Allina Hospitals & Clinics EMR Implementation - · PDF fileExcellian Risk Management ... FACTS...

Allina Hospitals & Clinics EMR Implementation

AllinA Commons At midtown ExChAngE2925 Chicago Avenue, Minneapolis, MN 55407

One Patient. One Record.

©2007 Allina Health System.® Excellian® and the Excellian logo are registered trademarks of Allina Health System.

Kimberly Pederson Excellian Vice President

Jill Truitt Excellian Program Director

Andrew Mellin, MD Excellian Medical Director

Sharon Henry Director,

Clinical Decision Support

Susan Heichert Director,

Excellian Implementation

Kelly Nueske Director,

Excellian Risk Management

Kim Buhr Director,

Marketing & Communications

Todd Aldrich Director, Excellian Support

Phil Aarness Director, Excellian Training

Mary Lambert Director, Process Integration

Lana Scott Manager, Special Projects

Tammy Boyd Manager, Quality Assurance

Chris Hirsch IS Integration Manager

Sharon Bresnahan Manager, Excellian

Ambulatory and Clinical Support

Kelley Schneider Manager, Data Analysis

Contributors:

Allina Hospitals & Clinics Table of Contents

MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .01

EMR System Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .01

Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

FUNCTIONALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Target Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Information Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Clinical Decision Support Functionality . . . . . . . . . . . . . . .20

Workflow and Communications . . . . . . . . . . . . . . . . . . . . . . .23

Data Sharing With Other Organizations . . . . . . . . . . . . . . .25

Other Operational and Strategic Activities . . . . . . . . . . . . .25

User Satisfaction, Productivity and Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Scope and Design of EMR System . . . . . . . . . . . . . . . . . . . .28

Security and Data Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

VALUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Success in Meeting Expectations of the Project Goals, Business Case, and Targeted Processes . . . . . . . . .34

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

APPENDIX

Allina Hospitals & Clinics MANAGEMENT

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FACTS AND FIGURES — Allina Hospitals & Clinics

$2,216,572,000 NetOperating Revenue

8.1 million lab tests performed

2.6 million clinic visits (including HBCs)

799,925 hospital outpatient visits

679,281 prescriptions filled

220,483 emergency care visits

170,365 medical equipment orders filled

103,171 inpatient hospital admissions

55,138 outpatient surgeries

39,613 ambulance transports

32,610 inpatient surgeries

22,590 employees

15,161 newborn deliveries

1,677 staffed hospital beds

52,702 hospice visits

MANAGEMENT1. EmR systEm PlAnning

OVERVIEW OF THE ORGANIZATIONAllina Hospitals & Clinics is a not-for-profit integrated delivery system of hospitals, clinics and other health care services . Our nearly 23,000 employees, 5,000 physicians and 2,500 volunteers are dedicated to meeting the lifelong health care needs of communities throughout Minnesota and western Wisconsin .

The number of sites, the sharing of patient records among those sites and the breadth of software being implemented make Allina’s electronic medical record and revenue cycle system, called Excellian, one of the largest, most integrated systems in the country . As of May 2007, 65 clinics and eight of Allina’s 11 hospitals, (including Allina’s four metro hospitals) are using Excellian . Three smaller Allina hospitals will implement Excellian following a software upgrade scheduled for 2008, bringing the total number of Allina hospitals using Excellian to 11 .

Entity Figures Types of Services

AbbottNorthwesternHospitalMinneapolis, MN

Phillips EyeInstitute*Minneapolis, MN

United HospitalSt. Paul, MN

Buffalo HospitalBuffalo, MN

CambridgeMedical Center*Cambridge, MN

New UlmMedical CenterNew Ulm, MN

River FallsArea HospitalRiver Falls, WI

St FrancisRegionalMedical CenterShakopee, MN

OwatonnaHospital*Owatonna, MN

Allina MedicalClinics (AMC) 65 locations in MN

Mercy & UnityHospitalsCoon Rapids and Fridley, MN

$696,175M net revenue5,200 employees 1,649 physicians

38,511 inpatient admissions 245,017 outpatient admissions621 beds

3700+ employees and 842 physicians

MERCY$267,387M net revenue19,302 inpatient admissions95,599 outpatient admissions271 beds

$26,397M net revenue168 Employees179 physicians

UNITY$157,911M net revenue12,769 inpatient admissions68,741 outpatient admissions275 beds

15,861 outpatient admissions453 inpatient admissions20 beds

Complete medical, surgical and critical care for patients from age 12 to older adults; 24-hour emergency services; multi-specialty care and clinical expertise in behavioral health, cardiovascular services, medical/surgical services, neuroscience, oncology, orthopedics, rehabilitation, spine care and women’s health; outpatient care in more than 50 different specialty areas.

Emergency services, Bariatric and weight loss center, behavioral health, breast care program, women’s and children’s services cancer center, cardiac centers, diagnostic imaging, rehab services, orthopedic and neuroscience.

Diagnosis and treatment of eye problems, inpatient care, eye care for children, LASIK Surgery, and Vision Rehabilitation.

$382,792M net revenue3,300 employees1,400 physicians

27,402 inpatient admissions99,394 outpatient admissions553 beds

Bariatric surgery, birth center, cancer care, day surgery, emergency services, integrative therapies, heart hospital, neuroscience center, radiology, menopause center, psychiatry and behavioral health, rehab, eye surgery center, accident and injury clinic, and vascular center.

$40,395M net revenue415 employees180+ physicians


Emergency services, intensive coronary care, oncology and urgent care, specialty services, including Birth Center, Cardiac Center, Sleep Center, and the Sister Kenny Rehabilitation Institute.

$105,360M net revenue1,130+ employees50+ providers


Clinic services, behavioral health, emergency services, eye care, Breast Feeding Clinic, radiology, surgery, therapy and rehab services, and respiratory care.

$51,406M net revenue504 employees40 physicians

2,387 inpatient admissions68,609 outpatient encounters48 beds

Emergency services, renal dialysis, respiratory therapy, chemotherapy, birth center, surgery center, mental health, and substance abuse.



Diagnostic services, emergency services, heart care, homecare and hospice, The Birth Center, The Sleep Center, and Sports Medicine Rehabilitation and Wellness Center.



Emergency services, Birth Center, Cancer Center, hospice and palliative care, rehab and sports medicine, and diagnostic services.


2,664 inpatient admissions32,038 outpatient visits48 beds

Birth Center, Center for Rehab & Wellness, Chemical Health Program, emergency and urgent care, hospice, home and palliative care, mental health services, Sleep Center, and Surgery Center.

$275,476M net revenue 369 physicians3,786 employees

1,913,601 outpatient visits Acupuncture, allergy, audiology, cardiology, chiropractic, pediatrics, ENT, family practice, surgery, gynecology, infectious disease, internal medicine, radiology, obstetrics, occupational medicine, oncology, optometry, orthopedics, physical therapy, plastic surgery, travel clinic, ultrasound, urology, and vascular services.

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* Hospitals scheduled to go live in 2008

NOTE: Please see Appendix for go-live schedule .

With Excellian, Allina is replacing all of its core clinical and revenue cycle systems (with the exception of lab) in both the ambulatory and inpatient settings with an integrated electronic medical record and revenue cycle system (from Epic Systems Corporation) that supports Allina’s vision of “One patient. One record .”

VISIONIn 2002, Allina had many disparate legacy systems for tracking and managing revenue cycle and clinical operations . Allina’s senior leadership commissioned two teams – one for clinical care and one for revenue cycle – to develop an EMR vision . Together those two visioning teams ultimately created Allina’s vision of “One patient . One record .” established through one system that could integrate clinical processes, care experience, and business processes while improving the patient’s experience .

The teams realized early on in the visioning process, that the clinical and revenue cycle experience could not remain separate . It became clear that Allina’s objective of a patient-focused experience needed a single vision and a single enabling system .

The clinical and revenue cycle visioning teams, consisting of providers, caregivers and others from across the organization, spent 18 months developing the vision and outlining the attributes of an ideal model for an improved patient experience .

Automated medical Record Vision• Patients, families and caregivers have the information

required to navigate Allina

• Patients, families and caregivers receive timely and appropriate information and services

• Caregivers identify the appropriate care needs of patients and families

• Caregivers deliver safe, appropriate, efficient and effective care to patients and families

• Caregivers provide ongoing care management to ensure maximum effectiveness of and satisfaction with care provided

• Reliable and valid clinical, functional, satisfaction, safety and cost outcomes data is stored, retrieved, analyzed and made available to caregivers in a timely manner

Revenue Cycle Vision• One-stop scheduling and registration

• Collection of patient financial and clinical information is done once

• Patient eligibility and financial obligation is known

• Charging is driven by documentation at point of care

• Easily understandable and accurate bill

• Immediate answers to patient financial inquiries

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ObjEcTIVES/GOAlS The Excellian implementation was the primary strategic initiative for the organization. Failure was never considered an option. This project brought Allina together to accomplish a major objective in a way it had never been challenged in the past.

Key strategic objectives for Excellian were developed during the revenue cycle and clinical visioning process with a focus on developing an integrated system . The goal was to have an integrated system between the hospitals and clinics, as well as between revenue cycle and clinical systems . As such, Allina’s strategic objectives were:

• A system that reflected the vision of one patient, one record

• Standardized work processes across the organization

• Project to be led and owned by Operations

• Use of standardized (non-custom) software from the chosen vendor

• Use of best practices where appropriate .

These strategic objectives were consistently at the forefront for any decision-making and design considerations, including the following guiding principles:

• A common clinical terminology will be utilized .

• Allina’s standard will be significant adoption of CPOE (> 80%) in order to achieve the considerable benefits tied to this goal.

• Design for a paperless environment .

• Bar coding patient identification is out of scope, but in scope for chart/film management.

• Facilitated scheduling (some centralized and some decentralized) will be considered .

• Adequate and appropriate hardware (workstations, printers, peripherals, and network connectivity) will be available .

• There will be one Charge Master (service catalog) across all hospitals (common descriptions, codes, and methodology) . There will be a single Procedure Master for clinics . man

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Business Care Clinical

Information/Orientation

Access

Assessment

Treatment

Follow-up/Continuation

• Consumer Health Information• Benefits Information• Enrollment

• Scheduling• Registration• Verification• Record Generation

• Documentation Compliance• Billing and Coding

• Order Execution• Documentation, Billing• Referral• Information Transfer

• Scheduling• Referral• Billing• Documentation and Record Maintenance

Functional• Return to Work

• Activities of Daily Living

• Pain Assessment

Safety• Errors That Cause Harm

• Adverse Drug Event

Cost of Care• Prescription and Procedure Cost

• Length of Stay

Clinical• Mortality

• Nosocomial Infection

• Best of Practice

Service• Patient/Provider Satisfaction

• Timeliness

• Provider Approved Health Information• Self-Assessment/Care Tools

• Triage• Provider Assignment

• Record Review• History and Physical• Lab and Imaging

• Evidence Based Medicine Tools• Prescription• Procedures

• Response to Prescription• Referral

CARE

Integrated View – Revenue cycle and clinical

• There will be one professional fee billing office and one hospital fee billing office.

• There will be one guarantor statement across all Allina Medical Clinic sites and hospital-based clinics .

• There will be one guarantor statement across all hospitals .

Clinical design guidelines were defined as follows:

• Design will support new forms of interdisciplinary collaboration and communication to coordinate and realize the highest possible standards of patient-centered care . Roles and responsibilities may be modified to achieve higher and more consistent levels of patient care .

• Clinical decision support tools will be applied throughout the health system to guide real-time clinical decision making .

• Unnecessary variations in care will be minimized through common processes and replication . Common care standards (e .g ., processes, documentation tools, order sets, care plans and drug protocols) will occur across Allina sites where appropriate .

• Patient information will be shared across the continuum of care (One patient . One Record .), based on security rights .

• Clinicians will view information in a manner that improves workflow required to deliver discipline-specific care.

• Clinical documentation will be multidisciplinary with a patient-focused approach eliminating the need for paper tools .

• Clinicians will document at the time care is provided .

• “Charting by exception” will be the standard documentation practice .

• One point of data gathering with multiple points of data sharing; eliminate duplication of data collection/validation across caregivers .

Revenue cycle design guidelines were defined as follows:

• Scheduled patients will be pre-registered and pre-verified.

• Insurance eligibility/ benefits will be verified prior to service .

• Clinic scheduling for patients will be available 24 hours a day, seven days a week .

• Appointment reminders will be given to pre-determined patient types, based on site criteria .

• Patient instructions will be linked to scheduling – information is provided to patients in advance of their visit .

• Information about financial options/obligations, service location, and parking will be provided to patients prior to service .

• Co-pays will be requested at the time of service .

• The patient will receive care as appropriate based on condition .

• The clinician will be responsible for complete and accurate documentation of visits, services performed, and the patient’s disease/condition at the time of service .

• Facility and professional fees will be captured at the time of service .

• Charging will occur at the time service is delivered and documented .

• Coding and data entry will be completed within 24 hours of discharge or the last date service was provided .

• Coding and documentation will adhere to Allina Hospitals & Clinics policies and procedures for coding and documentation compliance .

• Utilization will be appropriately monitored based on contractual requirements .

• All utilization monitoring will be a derivative of documentation .

• 100 percent of all claims will be error-free .

• Compliance editing/monitoring will be automated, and upstream processes will be designed to eliminate the need for downstream edits (e .g ., charges outside the date of service, research account holds, PT/OT/Speech Authorization holds, onset date hold, missing authorization/missing certification hold, Medicare therapy visit count, interim bills, missing room charges, 72 hour and “same day” rule charge transfer) .

• The benefits of HIPAA standard transactions will be realized in the design, especially eligibility 270/271, insurance claims 837, remittance 835, and claims status 276/277 .

These design guidelines tied back to the strategic objectives and framed all decision making around the design of the system . Project team members were empowered to make design decisions in support of the guidelines .

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VENDOR SElEcTIONAllina’s vision was the basis for the development of the request-for-proposal (RFP) requirements for Excellian . More than 600 people from across Allina were involved in the development of the system requirements and the RFP review process . The RFP was sent to seven vendors outlining the functionality required to deliver the integrated clinical andrevenue cycle processes and outcomes that Allina sought for the ideal patient care experience .

All of the RFPs were reviewed and compared to the list of requirements using a weighted numbering system . Once the RFP review was complete the list of potential partners was narrowed to two finalists. The vision was used to develop detailed scenarios for vendor demonstrations . More than 750 people, representing every operating unit and operational area, participated in the demonstrations to evaluate both finalists against Allina’s vision for the patient experience . Allina had never had a process that was so broad and inclusive in terms of involvement - it was very well received .

Based on the RFP and the demonstration evaluations, Epic Systems Corporation was selected, and by March 2003 the contract was signed and implementation planning was underway . The next four months involved budget review, implementation sequencing and timeline development .

Allina’s design guidelines for an integrated system between the hospitals and clinics, as well as integration across

revenue cycle and clinical areas were the major drivers for our selection of Epic . Hyland was selected for the document management system . Other key components of the Excellian strategy that were in place included Emageon for the PACS system and GE for the lab system . This integrated strategy was a major change for Allina, as previously Allina had a best-of-breed approach and interfaced those applications together . (See table on page 20)

Ownership of the Excellian strategy was solely upon Allina – risk was not shared with other parties/vendors . Allina did work with other consulting groups to provide implementation planning support, subject matter expertise, fill key positions where we could not find qualified employees and for special projects and staff augmentation . We also worked very closely with Epic to establish a collaborative customer/vendor relationship .

lEADERSHIp/GOVERNANcE At the beginning there was no project governance in place outside of the Excellian Steering Committee (ESC) . The ESC consisted of Allina’s senior leaders - the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Medical Officer (CMO), hospital presidents from the four large metro hospitals, the regional hospital Vice President (VP), the VP of Nursing and four additional physician leaders . The Chief Information Officer and the VP of Revenue Cycle Redesign,

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along with Epic and First Consulting Group, supported the ESC and drove the meeting agendas, minutes, etc .

Allina had never undertaken a project this large and needed to establish a new governance . The new governance structure was developed as part of the implementation kickoff in August of 2003 .

The following leadership and governance groups have played a key role in the Excellian implementation:

• Excellian oversight Committee (EoC) – a subgroup of the Allina Board of Directors which guides the overall strategy of the Excellian implementation and reviews the project’s status and budget on a quarterly basis .

• Excellian steering Committee (EsC) – serves as the major approval body, governs the operational aspects of the implementation, and assists the Project Management Office in decisions related to the implementation. This group approves strategic direction, timeline changes, sequencing changes, and implementation scope changes .

• Project Management Office (PMO) – provides day-to-day operational leadership of the Excellian implementation .

• Excellian Physician Engagement team (PEt) – formed to foster stronger physician engagement of Excellian .

