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Case Study The Yale New Haven Integrated
EMR Experience
Daniel BarchiCIO
Yale New Haven Health System
Yale School of Medicine
2006 - 2010
400 Employed Physicians
7 Hospitals – 1,100 beds
2010 – 2013
1,000 Employed Physicians
150 Community Physicians
3 Hospitals – 1,900 beds
Varying Standards
Varying Applications
Duplication
• PACS (2.5) – Fuji a, Fuji b, DR Systems• Lab (3) - Soft, Cerner, Meditech• Bloodbank (3) - Hemocare, Cerner, Meditech• Dietary (3) – Healthtouch, CBord, Picis • Document Imaging (4) - ImageNow, 3M
ChartScan, Lynx, McKesson HPF• Bed/Patient Tracking (5) – Firstnet, Premise
BMD, Allscripts SCM/SDK, Navicare, Teletracking
Journey
83 Distinct Clinical / Operational Areas(Bed Management, Physician Credentialing, Pathology)
Journey
83 Distinct Clinical / Operational Areas(Bed Management, Physician Credentialing, Pathology)
2010 192 Applications
Journey
83 Distinct Clinical / Operational Areas(Bed Management, Physician Credentialing, Pathology)
2010 192 Applications
2012 160 Applications
Journey
83 Distinct Clinical / Operational Areas(Bed Management, Physician Credentialing, Pathology)
2010 192 Applications
2012 160 Applications
9/12 203 Applications
An EMR is a tool
An EMR is a tool
Transformation is:
Development of an integrated EMR
Outcomes of implementing an integrated EMR
Transformation
Development of an EMR
• Is not an IT project
• Demands collaboration
• Forces examination of current practice
• Requires standardization
Transformation
Outcomes of an integrated EMR
• Patient data across the continuum of care
• Evidence-based orders and workflows
• Metrics and benchmarked reporting
• Improved office workflow• Results• Referrals
Transformation: Defined Common Standards
Training
Documentation
Order Sets
Specialty Practice
PharmacyOR
ED
Imaging
LabInpatient Care
875
3M Coding
Siemens Invision
Lawson
Sybase Integration
Engine
125, 135, 219, 223, 245, 760, 594, 676, 765, 1029, 1039, 1093, 1095
780, 805, 808, 814, 816, 830, 837, 842, 844, 849, 856, 858, 860, 862, 864 866, 900, 907, 915, 927, 935, 955, 962, 970, 976, 992, 1000, 1005
840
839
20
Misys Vision
1 of 2
850, 10151020
155864
612, 620624, 639
641
127, 170 185, 221695, 866
1026
145,146,147148,149 150152,153,154,155,158,159
160
915
158, 641, 970
962
808
730
390
CPSI2 of 2
95, 126, 154, 220266, 862
1025 263, 556, 558,562, 564, 568,
570, 572, 582, 594, 596, 583, 597,604
500
1036
VariousDatasets
PerSe1 of 3
TSG Application Interface Chart
725
1070995950
FinancialServices
Restricted WebSite
Planning& Budget
FinancialSupport
Softmed2 of 2
873
778843925 930
792, 800, 886, 890
825
826
878
McKesson Horizon
(Pathways)
760762765
Updated: December 1, 2006TOTAL Number of Interfaces: 509
75
975
149842
660, 662674, 676682, 666668, 670
677
810
626628
161
35, 133148, 520,564, 624
670
121, 132,515, 562
1091
410 402
405
Sovera PFS1 of 2
632640
600
960
206
622
689
920
175
Datis
812
1040
1050
HBOREV3
HBO-CDM
SiemensFinancial
RMHIS
Softwise
530
DynamedixGenesys
Hyperion
Trendstar
KRONOS
OneStaff
Sanitas
RescueNet
Medicaid
HQM
SSI 2 of 3
Medicare
MedQuestTranscription
SoveraHIM2 of 3
Novius Radiology
PACS(IMPAX)180
660510, 515,
520
FACS1 of 2
WellsoftEDIS
159,263,189,604,
682,1000,1027
184837
Pyxis1 of 2
Eclipsys EMPI1 of 2
180, 181183, 184185, 186 187, 189
147, 201620, 814
Credit Card
Payment
Coro-metics
Fetal Mon.
