Implementing EHRImplementing EHRA best practices guide to implementing EHR

A Lecture to U�LV School of Public Health

For Tip Ghosh

4/6/2006

By James Muir

EHRs are Big ProjectsEHRs are Big Projects

“A group can’t just go out and buy

an EHR – the acquisition of an EHR

is not the same as buying software

from the local computer store and from the local computer store and

implementing it out of the box.

Adopting EHR functionality involves

many steps and much planning.”

– Margret K. Amatayakul

Before Starting Your ProjectBefore Starting Your Project

• You MUST have buy-in from all key

stakeholders

– Executive Management

– Physicians & Care-givers

Creating Your EHR Project TeamCreating Your EHR Project Team

• Who needs to be on the team?

– All key stakeholders

– Physician Champion(s)

– Executive Champion

– Project Manager*

– Content expert/developer*

– IS team

• Plan to hire talent for your project

Executive LeadershipExecutive Leadership

• For practices larger than 10 providers executive leadership support is the single biggest success factor.

• “Most organizations with exemplary implementations of EHRs indicate that wheras lack of physician support is the single point of failure, executive management support is the most critical success factor.” – Margret K. Amatayakul

• Executive Leadership Responsibilities• Executive Leadership Responsibilities– Assure goals are defined and communicated in advance of the project

– Create alignment amongst all stakeholders

– Communicate consistently with all stakeholders

– Gain commitment from all stakeholders

– Maintain commitment to the project

– Advertise project successes

GoalsGoals

• Why they are critical– Focus – project is potentially overwhelming

• What to do first

• Scope creep

– Metrics for measuring success

• Did we succeed?

• How much success did we receive?• How much success did we receive?

• Balancing goals from different parties

• Budgeting goals

• Used for assessing solutions– Ideally goals should be defined before assessing EHR solutions

How to define your EHR goalsHow to define your EHR goals• Collect issues & goals from all parties

– Both personal and professional

– Issues are move-away motivation

– Goals are move-toward motivation

• Group issues together

• Measure the impact of each issue or the upside of each goal– Some thing can be measured easily some are less so

• Hard measurements (time, money, counts)

• Soft measurements (quality, satisfaction, risk)

• Do Workflow & Process Analysis

• SWOT Analysis• SWOT Analysis– Strengths, Weaknesses, Opportunities, Threats

• Be Practical & Realistic

• Prioritize– Focus on what will have the greatest impact on the organization

• Determine the scope– How much can you do?

– Chunking

• Target dates

• Communicate your goals to everyone– Create a goals (scope) document

Workflow AnalysisWorkflow Analysis

• Define existing workflow & processes

“Workflow analysis is becoming one of the most critical steps in integrating information systems and moving toward the EHR. … E&M coding support through the EHR should yield significant benefits in cash flow, time savings, collection fees and revenue optimization. These benefits are achieved, however, only if steps are taken to ensure that the work flows and processes to support them are in place.” work flows and processes to support them are in place.”

– Margret K. Amatayakul

• Involve all stakeholders in workflow development

• Re-engineer new workflows with EHR in mind

– SIDEBAR - Why tasking and workflow in EHRs is critical

• Reassess goals based on Workflow analysis

Walker’s Fourth Law of InformaticsWalker’s Fourth Law of Informatics

FOURTH LAW: “Everyone want to use the

EHR to make someone else do something.”

Evaluating & Selecting a VendorEvaluating & Selecting a Vendor

• Create a scorecard based on your goals

• Focus –

– features are interesting, and you will get to

them, but first things firstthem, but first things first

Organizational

Issues

Organizational

IssuesIssuesIssues

Pre-Kickoff Meeting(s)Pre-Kickoff Meeting(s)• Review project goals (scope document)

• Create responsibilities document

• Review implementation and goals timeline

• Determine who the super-users will be

• Define project team(s)

• Develop implementation plan & project schedule

• Governance– Include key stakeholders– Include key stakeholders

– Determine how decisions will be made

– Decide who issues will be escalated to

• Develop training schedule

• Develop communications plan

• Create Project Orientation Materials for Kickoff Meeting– Project Goals (scope document)