• Clinical decision support (Cds) – accountable for the development and maintenance of all clinical content

tools in the EMR including: note content documentation, order set content, rules and alerts, protocols, care plans, flowsheets, and evidence links, as well as educational materials (e .g ., patient and family, caregivers) .

• detailed Advisory groups – composed of subject matter experts from across the organization to help make Allina-wide design decisions for the system .

• hospital, Ambulatory, Revenue and Physician Advisory groups – four separate advisory groups composed of experts from across Allina that govern design decisions for their respective areas .

For the majority of the implementation, the Excellian Team was comprised of approximately 250 full-time employees, most of whom came from other positions within Allina . The project team was initially structured by application . As the implementation progressed, application teams were reconfigured to form a metro hospital team, a regional hospital team and an ambulatory team . This structure better enabled project team members to cross train on various applications (e .g ., scheduling, registration, clinical documentation and orders) .

The main governing body for the project was the Program Management Office (PMO). The PMO reported to the project vice president, who in turn reported to the COO/ESC . The EOC also played an integral part in the governance in an oversight capacity .

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The roles and responsibilities of the Excellian Steering Committee (ESC) were to authorize overall strategic and operational project goals to ensure that the Excellian implementation remained aligned with the operational and financial goals and objectives of Allina. The ESC was also responsible for ensuring the implementation of consistent processes across the system . Decisions made within the project were to be communicated and supported by the ESC and driven through the organization . The ESC also served to resolve critical issues that could not be otherwise resolved at lower levels of the project organization . Recommendations regarding scope, timeline, project processes and budget were also approved by the ESC .

The Advisory Groups were also an integral component of the implementation . Detailed Advisory Groups were formed for each product area and were comprised of users from all hospitals and clinics . The project teams made decisions with input from the Detailed Advisory Groups . Then decisions were approved and affirmed by four broad advisory groups – the Hospital Patient Care Advisory Team (HPCAT), Clinic Patient Care Advisory Team (CPCAT), Revenue Cycle Advisory Team (RCAT) and the Physician Advisory Team (PAT) . These groups met in person and via teleconference and videoconference . Any time that the project teams could not reach agreement on design decisions, they were escalated to one or more of the four broad advisory groups as appropriate . If the advisory groups could not reach agreement, then issues were escalated to the ESC. See the process flow for the Advisory Groups on the previous page .

Clinical decision support

Clinical Decision Support has developed and interacts with several oversight committees . These groups oversee and review the clinical content used in Excellian .

• Expert Content teams/order set development A total of 53 Expert Content Teams participated in the development of more than 1,300 Excellian master order sets . Teams included physicians who are Medical Directors of services at their respective sites or are nominated by their hospital Excellian site leader . A clinical nurse specialist for the case type and a pharmacist are also assigned to each expert team .

• site Physician Champions Site Physician Champions are appointed by the clinic physician lead or hospital Vice President of Medical Affairs . They champion the physician aspect of the site go-live and are members of the Physician Advisory Team (PAT) . During development, all order sets were emailed to the Physician Champions prior to the monthly PAT meeting where they were endorsed . Upon endorsement, Physician Champions were asked to communicate new and changed orders set(s) to their colleagues .

• Rules and Alerts Committee Inpatient physician, nursing and pharmacist representatives manage the rules and alerts aspect of Excellian . The committee is chaired by a Physician

Champion from one of Allina’s largest hospital, and meets monthly to review new alert requests .

• nursing Practice Council The Nursing Practice Council has oversight of all content related to nursing documentation tools and workflows in Excellian .

• Pharmacy management/Clinical Council Pharmacy-related features in Excellian are managed by the Pharmacy Management/Clinical Council . The pharmacy content is developed by the pharmacy implementation team with weekly oversight by the system-wide pharmacy clinical managers and monthly oversight by Pharmacy Detailed Advisory Group .

• Ed/md User group Both the ED order sets and smart tools are developed by the ED Implementation team with the ED/MD User Group providing oversight . They meet monthly and endorse new tools and changes .

Mid-2006, the ESC was downsized to consist of the COO (Chair), CFO, CMO and one metro hospital president . This new ESC was supported by the VP of Excellian and the CIO . In addition, as the implementation neared completion and more sites were live on Excellian, a new User Group structure was recently developed to replace the Detailed Advisory Groups and the Hospital, Ambulatory, Revenue and Physician Advisory Groups . Please see chart on the next page.

The Allina-wide Excellian User Groups are designed to support ongoing two-way communication between Excellian and the sites . The responsibilities of the Allina-wide user groups are:

• Prioritization of system enhancements, build, redesign and support-related project work

• Evaluate, recommend and approve Allina-wide system design configuration

• Idea sharing and best practice identification

• Champion Excellian within the organization

• Promote adoption and proper use of the system

• Participation in Allina-wide initiatives, such as system upgrades

Moving forward into post-implementation the ESC has been replaced by the Operations Leadership Team (OLT) . This is the CEO/COO senior leadership team . It consists of the CEO, COO, CCO, CFO, CIO, the major business unit and hospital presidents, the medical group president, corporate counsel, and key physician leadership .

Various site-based work groups, such as the Patient Care Excellian Workgroup (PCEW) operate within their site and with other Allina sites to improve workflows that are supported by Excellian. Those workflows then drive system enhancements that will better enable service delivery to patients . This is a continuous process designed to facilitate helpful changes using the functionality that currently exists . man

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cOST/clINIcAl AND REVENUE bENEFIT pROjEcTIONSAllina completed a ten-year cost-of-ownership analysis as part of the approval phase of the project . First Consulting Group was engaged, as well as Epic, to help fully estimate the costs of implementation and on-going operating costs of Excellian . The three entities worked jointly to estimate the required resources, such as hardware, software, infrastructure, implementation staffing, interfaces, training, and on-going support staffing. That work was combined with the benefits identification work to estimate a return-on-investment (ROI) for Allina . Allina used the results of this analysis to create the project capital and operating budgets, as well as to populate the Allina-wide financial plan. This analysis predicted future on-going costs to support Excellian .

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USER GROUp STRUcTURE

(000’s)

Please see the Values section for further discussion of cost in relationship to benefits.

Project leadership managed against this analysis very closely throughout the implementation . The overall capital budget for the project was $242 million . The project was completed for just under $248 million with a 2 .5% unfavorable budget variance . This variance was primarily driven by increases in project scope . The operating budget was more of a challenge . While estimates for training and other known operating costs were included, costs due to the end users’ learning curve were not anticipated . A $17 million unplanned expense occurred at our largest hospital, due to not budgeting for learning curve and productivity impacts . In subsequent implementations, these costs were included as part of the annual operating budget .

The benefits expectations were developed into a realization model to review accomplishments on an ongoing basis . The following shows the expected clinical and revenue cycle benefits that were aligned with Allina’s patient care model.

For a comprehensive overview of Allina’s approach to achieving benefits, please refer to the Journal of Healthcare Information Management – vol.19, No 1, Benefits Planning for Advanced Clinical Information Systems Implementation at Allina Hospitals & Clinics .

pROjEcT RISk MANAGEMENT Allina engaged First Consulting Group to assist with an overall risk assessment related to the implementation of Excellian . The process included interviewing Allina employees, senior management and board members; conducting a literature search on implementation risks that other organizations experienced; and “visioning” sessions with Excellian project teams . The information was compiled, reviewed and categorized by the PMO into one or more of the following risk buckets: business unit risks, organizational

risks or Excellian project team risks . Then management accountability, risk mitigation strategies and measurements for each risk were identified.

Business unit risk was mitigated through the development of an implementation/risk plan template . The risks that needed to be managed at the sites were related to training, resources, communication, physician engagement, non-physician engagement, business continuity planning, workflow, benefit realization and device planning . The implementation/risk plan included the risk mitigation strategies in the form of action items with measurements and milestone dates for completion . The business unit site implementation lead, with the support of the Excellian implementation lead, was responsible for managing the plan and reporting progress on a weekly basis . Implementation/risk plans were monitored weekly by the Excellian Director of Risk and Regulatory and

the Project Management Office (PMO). A process was in place to escalate concerns to business unit senior management if any aspect of the implementation was in jeopardy .

Organization risks were mitigated by assigning ownership of potential risk areas to various Allina senior leaders . Senior leaders were provided with mitigation strategies and measurements . In addition, if organization risks were jeopardizing the project, they were escalated to the Excellian Steering Committee .

Excellian project team risks were mitigated through various project management tools . Each application team was responsible for a project plan, risk identification, mitigation strategies and weekly reporting to the PMO . If a team identified a potential risk, it was indicated in their weekly report along with a mitigation strategy . Through weekly reporting, concerns were escalated to the PMO so that barriers could be eliminated if necessary . man

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2. imPlEmEntAtion

IMplEMENTATION plANNING pROcESS Four months of implementation planning began in April of 2003 . During that time, the following were addressed: which site(s) would go live first, the implementation rollout timeline, the implementation budget and benefits, and decisions about who would determine the core features of process and systems (standardization) . A decision rights process was developed for each of these aspects that identified who the stakeholders were, who the initiator (or process owner) would be, who had input into the decision, who would be the decision maker, and then who would implement the decision . Decision rights were presented to the Steering Committee for vetting and subsequent approval . The Steering Committee met for two hours every other week during implementation planning .

The following are the implementation guiding principles:

pRINcIplE 1:UseExcellianvendor(Epic)wheneverpossibleforneworenhancedapplicationrequests.(i.e.,Cardiology,Obstetrics,etc.)

pRINcIplE 2:Allina-widedesigntobeusedbyallbusinessunits.(Standardization)

pRINcIplE 3:Installgenerallyavailablesoftware.(Limitedcustomization)

pRINcIplE 4:ShiftfocusandresourcesfromsupportandenhancementofcurrentsystemstothedesignandbuildofExcellian–theorganization’sprimaryfocuswastheimplementationofExcellian.

pRINcIplE 5:Technologychangeinitiativestobeownedanddrivenbyoperationalleadership(notanITproject).

pRINcIplE 6:Understandworkprocessandchangemanagementimplicationsandprovidethenecessarysupporttoeffectivelymanagechange.

During implementation planning, the Project Management Office (PMO) was not yet in place. It wasn’t until the actual implementation was initiated in August of 2003, that the PMO was staffed for the project . In hindsight, the PMO should have been staffed at the beginning of implementation planning so that those individuals could have been involved in the decision making that occurred as part of implementation planning process and there would have been less “catch up” as new members of the PMO came on board .

IMplEMENTATION pROcESSAt the beginning of the Excellian implementation, Allina worked with Epic and FCG to develop an innovative Rapid Design approach to “jumpstart” the implementation process .

During Rapid Design, a clinical scenario was developed within Excellian to show the workflow of how a fictitious patient would move between the outpatient and inpatient settings, as well as between the revenue and clinical components of the system .

Allina set a very aggressive goal of having the clinical scenario developed within four months so that the system could be demonstrated to operations employees and leadership across Allina . Rapid Design prompted the quick development of governance structures and processes so that decision making and escalation processes could be validated .

The demonstration was presented 45 times to approximately 2,200 people (approximately 11% of all Allina employees) . A total of 1,600 evaluations were received with an average score of 4 .02 on a 5-point scale indicating that audience members liked what they saw . This initial feedback was then used to help guide how the actual system would be designed .

Once the demonstrations were complete, the next phase of implementation began - Design, Validate, Build (DVB) . The purpose of this phase was to gain insight into how the system should be built, processes would be redesigned, and workflows validated. This step was essential in order to narrow down the number of system configurations. The goal of each DVB session was to address a topic with relevant site experts participating so decisions and recommendations could be made . These choices were then tested and validated with key stakeholders across the system . Many of the people involved in this phase later became members of the Detailed Advisory Groups .

Please see the Appendix for the schedule of hospital and ambulatory go-lives.

hospital implementations

The hospitals were implemented according to the following schedule . Clinics associated with each hospital went live prior to the hospital’s go-live in order to maximize the patient experience and enable staff to be fluent in the system before they use it in the inpatient setting .

Allina decided early on to employ a modified clinical “big bang” approach, which would be less confusing to the clinician and to promote better patient safety, since clinicians would then not be living in both the paper and the electronic worlds at the same time. The approach for the first hospital go-live (pilot site in Sept . 2004) involved all applications going live on day one of go live, except the physician users began computerized physician order entry (CPOE) four weeks later and clinical documentation four weeks after CPOE . It became apparent that physicians were very capable of using clinical documentation on day one of go-live and that they found it easier than order entry .

Therefore, the approach for the July 2005 go-live at the second hospital (which has a very large number of physicians) was to utilize clinical documentation tools on day one of go-live, and to deploy CPOE over three months in staggered phases . Due to the integrated nature of the applications, delaying man

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CPOE impacted the patient discharge process - almost 30 additional minutes of nurse time was necessary to complete each discharge documentation . Consequently, with the third hospital go-live, CPOE was delayed by one month, but all physicians began using CPOE at the same time . The success of this even bigger bang approach led to pushing the envelope further and now all applications for all users are activated on day one of go-live . Clinicians have seen the success of the implementations to date and, therefore, are willing to take these calculated risks with the project team . Training was revised to mitigate the risks of big bang activation, and the clinicians validated that this approach worked best for all involved .

As for implementation sequencing, one of Allina’s smaller regional hospitals was chosen to be the first to implement the EMR . The site was chosen based on the support of the administrative and clinical leadership, the culture of the hospital and their amenability to change, as well as understanding the risks and benefits involved with being the first site. The next hospital after the pilot site was Allina’s largest . Although it was debated as to whether a medium size metro hospital should have been chosen to slowly build from the simple to the complex, in hindsight, implementing the large, complex hospital provided the opportunity to understand almost every workflow that would be encountered at the remaining hospitals . With every subsequent hospital, the process was further refined to improve the efficiency of clinical and revenue cycle users . After the third hospital, the team was proficient enough with the product to create two separate teams – a metro team which focused on implementing the large metro hospitals and a regional team which focused on the smaller hospitals . Although the teams had separate assignments, they maintained working relationships with each other to share what they were learning as they implemented . During go lives, the “all hands on deck” approach was used, which required all implementation team members to assist with the go live and understand the nuances of the system for that particular site .

During the implementations, groups of users gave input to the process at a variety of levels . The Detailed Advisory Groups provided input into product design and decisions . Super Users were identified at each site early in the implementation planning stages . As implementation experience grew, Super Users became the primary drivers of workflow adaptation and understanding for their individual areas . In many hospitals, Super Users became the foundational members of the Patient Care Excellian WorkGroup . The need for this type of group was recognized after the implementation at the second hospital and subsequent hospitals have since created this group prior to implementation . It has served as an excellent forum for the site to work together to solve workflow problems.

Ambulatory implementations

The ambulatory implementation timeline was aggressive . The timeline was re-evaluated after the pilot sites’ go-lives (the first being July 2004), but then varied little. The four pilot sites for the implementation used a big bang approach for

go-live . The big bang approach included implementing both the Practice Management (revenue cycle applications) and the EpicCare Ambulatory (clinical applications) components simultaneously at a site . Based on learnings from these pilot implementations, two separate, but closely linked, ambulatory implementation teams were formed – one for Practice Management and one for EpicCare Ambulatory .

Subsequently, the timeline was revised to create a staggered implementation where Practice Management was implemented prior to EpicCare . The Practice Management (PM) implementation cycle was the same length (12 weeks) as the EpicCare Ambulatory, however the PM team was able to implement more clinics concurrently due to the standardization of the revenue cycle processes . The PM implementation schedule was completed nearly a year earlier than the EpicCare Ambulatory implementations. The main benefit seen with the separate Practice Management and EpicCare go-lives was the reduced patient wait times . Introduction meetings occurred six weeks prior to the site’s implementation kick-off meeting, which allowed the clinic manager to better plan for training and any additional resources .

In order to meet the aggressive timeline, the ambulatory team developed the Roadmap for the ambulatory implementation during the initial pilot phase . The Roadmap contained a detailed implementation work plan, standard meeting agendas and presentations, as well as structured build checklists . The Roadmap was used by the implementation site lead before, during and after the implementation . Lessons-learned sessions were completed after each implementation to determine what did and did not go well with the implementation process . Aspects that went well were included in the Roadmap for all future implementations . Mitigation plans were developed from the learnings and documented in the Roadmap .

hospital and Ambulatory implementation Processes

As the implementation progressed, it became apparent that many different aspects of Excellian and Information Services (IS) needed to be coordinated . This resulted in the creation of the Scope, Communications, Release, Integration, Planning, and Testing (SCRIPTS) meeting . The purpose of this meeting was to coordinate dependent milestones for the implementation, the Excellian environment, review and coordinate activities, and timelines . Each week, the managers would get together to review the master milestone document and provide updates . If milestones were in danger of being missed, appropriate mitigation action was taken . If a milestone was missed, subsequent milestones were adjusted .

