Transcript The Clinician`s World: 15 Minutes Till the Next Patient

EMR:
IMPLEMENTATION LESSONS
LEARNED THE HARD WAY
Paul Kaye, MD
Medical Director
Hudson River Healthcare
November 2005
Hudson River Healthcare
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12 practice sites in 5 counties
42 primary medical care providers
130,000 visits/year
Urban, migrant, homeless, public
housing, and Ryan White funding
JCAHO 1998, 2001, 2004
Diabetes, HIV, Prevention Pilot
Collaboratives
EMR Project History
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1999 Initial Contact with vendor and software
developer
2000 Beta test site agreement
Initial site:Adult Medicine at main site
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Server on site
Integration with practice management system
Desktop PC in all exam rooms and provider offices
Computer readiness survey
EMR Project History
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Initial group: 6 providers
Results: 2 proficient providers, 2
reluctant providers, 2 hapless souls
2001: Pediatrics-Peekskill
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Wireless laptops used
Higher cost per PC but less needed;overall
hardware cost the same
EMR Project History
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Results: 2 proficient providers, 2
reluctant providers, 2 hapless souls
2001: Pediatrics-Peekskill
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Wireless laptops used
Higher cost per PC but less needed;overall
hardware cost the same
EMR Project History
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Pediatrics implementation successful
Less efficient because of previous use
of checkoff sheets
Time savings for physicals, school
immunization sheets
2003 test: Tablet computer
EMR Project History
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2002-3 3 sites added, wireless setup
Server at main site
Connectivity issues surfaced
Rapid training and provider use
Pre-entered problem lists, long term
medications, immunizations
Implementation schedule formalized
EMR Project History
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Additional sites added in 2003-5
New Start 2005 opened with EMR
3 sites wired and awaiting rollout
Lingering Issues
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Interface with labs
Interoperability with local countywide
network
Dual use of EMR and PECS
Choosing an EMR
It’s the Support not the Product
Contract Issues
Clinical Expertise
Compatibility
Company
Choosing an EMR
Check interfaces with existing software-ask to
see working examples
Buy it ready made-customizing is hard
EMR: Myths
Less paperwork… yes but longer data entry
time
Easier Information Retrieval… but that means
more information to retrieve and
address
Cost Savings-only in your dreams
IT Implementation Issues
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Network Structure
Hardware Selection and Placement
Network Reliability
Internet Connectivity
Redundancy
Technical Support
Software Support
Network Structure
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Client-Server
Thin Client
Citrex (multiple sites)
Consider ASP Model
Hardware Selection
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Little hardware leadership from vendors
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Initially--providers chose devices
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They will support multiple platforms as a
marketing issue
“If they choose it they will use it"
didn't succeed
costly to support
Now--IS selects hardware
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if it works, they will use it
Hardware Issues
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Tablet/Wireless/Wired/Thin Client
Printer Location
Nurses Station
Placement within Exam Room
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Wall vs Countertop
More IT Issues
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Reliability
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EMR needs higher level of reliability and
less down time than business functions
Change of midnset for IT support staff as
well as planning for redundancy
Connectivity
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Need T1 level connection; DSL, cable
inadequate
Training Issues
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Rate-limiting step
Keep the user’s
perspective
Start with easier
functions
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Solve problems,
don’t automate
them
Workflow discussion
should proceed
training
Develop a schedule
and STICK TO IT
Training Issues
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Users missing basic computer skills
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Delete key, tab key, back key
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Typing skills
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holds back team training and whole
implementation
Training Approach
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Work closely with vendor
Support Staff
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Train first or concurrently
2-4 hours
Clinicians
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2 weeks training
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AM and PM sessions
AM Classroom, PM Live
2 weeks followup support
Clinical Implementation
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Avoid Democracy-Embrace Dictatorship
Set clear expectations
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3rd visit:Medications and problem lists
5th visit: Full Medical History
Preload some information
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Pediatric Immunizations
Clinical Implementation Issues
Don’t automate a bad procedure
Rethink information flow
Rethink nursing and support staff
roles
Rethink how to capture information
Clinical Implementation
Issues
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Letters
Referrals
Templates
LabCorp interace
Registry interface
Reports
mobile access
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Scanned document
input
Patient access
Specialty services
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mental health
nutrition
dental
Clinical Implementation
Issues
Template Development
Individual vs organizational
Agreement on Standardized Use
Process for Review
Database Upkeep
Pharmacies
Specialists
Access
Leadership Issues
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Senior Leadership Responsibility
EHR key part of Strategic Plan
Initial and Ongoing Funding
Information Management Issues
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Redefine Medical Records role
Security and Password Management
HIPAA Compliance
Resource Issues
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Dedicated clinician time to develop
functionality
Anticipate decreased productivity
during implementation-between 1 and
3 months
Ongoing training costs-new providers,
more detailed functions, new
processes
Administrative Issues
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Exercise rigorous oversight of all
consultants/vendors
Identify responsible parties for issues
and track to resolution
Provide feedback on usage to staff and
Board
Administrative Issues
Leverage consultants for necessary
expertise, including strategy development
if needed
Recruit/retain CIO type expertise
Don’t underestimate workflow and
organizational changes