Siemens Pharmacy
1 or 2
CPSI1 of 2
GECentricity
Pillbox
CTVision
SSI1 of 3
Antrim MisysLab
Sovera HIM1 of 3
1030
CoPath
140
560130. 131 132, 133134, 135136, 137138, 139141, 142
265
GE CardiologyMUSE
183
755
710
965971
Rauland Borg - Nurse Call
900
415OASIS
SunTrust
1045
592 MAK
639 955
SiemensSoarian
1 of 2
136186596677927
1105102510261027
207, 210
SCA
735 1035
Internal Audit 846
225
PaWS
1110
SoveraPFS2 of 2
MEMSRosebud
540860
25702
704
GEORIS
NC AVAYANC CRMH
720722
Common Master Tool Kit
GroupWise
120, 121, 123 124, 125, 126
127, 128
123
PharmacyOneSource
876
10901091109310951105
PowerScribe
674
Delta Dential375
Automated Mailing Service
100
164
FACS2 of 2
162
Various Clients & Web 212
215
68
Atlas Labworks
HEDIS
130, 260556,
134568
240
Wachovia 401
SHPS400
Sovera HIM3 of 3
638
OmniCell
685
PerSe2 o f 3672
750
777
Quantum Med
CarePort
120, 131,145181, 200, 510, 558, 612 662,
780, 1090,1075
Teletracking992
580VA
Medical680
35
90 95
Intergual124,849
150
Harford
DecisionSupport
PR Dept
377
693
397399
695
586
Dublin Family Practice
666
Pyxis2 of 2
716
IDSCarousel
714
HEDISDB
Internet WebSites
870, 795, 820, 770, 848, 776
ComputritionDietary
805
IMPAC844
907
65
PaWS2 of 2
708
Anthem
50
55
151
153858
245
Digisonic170668
250
Eclipsys EMPI2 of 2
188
220221222
Lab Outreach
eMPI Helper
260
200201
softmed1 of 2
1871029
Health Stream 380
LabPort266
394
SSI3 of 3
505
572138, 90
128, 139265, 582
MS4650
678
712
eDischarge
LBS142583
146816
Xtend160
1005
137, 935597, 762
Professional Research
Professional Billing
880
882
Soarian2 of 2
1028
1078
VA Dept Health
1077
10751078
PowerCampus
387
PerSe3 of 3
630
LabCorp
262
156205217
235
Quantum Billing
141Various
Websites
Anthem
Centricity
379
374
396
b2b Vision
CASB 616, 618
610
CASB-FS
CCL&PA
NCHS
785
790
865
B2b Optma
230
Interfaces not on diagram: 103, 105, 110, 195, 196, 525, 550, 584,
636, 687, 692, 700, 1041, 1112
223Lawson2 0f 2
Paitent Keeper
102
MDAssociates152856
838
223
625
222
1038
Vision 2 or 2
997
GE Centricity Cardiology
218219
Trendstar 2 of 2
643
WellsoftEDIS2 or 2
1094
642
830
157
Pharmacy2 of 2
761
976
1039
BPI.net101
779
Total Interfaces: 509
MPIInterface Engine
Home grown apps: non Cerner 1. You Make a Difference 2. MyNetwork (Resident Sign
Out form & Physician Note taking App)
Kronos
AthenaNet (Mill Hill)
GE: Centricity, QS, Ecin
Smar t-web
Lawson
SDK
Instr. MDI
Rad Net
Path-Net
First Net
Surgi-Net
Pharm Net
Scheduling
CERNER
OCF PowerChart
Home grown apps: 1. RIMS 2. CARE
Softmed
Xcelera (Echo)
Pyxis
Muse
Quest
Dictaphone
Lab & Rad results MD link
HealthFacts
Cmore
View Point
Dietary– Health Touch
* All interfaces route through e-link at YNHHS
E clinical works
Lab results
ADT Copath Path/Cyto results
Bed tracking ADT
Ad Rad Eclipsys
MRI results
DR PACS Orders
ADT ACI
Charges: Lab/ Rad/Pharm/Resp
Orders Reports Status
ADT Transcribed Docs
Tran
scrib
ed D
ocs
Orders Lab Results
