Hospital EMR's: Getting it Right the First Time

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PowerPoint PresentationHospital EMRs: Getting it Right the First TimeThomas G. Zimmerman, DO, FACOFP, CPHIMSSouth Nassau Communities HospitalOceanside, NY1Hospital Demographics440-bed community hospital in suburb of NYC1023 Medical Staff850 Physicians (of which 75 are hospital-employed)3000 Employees 720 RNsDually-Accredited Family Medicine Residency (18)Visiting Residents (OB, Surgery, Peds total 18) Thomas Zimmerman, DO, FACOFP, CPHIMS2Do your homework!!Thoroughly evaluate the projects feasibilityPreliminary architecture and design specificationsInformed consent of all stakeholdersConsider the financial impact of the project (as well as work-hours involved)Complete EHR, or phased approachPhase 1 Orders and ResultsPhase 2 Clinical Documentation Thomas Zimmerman, DO, FACOFP, CPHIMS3PlanningClarify Project Objectives and ScopeProposed TimelineCost and Quality objectivesScope of ProjectDeliverablesVerify that all stakeholders agree to these guidelines to avoid confusion, wasted effort or duplication, and/or project failure. Thomas Zimmerman, DO, FACOFP, CPHIMS4PlanningIdentify a single leader of the projectA 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 obstaclesSteering committee can serve as a resource to the project leader to discuss issues and find solutions Thomas Zimmerman, DO, FACOFP, CPHIMS5PlanningFull-Time Project ManagerDay to day management, execution, and delivery of the implementationReports to Project Sponsor / Steering CommitteeShould have experience with IT implementations Thomas Zimmerman, DO, FACOFP, CPHIMS6PlanningInterdisciplinary Implementation TeamsExecutive SponsorsDepartment or section leadersExperienced Subject Matter Experts (SMEs)Physicians, IT techs, EMR consultantsEnd-users with AND without IT experienceDepartment of Medical EducationResidents, students (of all types) Thomas Zimmerman, DO, FACOFP, CPHIMS7PlanningStrong Administrative Sponsorship and InvolvementEnsures that each implementation team (not just the Steering Committee) has the authority to make decisions that will stickExpresses the strong commitment of the hospital for this implementation (to the end-users)Ensures better communication and awareness Thomas Zimmerman, DO, FACOFP, CPHIMS8 Thomas Zimmerman, DO, FACOFP, CPHIMS9PlanningCore Analyst TeamHire 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 projectInterfacesLab / Rad / Dietary / AdmittingMake sure the time and costs for the development/testing/verification for all of these are appropriately accounted for in negotiations, contract, and scope Thomas Zimmerman, DO, FACOFP, CPHIMS10Identify RisksTechnical interface issues, equipment compatibility issues, delays in upgradesEnd 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!) Thomas Zimmerman, DO, FACOFP, CPHIMS11Question the VendorDont accept its hard coded or its working as intendedClinicians need to drive the train for patient safety Thomas Zimmerman, DO, FACOFP, CPHIMS12Staffing ConcernsClarify time commitments for staff members involved with the implementationIdentify times where their hours will need to be back-filled with other staff to meet daily operational needsIf activities will occur after work hours, consider what type of compensation will be provided Thomas Zimmerman, DO, FACOFP, CPHIMS13Review PoliciesPractice and policies will need to reflect the new world orderDont feel that you need to own the practice of the entire hospitalUsers will ask you to make the doctors and nurses do. Avoid the temptation! Thomas Zimmerman, DO, FACOFP, CPHIMS14RememberEveryone still needs to talkAvoid the illusion of communication that follows implementation of an EMR Thomas Zimmerman, DO, FACOFP, CPHIMS15ScopeDefine the scope of the project, and really think it throughIn-patient only?Out-patient areas?Ambulatory areas vs. Procedural areas?Consider areas that serve a combination of in-patients and out-patients Thomas Zimmerman, DO, FACOFP, CPHIMS16Scope (cont)Will you use niche products in areas such as:Cath LabLabor & Delivery SuiteORGeneral EMRs are a mile wide, and an inch deep while niche products are an inch wide and a mile deep Thomas Zimmerman, DO, FACOFP, CPHIMS17Create a detailed project planGantt Chart or Excel spreadsheetDocument all major outcomes/deliverablesTarget datesResponsible Sponsor / ResourcesApproximate work effortUpdate these tasks as they are completed or delayed/modified Thomas Zimmerman, DO, FACOFP, CPHIMS18Scope CreepThe expansion of the project to include additional products/functionalities not originally accounted for in the project plan and/or contractExtra Time / work effortExtra CostsIncreased complexity, confusion Thomas Zimmerman, DO, FACOFP, CPHIMS19Change ControlChanges to the original software are inevitable; the product must be tailored to suit the individual needs of your organizationBe prudent in making modifications to the core softwareDocument all changes in detail:Date of changeReason modification was neededExact description of the change (in case it needs to be restored after an upgrade) Thomas Zimmerman, DO, FACOFP, CPHIMS20Current State & Future State DesignAll stakeholders involved better design, more user acceptance/skillsIdentify 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 provideIdentify key issues / problems created by the EMRDocument the future state of operations clearly Thomas Zimmerman, DO, FACOFP, CPHIMS21Sample Workflow Diagram Thomas Zimmerman, DO, FACOFP, CPHIMS22Key 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 Thomas Zimmerman, DO, FACOFP, CPHIMS2324Key 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 Thomas Zimmerman, DO, FACOFP, CPHIMSTimelineNov. 