– Org chart showing responsibilities

– Description of which person each type of question should be directed to

– Contact information for everyone involved

• Revise policies and procedures manual at this time

Kickoff MeetingKickoff Meeting

• Present the goals (scope document) to all

practice personnel

• Present the responsibilities document to

all practice personnelall practice personnel

• Demonstrate the EHR to all practice

personnel

• Identify any additional issues that are

uncovered by practice personnel

EHR Team MeetingsEHR Team Meetings

• If warranted by your size meet weekly to

– Identify issues

– Elicit input from the practice

– Plan solutions– Plan solutions

– Plan what will be communicated to the clinic

Pre Go-live TasksPre Go-live Tasks

• Enter each providers preferences

–SIGs, ICD9s, Chief Complaints, Etc.

• Complete Go-live checklist*

• Dress rehearsals • Dress rehearsals

Pre Go-live meetingPre Go-live meeting

• For the target site, pod, provider, etc.

• Reduces anxiety before go-live

• Review progress and successes so far

• Collect and address concerns to the • Collect and address concerns to the

implementation

• Will prevent postponement

Implementation

Issues

Implementation

IssuesIssuesIssues

Work out interfacesWork out interfaces

• Practice Management

• Lab

• Diagnostics

• Devices

• Hospital

• ePrescribing

Testing of InterfacesTesting of Interfaces

• Some interfaces must be implemented at go-live

– Practice Management

• Desirable (but not required) at go-live

– Lab

• Backloading Lab Data• Backloading Lab Data

– Diagnostics

– Devices

– Hospital

– ePrescribing

Testing of the Knowledge-baseTesting of the Knowledge-base

• Enter 30-40 charts before presenting it

to the doctor

– Learn how the EHR works

• (so you can describe it to the doctor)

– Learn how the doctor does things– Learn how the doctor does things

– Learn what is missing that the doctor likes

to include

– Learn what is going to slow the doctor down

Clinical ContentClinical Content

• Create a Clinical Advisory Team

• Decide how clinical content will be added /

modified

• Dedicate a content expert/developer

• Incorporate the feedback loop• Incorporate the feedback loop

Chart AbstractionChart Abstraction

•Manual

•Scan

EHR

•Scan

•Electronic– Import Text

• RTF File Monitor

– Parse

The Dynamics of Chart AbstractionThe Dynamics of Chart Abstraction

• Scanning– Lower HR getting in

– Longer time for provider to review

– Some technology can be applied (bar coding)

– Need may diminish over time• Some Specialists

• Primary Care

• Manual– Higher initial HR costs– Higher initial HR costs

– Shorter time for provider to review

– Need will diminish over time

• Electronic– Web Portal

– Patient Kiosk

– DocuScan

– Conversion• Dictation

• Detail

What to abstract?What to abstract?

• Allergies

• Problems

• Medications

• Medical history• Medical history

• Family History

• Social History

• Lab Results

ImplementationImplementation

Implementation ApproachesImplementation Approaches• Big Bang

– Faster payoff

– More challenging to learn

– Smaller group

– Forced to because converting form an existing EMR

– More planning

– More change

– More stress on certain staff

• Incremental• Incremental– More gradual payoff

– Easier to learn

– Required by larger organizations

– Differing workflow issues for staff

• Logical Divisions of Focus for Incremental EHR Rollout– Access

– Workflow, Messaging, Results review

– Order entry & documentation, Decision Support

TrainingTraining• Use your own trainers with a Train the Trainer approach

• Adults measure their learning by competencies gained, not by seat-time– Competency-based training is best

• Decreased employee time spent training

• Increases trainer availability

• Self-paced learning– eLearning

– Help desk• Question tracking

• Feedback loop• Feedback loop

• Combine classroom and self-paced learning

• Determine training needs– What are the best times for training?

– Should various caregiver types (e.g. physicians, admin, other) be trained together or separately?

– What are appropriate training scenarios (and other content)?

– Who may need special help with training?

– Should you consider reducing patient load for some providers?