UB Data Lab results/Pharm orders
Orders ADT Dispense/Med loads
ADT EKG results
ADT Endo results
ADT Echo results
ADT
ADT
ADT
Linx Printed/Faxed
ADT
Home grown apps: 1. Charge reconciliation 2. SurgiNet Schedules 3. Blood Bank History 4. Downtime Reports
Manually entered charges
Manually entered charges
Manually entered charges
Miscellaneous
Interface Engine
InterfaceEngine
SDK
PYXIS
7000
HubLink
7000
HubLink
7000
RP
ORIS
3M
A
A
R
AA
PYXIS
Cerner(Classic)
$A
$
A
ORIS
EPIC
SoftMed
Logician
IDX (YSM)
CoPath
Pceis
ACI
SoftMed
PACS
3M
OCF(Classic)
CDR
JRS
A
A
R
A
R
AA
A
A
A
A
R
A
AR
A, $
A, $
A
A
A
OMNI$
$
$R
DataPrep
DI
LabMed
R
R
$
$
$
MUSE
ComuSenc(MillHill)
DictaPhone
SurgiNet
$$
$
$
$
$
$
$$
$
AVOID
R
$
MicroBio
Billing - ($)
Under Development
BpH YNHH
O
Endoscopy
$
$
$
09/27/1011:50 VisioDocument
R
R
Cardiology
$
Results / Orders(R)
Hublink to SDK - (A)
HubLink from SDK - (A)
"On the Move" - (A)
A
Core Matrix
Fetal Monitor
A
Cerner(Millenium)
OCF-A
OCF-R
$
O
O
OCF-R
P
Phyn (P)
DRG & APCGrouper
APC Grouper +
IDXLink
IMNET Dietary Orders Pharmacy Nurse Dept. DILabMedADT
HEALTHvision EPIOH Test
GH
HS
EPI - ADT
ORIS
7000
Healthvision
Advantix
AA
IDX to SDK (A)
LabMed
DI
Co-Path
ClaimMaster
A
Integrated EMR Benefits
After Action Report
After Action Report
Goods
After Action Report
Goods
“Others”
Lesson Learned: Scope and Quality
• System latency (ms)• Network throughput (Mb/sec)• Cumulative Downtime (minutes/year)
• Hospital Acquired Infections (% of admissions)• Expected Mortality (1.0 scale)
• Infection – Morbidity – Mortality - Errors
• No Acceptable error rate – from the public’s perception, zero is the benchmark
• How do you openly address issues of quality when no deviation is acceptable?
Lesson Learned: Scope and Quality
Product Acceptable Contamination Levels
Fewer than 4 rodent hairs per 100 grams
Fewer than 5 (average) whole insects per 100 grams
Fewer than 1250 insect fragments per 10 grams
Fewer than 5 rodent hairs per 5 grams
Lessons Learned: EMR Scope
It’s all in, unless it’s out• Inpatient Physician and Nursing Documentation• Emergency Department • Surgery / OR• CPOE• Radiology• Outpatient Physician and Nursing Documentation• Bedside Medication Authentication
Rew
ard
Risk
Lessons Learned: EMR Scope
Lessons Learned: Existing Technology
Lessons Learned: Existing Technology
Lessons Learned: Existing Technology
Lessons Learned: Existing Technology
Lessons Learned: Leadership
Lessons Learned: Leadership
Lessons Learned: Leadership
Lessons Learned: Leadership
Lessons Learned: Leadership
Lessons Learned: Leadership
Lessons Learned: Leadership
“If you do not complete your EMR training and receive your password to access the system by July 26 you will not be prepared to care for patients. Should this happen, I will take your decision to not be trained as a voluntary resignation from the organized medical staff.”
