Hospital EMR's: Getting it Right the First Time

PowerPoint Presentation

Hospital EMRs: Getting it Right the First Time

Thomas G. Zimmerman, DO, FACOFP, CPHIMS

South Nassau Communities Hospital

Oceanside, NY

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Hospital Demographics

440-bed community hospital in suburb of NYC

1023 Medical Staff

850 Physicians (of which 75 are hospital-employed)

3000 Employees

720 RNs

Dually-Accredited Family Medicine Residency (18)

Visiting Residents (OB, Surgery, Peds total 18)

Thomas Zimmerman, DO, FACOFP, CPHIMS

2

Do your homework!!

Thoroughly evaluate the projects feasibility

Preliminary architecture and design specifications

Informed consent of all stakeholders

Consider the financial impact of the project (as well as work-hours involved)

Complete EHR, or phased approach

Phase 1 Orders and Results

Phase 2 Clinical Documentation


3

Planning

Clarify Project Objectives and Scope

Proposed Timeline

Cost and Quality objectives

Scope of Project

Deliverables

Verify that all stakeholders agree to these guidelines to avoid confusion, wasted effort or duplication, and/or project failure.


4

Planning

Identify a single leader of the project

A large steering committee by itself does not allow for personal responsibility and action.

CMIO / CIO / VP EMR/HIM should take the lead in monitoring progress and addressing obstacles

Steering committee can serve as a resource to the project leader to discuss issues and find solutions


5

Planning

Full-Time Project Manager

Day to day management, execution, and delivery of the implementation

Reports to Project Sponsor / Steering Committee

Should have experience with IT implementations


6

Planning

Interdisciplinary Implementation Teams

Executive Sponsors

Department or section leaders

Experienced Subject Matter Experts (SMEs)

Physicians, IT techs, EMR consultants

End-users with AND without IT experience

Department of Medical Education

Residents, students (of all types)


7

Planning

Strong Administrative Sponsorship and Involvement

Ensures that each implementation team (not just the Steering Committee) has the authority to make decisions that will stick

Expresses the strong commitment of the hospital for this implementation (to the end-users)

Ensures better communication and awareness


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Planning

Core Analyst Team

Hire flexible thinkers who have a sense of perspective and a sense of humor you will need both.

Consultants Caveat Emptor!!

Enlist their services judiciously, respect and acknowledge their expertise, but make sure that hospital staff retain ownership of the project

Interfaces

Lab / Rad / Dietary / Admitting

Make sure the time and costs for the development/testing/verification for all of these are appropriately accounted for in negotiations, contract, and scope


10

Identify Risks

Technical interface issues, equipment compatibility issues, delays in upgrades

End User Acceptance resistance to change (computerized physician order entry, medication reconciliation, etc.)

Recognize, monitor, and address these risks in a timely manner, and ensure communication between stakeholders (no surprises!)


11

Question the Vendor

Dont accept its hard coded or its working as intended

Clinicians need to drive the train for patient safety


12

Staffing Concerns

Clarify time commitments for staff members involved with the implementation

Identify times where their hours will need to be back-filled with other staff to meet daily operational needs

If activities will occur after work hours, consider what type of compensation will be provided


13

Review Policies

Practice and policies will need to reflect the new world order

Dont feel that you need to own the practice of the entire hospital

Users will ask you to make the doctors and nurses do. Avoid the temptation!


14

Remember

Everyone still needs to talk

Avoid the illusion of communication that follows implementation of an EMR


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Scope

Define the scope of the project, and really think it through

In-patient only?

Out-patient areas?

Ambulatory areas vs. Procedural areas?

Consider areas that serve a combination of in-patients and out-patients


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Scope (cont)

Will you use niche products in areas such as:

Cath Lab

Labor & Delivery Suite

OR

General EMRs are a mile wide, and an inch deep while niche products are an inch wide and a mile deep


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Create a detailed project plan

Gantt Chart or Excel spreadsheet

Document all major outcomes/deliverables

Target dates

Responsible Sponsor / Resources

Approximate work effort

Update these tasks as they are completed or delayed/modified


18

Scope Creep

The expansion of the project to include additional products/functionalities not originally accounted for in the project plan and/or contract

Extra Time / work effort

Extra Costs

Increased complexity, confusion


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Change Control

Changes to the original software are inevitable; the product must be tailored to suit the individual needs of your organization

Be prudent in making modifications to the core software

Document all changes in detail:

Date of change

Reason modification was needed

Exact description of the change (in case it needs to be restored after an upgrade)


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Current State & Future State Design

All stakeholders involved better design, more user acceptance/skills

Identify every workflow in every department of the hospital: clinical, administrative, financial.

Critically evaluate current policies and procedures, and watch for opportunities for improvement that the EMR may provide

Identify key issues / problems created by the EMR

Document the future state of operations clearly


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Sample Workflow Diagram


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Key Theme DescriptionClinical Excellence Quality and Outcomes FocusWhat will the approach be for identifying outcomes as part of the EMR implementation? Which outcomes are of the highest priority? Care StandardizationDetermines the extent to which care and clinical applications will be standardized. CPOE Strategy This defines the degree to which CPOE will be rolled out as standard practice or policy. Medical executive committee establishes expectations regarding compliance and consequences for physician non-compliance. Clinical Documentation Describes the approach to clinical documentation: what types data will be entered, who will enter it, and how.Clinical Decision SupportDescribes the approach to the tools that guide real-time clinical decision-making.

