EHR – The Implementation Process

Clayton Gillett

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization

Aspects of Assessment

• Determine Organizational Needs • Identify Required Functionalities• Determine Measures of Success• Identify Appropriate Resources• Identify Approach to Meet Business Needs

Assessment: Identify Organizational Needs

Return on Investment(May not be financial)

Change Manageme

nt

Productivity

Quality

Aspects of Planning and Preparation

• Refine Goal Setting • Assemble The Stakeholders• Develop a scope

Service LinesInterfacesFunctionalityImplementation Options

• Gather and analyze resources• Determine Selection Process

Assessment: Identify Organizational Needs (Cont.)

• QualityPopulation Management

• Disease Management• Preventive Care

Improved DocumentationReduced Errors Clinical Decision Support

• Active• Passive

Clinical Coordination Across SitesClinical Coordination with Hospital or Other Systems

Assessment: Identify Organizational Needs (Cont.)

• Productivity and Billing Improved Documentation for BillingCapitalize on Grants or Technology FundsReduced Dependence on TranscriptionReporting

• Transformational CarePersonal Health RecordsHealth Risk AppraisalsAutomatic Lab Notification

Assessment:Identify Required Functionalities

• Computerized Physician Order Entry• Connections to External Systems (Interfaces)• Connections to Internal Systems

Devices Lab / Radiology

• Scanning• E-Prescribing• Specialties to Consider

Mental HealthOral Health

Assessment: Develop Measurements of Success

• Productivity Pre and Post Implementation• Clinical Quality• ROI?• Provider Satisfaction• Patient Satisfaction

Assessment:Identify Resources

• Implementation Funding

• Maintenance Funding• Appropriate Space

ACPower Backup Secured LocationHigh Speed Internet

Capabilities• Clinical Content

Development

• Internal Staff RequiredAvailability of Trained

StaffTraining and

Maintenance Costs of Staff

Help Desk Support Interface

Management

Assessment: IdentifyApproach to Meet Business Needs

Vision• Organizationa

l Needs• Required

Functionality• Measures of

Success

Resources• Staff Support• Staff Turnover• System

Requirements• Implementati

on Funding• Maintenance

Funding• Physical

Facility• Culture /

Content

Identify Approach• Build It

Yourself• Customize a

Vendor Product

• Identify Proven Vendors

• Software as A Service

• Health Center Controlled Network

• Collaborative

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization

Planning and Preparation:Refine Goal Setting• Tie project goals to organization’s strategic goals where possible

EHR as an enabler• How will goals be measured?

Pre-EHR: manual chart audits, undocumented workflows With EHR: electronic chart audits, documented workflows,

reporting• Think broadly

Clinical• Ex: HbA1c and Health Maintenance Alerts

Operational• Ex: 2 areas of PI (rx refills, referrals)

Project related• Ex: Immediate access to patient’s chart at time and location

needed• …and short term before long term

Be realistic Goals can be phased

Planning and Preparation:Assemble the Stakeholders

• Medical, operations, information technology Sponsors

• Leadership/decision makers: providers, clinic management, nursing staff, medical records, IT, front desk and financial operationsClinical Implementation Team

• Supervisors/leads/subject matter experts: lab, x-ray, pharmacy, referrals…..Targeted planning discussions, workflow reviews,

communications, communications, communications

Internal – Identify and engage them in the process

Planning and Preparation:Assemble the Stakeholders

• Patients In-clinic communications, mailers

• Hospitals Service coordination

• PharmaciesElectronic (eg, SureScripts), new script look

• Lab Agencies Interface, requisitions

• Radiology Services• Supply houses, referrals

External – Identify, engage where needed, and communicate changes

Planning and Preparation:Develop Scope

• Service LinesPrimary Care SpecialtiesMental HealthPublic Health

• InterfacesEssential, desired, options Lab, pharmacy, radiology, Scanning State databases (immunizations), Federal health

disparities collaboratives (BPHC PECS)

Planning and Preparation:Develop Scope

• FunctionalityProgress notesOrdering labs, x-rays, meds, referrals InBasket Decision supportCare team communicationsReferrals managementChart trackingReporting Integration with front office and billing/claimsConnectivity to internal and external systems Scanning

Planning and Preparation:Develop Scope

• Beta – an essential• Big bang

All functionality, all locations Reduces dual process timelines Start realizing benefits more quickly Can your organization manage this much change at once? Requires more resources

• Paced All functionality, clinic or group of clinics at a time Learn from previous clinic with potential for

improvements Organizational change may be more manageable Resource requirements are spread out

Implementation Options

Planning and Preparation:Develop Scope

Scope

Resources Time

• Balancing the plan…..