Lessons Learned: Leadership
Lessons Learned: Aggressive Schedule
Lessons Learned: Aggressive Schedule
Benefits:• Reduces debate• Demands intense collaboration• Delivers results more quickly• Demands more participation from
clinical customers• Accomplishes the most difficult work
early in the project
Lessons Learned: Aggressive Schedule
In 18 Months
- Consolidated 1,000 + order sets into 300
- Drove 90%+ CPOE
- Mandatated full EMR use
- Developed full clinical content
• Medical Records (HIM) Committee• Integrated nursing leadership – CNO Council• Physician Advisory Group (PAG)• Pharmacy Advisory Council (PhAC)• Policy Standardization Committee• Formulary Integration Committee• Revenue cycle standardization• Laboratory Leadership Advisory Group• CPM Documentation Standards Group
Lessons Learned: Standardization
EMR as a transformational tool
Preliminary Key Decisions/Questions
1. Defined protocols, orders, standing orders with authentication, and standing orders without authentication (Protocol Team)
2. All blood orders will include a Transfusion Reaction Workup Protocol so the nurse or blood bank can initiate the workup based on symptom criteria for transfusion reaction (Blood Administration Team)
3. ED patients held for observation in the ED Behavioral Health area (sometimes 3-4 days) or Cardiac area are only billed for the ED charge. Investigate processing these patients as observation (< 24 hours or admission > than 24 hours) and receiving that revenue? (ED Inpatient Admission & Disposition Team)
4. To decrease cost of unnecessary ICU days and manage beds better, community physicians can admit and care for patients in the ICU but decisions on whether to admit or discharge from the ICU should rest with the Intensivist on duty. (Inpatient Handoffs Team)
Integrated EMR Benefits
Lessons Learned: Optimization
Pre-work
80% of customization is wasted
Lessons Learned: Optimization
Pre-work
80% of customization is wasted
Post go-live
95% of support adds value
Lessons Learned: The Team
“It’s my job”
Not my job
Not my job
Lessons Learned: Celebration
Lessons Learned: Celebration
Lessons Learned: Celebration
Lessons Learned: Celebration
Although the general consensus is that the implementation of CIS-Epic went more smoothly than expected, the first few days have not been without challenges: physician access and log-in problems, difficulties with writing orders and discharging patients, use of computers on wheels (COWs), Pyxis, Centricity, OpTime, Teletracker and barcode scanning.
Almost all of the highest priority issues were resolved in the first five days, while other issues, including the patient discharge process and OpTime functionality, continue to be actively addressed.
As we approach the end of month three of our go-live the Clinical Transformation Governance Group, leadership team, and Clinical Transformation team together with our partners from Epic acknowledge the ongoing challenges and difficulties we are experiencing transitioning to our new EHR. We are committed to improving our configuration so that it meets our needs.
Epic has been on-site this week and coupled with feedback we have received from the survey we are developing both immediate fixes and longer term fixes. Epic has also established an incident command in Wisconsin to assist our team in working through the multiple incidents that remain outstanding.
We also want to take the opportunity to address some rumors: this is the full, current version of Epic - not a discounted one.
We collaborated with Epic to determine the strategy for implementation. We followed their guidance to implement as fast as possible then stabilize/optimize. All of us are committed to following through on our plan.
As we approach the end of month three of our go-live the Clinical Transformation Governance Group, leadership team, and Clinical Transformation team together with our partners from Epic acknowledge the ongoing challenges and difficulties we are experiencing transitioning to our new EHR. We are committed to improving our configuration so that it meets our needs.
Epic has been on-site this week and coupled with feedback we have received from the survey we are developing both immediate fixes and longer term fixes. Epic has also established an incident command in Wisconsin to assist our team in working through the multiple incidents that remain outstanding.
We also want to take the opportunity to address some rumors: this is the full, current version of Epic - not a discounted one.
We collaborated with Epic to determine the strategy for implementation. We followed their guidance to implement as fast as possible then stabilize/optimize. All of us are committed to following through on our plan.
Lessons Learned: Celebration
Lessons Learned: Trust the Process
Pre-Epic July 1-25 79no valid data
Post-Epic Aug 15-31 67Sep 1-28 74
95.7198.1397.1798.6599.4199.4399.37
0
10
20
30
40
50
60
70
80
90
100
Stat Medication TurnaroundTarget: 15 Minutes
% S
ucc
ess
CPOE
Late Chart Sign-Off
80
ACO Diabetes Pilot Program - Dashboard
81
Diabetes Registry – Metrics
82
ACO Diabetes Pilot Program – drill-down
83
Thank you
Daniel Barchi
(o) 203.688.1881
(m) 203.506.7309