Another team that was formed to improve coordination was the Process and Systems Integration (PSI) team . PSI team meetings provided a forum to review integrated design decisions across all teams (i .e ., hospital, ambulatory and Information Services), validate that all impacted teams were included in design decisions, and communicate project processes that required involvement from all teams . man

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TRANSITION TO NEW pROcESSES One of the benefits of the big bang approach (clinical and revenue cycle) is that the transition from paper to electronic records happens quickly and immediately . However, since Excellian changed the way clinicians and revenue cycle staff work rather than just automating existing processes, unanticipated process issues appeared that needed to be addressed . Several of these were the indirect effects of information being available to all caregivers in a wide variety of locations . This information accessibility had many positive effects, but also some unintended consequences . An example of this is the Transfer Level of Care (TLC) .

The TLC issue involved a patient moving from one setting, for example, the post-op area (i .e ., PACU) to another (i .e ., ICU) . On paper, PACU records were completely different from ICU records . When a patient transferred, PACU records were simply filed behind the PACU tab and new ICU forms were added to the chart . With Excellian, PACU nurses were now required to address each item of care so that the status of the item was clear to any caregiver going forward . This was seen as “extra work” and with initial use of the system was frequently not done . This issue was addressed within the PCEW . With further understanding, education and reinforcement, TLC did improve .

One of the strengths of Allina’s implementation approach has been to deliberately not make the project team solely responsible for how the system is used, but to place a good deal of the accountability on the sites . An implementation of this size and scope could not otherwise be successful . This responsibility does create a decision point for the site – will they take on and manage the accountability to improve their operations or will they allow the system to direct their processes? The choice can be a stressor to the organization’s culture, and although Allina is an integrated health system, it is still moving along the path towards “systemness .” Some sites stepped up admirably to the challenge, while others required additional support from the corporate level, as well as from other sites .

In the course of implementing Excellian, the process for introducing the sites to the Allina-wide Excellian design and preparing for new workflows underwent several improvements, based on learnings from each go-live site . After the second hospital implementation, it was evident the sites needed application training before being introduced to workflow decisions; so training was provided to lead Super Users before the workflow activities began. Beginning with the fourth and fifth hospital go-lives, a new type of change management methodology, called Adaptive Design, was implemented .

Adaptive Design uses principles from the Toyota LEAN production model and puts the responsibility for understanding what the work should be and how the tools will support that work in the hands of the Super Users . The Adaptive Design approach emphasized practicing one’s own workflows in Excellian before go-live, to establish deeper workflow knowledge and uncover problematic issues before go-live . The level of system ownership this methodology

engendered in the Super Users and end users enabled less at-the-elbow support by the project team and more rounding-level support . Go-live support is only planned for 10 days at a regional site and two weeks at a metro site .

As mentioned above, Allina used a big bang implementation approach versus phasing in the system . Perpetual refinement of the change process was what allowed Allina to minimize disruptions to patient care during the Excellian implementation . Allina’s current use of Adaptive Design principles allowed the sites to move from the “novice” state of understanding the system, which you experience immediately post-training, to a “ready” state prior to caring for an actual patient . Some preventive measures were used during the go-live time period, such as decreasing the surgical schedule for a short time, as well as decreasing the number of appointments scheduled for individual providers in the clinic . Allina also planned on heavy Super User and manager presence during the “go live” timeframe (typically two weeks) .

TRAINING With the depth and breadth of the Excellian implementation, a considerable number of resources were, and continue to be, dedicated to training . The training team has evolved considerably over the course of the implementation . At the start of the implementation, the training team was centralized (separate from the application team) . As the implementation matured, training became more integrated with specific application teams . Then as implementation neared completion, a return to a centralized model made sense .

It became clear that the speed and volume of training required specific roles within the training organization that were focused on operations and eLearning (training conducted electronically) . Training operations focused on training space and schedule management . During peak training times, as many as 40 training rooms were in use .

elearning

When implementation began, the role of training (let alone the role of eLearning) was not well defined. Physicians were not being compensated to attend training, so the need for eLearning became readily apparent to minimize the amount of classroom time for physicians . Thereafter, eLearning became a pre-requisite to classroom training . The following are lessons learned:

First, eLearning did not offer a level of flexibility that was desired . Usually, system content changes were happening too fast for a significant number of eLearning scripts and screen shots to be updated . To mitigate this problem, a group of physicians with Excellian experience helped refine the eLearning curriculum, as well as the classroom sessions . The eLearning design is now focused on base functionality, which requires less change, while the classroom sessions are now focused on workflow and other, more dynamic, aspects of the system . man

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Second, sites need the appropriate infrastructure available to make eLearning accessible to end users . Does your target audience have access to personal computers? Can the eLearning be accessed outside of the organization’s network (i .e ., intranet/internet)? Do you have tools available to build eLearning and does your corporate technical infrastructure have the bandwidth to handle the utilization of eLearning by end users? These questions all had to be addressed in order for eLearning to be successful . Investments were made to have more computers accessible at the sites, to obtain additional eLearning development tools and to implement a learning management system to deliver and track the use of eLearning .

Third, the success of eLearning had much to do with the corporate culture surrounding the use of the technology . If the organization had difficulty with staff having limited PC skills or conversions to new technologies, eLearning was not as ideal . Prior to the start of training, it was important that staff self assess their computer skills and that the necessary tools to increase their proficiency were provided. Allina provided easy access to PC skills training and change-management training to effectively prepare staff for the new system .

training operations

Key learnings from our first hospital go-live site carried over to all subsequent site training programs - both ambulatory and hospital . These key learnings pointed to the need for a centralized training site, centralized training scheduling, a learning management system and patient-rich training environments . The centralized training location enabled users from multiple sites to train in a controlled learning environment . This accelerated training and increased efficiency and capacity. For example, nearly 3,500 individuals attended classroom sessions in the first quarter of 2007. The centralized facility enabled as many as 300 individuals to be trained per day . Centralized training scheduling enabled training requirements for each site by role and by name to be determined . This allowed the training team to construct training schedules six to eight months in advance to plan for and accommodate large, diverse populations of students . Both the centralized training location and centralized training scheduling were maximized by the utilization of a learning management system (Saba) . This system allowed class offerings to be part of a real-time enrollment tracking process and provided a platform to securely deliver eLearning modules . Managers could then easily enroll their staff into scheduled courses and know their status at anytime . In addition, the system could deliver and score assessments to trigger security access or remediation for the end user . Considerable effort went into the technical and user build of training environments . Ten thousand training patients were created in the training system and designed to give end users a realistic view of how they would use Excellian . A separate playground environment was also made available to help end users maintain skills following their training .

ApplIcATION SUppORTOngoing Excellian Support is comprised of three areas: 1) Application Support teams (both revenue cycle and clinical), the Enterprise Master Patient Index Team (EMPI) and the Excellian Site Liaison . The Application Support teams are accountable for resolving incidents submitted by Excellian end users and performing moves, additions and changes (MACs) to facilitate operational access to the software . The EMPI team is accountable for merging and unmerging patient records within the system (currently four million patient records), as well as moving incorrectly placed data . The Site Liaison is dedicated to the relationship between Excellian Support and the business units and recommending changes for both sides .

Prior to each hospital go-live, a physical Command Center is created to address the issues identified during the go live. This structure provides one place where all issues, including complicated cross-application questions, can be resolved quickly . It also allows for centralized monitoring of all staff who are working on the issues, as well as coordination among teams .

During go-live, the management team meets with the senior leadership of the hospital or clinic on a daily basis to discuss implementation status . Excellian Support reports on process and provides incident volume and resolution rate statistics . The site then identifies the top issues (no more than 10) that they would like to prioritize for resolution regardless of the issue’s severity . Efforts are then focused on resolving those top-priority issues as quickly as possible . This allows the site to have more control over what is resolved and when . It also allows resolution of incidents identified by key stakeholders, which in turn, allows for a better overall adoption of the system .

transition From go-live to on-going support

Ambulatory: Following the first weeks of go-live, a transition meeting was held with ambulatory management and Excellian to formally move from go-live support to ongoing Excellian support . At that time, incidents are reported through the Allina Incident Management process utilizing the Technology Support Center (TSC), Allina’s help desk, as the first level of support . If incidents are not resolved, they are triaged based on a number of requirements in order to direct the incident to the appropriate support group for the next level of support .

Hospital: As the level of incidents declined, the Command Center gradually ramped down . Transition meetings occurred between the implementation team and post-live support . This allowed the Support Team to become familiar with the current issues and prepared the site for when on-site support was no longer available .

incident management

Once the implementation and go-live phases are complete at a site, incidents are routed from the TSC to the Excellian Support Application Teams . man

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When a user identifies an issue in Excellian, their first step is to call Allina’s TSC . The TSC staff record basic information about the user and the incident and based on criteria assigns a severity level to the issue, which determines the resolution prioritization . If the TSC staff cannot resolve the issue, they will triage it to the Excellian Support Team to address the issue . High-priority calls are triaged from the Allina Technology Support Center to individuals in Excellian Support referred to as the “Hot Seats .”

When any changes in the system are identified, the Release Management process is implemented . This process uses the Information Technology Infrastructure Library (ITIL) methodology . The release management process has been enormously successful as Allina has exerienced no unscheduled or emergency downtimes in the last six months .

Excellian Support created on-line help documentation to assist the TSC in answering calls . Since implementing the on-line documentation tool, there has been a marked decrease in the number of calls transferred from the TSC to Excellian Support .

Support Staffing LevelsThe Revenue Cycle Support team is responsible for registration, scheduling and billing functions with a staff of 28 FTEs . The Clinical Support team is responsible for the EpicCare Ambulatory and EpicCare Inpatient clinical applications with a staff of 39 FTEs . The Excellian Support EMPI and Data Quality teams are responsible for maintaining the Enterprise Master Patient Index with a staff of 10 FTEs .

From the inception of the project, leadership determined that the project would be overseen by Operations rather than Information Services (IS) . This structure supported the goal to have the operating units directly involved in the design and build of the Epic applications . As a result of this decision, a separate project department was created to implement the software .

IS involvement was critical to the success of the implementation and so a very strong relationship between the project and IS was structured . Some examples of this were the involvement of the CIO in the Project Management Organization; IS owning the responsibility for the upgrade and maintenance of the hardware and infrastructure components; the integrated nature of the interface, application technical support and release management teams and the Excellian team; the Excellian production change process utilizing the Change and Release Management guidelines established by IS; and the key IS teams that perform change management operations close connection to Excellian .

Currently, responsibility for clinical applications is divided between IS and Excellian . Excellian has accountability for the Epic applications and IS has accountability for all other clinical applications (Lab, Radiology, etc .) . This arrangement is true for all established users as well as new implementations . IS and Excellian continue to partner to deliver high quality automated tools which meet user SLA expectations .

3. oPERAtions The Excellian system has many built-in safeguards to assure that data entered into the system is complete and accurate . Most of these mechanisms function at the user level so feedback is immediate and clear. For example, flowsheet

parameters are set to prevent impossible values from being entered. Required fields are color-coded to indicate that the user must enter data . Stop signs, which prevent users from moving to another screen until the required information is entered, are used for critical information that is necessary to provide safe care . On the revenue side, a variety of workqueues have been developed, which are populated with flags identifying problems that might cause issues further downstream . These queues are monitored by revenue cycle staff who are specifically trained to resolve issues . This process enables the patient to be admitted without delaying treatment for something that could be addressed at another time . The Allergy Alert is another example of system functionality that supports timely and clinically-sound data entry - no medication order can be signed unless the patient’s allergies have been verified during the encounter.

Two Excellian reporting tools – Clarity and Reporting Workbench – provide a variety of data for managers to use in determining if certain minimum data collection requirements are not being met . Reporting Workbench Compliance reports show many data requirements and identify patient charts that are not complete/compliant with documentation policies . The greatest benefit of Reporting Workbench is that it provides real-time compliance feedback, which enables immediate intervention .

SySTEM AccESS/cONFIDENTIAlITyEvery Allina employee is assigned a unique network identification number (ID) and password when they begin employment at Allina . To obtain Excellian access, appropriate training must be completed and users must pass the training assessment . An Excellian security class is assigned based on the user’s primary role in the organization . The user’s role and security class drive what the user is able to access in Excellian .

ONGOING plANNINGAs the implementation process neared completion, Allina began to develop an ongoing support model and processes for post go-live . This structure/model evolved over the course of several months . The comprehensive support model consists of three major areas; one for ongoing support, another focused on upgrades and a third dedicated to system optimization . training will manage new hire/upgrade training, curriculum/eLearning development, as well as, management of all Excellian-related environments . The Clinical decision support department has been in place during the implementation and remains as part of the ongoing model . information services continues to maintain the technical infrastructure to support Excellian (i .e ., release management, system administration, networking, etc .) . Excellian Application Technical Support (EATS) provides technical expertise when changes need to be made to the applications . Quality Assurance (QA) controls the change and release management process . Release and Data Integration manages the interfaces between the Epic and non-Epic applications .

These four areas report to the COO/CCO, who work together on an annual basis to provide ongoing planning for Excellian . A major system upgrade is planned for every other year . Allina’s annual budget process supports the ongoing Excellian strategic planning . This insures that Excellian-related work continues to be aligned with major strategic initiatives .

The User Group structure was developed to provide input and prioritization for the system . Please see the Leadership Governance Section . man

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MONITORING/EVAlUATION Epic conducted three post-implementation reviews with the four ambulatory and first hospital pilot sites. A survey was sent to each user followed by a two/three day site visit by Epic and Excellian Support team members. In the first survey, respondents indicated general user dissatisfaction . Subsequent changes to functionality addressed feedback collected during the initial surveys . This resulted in respondents indicating desired improvements had been achieved .

In addition to site surveys, Allina’s TSC surveys all end users . When an incident has been resolved, an electronic survey is sent to the end user to address satisfaction with the resolution. Using a five-point scale, the goal for Excellian Support is to achieve a score of 18 out of 20 (latest survey score of 18 .4 achieved) .

Allina also performed circle backs to each clinic approximately eight weeks after each go live . Questions were collected ahead of time in case research was needed . Time was spent communicating the answers back to the site in a Lunch and Learn format along with additional training .

EVAlUATION OF MANAGEMENT OF ExcEllIAN One of the keys to Allina’s successful Excellian implementation was the ability to continually evaluate the good, the bad and the ugly related to every aspect of the implementation . Hundreds of lessons learned and action plans have been documented thus far . The philosophy of Excellian leadership was that mistakes would be made at each step along the journey, but that they should not be repeated .

Implementations as large as Allina’s are frequently plagued with timeline extensions . Due to leadership’s diligent and perpetual efforts in re-evaluating the timelines and committed resources, and reviewing new learnings and their mitigation strategies, the implementation was able to remain on track . The number of clinics and hospitals live to date are a clear testament .

After each major effort, whether it was design, build or implementation, a formal learning process was initiated that included both Excellian team members and site representatives. Things that went well were identified to ensure they were repeated . Where there was less success, or even failures, a root cause analysis of the problem was conducted along with steps to ensure the problem was not repeated .

One of the first learnings emerged during the build of the Charge Master in Excellian . The Charge Master build started in each of the individual applications within Excellian . Each application team was building differently and sometimes overwriting the work of other teams . When it became apparent what was happening, the system build of

the Charge Master was stopped for three weeks while a root cause analysis was completed and appropriate corrective actions were determined . This led to the creation of the PSI integration team (please see chart on page 24) who reviewed decisions having implications across applications . Doing so enabled issues and concerns to be identified and discussed prior to further build and potential problems .

Another example of Allina’s responsiveness through continual evaluation was that the implementation teams were periodically revamped in order to accomplish added tasks while maintaining the timelines . In addition, leadership collected feedback from end users and advisory teams and responded by forming ad hoc workgroups in response to feedback. This enabled delivery of new workflows/functionality, again while continuing to stay within the time parameters initially defined.

Following the first hospital implementation, it became clear that more physician involvement and leadership was needed . At that time, the Physician Engagement Team (PET) was formally organized and staffed to facilitate the physician change management process . This contributed to ever-increasing successes at subsequent hospitals . Long term, having the PET in place has allowed Allina to achieve a higher percentage of CPOE use by physicians than many implementations nation-wide .

Following the implementation of our second hospital, physician adoption of CPOE was not as high as anticipated and ICU nurses were identifying a number of barriers with the use of clinical documentation . A new adhoc team, called the Adoption Team, was formed from staff already working on the implementation . The main areas of focus for the team were revising physician training, updating order sets, improving surgical services tools, improving flowsheets, and resolving ergonomic and hardware issues . The team was in place for six months, and changes in workflow and in the system were made to address the issues . During this time, a mandate for adoption of CPOE was initiated by Allina leadership . The major outcomes of this work were the successful adoption of CPOE by the physicians and the successful adoption of documentation by the nurses .

Additional learnings that were implemented during the course of the past several years included:

• Begin standardization across all sites as early as possible (i.e., terminology, coding, order sets, workflow, rules, alerts, formulary) .