Training (continued)Training (continued)

• Timing– To be effective training needs to be JIT (just in time)

• Week or two before go-live

• Justification– Try and include “why” things are done instead of just “how”

• Content– Create modular training content

– Scaled repetition

– Physician Training Example• Phase I – 6 scaled repetition encounters• Phase I – 6 scaled repetition encounters

• Phase II – Practice more comprehensive test notes

• Phase III – Document their own notes (the 30-40 used for testing the KB)

• Phase IV – Document their own notes (that have not been tested)

• Go-Live Shadowing (see separate slide)

• Follow-up training– Communications

– Shadowing

– Classroom

– Self-paced

The Dynamics of ShadowingThe Dynamics of Shadowing

• Why Shadowing is the best training practice– Confidence – real-time support

– Immediate feedback

– Beginning of the improvement cycle

• How it works– Help physicians remember where everything is

– Documenting provider use of safety-nets• Appropriate use

• Forgotten from training

• Shortcoming of the knowledge-base– Feedback loop*– Feedback loop*

• Logistics– 1 on 1 shadowing or 3 support personnel for one pod

– 1 on 1 shadowing in the exam room for 20-60 encounters for Physicians

– 1 on 1 shadowing in the exam room for 10-15 encounters for MAs

– Super-user provides on-site support for 1-2 weeks after go-live

• Bodies – the limiting constraint

• Follow-up shadowing– Observe

– Retrain

– Feedback loop

Training Approach EffectivenessTraining Approach Effectiveness

On-SiteOn-Site Personal TrainingOn-Site Group Training

Sweet Spot

Off-Site

Group Training Personal Training

Off-Site Personal Training

Off-Site Group Training

Computer-based Training

Manual-based Training

Go-live – What to expectGo-live – What to expect

• From the first patient the physician knows the

system

• The physician does little or no typing

• Will gain efficiency after 20-60 patients

• After 4-12 weeks (900 encounters) point & • After 4-12 weeks (900 encounters) point &

click method of documentation becomes very

fast

Strategies for Retiring the ChartStrategies for Retiring the Chart

• Give the provider the chart for

two visits

–Sticker method

–Marker method–Marker method

–Note method

Post Go-live SupportPost Go-live Support

• Shadowing

• Make EHR a standing agenda item at meetings

• Have regularly scheduled post EHR training

– Start about 3 months after go-live

– For Providers

– For Clinical support– For Clinical support

– Have attendees prepare questions and suggest changes

• Keep communicating milestones and successes to

everyone

Is it possible to go-live without

seeing less patients?

Is it possible to go-live without

seeing less patients?

• Yes, if that is your goal

–Time takes precedence over EHR

–Multiple Strategies

• Scaling

Top 10 EHR Implementation MistakesTop 10 EHR Implementation Mistakes

1. Proceeding without executive support

2. Skipping the goals process or setting unrealistic goals

3. Trying to do too much at once (or too soon)

4. Underestimating the total cost / opportunity cost

5. Simply piling EHR project management responsibilities onto existing staff responsibilities

– �ot having an internal project manger– �ot having an internal project manger

– �ot having a content expert / developer

6. Skimping on training & implementation

7. Expecting the vendor to do everything

8. �ot communicating

9. �ot testing the knowledgebase

10. Implementing EHR at the same time as Practice Management

Top EHR Implementation

Best Practices

Top EHR Implementation

Best Practices

You just heard many of them

TipsTips• Use Incremental training process

• Shadow providers, observer, create feedback loop

• Test the vendors knowledge base by entering 30-40 actual charts (for each provider) before you present it to the doctor.

• Define preference lists for providers before go-live– Medications

– SIGs

– ICD9s

– Chief Complaints

– Etc.

• Let patients know you are transitioning to computerized patient records– Letters

– Posters

– Brochures

– News Media

– Face to face– Face to face

• Publish your practical EHR tips in a document or on your internal web site and send them out every two weeks or so

• Attend your vendors user group meetings

• Complete all training and self-paced learning

• Keep go-live groups modular [reword]

• Don’t schedule go-live during peak season

• Get computer training before training for those not as computer literate [reword]

• Have as many super-users as possible

• Celebrate small victories

• Create three EMR environments – Demo, Test & Production

• Be 100% committed

• Provide your project manager all the resources they need to succeed

• Don’t under-resource your technology

• The IT staff cannot do everything. IT is just one of the skill sets required for successful implementation