2009 Presentations by 2 VendorsJan-March. 2010 Site visits to nearby Hospital using each systemJuly 2010 Contract signed with VendorJanuary May 2011 Current / Future State Design SessionsAugust 2011 Present Physicians Advisory Group MeetingsJune 2012: Go-Live! Thomas Zimmerman, DO, FACOFP, CPHIMS25Site VisitsTwo hospitals with similar demographicsCommunity hospital with residency programsBed size, service lines, patient populationEvaluation TeamHIM (VP HIM, EMR Manager, Coding Director)IT (CIO, Network specialist)Financial (VP Finance and staff)Medical Staff (President of Med. Staff, Physician champion) Thomas Zimmerman, DO, FACOFP, CPHIMS26Site Visit ItineraryPresentation by Hospitals CMIODivide and Conquer:Medical Team: Floors, ICU, ED, Ambulatory ClinicIT Team: IT dept., floorsFinance: Administration, Billing/CodingCoding: HIM department, Billing/coding Thomas Zimmerman, DO, FACOFP, CPHIMS27Core Build Extensive work effort to establish the pharmacy formularyOrder sets Diagnosis BasedCore measures (VTE assessment, time to treatment, etc.)Meaningful use measuresConvenienceCongruent to Paper forms (for downtime episodes)Communication / Workflows for ancillary processesRespiratory therapy, Floor-obtained samples, CodesDischarge Process Thomas Zimmerman, DO, FACOFP, CPHIMS2828Pharmacy BuildHave 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 eMARBack-end needs Pharmacy needs consistency of build and a full view of the medications ordered and access to the patients clinical pictureTEST each item from order entry, to dispensing and delivering, to display on the orders tab and eMAR, to medication administration Thomas Zimmerman, DO, FACOFP, CPHIMS29Downtime PlansHave firm downtime plans and tools well before Go-LiveDevise 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 downtimePatient list by locationOrders report with all active, on hold, suspended ordersMAR with a list of all medications administered within the prior 48 hours, with a list of all tasks for the next 24 hours Thomas Zimmerman, DO, FACOFP, CPHIMS30Downtime PlansCreate a Meaningful Use ChecklistEnsure 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 Thomas Zimmerman, DO, FACOFP, CPHIMS31TrainingNo amount of training is too much!!Combination of delivery methods to account for differences in end-user preferences and schedulesLive, classroom-based sessions (at hospital or office)Web-Based Training Modules (auto-tutorial)Remote webinar sessionsOne-on-one Thomas Zimmerman, DO, FACOFP, CPHIMS32SuperusersEssential to have key team members receive extra training and practice with the systemCreates a cadre of first-line support at the unit level during Go-Live and thereafterImproves end-user acceptance, they serve as ambassadors of the EMR teamHelps identify issues in the system earlier in the process (these people know what works and what wont work!) Thomas Zimmerman, DO, FACOFP, CPHIMS33Preparing for Go-LiveBig-Bang vs. Phased ApproachEntire House or Unit by UnitCentral Command CenterEmbed IT and EMR support personnel throughout the buildingSuperusers, hospital IT/EMR staff, vendor supportDeploy more staff in busier or more critical unitsTwo weeks minimum, 24/7 Thomas Zimmerman, DO, FACOFP, CPHIMS34ActivationTelephone Support CenterHave 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 laterKeep detailed logs of all issues (as well as their solutions) Thomas Zimmerman, DO, FACOFP, CPHIMS35Allow for Decreased ProductivityOverstaff units (especially ED, ICU, OR, other critical areas of the hospitalConsider 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 Thomas Zimmerman, DO, FACOFP, CPHIMS36Questions? Thomas Zimmerman, DO, FACOFP, CPHIMS37Inpatient Documentation of Home Meds ListEitherClinicianProviderNurseProvider sees patient before RN assessmentHave home meds been documented in Rx Writer?Validate list with patientPerform Copy from Rx Writer functionAdd last dose date & time info for home medsNurse interviews patient before provider assessmentAdd home meds to patient profile in Rx WriterEndContinue with Admission Reconciliation processNoYesMD optionThe 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 ListNurseProviderEither ClinicianProvider sees patient before RN assessmentHave home meds been documented in Rx Writer?Validate list with patientPerform Copy from Rx Writer functionAdd last dose date & time info for home medsNurse interviews patient before provider assessmentAdd home meds to patient profile in Rx WriterEndContinue with Admission Reconciliation processNoYesMD option