• Design and implement enterprise governance for efficient and effective decision making

• Define clear governance scope/responsibilities (i.e., issue escalation and decision-making authority)

• Test governance to ensure effectiveness

• Document scope throughout implementation planning

• Define how controversial decisions will be mediated and final decisions made man

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• Realize that such a large, complex implementation takes enterprise decision making to a new level – any assumptions about the organization’s ability to make efficient decisions were usually false

• Define roles and responsibilities – critical to be very clear about who is responsible and how they will fulfill their accountability

• Identify gaps and overlaps

• Formalize job descriptions

Learnings that would have been beneficial/appreciated more from the start:

• Need for strong risk mitigation

• Human Resources efforts, in general, were greater than expected

• Develop a turnover plan to keep the project moving if critical staff leave during the implementation

• Lack of Process/System Integration Specialists (build your own early)

• Hire training/interfacing/reporting/extract/conversion teams at the start

• Necessary Support infrastructure of an integrated system was underestimated

• Integrating a benefits focus into site operations proved more difficult than anticipated

• Status reporting proved to be a challenge, but critical for such a large implementation

• Communicate! Communicate! Communicate!

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Allina Hospitals & Clinics FUNCTIONALITY

FUNCTIONALITY

1. tARgEtEd PRoCEssEs Almost every clinical and revenue cycle process was impacted by the implementation of Excellian . The integration between inpatient and ambulatory, as well as between clinical and revenue cycle, forced Allina to look at all processes and to redesign those processes . The integration highlighted the interdependencies of the sheer number of applications that were designed and implemented together – i .e . surgery, pharmacy, ED, registration, billing, scheduling, CPOE, clinical documentation, HIM, document management .

Please refer to the OBJECTIVES/GOALS section outlining Key Strategic Objectives and Guiding Principles; which includes Allina’s design guidelines . In addition, examples describing how processes have been developed or redesigned are noted throughout this document .

2. inFoRmAtion ACCEss

cOMpREHENSIVE DATA Because of Allina’s commitment to automating all of its hospitals and clinics, longitudinal data is available in a searchable, electronic form for those patients who receive care within the Allina health system . For the provider and other caregivers, Excellian is the single source of patient information – the paper chart is no longer necessary and caregivers do not need to access other systems for any information pertinent to the patient’s care at Allina . Information generated in external systems, such as the Cardiovascular Information System (Lumedx), is interfaced into Excellian so the provider can rapidly retrieve the cardiovascular procedure data in the same context as other clinical information . Data from Allina’s Ultra lab system is sent to Excellian and is available for viewing, on-demand trending and graphing . All of Allina’s hospitals and clinics share a single database . For patients who may receive care at a non-Allina facility, their paper record is scanned into Excellian so that the information is available to anyone involved in the patient’s care . Excellian provides a powerful source of information to support Allina’s revenue and care processes . Allina’s utilization management database, Canopy, receives vital care data elements interfaced from Excellian .

DATA cApTURE Excellian is a flexible solution that pairs the appropriate data capture tools with the best workflow for the end user. Depending on the setting, the data gathering tools have been matched with the needs of clinicians and the organization . Examples of these tools and the organizational impact include:

• Form/wizard: Excellian provides form-based tools that guide the user through data collection (both clinical and revenue cycle) .

For example, a registration clerk is required to capture patient demographic and insurance information . Excellian indicates which fields are required (an exclamation point in the field) and which fields have information that is strongly suggested, but not required (a yield sign). Some fields have been designed for data validation based on required characteristics (e .g ., numeric, alphanumeric, date ranges) or can populate via pick lists that limit the user’s choices to pre-defined options. When the user completes one form, the system clearly guides the user to the next form until all data collection is complete . This ability to validate data results in cleaner claims and a more efficient workflow.

• Codified data: Certain portions of Excellian, such as the problem, allergy and medication lists, and historical patient information are documented using specific forms/components that draw from a codified list of choices and allow the user to associate appropriate attributes for a given item (e .g ., date of onset, priority, and status of a problem) . This results in greater patient safety and more accurate clinical information .

• note Entry: Most caregivers’ documentation is created using a note entry . SmartText (see table on page 22) is frequently used to generate the initial portion of the note . Within the SmartText template, users are prompted with pick lists or places to type in text . At any point, a user can edit the template, similar to a standard word processor, to modify the text to meet the documentation needs of the specific patient. Some template pick lists are codified for query and analysis purposes . Users can also create personal SmartPhrases . Finally, users can include SmartLinks in their note (either via a SmartText/SmartPhrase or on demand) . SmartLinks are text snippets that pull information from the patient chart, such as vital signs, which saves time and minimizes copying errors . These templates can also contain best practice suggestions based on the content included in the template . With notes, users have the time-saving ability to copy previous notes, with the SmartLinks automatically udpating . This practice promotes consistency of use and supports best practices . More complete documentation also provides better coding support .

• Flowsheet: Some nursing and ancillary documentation is entered using a flowsheet, a row/column/cell-based, time-stamped, data entry mechanism . The nurse will use one or more flowsheets for a given patient and can include additional data elements as needed . Shortcuts are available to speed data entry and improve consistency among caregivers . One of these shortcuts is the copy forward function, which allows the caregiver to copy data from a previous time in the flowsheet and make changes to only those elements that have changed . Drop down lists and selection lists are other means of providing a quick and accurate way to enter data . Color-coding is also used in certain spreadsheets to indicate required data entry fields. Screens are designed to prevent the user from exiting the fun

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Live Sites Providers Clinical Staff Support Staff

Buffalo HospitalAbbott Northwestern HospitalNew Ulm Medical CenterMercy & Unity HospitalsSt. Francis Regional Medical CenterRiver Falls Area HospitalUnited HospitalAmbulatory Sites

1571,665

6359618336784978

3014,567244

3,586772225784

1,429

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screen until required data elements have been completed . The flowsheet cells can include validation mechanisms, such as a check against numeric ranges. The flowsheet cells can also contain calculated values based on other entered values and data automatically populated from external devices, such as a ventilator . Cardiac monitors and ventilators generate up to 40-50 data values, including vital signs such as heart rate and blood pressure, every minute . Biomedical device interfacing (BMDI) sends these values to a temporary data base accessed by Nursing and Respiratory Therapy . The values are then reviewed for clinical appropriateness and validated (filed to the chart) with a few mouse clicks. A tremendous amount of documentation time is saved and the data is available throughout the medical record as soon as it is filed. During a crisis event caregivers can focus on the patient knowing they can retrieve and document vital sign data once the crisis has passed . Allina has implemented this functionality in the ICU areas and some EDs, and is expanding to the remaining EDs and step-down areas as well based on user demand .

• Form-based entry: Excellian also allows Windows-based forms to be included in the documentation process, with standard tools such as buttons, checkboxes, pick lists, and text boxes. Validation of any field is possible with any type of programmable criteria . For example, in the ED, a form-based documentation tool allows the provider to quickly document the review of systems and physician exam via checkboxes/normal defaults, while providing a text box for a free-form history and assessment that is typically entered via voice recognition (see next) . This combination of tools provides efficiency in the ED environment leading to higher physician adoption rates .

• Voice Recognition: In the ED, Nuance’s Dragon Naturally Speaking is used (in conjunction with a form) for documentation of the encounter . The provider typically completes the visit documentation during or immediately after seeing the patient .

• navigator Components: A typical navigator can allow for review and updating codified data sections (e.g., a medication list), data entry into flowsheets via buttons and note generation. Allina defined navigators gather multiple data entry and review components based on the user’s role, location, and specific workflow into a single screen – again enhancing safety and efficiency across the organization.

cOMpUTERIZED pHySIcIAN ORDER ENTRy (cpOE) Providers enter all orders directly into Excellian, including medication, laboratory, communication, referral, and nursing orders . The system manages present and future orders and providers use CPOE to manage orders during transitions in care (e .g ., pre-op orders prior to a patient being admitted for a procedure) . There is only a small subset of specialty orders that Excellian cannot manage (e .g ., chemotherapy orders) . In those cases, providers write a paper order that is then entered into Excellian by a pharmacist . Order-related questions in the admission and discharge order sets collect Core Measure data . Allina’s CPOE model supports quality, patient safety, efficiency and communication.

All orders are checked in real time against the decision support criteria as described in the Decision Support section that follows .

INFORMATION AVAIlAbIlITy AND AccESS Excellian can be accessed throughout Allina wherever patient care or patient administrative functions are performed . In the clinics, computer terminals are available in exam rooms, nursing stations, physician offices, and administrative areas . In the hospitals, computers are deployed in multiple areas—patient rooms, nursing stations, mobile carts, physician lounges, triage areas, registration areas, health information management departments, etc .

All providers who deliver care at an Allina facility are offered remote access to Excellian . Remote access to Excellian is available using Citrix, enabling providers to interact with Excellian exactly as they would if they were at an Allina site . Providers are given an RSA Secure ID token, which provides an additional level of authentication via the Internet . In addition, all non-Allina clinics that have physicians affiliated with Allina are offered access to ExcellianWeb, a secure, web-based, read-only version of Excellian . The non-Allina clinic staff can view appropriate patient information for billing and continuity of care purposes. Currently, 112 affiliated clinics use ExcellianWeb to access this information .

Excellian provides the Health Information Management system functions for deficiency management, record tracking and release-of- information .

USER AccESS The following chart shows the number and types of Excellian users and a snapshot of the major functions that can be performed in Excellian .

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Application(Date of Initial Implementation) Functions

Cadence Ambulatory (July 2004)

Cadence Hospital (Sept. 2004)

Clarity (July 2004)

Health Information Mgmt. (HIM)/Chart Tracking (Sept. 2004)

EpicCare Ambulatory (July 2004)

EpicCare ED (Sept. 2004)

EpicCare Inpatient (Sept. 2004)

Epic Rx (Sept. 2004)

OpTime (Sept. 2004)

Prelude ADT (Sept. 2004)

Prelude Ambulatory (July 2004)

Radiant (Sept. 2004)

Resolute ProfessionalBilling (July 2004)

Resolute Hospital Billing(Sept. 2004)

OnBase (July 2004)

MyChart (Feb. 2005)

Full scheduling capabilities for ambulatory clinics.

Full scheduling capabilities for inpatient.

Ability to access reports built by the project’s Clarity reporting team.

Chart and file management and tracking, Release of Information, Coding,and Deficiency Management.

Clinical documentation tools including notes and templates, vital signs entry,and all forms of documentation.

Status board, documentation tools, and order sets.

Computerized Physician Order Entry (CPOE); nursing documentation and workflow support; Medication Administration Record (MAR); interdisciplinary clinical notes; care plans, patient education, and charge on documentation.

All pharmacy functions including pharmacy worklist, Pyxis integration,medication charging, allergy and drug alerting, and medication database.

Surgery application - boarding, OR/PACU documentation, charging andmaterials management.

Hospital registration and ADT (Admission, Discharge and Transfer)application for collecting patient demographic and insurance information, including insurance verification.

Clinic registration application.

Radiology application including radiology worklist, exam statusing, andintegration with PACS.

Billing, claims, collections, and A/R management application for professional fees.

Excellian’s billing, claims, collections, and A/R management application for hospital fees.

Non Epic product interfaced to EMR for document management and scanning.

Patient portal allowing patients online access to portions of their medical record such as labs, medications and appointment scheduling.

3. CliniCAl dECision sUPPoRt FUnCtionAlity The primary value of Excellian is to enable users to make more informed, better decisions with comprehensive, accurate data in an efficient, timely manner. Virtually every aspect of Excellian has been designed with that in mind, ranging from how data is organized for review to “pop-ups” for when immediate action is necessary before a decision is made .

ORDER SETSExcellian master order sets are used Allina wide as a starting point to help clinicians work more efficiently. Over 1,300 Excellian order sets have been developed by 53 expert content teams .

The order sets include all orders required for the care of a patient with a given condition, including the core measures, and guide the provider to make appropriate choices based on the specific patient. Order sets are delivered with the

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Details

Drug-Druginteraction

Drug-allergy alert

Medication, orderdefaults & restrictions

Auto-substitutions

Last three labvalues shownduring order entry

Order entry

Protocols

Best Practiceand HealthMaintenanceAlerts

Recall alerts

ImagingGuidelines

EnterpriseProblem List

Care Plan

SmartTexts

SmartSetswith imbeddedguidelines

Flowsheets

Discharge Writer

Patient SummaryReports

Synopsis

Chart/ResultReview

Navigators

ExternalInformationAccess

Physicians, nurses and pharmacists see drug-drug interactions upon signing the order. Physicians andnurses see the “contraindicated” alerts, whereas pharmacists see all levels of drug-drug interactions.Once the alert is displayed, the provider can continue and override the alert by noting an override reason,or discontinue the medication.

The provider is warned when ordering a medication if a patient’s allergy field is blank or has not been verified. Physicians, nurses and pharmacists also see drug-allergy interactions upon entering the order.

Medication files have been built with common dose, route and frequency buttons and where appropriate, the most common of each have been defaulted.

Alerts have been created to notify the user of auto-substitutions approved by the Pharmacy and Therapeutics Committee. For example, if the provider chooses “Zantac,” an alert will fire explaining the auto-substitutionand also suggesting “Pepcid” as the item to choose allowing the provider to place the order without having tostart over.

During inpatient medication order entry the last three values for appropriate labs are displayed. For example,the serum creatinine is displayed for any medication that is renally cleared. If the lab value is outside the normal range, it will be followed by a “!” and the normal value will be displayed.

Built-in preference lists of common orders by specialty help to facilitate appropriate ordering. Orders canbe chosen from pick lists that are organized into clinical categories to assist the provider in locating theappropriate tests.

Protocols enable providers to use standardized methods to manage common clinical conditions, such as the use of heparin for anticoagulation and the replacement of potassium for hypokalemia. The provider orders the protocol in Excellian via a single order, and the nursing and pharmacy staff use custom decision support tools linked from Excellian to determine the appropriate orders and treatment. In addition, Excellian supports the use of protocols for groups or sites that wish to engage in trial quality improvement initiatives.

Alerts such as health maintenance reminders (e.g., flu shot reminders) are built into the system as are best-practice alerts for conditions such as diabetic A1C and lipids monitoring. For example, the lipid panel reminder flag will display if the patient is age 18 or over, has a health maintenance modifier of “Diabetes Registry Active” and hasn’t had a lipid panel in one year. Selective alerts, such as for flu shots, are also communicated to the patient via MyChart.

Alerts for situations such as FDA recalls have been created – an example would be the Bextra and Vioxx recalls. An alert was created that “fired” upon choosing the medication. The alert has text explaining the reason for the alert, including web links, as well as alternative medications to choose. The system is also used to notify patients via MyChart and providers who have patients on the recalled medication. The recalled medication is also removed from all order sets and system-level preference lists.

Payers in the state of Minnesota recently instituted the need to obtain a pre-authorization via phone call formost common high tech imaging studies in the ambulatory setting. Excellian has embedded order questionsthat show the providers the clinical appropriateness for the test based on the reason for the exam and promptthe provider to choose a reason. The payers have agreed that this clinical decision support is an adequate substitute for the pre-authorization phone call. The clinical content for this decision support was developed collaboratively in the community.

Providers are responsible for maintaining an enterprise problem list, based on ICD9 codes with synonyms provided by Intelligent Medical Objects (IMO). The problem lists drive SmartSet prompts and are used toidentify sub-populations of patients for reporting and monitoring (e.g., diabetes in the ambulatory setting)and for specialized care management (e.g., CHF in the inpatient setting).

The Care Plan activity in Excellian is a tool for building, reviewing, and documenting a patient’s plan of care and is meant to be the central organizing tool for documentation and communication. There are currently 125 care plans available in Excellian, which are based on best available evidence or on national standards. Many of the care plans were developed using structured nursing vocabulary for the selected patient populations. The use of structured language facilitates the ability to manage information in an electronic format and compare clinical outcomes across the many care settings within Allina. It also provides a common means of communication and language among caregivers.

Providers and other clinicians use SmartText and SmartPhrases in Excellian to create documentation. SmartTexts were designed with input from caregivers and are standardized across all care settings. SmartTexts are created with four goals: 1) Automatically include key information from the chart (e.g., vitals, certain lab results) for a final review in the note 2) include all sections necessary to guide providers to appropriate, efficient, and complete clinical documentation for the patient’s problem(s) 3) include all sections required for appropriate billing regulatory requirements in the note 4) allow enough flexibility so providers can tailor the note to their personal preference and to allow them to be able to “tell the patient story” coherently.

SmartSets in the ambulatory setting are suggested based on reason for visit and patient problem. SmartSetsembed content such as Institute for Clinical Systems Integration (ICSI) guidelines (e.g., cough, sinusitis, diabetes) and United States Preventative Task Force (USPTF) guidelines (e.g., male and female physical exams) to help guide the user on lab, medication, documentation, coding and patient education best practice choices.

