Transcript File

Implementing an Electronic Medical Record
System at OK Care Hospital
Medical Informatics 404-DL
Fall 2009
Group 5
Tammy Gray, Beena Joy, Emad Osman, Joseph Ryan, Natalie Schwartz
PROJECT OVERVIEW
To implement a fully integrated patient-centered EMR in a 250
bed medical surgical hospital
• Institutional Goals
– To improve the quality of patient care
– To improve patient outcomes
– To improve patient safety
– To improve organizational efficiency and productivity
– To effect cost reduction
– To improve service and satisfaction to our patients, providers,
and staff
HOSPITAL SYSTEM
OVERVIEW
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General Medical Floors
– 155 beds, 5 floors, 15 double
and 1 single occupancy rooms/
floor
General Surgical Floors
– 60 beds, 2 floors, 15 double
occupancy rooms/ floor
Medical ICU/ CCU
– 16 beds
Medical Step-Down Unit
– 6 beds
Surgical ICU
– 8 beds
Surgical Step-Down Unit
– 5 beds
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Labor and Delivery Unit
Operating Rooms and Delivery
Suites
Emergency Department
– 15 beds
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Pharmacy Department
Laboratory Department
Radiology Department
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Outpatient Clinic
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300 staff physicians
– Voluntary & hospital-employed
STRATEGIC PLAN: CURRENT STATE
CURRENT SOFTWARE
CURRENT HARDWARE
 ADT/ PATIENT REGISTRATION
Siemens
• Terminals in the Admitting
Department, Patient Registration,
Emergency Department, Billing
Department, Pharmacy,
Laboratory, Radiology,
Outpatient Center
• Terminals at each central nursing
station
 PACS
GE Healthcare
• 2 terminals at each central
nursing station (retrieval)
• 6 terminals in radiology dept. for
retrieval and MD reading
STRATEGIC PLAN: FUTURE STATE
ACTIVE, PATIENT-CENTERED EMR
COMPONENTS AND FUNCTIONALITY:
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Health care information and data- “anytime, anywhere access”
Full Integration of test results and management- laboratory, PACS
CPOE and e-prescribing
Barcode-enabled point of care- medication administration
Decision-Support systems- evidence-based standards of care
Electronic communication/ connectivity- E-mail, Intranet, Internet
Clinical Reporting- Accrediting agencies, insurance, audits
Clinical Research and Trials
Chronic Disease Management (includes Case Mgt.)
Data-Mining
Fully integrated with ADT and Patient Registration Systems
Other administrative processes- insurance verification, preauthorizations
STRATEGIC PLAN: FUTURE STATE
ACTIVE, PATIENT-CENTERED EMR
CPOE:
 Improved patient outcomes
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Reduction in medical errors
Reduction in adverse drug events
Improved adherence to clinical protocols
Decision-support tools- alerts, reminders, call-backs
 Cost savings
• Reduction in medication errors and adverse events prevent
unnecessary hospital days, reduced liability
• More cost-effective choice of medications
 Improved Revenue
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Improved accuracy and timely billing
Increased transaction processing rates
Reduced LOS
Improved compliance with core measurements
NEEDS ASSESSMENT (1)
 Strong commitment from senior level healthcare administrators
 Physician Champion- passionate, respected, strong communication skills,
strong leadership ties to medical community
 Provider buy-in and adequate representation in the design and
implementation of the system
 Strong and committed leadership from major hospital departments
 Search for qualified vendors- vet organizational and financial stability, track
record for service and response, pricing, upgrades, system expandability
 Formalize a contract with selected vendor(s)
 Develop a business plan- define capital and operating costs, costs of
upgrades, organizational financing, government stimulus funding, ROI
 Identify the sources of data and systems that need to be integrated
 Identify storage space, electrical requirements (power, shielding,
ventilation), physical space of clinical and IT activities, present and future
capacity
NEEDS ASSESSMENT (2)
 Determine information system architecture- integrated platforms and IT
infrastructure (servers, operating systems, networks)
 Develop solid and reliable administrative, physical, and technical
safeguards for 24/7- 365 days/year operability
 Solid disaster recovery plan
 Human resources analysis
 Create a strong and dedicated IT Team, including a CIO, CTO, CSO,
CMIO, CNO, system analysts, programmers, database administrators,
network administrator, telecommunications specialist, in-house IT staff to
establish connections, load and test applications, troubleshoot, staff help
desk, training, upgrades
 Workflow Analysis- determine # and location of workstations, space
requirements, re-design of work areas
 Identify training staff and provide dedicated training time
 Develop a practical timeline for implementation across the hospital
CRITICAL NEED:
IT ALIGNMENT AND STRATEGIC PLANNING
 Ensure a strong and clear alignment
between IT decisions/ investments and
the hospital’s overall strategies, goals,
and objectives
 Use IT to support the momentum of the
hospital’s vision, not to create the vision
 Strong senior leadership and understanding
of the benefits and limitations of the IT
initiatives to achieving organizational goals
 Strong IT governance
CRITICAL NEED:
PHYSICIAN BUY-IN
WE NEED TO MAKE THE
PHYSICIANS PART OF THE
SOLUTION,
NOT PART
OF THE PROBLEM !!!
