Usage & Disposition,

Kiosk DeploymentClient Identity and Encounter

Management, EMPI, Merging

HIM Coding & Transcription Evolution

Abstraction

Coding

Form Design

Coder to Physician Queries

Transcription

Report Faxing

HL7- Automated Data Capture

Computer Assisted CodingData MappingClinical Document Improvement

EHR Design and Clinical Nomenclature Standards, Problem list mapping

Front End Speech Recognition

Health Information Exchange; EHR to EMR Integration

HIM Document Imagingaka “Transitioning to an EHR”

What is it?Why?Impact on HIM?Alternatively…What is a Hybrid Record and why

does HIM usually oppose them?

Selected Topics: Breaking down barriers from an HIM Perspective

• Governance and Org Structures• People part of IT• Localization, Big Bang V. Incremental Deployment• Interoperability• Data Quality• Clinical and System Transformation• Physician Engagement

Top 5 ways to know you’re facing barriers or …HITting the wall..

1. People have more faith in the Canucks than your health informatics project

2. You’re leading an interoperability HIE project but there are no messaging standards

3. Clinicians want hospitals to send them patient records but don’t want to share their private email with Medical Affairs

4. You’re reading about your system’s privacy breach in the Vancouver Sun

5. Staff think “EHR adoption” means executives bought some one else’s “baby”

Governance/Organizational StructuresImpact on IT

• IT needs business process standardization-this requires “the business” to lead projects.

• LM Consolidated areas mandate to standardize conflicts with HA interests. Current mitigation is via relationships.

• Weak alignment between IM goals and physician incentives (e.g.documentation practice - compensation)

• No integrated clinical leadership (MAC Structure)• Environmental complexity (separate Risk Mgmt, Privacy,

Finance, IT etc.)• Unclear/diffuse accountabilities and roles for EHR,

Registries, Clinical Terminology Standards, Report Distribution, Access, Data, policies etc

People part of IT

– Labour Relations: Stories from Transcription– New HIM Roles

• CDI• HIM Informatics• Message Centre• HIE• Remediation Experts

– Automation and Centralization

People and Change Mgmt

•Start with stakeholder analysis – involve them from the start

•Manage expectations•Be transparent

•Minimize impact to direct care

•Fix what you break

Location, Location, Location

Localized Issue Management

Number of Transcription Project Issues Tracked by Organization

Issue Tracker per Implementation

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Big Bang vs. IncrementalWell defined scope More complex projects

Lower risk projects Phased implementation with foundational/priority elements first

Requirements don’t change after testing

Need for high quality from earlier testingProcess driven by frequent feedback

Aguanno, Kevin, 'Agile Bootcamp for Project Owners & Business Stakeholders', 14 February 2012, GenXus Management Consulting.

Client Identity Management

Published studies estimate as high as 10 of 17 hospital deaths have client identity issues as causal factors.

Registration Data

Survey of 10 core registration systems in 2012/13Duplicates:

– Range across the systems of an average of 2 to 330 duplicates created per month

Overlays:– 1-45 overlay records created per month

Thin Data:– Across systems 1-40% or records missing PHN– 1-30% of records missing PHN and Address

• Health System costs of non-integrated solutions are significant (e.g. learning from a LMC scheduling project).

HIE and Data Quality

Client Identity Management and Patient Safety Issues Loom Large

Interoperability-are we ready?• Client Identity• Provider Identity• GP identification• Standardization of Form Usage, Content Standards

• We can choose CDA..FHIR, LOINC.. Etc, but …HIM Reality Check: Accuracy of GPs, Client ID, Provider ID, Form Types, Content Standards…all are foundational.

• Provincial Interoperability will require provincial business and clinical standardization and this will require a provincial HIM approach to support.

Culture Eats Strategy For Breakfast (Peter Drucker)

Business Process Eats IT For Breakfast (Yoel Robens-Paradise)

Clinical and System Transformation

How to get from point A to B

1st Baseline: Stakeholders Share Strategic Vision 2nd Governance and organizational structure3rd Clinical/Business Process Standardization4th Design and Build

CST: Getting IT done...

Physician Engagement

• Champions are critical• Work the MAC structure• High Touch• Leverage Risk Management & College• Show them data (theirs and others) & Research• Respect their EMR/EHR reality (Parallel

Universes)• Cultures vary enormously

HIM Services Help EHR Deployment

Known Project Challenges and Examples of Areas of HIM Expertise

• Governance: 4 separate organizations yet centralized HIM business leadership

• Non-integrated records: Client Identity Strategy and Data Remediation

• Hard to automate some paper processes: Document Imaging Strategy

• Can’t structure all data: Dictation - Front-end Speech Recognition

• Data Definitions not standardized: HIM expertise in ICD10, SNOMED, CIHI and MOH guidelines

• Access Model Complicated: Well established Release of Information guidelines

A few questions to ponder:1. What is your understanding of HIM’s role as it

relates to Health Authority’s Electronic Health Records?

2. When people say, “IT is an enabler…projects should be clinically or business driven”, what does that look like in practical terms?

Thank you