Excellian flowsheets are standardized throughout Allina and guide the caregivers by providing a consistent and appropriate location for documentation of vital signs, I&Os, assessments, interventions and treatment, IVs and other vascular access devices, as well as medications and their dosages.

The discharge writer allows nurses to provide clear, consistent, and comprehensive instructions to the patient at discharge. These instructions include specific, Allina–wide approved, content for the patient which also satisfies core measure requirements. The document is automatically populated with physician discharge orders and medication changes. The clinician can also include a heart failure pictorial for the patient.

Patient Summary Reports are highly flexible tools that aggregate information from multiple sources into one screen and present them to the provider in a manner to support rapid, efficient information review. These are primarily view only reports, although some reports allow limited interaction. These reports are created to meet specific data needs during the patient encounter. Reports contain coded information (e.g., problems, medications, allergies, DNR status), recent documentation, and nursing information (e.g., vital signs, nursing flowsheet documentation), lab data, and medication administration information and caregiver communication information. The reports are designed to meet the information needs of a user in a given role and in a given patient context.

The synopsis tool lists key events in chronological or event type sequence for inpatient, for example medications given and labs completed. By clicking on any item, the event is correlated with a graph of the patient’s vital signs, so a provider can quickly understand relationships in regards to how the care provided impacted the patient, such as correlating an antibiotic given with a fever spike or a medication given with hypotension. Synopsis is an event tracking tool that allows review of lab and medication events and can correlate these events with changes in the hemodynamic state of the patient.

Chart and Result Review provides access to the core, longitudinal repository of all patient data, such as inpatient and ambulatory clinical documentation, EKGs, radiology results, and procedure notes. The data can be filtered and sorted for easy review.

Navigators are workflow tools that guide end users through all of the necessary steps to complete a particular workflow without requiring them to access other parts of the chart.

Links are available from within Excellian to information about medications, diseases, patient education handouts, Allina-wide standards of nursing care, the Allina library (including MicroMedix and CareNotes), and Allina nursing/pharmacy protocols.

Clinical DecisionSupport

most common orders pre-selected (best evidence, consensus-based), as defined by the expert group. Providers can also save defaults for the order sets where details of a specific order can be saved based on the provider’s preference (e .g ., bandage changing instructions); however, providers cannot add additional medications, labs or other new orders to a saved order set . Providers can also access other provider’s saved order set defaults, and many groups designate a single provider to set defaults for the group and then the entire

group “subscribes” to those provider’s orders to standardize care . As many patients present with multiple problems, many providers use a general admission order set followed by one or more secondary order sets . A secondary order set is a problem-specific order set that contains only the orders necessary for that situation (e .g ., recommended labs, medications, antibiotics) but does not contain the general admission orders (e .g ., vitals, I&O’s, etc .)

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Details

Drug-Druginteraction

Drug-allergy alert

Medication, orderdefaults & restrictions

Auto-substitutions

Last three labvalues shownduring order entry

Order entry

Protocols

Best Practiceand HealthMaintenanceAlerts

Recall alerts

ImagingGuidelines

EnterpriseProblem List

Care Plan

SmartTexts

SmartSetswith imbeddedguidelines

Flowsheets

Discharge Writer

Patient SummaryReports

Synopsis

Chart/ResultReview

Navigators

ExternalInformationAccess

Physicians, nurses and pharmacists see drug-drug interactions upon signing the order. Physicians andnurses see the “contraindicated” alerts, whereas pharmacists see all levels of drug-drug interactions.Once the alert is displayed, the provider can continue and override the alert by noting an override reason,or discontinue the medication.

The provider is warned when ordering a medication if a patient’s allergy field is blank or has not been verified. Physicians, nurses and pharmacists also see drug-allergy interactions upon entering the order.

Medication files have been built with common dose, route and frequency buttons and where appropriate, the most common of each have been defaulted.

Alerts have been created to notify the user of auto-substitutions approved by the Pharmacy and Therapeutics Committee. For example, if the provider chooses “Zantac,” an alert will fire explaining the auto-substitutionand also suggesting “Pepcid” as the item to choose allowing the provider to place the order without having tostart over.

During inpatient medication order entry the last three values for appropriate labs are displayed. For example,the serum creatinine is displayed for any medication that is renally cleared. If the lab value is outside the normal range, it will be followed by a “!” and the normal value will be displayed.

Built-in preference lists of common orders by specialty help to facilitate appropriate ordering. Orders canbe chosen from pick lists that are organized into clinical categories to assist the provider in locating theappropriate tests.

Protocols enable providers to use standardized methods to manage common clinical conditions, such as the use of heparin for anticoagulation and the replacement of potassium for hypokalemia. The provider orders the protocol in Excellian via a single order, and the nursing and pharmacy staff use custom decision support tools linked from Excellian to determine the appropriate orders and treatment. In addition, Excellian supports the use of protocols for groups or sites that wish to engage in trial quality improvement initiatives.

Alerts such as health maintenance reminders (e.g., flu shot reminders) are built into the system as are best-practice alerts for conditions such as diabetic A1C and lipids monitoring. For example, the lipid panel reminder flag will display if the patient is age 18 or over, has a health maintenance modifier of “Diabetes Registry Active” and hasn’t had a lipid panel in one year. Selective alerts, such as for flu shots, are also communicated to the patient via MyChart.

Alerts for situations such as FDA recalls have been created – an example would be the Bextra and Vioxx recalls. An alert was created that “fired” upon choosing the medication. The alert has text explaining the reason for the alert, including web links, as well as alternative medications to choose. The system is also used to notify patients via MyChart and providers who have patients on the recalled medication. The recalled medication is also removed from all order sets and system-level preference lists.

Payers in the state of Minnesota recently instituted the need to obtain a pre-authorization via phone call formost common high tech imaging studies in the ambulatory setting. Excellian has embedded order questionsthat show the providers the clinical appropriateness for the test based on the reason for the exam and promptthe provider to choose a reason. The payers have agreed that this clinical decision support is an adequate substitute for the pre-authorization phone call. The clinical content for this decision support was developed collaboratively in the community.

Providers are responsible for maintaining an enterprise problem list, based on ICD9 codes with synonyms provided by Intelligent Medical Objects (IMO). The problem lists drive SmartSet prompts and are used toidentify sub-populations of patients for reporting and monitoring (e.g., diabetes in the ambulatory setting)and for specialized care management (e.g., CHF in the inpatient setting).

The Care Plan activity in Excellian is a tool for building, reviewing, and documenting a patient’s plan of care and is meant to be the central organizing tool for documentation and communication. There are currently 125 care plans available in Excellian, which are based on best available evidence or on national standards. Many of the care plans were developed using structured nursing vocabulary for the selected patient populations. The use of structured language facilitates the ability to manage information in an electronic format and compare clinical outcomes across the many care settings within Allina. It also provides a common means of communication and language among caregivers.

Providers and other clinicians use SmartText and SmartPhrases in Excellian to create documentation. SmartTexts were designed with input from caregivers and are standardized across all care settings. SmartTexts are created with four goals: 1) Automatically include key information from the chart (e.g., vitals, certain lab results) for a final review in the note 2) include all sections necessary to guide providers to appropriate, efficient, and complete clinical documentation for the patient’s problem(s) 3) include all sections required for appropriate billing regulatory requirements in the note 4) allow enough flexibility so providers can tailor the note to their personal preference and to allow them to be able to “tell the patient story” coherently.

SmartSets in the ambulatory setting are suggested based on reason for visit and patient problem. SmartSetsembed content such as Institute for Clinical Systems Integration (ICSI) guidelines (e.g., cough, sinusitis, diabetes) and United States Preventative Task Force (USPTF) guidelines (e.g., male and female physical exams) to help guide the user on lab, medication, documentation, coding and patient education best practice choices.

Excellian flowsheets are standardized throughout Allina and guide the caregivers by providing a consistent and appropriate location for documentation of vital signs, I&Os, assessments, interventions and treatment, IVs and other vascular access devices, as well as medications and their dosages.

The discharge writer allows nurses to provide clear, consistent, and comprehensive instructions to the patient at discharge. These instructions include specific, Allina–wide approved, content for the patient which also satisfies core measure requirements. The document is automatically populated with physician discharge orders and medication changes. The clinician can also include a heart failure pictorial for the patient.

Patient Summary Reports are highly flexible tools that aggregate information from multiple sources into one screen and present them to the provider in a manner to support rapid, efficient information review. These are primarily view only reports, although some reports allow limited interaction. These reports are created to meet specific data needs during the patient encounter. Reports contain coded information (e.g., problems, medications, allergies, DNR status), recent documentation, and nursing information (e.g., vital signs, nursing flowsheet documentation), lab data, and medication administration information and caregiver communication information. The reports are designed to meet the information needs of a user in a given role and in a given patient context.

The synopsis tool lists key events in chronological or event type sequence for inpatient, for example medications given and labs completed. By clicking on any item, the event is correlated with a graph of the patient’s vital signs, so a provider can quickly understand relationships in regards to how the care provided impacted the patient, such as correlating an antibiotic given with a fever spike or a medication given with hypotension. Synopsis is an event tracking tool that allows review of lab and medication events and can correlate these events with changes in the hemodynamic state of the patient.

Chart and Result Review provides access to the core, longitudinal repository of all patient data, such as inpatient and ambulatory clinical documentation, EKGs, radiology results, and procedure notes. The data can be filtered and sorted for easy review.

Navigators are workflow tools that guide end users through all of the necessary steps to complete a particular workflow without requiring them to access other parts of the chart.

Links are available from within Excellian to information about medications, diseases, patient education handouts, Allina-wide standards of nursing care, the Allina library (including MicroMedix and CareNotes), and Allina nursing/pharmacy protocols.

Clinical DecisionSupport

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AGGREGATED DATA ANAlySIS In Excellian, there are two main types of reporting tools for aggregated data analysis and reporting – Application and Clarity reports . Application reports are available real time in Excellian and are mainly used for operational purposes; however they also help to identify specific patient populations for quality improvement and population-based care . Clarity reports are retrospective, aggregated, trending, and analytical data from a relational database . A combination of both reporting tools help aggregate and analyze data .

Application reports help in many ways to improve clinical quality and patient safety . Some reports generate lists of patients that are being treated with certain medications and include relevant lab values . For instance, one Application report identifies all patients on Total Parenteral Nutrition (TPN) and their latest renal function lab value . This report helps pharmacists to verify that the TPN is not negatively impacting the patients’ kidneys, which is a common side effect of TPN . Another type of application report provides graphing functionality that enables providers to visually monitor relevant lab results and evaluate their patients’ clinical patterns . For instance, a provider is able to select the Hemoglobin A1C and Creatinine values of a patient with diabetes and create a line graph of the two lab values over time . The provider can then more easily evaluate the impact of the patient’s diabetes status on their renal function .

There are Clarity reports available to assist with finding any inefficiency within workflows. Some examples are, operative reports that evaluate surgical delays; Emergency Department ‘door to floor’ reports that provide time statistics from ED arrival to triage, triage to ED bed, and ED bed to discharge or admission . A discharge order to discharge time report is used to identify departments that may need more efficient processes in discharging a patient. Time stamps entered in Excellian can be used for analysis .

Reports identify patients with Core Measures ICD codes in their problem list . Patients with diagnoses of heart failure, acute myocardial infarction, or pneumonia are identified in this manner so concurrent review of the patient’s care can occur . Summarized Clarity reports are available to measure provider compliance with Core Measures . For instance, one Clarity report identifies the number of heart failure patients where the Heart Failure Order Set was used, appropriate medications were prescribed, and the patients’ heart function documented .

Together, the Application and Clarity reports help Allina monitor and achieve optimal care for patients with Core Measure diagnoses, as well as Community Measures diagnoses . For example, the Diabetes Exception report monitors patients that are active on the diabetes registry . The report monitors the patient’s Hemoglobin A1C value, LDL value, BP, and aspirin usage and flags any out-of-range values . Another report aggregates monthly values over the previous 12 months at the Allina Medical Clinic level and the Primary Care Provider level . This allows clinic managers and providers to evaluate how well they are caring for their diabetic patient population and identify performance improvement opportunities .

Community Wellness reports are also available in Clarity . Reports of tobacco screening, tobacco use, and documentation of smoking cessation are available for both adolescents and adults . Pediatric exposure to second-hand smoke and pediatric immunization reports are also available to caregivers .

The combination of Application and Clarity reports also help to monitor medication reconciliation . An Application report monitors a department census and identifies patients who have, and have not, had their medications reconciled on admission, transfer, or discharge . An accompanying Clarity report measures the number of patients in a department and the medication reconciliation completion rate over a given time period .

Clarity data is often used to supply external registries and community measurement, such as The Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries .

4. woRkFlow And CommUniCAtions

WORkFlOWExcellian supports the workflow of care delivery in many ways. Order entry enables the flow of information from the provider to every other discipline . In some cases, printed requisitions alert an ancillary department of an order; in other cases the order populates a system list (a type of workqueue) which the ancillary department will reference and manage . Results from tests and procedures are available at the order level, making it efficient to access a result related to the order . External results may be interfaced with Excellian, or scanned and made accessible through the order . Providers and other clinicians are alerted to new results through their patient census lists .

Patient flow is enhanced through the use of Excellian tools. The immediate access to information by all clinicians enables nursing units to better prepare for transfers . Outpatient orders populate workqueues for schedulers, prompting them to schedule patients . Scheduled patients then appear on workqueues to be pre-registered by the Registration Department . Handoffs between departments are streamlined, taking less time than previous methods of communication and also providing greater accuracy . The sophisticated integration of applications has led to greater dependency between functions and the need to understand the impact of one department’s work on all other departments .

The development of integrated workflows to understand handoffs and interdependencies was accomplished through a matrixed approach of the various applications involved in the care and revenue processes, as well as the ambulatory and hospital settings . see diagram on the next page .

Ongoing improvements continue to be made to Excellian-related workflows. Early in 2005 ambulatory users

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Hospital

Clinic

Clinical Revenue Cycle

Hospital OrdersClinical

DocumentationPharmacyOpTime

EmergencyDepartment

Radiant

Cadence Hospital

HIM

Hospital Billing

HospitalRegistration

EMPI

EpicCareAmbulatory

CadenceAmbulatory

ProfessionalBilling

AmbulatoryRegistration

Process/Systems

Integration(PSI)

recognized a need to improve the referral management and results management design of the Excellian workflow and application . A team of site representatives and Excellian team members was formed to determine and address workflow gaps. Both operational and system functionality issues were identified. Minor system enhancements and changes to system settings were made to address the issues . The results management redesign has had a significant impact to providers who are now able to access results more efficiently and consistently. During the implementation, the application teams defined workflow standards with input from the Advisory Groups. These workflows were to be used throughout the organization . The referral management redesign has had a significant impact to clinical and referral management specialists . This redesign has improved workflow processes and patient throughput in the organization .

cOMMUNIcATIONS Excellian caregivers are able to communicate real time, using a number of Excellian features . Following is a brief overview of some of those features .

Inbasket is a tool for sending clinic communication via staff messaging . It is also a messaging system that helps providers keep track of their patients and their care throughout Allina . Documentation completion requirements are communicated to providers via their inbasket .

Orders placed in Excellian are a way of communicating what tests need to be done, supplies that need to be used, or consults that need to occur . Inpatient orders populate a system list for ancillary departments, enabling them to track their patients and work .

Allina patients are offered online access to their Excellian record via MyChart . Patients use MyChart to view lab results, problem list, current medications, allergies, immunization record, health history, account information, health reminders and recent clinic and hospital visits . They can also schedule appointments, request appointment cancellations, update demographic information, and pay both hospital and professional bills . Normal lab results are now communicated via MyChart rather than in a letter or by phone . In the clinic, releasing the lab through MyChart replaces the normal activity of documenting the result as a “Result Note” with documenting the result as a “MyChart Release Comment.” Doing so eliminates all workflow steps after the documentation, including review by the provider’s assistant/nurse, creation of a letter, and mailing the letter or calling the patient .

Telephone encounters can be used as a triage for medication refills or patient calls. They serve as a form of documentation of communications with patients outside of a scheduled visit or hospital encounter .

Letters can be created and tracked within Excellian to show what has been communicated to the patient or other outside sources .

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Brief messages between providers and other caregivers are facilitated by “Dear Dr .” and “Staff Alert” tools . They replace post-it notes in the paper record, are immediately viewable when opening a patient’s record, and can be updated by any caregiver . A feature called “FYI” contains patient level alerts (e .g ., hearing impaired), and is shared longitudinally with any user providing care to a patient .

Workqueues represent a form of communication and handoff between departments . For example, when outpatient orders are received, they populate a workqueue for the patient to be scheduled for the test or procedure ordered .

A pharmacy communication “icon” is available through the MAR to enable nurses to immediately send a message to pharmacy about a medication .

A “sign-out” report function may be used by any discipline to share information efficiently at change of shift.