Need to Convince Physicians of the
Personal Value of a Hospital EMR
Must align the value of a hospital EMR with the value to physician practices !!!
Physician complaints:
Need benefits to outweigh MD complaints:
“My handwriting is legible”
“None of my patients have had medication errors”
“Why do I need to change my practice to benefit the hospital ?”
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Remote access to hospitalized patient data
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Can track their patients across the hospital
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Time for classroom or one-on-one training not reimbursed
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Can use CPOE from any site- within the hospital/ office
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Learning curve (may be steep for older MD’s)
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Cost of installing office technology for hospital linkage
difficult in current economy and reimbursement
environment
No more searching/ waiting for charts to enter notes
(e.g. chart is being used for nursing rounds, by case
manager, or another MD; taken off the floor for testing)
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Reduction in medication errors and physician liability
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Increased patient satisfaction with more integrated
hospital services and efficiency
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Can sign discharge summaries and operative reports
from their offices
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Improved patient billing services- fewer complaints
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Problems remembering multiple or single UserID’s/
Passwords
PROJECT STEERING COMMITTEE
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Project Sponsor: CIO
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Director: Admitting Department
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Physician Champion: CMO
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Director: Risk Management
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Director: Medical Records Department
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Project Manager: Consultant/IT Liaison
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IT Advisory Subcommittee
 Physician Advisory
Subcommittee:
Chairmen, Departments of Medicine, Surgery,
Ob/Gyn, Laboratory, Radiology, Emergency
Room
Respected representatives of the full-time and
voluntary medical staff must be involved from
the ground up and at every key decision point!
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Nursing Champion: CNO
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Nursing Advisory Subcommittee:
Nursing Supervisor, Nurse Manager (Medicine,
Surgery, ER, L&D, OR)
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Director: Quality Improvement
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Director: Billing Department
PROJECT STEERING COMMITTEE
Each department representative within the steering committee must:
 Perform a Stakeholder Analysis of their department
 Develop a list of CTQ’s (“Critical to Quality”)
 Perform a Workflow Analysis of their development
 Become the project champion for that area
Stakeholder SWOT Analysis
Threat
Short
Term
Long
Term
Opportunity
 ↑ Patient safety events
 ↓ Satisfaction of MDs, patients,
and staff
 ↑ continued delayed treatment
 ↑ potential in LOS
 Meet strategic goals
 Meet/exceed customer
expectations more often
 ↓ errors, delays in treatment
and LOS
 ↑ bed availability
 Loss of patients/business
 ↓ reputation and credibility
 Possible ↑ in liability,
susceptibility to litigation
 Financial impact resulting in ↓ $$
 Enhanced patient outcomes