Future State Design Guiding Principles


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Key Theme DescriptionTrainingIdentifies the approach and level of investment for how the hospital addresses staff training for clinical quality improvements to include use of advanced clinical systems.Access Strategy Remote and InternalThis defines the strategy for the placement of devices to enhance adoption and also determines the extent the physician portal and remote access will be utilized. Content StrategyThis will define the content strategy (order sets, clinical documentation, and clinical decision support) to ensure system utilization and improve quality and efficiency.Workflow OptimizationRedesigning current workflows with EHR as an enabler will allow hospital to maximize the integration of system utilization and clinical workflows.Communication StrategyAn institutional communication strategy that outlines the audience, methods, tools and frequency of communication must be developed to improve institutional ownership.

Future State Design Guiding Principles


Timeline

Nov. 2009 Presentations by 2 Vendors

Jan-March. 2010 Site visits to nearby Hospital using each system

July 2010 Contract signed with Vendor

January May 2011 Current / Future State Design Sessions

August 2011 Present Physicians Advisory Group Meetings

June 2012: Go-Live!


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Site Visits

Two hospitals with similar demographics

Community hospital with residency programs

Bed size, service lines, patient population

Evaluation Team

HIM (VP HIM, EMR Manager, Coding Director)

IT (CIO, Network specialist)

Financial (VP Finance and staff)

Medical Staff (President of Med. Staff, Physician champion)


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Site Visit Itinerary

Presentation by Hospitals CMIO

Divide and Conquer:

Medical Team: Floors, ICU, ED, Ambulatory Clinic

IT Team: IT dept., floors

Finance: Administration, Billing/Coding

Coding: HIM department, Billing/coding


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Core Build

Extensive work effort to establish the pharmacy formulary

Order sets Diagnosis Based

Core measures (VTE assessment, time to treatment, etc.)

Meaningful use measures

Convenience

Congruent to Paper forms (for downtime episodes)

Communication / Workflows for ancillary processes

Respiratory therapy, Floor-obtained samples, Codes

Discharge Process


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Pharmacy Build

Have a pharmacy build that reflects:

Front-end needs, i.e.

Physician needs for ease of item selection and understanding of order guidance. Will you build brand name synonyms?

Nursing needs for clarity on the orders tab and eMAR

Back-end needs

Pharmacy needs consistency of build and a full view of the medications ordered and access to the patients clinical picture

TEST each item from order entry, to dispensing and delivering, to display on the orders tab and eMAR, to medication administration


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Downtime Plans

Have firm downtime plans and tools well before Go-Live

Devise a method of running reports in the background that can be printed on demand in advance for a planned downtime, and just in time for an unplanned downtime

Patient list by location

Orders report with all active, on hold, suspended orders

MAR with a list of all medications administered within the prior 48 hours, with a list of all tasks for the next 24 hours


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Downtime Plans

Create a Meaningful Use Checklist

Ensure all MU measures during downtime are correctly entered during recovery period (backfill)

Strongly consider building a redundant database on a local server to be viewable during downtimes/no internet access


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Training

No amount of training is too much!!

Combination of delivery methods to account for differences in end-user preferences and schedules

Live, classroom-based sessions (at hospital or office)

Web-Based Training Modules (auto-tutorial)

Remote webinar sessions

One-on-one


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Superusers

Essential to have key team members receive extra training and practice with the system

Creates a cadre of first-line support at the unit level during Go-Live and thereafter

Improves end-user acceptance, they serve as ambassadors of the EMR team

Helps identify issues in the system earlier in the process (these people know what works and what wont work!)


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Preparing for Go-Live

Big-Bang vs. Phased Approach

Entire House or Unit by Unit

Central Command Center

Embed IT and EMR support personnel throughout the building

Superusers, hospital IT/EMR staff, vendor support

Deploy more staff in busier or more critical units

Two weeks minimum, 24/7


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Activation

Telephone Support Center

Have the Informatics team (Level 2 Help Desk) and the IT team (Level 1 Help Desk) share a Telephone Support Center where they handle calls from the users during Go-Live. It will pay off later with increased knowledge and compassion on both sides later

Keep detailed logs of all issues (as well as their solutions)


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Allow for Decreased Productivity

Overstaff units (especially ED, ICU, OR, other critical areas of the hospital

Consider Go-Live on a weekend, to avoid elective surgeries and imaging procedures (although ED may be busier)

If a weekday, reschedule as many elective procedures as possible


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Questions?


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Inpatient Documentation of Home Meds List

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Provider sees

patient

before RN

assessment

Have home meds

been documented

in Rx Writer?

Validate list

with patient

Perform Copy

from Rx Writer

function

Add last dose date

& time info for

home meds

Nurse interviews

patient before

provider

assessment

Add home

meds to

patient profile

in Rx Writer

End

Continue with

Admission

Reconciliation

process

No

Yes

MD option

The height of the text box and its associated line increases or decreases as you add text. To change the width of the comment, drag the side handle.

Inpatient Documentation of Home Meds List

Nurse

Provider

Either Clinician

Provider sees patient before RN assessment

Have home meds been documented in Rx Writer?

Validate list with patient

Perform Copy from Rx Writer function

Add last dose date & time info for home meds

Nurse interviews patient before provider assessment

Add home meds to patient profile in Rx Writer

End

Continue with Admission Reconciliation process

No

Yes

MD option

Documents

Hospital EMR's: Getting it Right the First Time