Along with the communication benefits that an EMR brings can be some unanticipated impacts . One of the unanticipated effects of implementing Excellian was a change in the communication patterns between physicians and nurses, especially in the ICU . Once CPOE went live, physicians had the capability to enter orders from a variety of locations . Nurses voiced concern that previously physicians would be on the unit, discuss the new orders with the nurse, and then write the orders . With CPOE, orders could simply appear and already be on their way to the various departments to carry out the orders before the nurse was aware of the orders . The ICU nurses in particular raised this issue .

Nurses and physicians had to re-establish communication channels and create new methods of communication . For instance, nurses might have to initiate a phone call to a physician who is off site creating orders so that the nurse can understand the rationale behind the orders . Nurses became adept at reviewing the physician documentation to gather additional information about why certain orders were placed . Other electronic features utilized for communication included the “Dear Dr .” feature, which allows staff members to document their questions for the physician electronically, but it is not saved as part of the legal record (similar to a sticky note) . Simply raising the level of awareness of the issue for the physicians helped us to improve the communication issues that were identified. As subsequent sites went live, nursing leadership from the live sites passed on these lessons learned, as well as the strategies for improving communication .

5. dAtA shARing with othER oRgAnizAtions There will always be a need to incorporate information from outside organizations into Excellian, as well as for Allina to share information from Excellian with external organizations .

Data from outside organizations is integrated into Excellian in a number of ways . Much of the information, such as, History and Physicals (H&Ps) from outside providers, is

scanned on receipt or shortly thereafter . Other information, such as a consult letter from a non-Allina provider, is scanned and associated with the original order so that the provider can review the information in the same manner as if the information was created internally . Certain coded information, such as information from a non-Allina provider prenatal visit, is manually entered into Excellian in a way that is consistent with internally-generated information .

Excellian also generates paper-based documentation when information cannot be transmitted electronically . Certain documents, such as inpatient H&Ps, consults, and discharge summaries are automatically faxed to the primary care and referring physician if those providers are not Excellian users . A legal, paper-based, medical record can also be generated on demand in Excellian for release-of-information requests by outside organizations .

6. othER oPERAtionAl And stRAtEgiC ACtiVitiEs

ADMINISTRATIVE INTEGRATION The integration of Excellian with other systems has improved the process of capturing and analyzing data . Allina created a centralized Performance Improvement Reporting and Analysis Department responsible for developing financial, clinical, regulatory and quality reports that managers can access and generate periodically . There is an enormous amount of data available to managers today that previously wasn’t accessible or had to be abstracted manually from paper records or various reports .

pATIENT SAFETyExcellian was designed with patient safety in mind and, therefore, has a number of tools available to prevent errors from occurring . The CPOE implementation reduces the number of handwritten orders; requires specific components be addressed in an order (i .e ., frequency and duration); doesn’t allow the use of abbreviations on the Safest in America’s “Do Not Use List;” and alerts providers to allergies or other contraindications . In addition, clinicians have immediate access to clinical documentation . Having this information at their fingertips supports good medical decision making in a timely manner .

Allina has an external database for tracking and trending patient safety incidents . The data is analyzed regularly to identify patterns of errors and enables development of strategies to prevent future occurrences . Excellian tools have been developed or enhanced to mitigate the possibility of errors . There is a strong partnership between the Excellian team and Allina’s Risk Management Department .

RESEARcHAllina is participating in an Agency for Healthcare Research and Quality grant with two other health systems in the Twin

INPATIENT DOCUMENTATION

PhysicianDocumentation

NursingDocumentation

AncillaryDocumentation

0

0

0

2%*

0

0

21%

0

0

1%**

0

0

76%

100%

100%

PercentPaper

Documents

Percent PaperScannedinto EHR

Percent dictated& transcribed

into EHR

Percent EnteredUsing VoiceRecognition

Percent EnteredVia Template orTyped into EHR

AMBULATORY DOCUMENTATION




0

0

0

0

0

0

25%

0

0

0

0

0

75%

100%

100%

PercentPaper

Documents



into EHR



INPATIENT DOCUMENTATION




0

0

0

2%*

0

0

21%

0

0

1%**

0

0

76%

100%

100%

PercentPaper

Documents



into EHR



AMBULATORY DOCUMENTATION




0

0

0

0

0

0

25%

0

0

0

0

0

75%

100%

100%

PercentPaper

Documents



into EHR



inpatient documentation

Ambulatory documentation

Cites area . The study will evaluate if Emergency Department care is improved for patients with congestive heart failure or asthma when their clinical information in MyChart is available to the Emergency Department provider . Allina is in the process of applying for more government and foundation grants . In addition, Excellian has improved the clinical trial recruitment process and all aspects of clinical trial management .

REGUlATORyOverall, Allina has achieved success when working with regulatory agencies in the electronic medical record environment . A number of Allina’s hospitals have had Joint Commission on the Accreditation of HealthCare Organizations (JCAHO) surveys shortly after their go-lives . The surveyors were quick to appreciate the value of Excellian’s positive impact on patient safety .

Excellian was designed with the JCAHO core measures in mind. The goal was to create discrete fields for reporting elements so the Performance Improvement Reporting and Analysis Department could easily extract core measure data . This foresight has reduced the number of resources necessary to report data .

The Food & Drug Administration (FDA) has conducted routine audits of Allina’s clinical trials . During that process, Allina was asked to provide documentation showing that it met the requirements in 21 CFR Part 11, which focuses on electronic medical record security when capturing data for clinical trials . Excellian met these requirements .

Excellian also provides robust audit trails to support the HIPAA Privacy and Security rules . Excellian provides the ability to monitor employee access to patient records and respond to concerns of inappropriate access .

7. UsER sAtisFACAtion, PRodUCtiVity And EFFECtiVEnEss

SySTEM USEAll caregivers across Allina are required to use Excellian . Policies are in place to promote adoption and consistency of care, including policies to address noncompliant users . Site leadership is accountable for enforcing these policies . Information from the patient chart is not routinely printed and paper orders are accepted only in rare instances . All progress note documentation and immediate post-op procedure notes are required to be documented directly in Excellian . Information that was previously dictated, such as H&Ps, discharge summaries, and procedure notes, can be dictated; although many providers have chosen to create that documentation directly in Excellian . The exceptions to this policy are for “rare” users, physicians with 12 or less patient contacts per year . Rare Users are not granted Epic login access . Each hospital has processes in place to identify a rare user and provide nursing support, including view access to the patient’s electronic record and assistance with computerized order entry . The rare user utilizes the paper version of the Allina Order Set(s) for orders . Handwritten progress notes are not accepted and must be dictated .

The rare user policy helps to set clear adoption expectations for providers regarding training and use of the EMR . It also allows the rare user to continue patient care at the hospital without having excessive training and time spent learning a system that they may not use for months in between patient encounters . The rare user policy helps to reduce the risk that an infrequent user creates .

* Only outside H&Ps

** Voice recognition only used in ED

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In some of the Allina EDs, another option for physician documentation is the scribe program . Scribes are medical students who partner with the physician to perform documentation in the medical record . They are utilized by physicians during peak volume periods, or by physicians who are less adept at using the automated documentation tools . Despite surging ED volumes in past 12 months, the ED for our largest hospital has improved efficiency on just about every measurable front including patient wait times for ED rooms and wait times to be seen by providers, while improving patient satisfaction at the same time . Providers are also able to manage more patients in a typical shift . From the perspective of their inpatient colleagues, including hospitalists, cardiologists and other consultants, notes are much more robust with richer details of present condition and past history, and are available for review in real time .

Pre-procedure orders for elective procedures can be faxed from the provider’s office if desired, or can be entered directly into Excellian . Finally, Excellian does not support certain types of complex orders, such as chemotherapy . In those cases, providers write a paper order that is then entered into Excellian by a pharmacist .

Virtually all departments have returned to or exceeded baseline productivity metrics after the expected transition time to Excellian . While provider adoption and usage of Excellian is monitored for a time following the implementation, ongoing monitoring is not needed . On the rare occasion that an inappropriate paper order is written or a provider gives inappropriate verbal orders to circumvent CPOE, the Site Physician Champion is notified by the nurse or unit coordinator to assist the provider in transitioning to Excellian . The percentage of orders entered directly by providers in the hospitals is 72 percent . (Note: The number of orders entered directly by CPOE is artificially decreased due to protocol, chemotherapy and pre-op orders categorized by the reporting system as verbal orders .)

In the ambulatory setting, all physicians are required to use CPOE and 85% of orders are entered directly (not just e-signed) by a physician, resident physician, nurse practitioner or physician assistant .

The adoption of documentation completed within Excellian is outlined below .

At Allina’s hospitals, the patient does have a shadow (paper) chart that contains limited information (i .e ., signed consent forms, telemetry strips) and is rarely accessed by caregivers . In the clinics, all incoming paper-based information from external sources is immediately scanned into Excellian, and the paper chart is no longer needed or accessed by providers after a transition period .

Users only need one user ID and password to log into Excellian to access the information they need to do their work . The large majority of users never log into any other systems outside of Excellian . However, a separate ID and password may be needed for other departmental systems to complete certain tasks (e .g ., CVIS) .

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“It’s been very helpful to have one source of patient information. I also work at the clinic and often use the chart review to triage patient calls. It’s very helpful to look back at clinic records to see what a patient’s prescriptions and diagnoses are when they come to the emergency department. It helps the doctors and nurses provide better care and triage properly.”

– Mercy Hospital Critical Care Float Pool Nurse and Excellian Super User

“Excellian has a positive impact on our work. We’re able to access the patient’s chart in an easy and quick manner. We don’t need to depend upon others to call back with details. Having simple information such as height and weight helps us gather pieces to the puzzle of ‘what’s going on,’ which is essential in critical situations. It’s also helpful to know the patient’s history so that we’re aware of what issues they may have had in the past and can apply that information to our current study.” – Echo staff at Mercy & Unity Hospitals

USER SATISFAcTIONIn late 2006, Allina developed a customer satisfaction survey to obtain feedback about Excellian The survey was conducted using a web-based program and consisted of eight questions, as well an open-ended question for general feedback . The audience was split into two different groups, physicians and non-physicians . The survey was conducted at the three hospitals with the longest Excellian history .

The non-physician survey period was January-February 2007 . Preliminary results indicate that 82 percent of non-physician users are satisfied with Excellian (i.e., combined ratings of good, very good, and excellent) . The physician survey period was February-April 2007 . Results are currently being tabulated . Future surveys are planned .

Allina has established several forums to obtain feedback from end users, including many of the forums discussed throughout this document such as the Patient Care Excellian WorkGroup, advisory groups and user groups .

Allina Hospitals & Clinics TECHNOLOGY

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TECHNOLOGY

1. sCoPE And dEsign oF EmR systEm

SySTEM DEScRIpTION, ARcHITEcTURE, AND DATA MODElservers

Excellian, which currently supports nearly 28,000 end users, is hosted across 24 dedicated servers . These servers are a mix of IBM AIX Unix (14) and Intel Windows 2003 (10) .

The AIX servers consist of four p570 16-processor backend servers providing database, database failover, and reporting functionality with an additional ten p550 4-processor application servers . The Intel servers are 2-processor servers providing reporting, printing, patient portal, and affiliate portal access functionality . All servers hosting critical functionality have been architected in a redundant fashion . The Unix servers utilize IBM’s HACMP technology or N+1 load balancing, while the Intel servers utilize either Microsoft clustering or N+1 load balancing . No critical single server component or complete server failure will cause system unavailability .

storage

Separate storage tiers have been implemented for different Excellian functionality . Performance and data backup requirements are the main drivers for storage tiers . The primary Excellian database is hosted on a dedicated IBM DS8100 storage array in a RAID 10 format . This database is currently 1 .5TB with a growth rate of approximately 3GB per day . Using IBM’s FlashCopy technology, Allina is able to back up the primary database with a minimal 20-second nightly system freeze . Reporting and other servers are hosted on either a shared IBM ESS800 or HP EVA storage arrays . The SAN fabric is fully redundant for all storage arrays independent of tier .

desktop

All Excellian clinical functionality is accessed via a single desktop client . Excellian is currently on 17,000 desktops . The clients are remotely loaded and managed (i .e ., updated) utilizing Novell ZENworks . The low-end desktop environment includes a Compaq 1Ghz Pentium, 1 .2GB hard disk with 256MB RAM . The current desktop standard is a HP 3 .0GHZ processor, 1GB RAM, with an 80GB hard drive .

Remote access

Remote access to Excellian data is provided in several ways:

• Citrix - All physicians are offered remote access to a Citrix-hosted Excellian desktop client . This client is accessible from any desktop with an internet connection and by using a RSA secure token . The remote access Citrix farm currently consists of 10 Intel blade servers, which can handle 500 concurrent users . Allina currently has 3,500 physicians using RSA tokens .

• MyChart – Clinic patients can request access to portions of their medical records via the web-based MyChart patient portal that is hosted on two load-balanced Intel servers . This capability is currently available at over half of Allina’s clinics with more clinics being added each month . Currently, 26,000 patients are signed up for MyChart access .

• ExcellianWeb – Affiliated clinics can access a subset of Excellian information via the ExcellianWeb portal . This access is only available to clinics via a secure connection (i .e ., RSA token, VPN LAN-to-LAN) . The ExcellianWeb portal is currently hosted on two load-balanced Intel servers and accessed by 3,000 users .

INTERFAcES/INTEGRATIONWhile the implementation of Excellian replaced multiple legacy systems with a single integrated system, some legacy systems and other medical equipment/devices remain .

The data in Excellian is either entered by the end user via the Windows Graphical User Interface on the desktop or electronically interfaced using an HL7 feed from other third-party systems . There are two main ways in which data integration occurs. The first way is importing data directly into the system through HL7 electronic interfaces and viewing it in Excellian . Lab results are interfaced this way and stored directly in the Excellian database . The second way is by storing a link in the Excellian database . When the hyperlink is clicked within Excellian, the link is opened with the appropriate data view . Document management scans are an example of this method . While it appears to the user that they are accessing information through Excellian, the data is actually stored within the document management system and just displayed in Excellian .

Excellian currently imports data from nine third-party applications; the majority of the data is transferred using HL7 interface feeds . This data includes transcription reports, lab information (e .g ., status, results, charges), radiology and EKG results, and pharmacy medication dispensing records . An average of 75K inbound HL7 transactions are processed by the system each day . If you include biomedical device interfaces, the system processes an additional 569K inbound HL7 interface transactions per day . Excellian also exports data (e .g ., pharmacy orders, ADT updates, and patient scheduling information) to other systems using outbound HL7 interfaces, which average 129K transactions per day .

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Excellian consists of a single database, which is shared by all applications . The single Cache database is hosted on a dedicated enterprise storage area network (SAN) . The daily growth of the Excellian database averages over 3GB per day

network

The Allina network is organized in a star, or hub and spoke configuration. WAN links for most remote Allina facilities, business partners, and Internet Service Providers are terminated at the main data center (“Park”) . Firewalls (Cisco) are installed for Internet/business partner security . The WAN is composed of a Qwest high-speed GeoMax fiber ring linking the major (“Tier 1”) facilities to Park with 2GB circuit bandwidth . A Single DS3 link connects regional hospital (“Tier2”) facilities . Qwest QMOE (10Mbps) is used for clinic locations (“Tier 3”) if geographically permitted . One or two T1 Frame Relay links connect most clinic locations . Internet bandwidth is 90 Mbps . Our Internet Service Providers (ISP) are Qwest and Verizon (UUNet) . We have a DS3 to each ISP . IPSec LAN-to-LAN and client-based VPN is supported . The standard LAN topology is Ethernet-10BaseT or 100BaseT running over Category 5/6 UTP station cabling . The standard networking protocol is TCPIP . Router, switch, and wireless equipment are from Cisco . Wireless coverage is mixed – several sites have wall-to-wall and some have hot spot deployments .

scalability

Allina has continued to adapt hardware capacity and system architectures to meet additional user capacity throughout the implementation . Allina is currently on its second generation database servers and SAN storage area network . This path was chosen so that expense was not incurred earlier than necessary and, as with all technology, would have soon become obsolete . The original servers and SAN storage are still being utilized in testing and training capacities . In addition, Allina has implemented Epic’s Enterprise Cache Protocol (ECP) application server architecture to scale to the required number of concurrent users . The implementation of the ECP architecture has extended the life of the backend database servers; and with the recent addition of two more ECP application servers, Allina has the hardware capacity to complete the implementation .

data model

All sites share a single database instance . If a patient is seen in one Allina facility, the Excellian data from that visit is instantly available at all Allina facilities .

INTEGRATION AND TRANSFERAbIlITyThe following graphics illustrate the information flow between Excellian and other major application modules, sources and repositories .

EMERGING TEcHNOlOGIES Excellian introduces over 300 changes into the Production system on a monthly basis . Allina has developed a rigorous release management and change control process which is executed for all new technologies . Each change is reviewed and classified as minor or significant. Minor changes are allowed into the system any time Monday through Thursday . Significant changes are allowed to migrate to production the first or third Tuesday of the month between 5am and 7am .