Planning and Preparation:Analyze and gather resources

• Equipment and Staff Resources Host hardware in secure and environmentally appropriate

space Connectivity Hardware/Software End user devices Software build/configuration Data architecture, management, reporting Interfaces Training Support System maintenance Optimization

• Vendor Product In-House• Application Service Provider (ASP)• Network

Planning and Preparation:Determine selection process

• Options for a Stark donationUnique requirements of FQHC?Stability of the donating organization?

• System selection direct to vendors• System selection to health center

controlled networks• Combination• Determine the need for external expertise

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization

EHR Implementation

Implementing an EHR will be the single largest change that you will make in your

health center in the time that you are there.

The project is larger even than the relocation to a new facility.

Build an Effective Implementation Team

• Organizational LeadershipExecutive Level ParticipationOperations LeadClinical Leadership (MD)

• Project Leadership• Site Specialists• Subject Matter Experts• IT Representation

Implementation Team Example

• Project Manager• Providers (physicians

and mid-levels)• Nurses• Medical Assistants• IT Management• Clinical Management• Administrative

Management

• Patient Support Services (Reception, Billing)

• Quality Improvement• Data Management• Medical Records

Management• Behavioral Health• Case Management

Implementation Team Expectations

• Weekly Meetings• Team members are expected to

communicate to constituencies.• Not a consensus driven process but full

participation is expected.• Decisions that are made are

communicated as a team.• Team members have time allocated away

from their regular work.

Implementation Team

• Documentation of Team Roles and Responsibilities and Qualifications for:Project ManagerClinic Implementation ManagerSite SpecialistsEtc…

Project Manager Responsibilities

• Manage the project.• Develop and manage

project plan. • Provide leadership in

change management areas.

• Keep all stakeholders involved and up-to-date in the process.

• Coordinate and ensure on-going progress through all the EMR implementation tasks.

• Report to clinic leadership and vendor / network / collaborative leadership

Project Plan: Tasks and Timeline

• Readiness Assessment• Requirements for Each Application Module• Workflow Redesign• Down Time Procedures• Communication Plan• Training Plan• Data Conversion / Abstraction / Preload• Interface Development• Hardware Purchase and Implementation• Connectivity

Project Approach

• On Site Kick Off Meeting Scope ConfirmationProject Plan Vetted Initial Data Collection (locations, preference lists etc.)

• Workflow Review and Redesign (on site)• System Build (letters, handouts, clinical doc.)• Test• Dressed Rehearsal (on site)• Conversion• Go-Live

Work Flow Documentation and Redesign

• Based on Standard WorkflowsIdentify VariationDetermine Response

• Engage billing and claims• Test with a complete walk through

Document All Final Workflows• Train to Workflows

Workflow Redesign Pitfalls

• Not all variation requires an application change.Policy is still an

effective tool. Some variation is

appropriate.

• Do not attempt to address all current problems prior to implementation.Prioritize Standardize

Key Workflows

• Scheduling• Registration• Office Visits

Workman’s Comp Immunizations Family Planning

• Walk In Patients• Rx Refill Requests

• Phone Calls• Lab Only Visits• Referrals• Medical Records /

Release of Information

• BillingGrant Billing Specific Payor Rules

Effective IT Change Control

• Develop and follow and tool for effective change control in the system.Manage build across Test and Production

environments.Require signoff in each location.

• Weigh carefully the need to move outside the change control methodology.Complex systems can have unanticipated resultsThe need to fix a problem may seem small when the

fix results additional problems.

Effective Change Management

• Team Communication ToolsProject PlanTraining Documentation

• Web Based Training• On Demand Resources

Workflow Documentation• Clinical Communications

Coop Current Clinic Communication ToolsDemo Early To All Staff

• Patient Communication

Efficient Testing

• Test using the workflows.• Test in production prior to go live.

Dressed RehearsalUnit Testing of Each ChangeRequire end user testing

• Maintain workflows when testing uncovers the need to change.

• Provide a mechanism to train users

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization

Stages of EHR Implementations

Assessment

Planning Part I – Getting Started

System Selection

Implementation Process

Working Towards Transformational Change

Improvement / Optimization