System performance is monitored during testing to proactively minimize degradation .

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2. sECURity And dAtA intEgRity

SEcURITy/cONFIDENTIAlITy AND HIpAA cOMplIANcE Each end user has a unique user ID and password to access Excellian . The system prompts users to change their password every 180 days . Desktops are generally set to timeout after 15 minutes of inactivity. In high traffic areas this time is shortened . Based on their role, users are assigned the appropriate access to the system . Allina’s strategy is “access with accountability .”

Allina’s Employee Standards of Business Conduct address confidentiality and protection of patient health information, which is reviewed with employees annually . Accountability is two pronged – personal and organizational accountability .

Personal accountability is defined as the user’s obligation to safeguard patient health information . The user will be held accountable for anything they do that is deemed inappropriate . Organizational accountability is defined as Allina’s obligation to ensure users have received education regarding appropriate use and the expectation to report inappropriate conduct .

Non-employee users are required to sign a system user agreement that includes expectations around use of the ID, password and electronic patient health information . Allina has a compliance driven monitoring process for end user access . Complaints are investigated using the audit trails generated by Excellian and the same audit trails are used to actively monitor access based on designated criteria . For example, Allina monitors employees accessing the health record of other employees. If inappropriate access is identified, the end user is subject to disciplinary action, which may include termination .

For certain patients that require additional levels of security, the “Break the glass” functionality has been implemented . “Break the glass” functionality is used by Allina Hospitals who have federally funded substance abuse programs as defined by CR-40. Any employee who attempts to “enter” the electronic medical record of a federally funded substance abuse program patient encounter, who is not pre-approved or has been added to the treatment team, will receive a warning on the screen which states: “This is a protected medical record . You are prohibited from entering this record unless you are involved in the care of this patient . Upon entering this record, your name will be reported to management as having entered this protected record .” The employee must also identify a reason for entering the record if they continue to proceed . Entering the record, whether there is a legitimate reason or not, is referred to as “Breaking the Glass” .

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All entries to a patient’s record by Breaking the Glass, are submitted in an electronic audit report immediately to the designated leaders in the facility, including leadership in the Behavioral Health Department . Leadership will normally review this audit report daily, but no later than 72 hours after an incident has occurred, and determine whether inappropriate access to a protected record occurred . If it is determined that an employee entered a record without an acceptable reason, he/she will be disciplined appropriately . Employees that are part of the substance abuse treatment team are pre-approved to have access to these records and would not receive a “break the glass” message . Members of this team would include nursing staff, aides and health unit coordinators assigned to this unit, substance abuse counselors, psychologists, pharmacists, dietician, coding staff, and designated physicians that routinely provide services to these patients . If there is a need for another health care provider, eg . physical therapist, etc ., to provide services to a substance abuse patient, an approved employee can add this provider to the “Treatment Team” within that patient’s electronic record, thus allowing that provider to have limited access to this record, for purposes of both reviewing and adding documentation . Members added to the Treatment Team will not have access to the substance abuse counselor’s assessment, progress notes, and other documentation that is related directly to the treatment process for the patient and is not needed to perform their duties .

SySTEM INTEGRITy/ cONTINUITy plANNINGExcellian integrity checks run regularly . All data elements are cycled/validated every two weeks . Excellian utilizes IBM’s FlashCopy technology for nightly backups of the database . In the event of corruption, Allina can use the previous night’s backup and replay journal files up to the point of corruption. The timing of this process is dependent on the point of corruption and how many journal files need to be replayed. When the Excellian system is unavailable to the end users, downtime reports are utilized as a point of reference and patient information is tracked on paper forms located in each business unit . Reports from Excellian are spooled to designated downtime PCs on a scheduled basis depending on the criticality of the information . This may happen as often as every ten minutes (i .e ., MAR) . This process is used for both planned and unplanned downtimes .

When the system is unavailable to users they have access to a read-only version of Excellian . This allows access to critical patient information .

Each site is responsible for the documentation and on-going training of the site business continuity plan . Beginning in 2007, Information Services is also conducting organization-wide downtime drills . These drills are scheduled to occur every other month for the entire year . The goal is to ensure all employees are prepared to execute business continuity plans in the event of an unplanned downtime . In addition, Information Services executes two disaster recovery tests a year . This test ensures technical resources are aware of how to activate the disaster recovery hardware, in addition to ensuring documentation is current .

Allina has a documented Disaster Recovery Plan that is designed to provide immediate response and subsequent recovery from any unplanned business interruption, such as a loss of a critical service (computer processing, telecommunications), a loss of building access (contamination, etc.) or physical facility catastrophe (fire, sabotage, etc.).

The full plan is executed twice a year by the technical support staff for the purpose of verifying Excellian system integrity . The testing ensures the functionality and configurations are current with the production environment .

An integrated test of the Excellian Disaster Recovery PRD environment and integrated Severity 1 applications including Cloverleaf (interface engine), Bridges, LDAP, Batch Scheduler, the PACS system, Document Management System, Blood Bank and Lab are tested together . This comprehensive test includes verifying the ability to pass orders/patient data between integrated systems .

Allina’s disaster recovery hardware is housed in a separate physical location from the production hardware . During normal business operations, these servers merely receive information real time and the utilization of these servers is minimal . The disaster recovery tests cut the link from production to the disaster recovery servers and emulate the use of the servers as if it were production .

DATA ARcHIVING AND STORAGEPatient information in Excellian is saved indefinitely. Selected non-clinical, non-patient information is periodically purged from the system .

3. stAndARds Although Epic tools allow customers a great degree of customization in screen design, it was an important principle of the Excellian project to maintain consistency in the user interface design . The reason for this consistency was not only expediency, due to a relatively short timeline, but to support the foundation of standardization across Allina facilities . Standardized design allows employees from any facility to use the Excellian tool in any other facility .

One limitation of Epic tools is the difference in the user interface between inpatient and ambulatory settings . Epic developed the user interface to maximize efficiency of the workflow in each setting. The extent to which we are able to provide consistency for those users working in both settings has improved over time . Epic is aware of this need and continues to make progress in this area . Going forward, we have put in place user groups with both ambulatory and inpatient representation which provide the input necessary to achieve better consistency .

The chart on the next page shows the many Excellian interfaces and their standards along with Allina’s messaging partners .

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Interface MessagingPartner

ProjectDuration(months)

3

9

6

6

3

18

6

9

4

6

12

9

18

3

Planning

Reg/Sched/ADT(Inbound & Outbound from EMR)

Scheduling Outgoing - HL7 (SIU)

ADT Outgoing - HL7 (ADT)

ADT Incoming - HL7 (ADT)



Transcription

Hospital Transcription Incoming - HL7 (MDM)

Ambulatory Transcription Incoming - HL7 (MDM)

Legacy Ambulatory EMR

Conversion

Vaccination Administration Incoming - HL7 (VXU^V04)

Medication Administration Incoming - HL7 (RDE^R01)Lab Results incoming - HL7 (ORU)

Vitals/History Incoming - HL7 (ORU)

Problem List Incoming - HL7 (PPR)

Legacy RIS

Hospital Radiology Incoming - HL7 (ORU)

Lab

Orders Outgoing - HL7 (ORM)

Order Status and Results Incoming - HL7 (ORM/ORU)

Charges Incoming - HL7 (DFT)

Document Imaging

Scanned Document Link Incoming - HL7 (MDM)

Batch Scanned Document Link - HL7 (custom)

Biomedical Devices

Device “gateway” implementation

Biomedical device results Incoming - HL7 (ORU)

Biomedical device results Incoming - HL7 (ORU)

IVR Systems (CBO, Bedtracker,Infinity, Transport)

Account Information Query/Response - HL7 (custom)

Housekeeping Bed Status Incoming - HL7 (ADT)

Abstract & Coding

Enterprise Coding Incoming - HL7 (ADT)

HDM HL7 Enhancements

X12 - Revenue Cycle & File Mannagment

Eligibility Query/Response Interface -X12 (270/271)

Claims Interface - X12 (837i/837p)

Remittance Interface - X12 (835)

Claims Status Request Interface - X12 (276/277)

Epic Standard Address Verification Interface -HL7 (QPD/RSP)

Pharmacy

Pharmacy Orders Outgoing - HL7 (RDE)

Pharmacy Dispense Incoming - HL7 (RDS)

Medication Load/Unload - HL7 (custom)

Retail Pharmacy integration - HL7 (ADT)

Instymeds integration - HL7 (ADT)

PACS/CVIS

Outgoing Orders and Results - HL7 (ORM/ORU)

Assorted “mini-pacs” and CV applications -HL7 (ADT)

CV/EP Procedure Orders - HL7 (ORM)

CV/EP Results - HL7 (MDM)

EKG Orders (ORM)

EKG Results (ORU)

Financial

CV Charges - HL7 (DFT)

Supply/Balance Masterfile Update Incoming -HL7 (MFN)

Various

Various

STAR (Legacy HIS)

Vitalworks (LegacyAmbulatory Reg)

BeyondNOW(Home care EMR)

Various

Dictaphone

Logician

Logician

Logician

Logician

Logician

Logician

STAR (Legacy RIS)

Ultra

Ultra

Ultra

Onbase

Datacaptor

Datacaptor

Drager

Avaya VoiceResponse

homegrown

HDM

various

various

various

HealthPartners

Search America

Pyxis Medstation

Pyxis Medstation

Pyxis Medstation

NDC Pharmacy

Instymed

Ultravisual

various

Apollo

Apollo

Muse

Muse

Witt

Lawson

4. PERFoRmAnCE System performance for Excellian has previously been addressed in two separate initiatives over the course of the implementation. The first initiative addressed what could be done immediately (2Q 06) to address growing concerns regarding system performance . This concern was mitigated by identifying application inefficiencies in the Epic code and concurrently implementing a dedicated Excellian storage server . The second initiative addressed how to maintain performance and to safeguard the system from performance issues . This initiative included monitoring system changes during the testing process, as well as throughout the migration to Production .

The scheduled downtime window was negotiated and agreed to with the business units and Information Services . Two scheduled downtime windows are available each month . The trend has been to utilize one or less downtime windows each month . In the past six months, there have been no unplanned downtimes and 732 minutes in scheduled downtime minutes . Excellian availability for 2007 is currently at 100% . Availability is tracked and reviewed once a month – the target as documented in the Service Level Agreement (SLA) is 99 .9% .

Following are the lessons learned as it relates to standards:

• While a narrowly-focused development approach to interfaces fostered rapid development (most completed by May 2005), this approach hindered Allina’s ability to design interfaces that consistently filed data logically in the patient chart. This required a significant optimization/clean-up effort required to standardize the appropriate location of clinical data .

• Centralized management for connectivity to payers for X12 EDI transactions was underestimated . Initially, there was no staffing allocated, and as such, Allina had to reallocate resources scheduled to work on other interfaces . There was also a lack of understanding from Epic on Allina’s payer connectivity .

• Allina initially experienced higher levels of interface errors for transactions triggered from “legacy” workflows. Lack of “coded” data (e .g ., meds, problems) in the legacy EMR caused significant numbers of errors during conversion, as well as during the interim period while multiple EMR’s coexisted . Master Patient Index (MPI) errors (e .g ., duplicates) not resolved in legacy registration and clinical applications, propagated after users converted to Excellian .

• Evolving change management procedures delayed full integration testing . Application changes required build in multiple environments (training, testing, etc .) and lack of enforcement (early on) of change control procedures in the test/development environments .

RESpONSE TIMEResponse time is measured by calculating Enterprise Cache Protocol (ECP) latency and disk service time . These calculations are tracked and reviewed monthly .

ECP Latency measures the time it takes for an ECP application server instance to retrieve a random block of data from the main database server . The threshold for this measurement is 12 milliseconds (ms) . ECP latency is collected every three seconds on all ECP server instances (40) . The SLA goal for this measurement is that 99% of all collected data points per month will fall below 12ms . See chart below .

Disk service time is a measurement of how long it takes the database server to retrieve a random block of data from disk . The threshold for this measurement is 15ms . Disk service times are collected every eight seconds across eight separate file systems. The SLA goal for this measurement is that 99% of a 64 second rolling average falls below 15ms . See chart below .

SERVIcE lEVEl AGREEMENTSThe Excellian SLA was created by site operations and IS staff . The focus of this agreement was to address two main pain points experienced in 2006, availability and performance, which are reported and reviewed on a monthly basis . The expectation is that the system is available 99 .9% of the time, that 99% of all data points collected for ECP latency are < 12ms and 99% of a 64 second rolling average falls below 15ms for disk service times .

UpGRADES AND ENHANcEMENTS All changes/enhancements introduced into the system follow the aforementioned Excellian Release Management Policy . Changes classified as significant are allowed into the system the first and third Tuesday of the month between 5 a.m. and 7 a.m.

Allina’s first upgrade was in late 2004. The next upgrade is scheduled for mid 2008 . Post implementation, Allina’s upgrade policy is to complete a major upgrade every other year .

AVAIlAbIlITy

Availability is tracked by utilizing the following formula:

Agreed Upon service time - Unplanned downtime min. * 100 = % Available

Agreed Upon service time

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n% DiskService Time % ECP Latency

Jan-07Feb-07Mar-07Apr-07

99.5199.5599.5498.50

99.3399.3299.3399.35

Allina Hospitals & Clinics VALUE

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Anticipated Total Annual clinical/Revenue Cycle Benefits:

$65,541,319 Annually

VALUE1. sUCCEss in mEEting ExPECtAtions oF thE PRojECt goAls, BUsinEss CAsE, And tARgEtEd PRoCEssEs

VAlUE/QUANTIFIAblE bENEFITSSince the early planning stages, Allina has focused on achieving measurable benefits from Excellian. Allina has several strategies to achieve desired benefits and formed a team to execute those strategies . An estimated ROI of approximately $65M annually is anticipated once Excellian is fully implemented in all of its hospitals and clinics . The tables to the right outline the areas, both clinical and financial, where benefits are expected.

Following is benefits data from Allina’s largest metro hospital (Abbott Northwestern) and a regional hospital (New Ulm Medical Center), which went live with Excellian in July 2005 and December 2005, respectively . Hospitals that implemented Excellian in 2006 have not been using Excellian long enough to realize measurable benefits. The improvements listed below were measured between December 2005 and November 2006 .

Clinical improvements• Improvement in time from ED to inpatient bed arrival up

to 50 percent .

• Improvement in wait time in the ED – 91 minute wait reduction at Allina’s largest hospital

• Dictation time reduced 17 percent at the largest hospital

• Improved nursing documentation – examples include:

~Nutrition screening = 28 percent improvement

~Documentation of response to pain intervention = 26 percent improvement

~Discharge screening = 17 percent improvement

~Weight documented within 24 hours = 3 percent improvement

• ADEs trending down at live sites

• Reduction in drug utilization costs by 29 percent

• Duplicate testing has been virtually eliminated

• Charge on documentation greatly reduced nursing time spent on administrative tasks

• Core measures data collected through electronic reporting and use of order set questions

• Improved compliance to core measure documentation using admission and discharge order sets with embedded core measure elements and the discharge writer tool in Excellian (example: ANW Improved Outcomes)

One example of how Excellian supports the ability to reduce drug utilization costs is through system lists . Various system lists for Pharmacy daily rounds have been created to assist with care improvement . One example is the drug therapy - iV to oral list . This list helps pharmacists determine which patients are currently receiving a specified list of IV products . Pharmacy, in conjunction with nursing, reviews those patient’s charts to determine if it is appropriate to change the route of the medication(s) from intravenous to oral . Each hospital determines its own list of medications for which pharmacy can change the route without contacting a provider. The benefits to the patient include decreasing the chance of infection from extended IV therapy, and potentially a decreased length of stay, as the ability to take oral medications can determine eligibility for discharge . Nursing time savings are realized from no longer needing to monitor and administer IV therapy . Preparing an oral product takes less time than preparing an IV product, resulting in Pharmacy time savings . Also, cost savings are realized as an oral product is less expensive overall than an IV product (both in medication expense and staff expense) . Allina does not have metrics on the savings generated, as this process has been in place for some time . Excellian provides the ability to produce these lists in an accurate, timely and efficient manner.

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Pneumonia Average Length of Stay (ALOS)

ANW

Mercy

United

Unity

2004

4.56

3.32

4.01

3.94

2005

3.90

2.63

3.30

3.32

Circulatory Disorders Average Length of Stay (ALOS)

ANW

Mercy

United

Unity

2004

4.29

4.12

4.58

3.30

2005

3.54

2.52

3.89

2.41

Pneumonia Average Length of Stay (ALOS)

ANW

Mercy

United

Unity

2004

4.56

3.32

4.01

3.94

2005

3.90

2.63

3.30

3.32

Circulatory Disorders Average Length of Stay (ALOS)

ANW

Mercy

United

Unity

2004

4.29

4.12

4.58

3.30

2005

3.54

2.52

3.89

2.41

• ALOS decreased significantly at the hospitals

• 45% of patients at United use ICU resources compared to 16% at Mercy

• The transfer of patients from Unity Hospital early in their care contribute to Unity’s lower cost/case

• ALOS decreased significantly at all metro hospitals

• All hospitals are at or below 2004 target inflated

bENEFITS REAlIZED AT AbbOTT NORTHWESTERN• Initially worked with Heart Failure (HF) patients cared

for by Minneapolis Cardiology Associates’ physicians on telemetry units; Work spread to all HF patients Spring 2006

• Changes tested:

~Developed/implemented standardized paper HF discharge paper order sets

~Worked closely with identified Physician Champions to help engage physicians’ support and use of paper order sets

~Worked with Mercy, Unity and United to develop Excellian HF discharge order set and HF discharge writer

~Order sets included ACEI/ARB and LV assessment core measures; Discharge (DC) writer included discharge instructions and smoking cessation information

~Excellian DC writer implemented May 2006

~Excellian order sets implemented June 2006

~Added smoking cessation information to all CV DC writers July 2006

• Reduction in Clinical Resource Utilization (examples – two graphs demonstrate ALOS trending down 2-4 years out)

4Q 2006 numbers preliminary: 30 patients reported

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oPtimAl CARE sCoREs


ExcEllIAN HF ORDER SET/DIScHARGE WRITER USE

AbbOTT NORTHWESTERN HOSpITAlUSE OF ExcEllIAN HEART FAIlURE TOOlS

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Revenue Cycle improvementsLargest Metro Hospital (Abbott Northwestern):• Accounts receivable days – 21 percent improvement

• Claims denied – 27 percent improvement

• Number of wrong insurance claims – 50 percent improvement

• Data Quality – 20 percent improvement

• Eligibility determination – 25 percent improvement

• Patient Identification – 25 percent improvement

• The number of Health Unit Coordinators (HUCs) was reduced by 20 percent from 2006-2007 due to physicians utilizing CPOE

• Transcription volume reduced by 25 percent

• Scanning reduced by 57 percent

• Bill pay online program instituted with 281 per month average and trending upward

Regional Hospital (New Ulm):• Accounts receivable days – 4 percent improvement

• Claims denied – 35 percent improvement

NOTE: Additional data quality benefits are not available due to the hospital’s transition to a Critical Care Access facility.

bENEFITS OF pATIENT AccESS AccOUNTAbIlITy MODEl (pAAM)PAAM is a methodology of accountability used in patient registration and verification – a process to capture pertinent patient information up front at the initial patient contact .

• PAAM used in concert with Excellian functionality leads to a reduction of denials due to incomplete or incorrect patient information collected at the patient access point to the hospital or clinic, a reduction of data quality errors, and leads to front-end collection of member financial responsibilities.

• These three areas account for the majority of the estimated Revenue Cycle Benefits. Examples of PAAM’s impact at Allina’s largest hospital:

~Denials decreased by 52 percent (from pre-Excellian implementation) within three months of PAAM methodology implementation

~Department consistently exceeds average cash collection goal every month since implementation

~Re-work of accounts due to errors is virtually eliminated

~Improved management decision making and reporting capabilities

INTANGIblE bENEFITS• Improved audit capabilities

• Provided the ability to share information across sites

• Increased patient and family satisfaction

• Improved quality of patient care with improved information access at point of care

QUAlITy/OUTcOME IMpROVEMENTSThe use of standardized order sets has increased the effectiveness of care in multiple specialties . One such area of note is the delivery of care to congestive heart failure patients, where use of the standardized order set demonstrates a strong correlation with reaching Allina’s Optimal Care score . Hospital sites with the highest usage of the CHF Discharge set demonstrate a correspondingly high score in their Optimal Care outcomes . These outcomes are measured through use of the EMR reporting tool as well as MedStat and other outcome metrics . Other examples of improvements are:

• Reduced variation of care among physicians due to development and use of standardized order sets and protocols

• Better continuity of care due to development and use of standardized discharge writer templates

• Improved population health management due to development and use of Health Maintenance Reminders

• Improved clinical collaboration during the development of standardized, best evidence order sets

• Improved data collection and quality monitoring using admission and discharge order sets for core measure case types

• Improved quality of diagnostic and outcome data to support diagnosis and research

OpERATING EFFIcIENcy• Ability to search for and remind caregivers of

incomplete data

• Improved patient care and medication documentation

• Improved legibility and organization of record

• Improved tools to navigate the chart and find data

• Less effort to enroll patients in clinical trials resulting in increased enrollment

cONTINUOUS IMpROVEMENTCommunication to all of our employees on our work towards continuously improving our ability to provide excellent care is very important to Allina . To facilitate this process, the Measures of Caring scorecard has been developed and posted on the main page of the company intranet . The scorecard gives detailed, trended information on our progress towards achieving core measures and best practice standardization in our ambulatory and hospital settings . Data is abstracted and reported monthly from the EMR utilizing the system’s reporting module and combined with data from other internal sources (e .g . the coding system) .

Single protocol for consistent practice process was complex and confusing Allina continues to explore ways to couple evidence based materials with deepening sources of internal quality data to enlighten and improve on internal best practice . An example is alcohol withdrawal protocols, where data is being used to compare practices at various Allina sites – including cost of care as well as clinical outcomes – so as to arrive at a single protocol for consistent practice .

Core measure improvement requires active monitoring of key data points within the EMR, consistent approaches to EMR work flow and data collection, and a collaborative model of system wide and individual site attention . The model seeks to achieve a balance of sharing and monitoring at the system level, including sharing of best practices and clear expectations from leadership on the results to be achieved . This includes key point people at each site accountable for delivering the results (local leadership sponsors), local and system project management, accountability at each site to communicate and involve all relevant stakeholders, and active Allina Leadership sponsorship . Every site has a communication plan for keeping employees informed of core measure results and improvement activities .

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As Allina becomes more adept at configuring our electronic tools, we continue to see improvements in our care measures . One example of an initiative attaining clinical benefit was the improvement of the workflow and tools to provide pneumonia vaccinations to hospital patients . The process had duplicative documentation steps; patients were not consistently being identified and given the vaccine; and the process was complex and confusing . A collaborative work team staffed by the performance improvement group, the clinical decision support team, the core measures team, site-based quality staff, and Excellian designers led to the creation and adoption of system-wide pneumonia vaccine guidelines that identify which patients are eligible and when nurses should give the vaccine . The guidelines are now designed to be immediately available to the nurse during the online admission assessment process . They are electronically prompted through the correct documentation on the admission flowsheet. Revised language made it more intuitive for the nurse to know when to give the vaccine . Administration of the vaccine was changed from discharge to Day 2 of the hospital stay, streamlining the ordering and administration process . The process and system changes make the process simpler for nursing and pharmacy and have shown measurable results on our core measures improvement scorecard .

Three Allina sites are not yet implemented . Although they are not large metropolitan sites, they do provide us the opportunity to return to our benefits framework and actively collect pre- and post- implementation metrics . We have approached our local university to partner with us to complete this work . One approach we are evaluating involves utilizing some of the existing quality data from live sites, baselining this against future sites, and monitoring improvement/movement against internal best practice .

cHAllENGES AND lESSONS lEARNEDBenefits Realization for a large implementation requires intricate planning and dedicated resources .

Some of the lessons Allina has learned from the Benefit Realization process are:

• Hold local leadership accountable to deliver on benefits.

• Establish a select few well defined core benefits to be monitored, consistent across all sites, with established baselines and outcome goals

• Agree up front on which data to collect, the data source, and the process for collecting and analyzing the data .

• Monitor both process metrics (from pre-implementation through a defined post-implementation period of 6-9 months) and outcome metrics .

Reasons why Allina reached a less than complete realization of benefits can be attributed to:

• Model too generalized and theory based . When it came to actually delivering benefits measures, the needs of care areas were not consistent with the model’s promised benefit. An example would be in reduction of unit secretary FTE’s: many areas require desk coverage while the model asked for a partial reduction in FTE, which could not be accommodated while continuing to meet the needs of the care center .

• Lack of full understanding of the model by sites . The paradigm in place was essentially a new method of benefit realization and preparation and system resources were not fully staffed to provide education to sites as well as follow up .

• Data collection and reporting was under resourced at both the corporate and site levels .

• Outcome and process metrics may well take longer to show improvements – do not underestimate the amount of change to work processes and approaches on the delivery against goals .

• Successful improvements are a measure of the EMR, work process improvement, and individual and collective learning. Any benefit approach requires a systemic model of improvement, which should be identified and in place prior to implementation .

Although Allina has achieved excellent outcomes and great savings in many areas we have struggled with some issues as well . Examples included:

• Allina has 11 different hospital drug formularies, which required different builds for each site’s order sets, necessitating more time and staff resources than anticipated . The order set vision was to build Allina-wide case type sets reducing variation in practice for patients at all of our sites . Allina has over 1,300 order sets, with no physician-specific order sets. If Allina had a val

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common formulary, we could have developed a system with approximately 500 sets .

• Physician leadership was weak at the beginning of the project and needed to be augmented with a physician leader assigned full time to the project to achieve the adoption outcomes Allina sought . In addition, the Physician Engagement Team was formed to work with sites on change management .

• It became clear at Allina’s largest hospital that full CPOE adoption would not be achieved on a voluntary basis . Allina then developed a mandatory CPOE adoption strategy at that hospital and for all of the remaining hospitals .

• Benefits were budgeted to affect the bottom line too early. Allina needed two years longer than estimated to achieve concrete savings and improvements .

• Allina had difficulty staying focused on the Excellian implementation and prioritizing other initiatives . It took two years to help leaders understand that a project of this magnitude required every manager’s attention to be successful . Developing project management skills need to be attended to early on to be prepared for actual planning and implementation .

• Integration of the system is what Allina was trying to achieve, but those attributes also had challenges . When something is changed somewhere in the build, it always affects other parts of the system .

Unanticipated impacts of the EmR implementation

During the EMR implementation, Allina also realized some unanticipated impacts on our processes and our staff . It is important to train at the elbow staff to not only assist caregivers with the intended functionality, but to observe individuals for unintended ways they use the automation tools that are both positive and unexpected . A few examples of unanticipated impacts of the EMR are:

• Improved collaboration and sharing among sites – The EMR forced stronger ties and relationships between sites as they worked together to solve common problems . These relationships have spread into areas other than the EMR and are creating more “systemness” for our health system . The hospital that was next in line to implement would have site visits with the hospital about to go live at various stages in the process so that they could better anticipate what was required for success .

• Individual growth – Individuals stepped up and used the implementation as an opportunity to grow significantly and positively as a leader in the organization and among their peers .

• Rapid Dependence on Automation – Despite complaints about the system functionality, when the system went down for any reason, there were even louder complaints to bring it back .

• Additional post-live education and support requirements – Complexity of ordering screens led to the need for extensive, additional, post-go-live education for complex orders (e .g .

insulin sliding scales, TPN) . Learning from this lesson, all subsequent metro hospitals hired a permanent physician support team to continue to provide at the elbow support to physicians during and after implementation .

• Incongruence of process change with existing mental model - We quickly learned that it was important to emphasize in training where “old” processes were not being replicated in the system to ensure certain displays of information would be interpreted correctly . Physicians especially would assume the context of the screen display based on previous ways of viewing information . Problematic workflows were identified and tip sheets and support guides were created by the next hospitals to go live for their super users and support staff .

• The “planned” process changes spawned unanticipated and sometimes uncommunicated process changes as users adapted to the system . One example was the change in the way physicians rounded on patients—more work is being done off the unit (in lounge, etc .) where physicians thought they could be more efficient with less interruptions.

• Emotions - Many caregivers became very emotional during the implementation, and sometimes these emotions were carried over to other caregiver interactions . Super users at subsequent hospitals were given some additional preparation to recognize and escalate these situations as needed .

• Order Sets – Although we developed system wide order sets for procedures, we discovered a need for far more additional order sets to support other clinical processes (e .g . daily rounding, complex orders, etc .) than anticipated . The project team has set up a system for ongoing user feedback for order sets, and continues to create and refine them.

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Allina Hospitals & Clinics CONCLUSION

Four years ago, Allina Hospitals & Clinics embarked on a “bet the company” strategy to implement Excellian, one of the most advanced clinical information systems in the country . Allina’s “One Patient . One Record .” vision was to enable a seamless care experience across the organization for patients, their families and Allina’s caregivers . In addition to implementing the system, the expectation was to do so on time and on budget .

Some of the most knowledgeable health information technology professionals in the country voiced that Allina’s vision and goals were impossible to achieve .

Four years later, Allina has nearly completed its long and rewarding journey . It has not been without challenges and painful learnings .

However, with

• the commitment to continuous improvement based on learnings

• the ability to inspire everyone involved to believe that the impossible was possible

• a never-wavering dedication to the vision and

• a strong and devoted leadership

the Excellian dream has become a reality.

Allina understands this is not the conclusion of the journey, it’s merely the beginning . Moving forward, Allina plans to celebrate future accomplishments knowing they will truly make a difference in the care provided to patients .

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CONCLUSION

Allina Hospitals & Clinics APPENDIX

APPENDIX

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2004 2005 2006 2007 2008

HOSPITAL IMPLEMENTATION TIMELINE

Buffalo Hospital

United Hospital

Abbot NorthwesternHospital

Mercy & UnityHospitals

New UlmMedical Center

Cambridge Medical CenterPhillips Eye InstituteOwatonna Hospital

St. FrancisRegional

Medical Center

River FallsArea Hospital

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AM

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LIVE AMBULATORY SITES PROVIDERS CLINICAL STAFF SUPPORT STAFF

Allina Behavioral Health - ANW 11 6 10 Allina Behavioral Health - Mercy 5 3 7 Allina Behavioral Health - Unity 7 3 5 AMC - Annandale 4 6 1 AMC - Buffalo 22 29 37 AMC - Cambridge Medical Ctr. 58 97 168 AMC – Champlin 21 34 22 AMC – Cokato 7 9 10 AMC - Coon Rapids 118 197 216 AMC - Coon Rapids Women’s Health 10 28 23 AMC - Cottage Grove 9 59 54 AMC - Eagan 27 40 38 AMC - Edina 12 18 12 AMC - Elk River 18 26 20 AMC - Farmington 10 23 15 AMC – Faribault 23 35 15 AMC - Fridley 9 21 10 AMC – Forest Lake 25 40 20 AMC - Hastings 45 4 16 AMC - Hinckley 5 3 2 AMC - IMS St.Paul 6 1 3 AMC - Litchfield 13 23 15 AMC - Maple Grove 10 27 17 AMC - Midwest Surgery 8 12 8 AMC - Mora 13 34 31 AMC - Nicollet Mall 15 28 18 AMC - North Branch 2 5 3 AMC - Parkview OB/GYN - Maplewood 8 11 5 AMC - Parkview OB/GYN - St. Paul 14 14 21 AMC - Pine City 0 1 2 AMC - Ramsey 14 29 14 AMC – Shakopee 8 12 6 AMC – Shoreview 20 25 14 AMC - The Doctors 8 12 14 AMC - The Isles 7 13 9 AMC - West St.Paul 22 51 31 AMC - Westhealth 14 21 24 AMC - Woodbury 62 113 79 AMC - Woodlake 17 37 28 ANW GMA-ANW Campus 72 17 7 ANW Gen. Med. Associates 12 22 9 ANW Medical Associates 5 4 8 APS 0 0 22 Chronic Pain Management 1 0 2 Chronic Pain Management Clinic 2 0 2 Kenny Rehab Mpls ANW 11 13 15 Midwest Internal Medicine 15 17 13 Mpls. Cardiology - Crosby 2 2 3 Mpls. Cardiology - Edina 6 10 11 Mpls. Cardiology - Heart Hosp. 60 100 107 Mpls. Cardiology - St. Cloud 0 3 0 Mpls. Cardiology - Westhealth 0 2 4 Mpls. Cardiology -Thoracic Surg. 9 4 3 Mpls. Heart Institute - Brainerd 0 2 1 Mpls. Neuroscience - Sartell 1 1 1 New Ulm Medical Center Clinic 35 71 42 Sr. Kenny Rehab St.Paul United 3 2 4 The Vascular Center Heart Hosp. 0 0 1 United Accident and Injury Clinic 2 1 1 United Neurosurgery Assoc. 7 2 12 United Pain Center 8 6 16 app

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TypE OF USER by AMbUlATORy SITETo see the type of user by hospital site, please see table on page 19.

Note: Name of patient has been changed

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SAMplE pATIENT cHART

AllinA Commons At midtown ExChAngE2925 Chicago Avenue, Minneapolis, MN 55407

©2007 Allina Health System.® Excellian® and the Excellian logo are registered trademarks of Allina Health System.

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