 ↑ business
 ↑ community reputation
SOFTWARE SPECIFICATIONS
RFI - VENDOR SELECTION CRITERIA
VENDOR SELECTION
REQUIREMENTS
MEDICAL STAFF PERSPECTIVE:
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CPOE capable
– Usability
– User-friendly GUI
– Order placing is intuitive (includes e-prescribing)
– Buttons, dials, links, etc., are logically placed
– Minimum number of mouse clicks per function
– Information display is useful and not confusing (“no wall of numbers”)
– Specialty modules in development
Voice recognition integration
Decision support capable
– Alerts appear in summary to reduce fatigue
– Linkage to citations
Value added
– Improves safety
– Enhances, not hinders, productivity and efficiency
VENDOR SELECTION
REQUIREMENTS
ADMINISTRATION AND NURSING ADMINISTRATION PERSPECTIVE:
 Willing to partner and grow with us-”scalability”
 Has an ongoing plan for moving us from A to B
– Accepts accountability for assisting the organization in the reengineering of all workflows
– Education plan includes ongoing support
 Demonstrated implementation satisfaction with other like organizations
 High level dashboard report capability for key indicators linked to
strategic goals
 Evidence that vendor’s EMR acquisition results in the improved patient
outcomes and cost savings over time
 Reporting is turn-key and non-proprietary
VENDOR SELECTION
REQUIREMENTS
NURSING STAFF PERSPECTIVE:
 Workflow promotes optimal face time with patients and real time
documentation
 GUI is intuitive and views customizable by user preference
 Terminology is dynamic
 Medication barcoding is integrated
VENDOR SELECTION
REQUIREMENTS
PHARMACY PERSPECTIVE:
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Medications and dosages are discreet fields
Smooth transition of orders from ER to inpatient
Alerts with decision support
Requires justification
– Alert overrides
– Non-formulary meds
Reporting is turn-key
CPOE
e-Prescribing
e-MAR
VENDOR SELECTION
REQUIREMENTS
QUALITY PERSPECTIVE:
 Core Measures abstraction is automated
 Reporting is turn-key
– All data are reportable and easily accessed through ODBC
connection
– Proprietary tools are not required
 Links with Laboratory, PACS, Pharmacy, both internal and
external
VENDOR SELECTION
REQUIREMENTS
INFORMATION TECHNOLOGY PERSPECTIVE:
• Full integration with all other disparate clinical & non-clinical
systems within the organization
• Scalable
• Roll-based access
• Audit trails
BUDGET
RETURN ON INVESTMENT
Current Key Costs
Medical Records
One Year
Salary & Benefits for Medical Records
$
# of Medical Records Staff
70,000.00
30
Chart Creation Cost
$
# of Charts Created a Year
10% of Patients
# of new patient a physician sees
2.00
220
Cost of Chart Storage
$ 2,000,000.00
Rx Pads
$
Clinician Costs
# of Physicians
77,220.00
300
Transcription Costs
$ 1,000,000.00
Coding Errors/Missing Charges
$ 1,200,000.00
Other
Billing Turn Around Time
Misc Office Expenses
Cost Per Year
2 weeks
50,000
$ 6,559,220.00
Return On Investment (ROI)
Current Key Costs
Medical Records
Salary & Benefits for Medical Records
# of Medical Records Staff
Chart Creation Cost
# of Charts Created a Year
# of new patient a physician sees
Cost of Chart Storage
Clinician Costs
Rx Pads
# of Physicians
Transcription Costs
Other
Coding Errors/Missing Charges
Billing Turn Around Time
Misc Office Expenses
Cost Per Year
One Year
$
$
10% of Patients
$
One Year
$
$
One Year
$
$
Percent
Savings Current
70,000.00
43% $
30
2.00
90% $
220
2,000,000.00
75% $
Percent
Savings Current
77,220.00
90% $
300
1,000,000.00
90% $
Percent
Savings Current
1,200,000.00
50% $
4 weeks 1 week
50,000
50%
6,559,220.00
After Saving
2,100,000.00 $ 1,197,000.00
132,000.00 $
13,200.00
2,000,000.00 $ 500,000.00
After Saving
77,220.00 $ 7,722.00
1,000,000.00 $ 100,000.00
After Saving
1,200,000.00 $ 600,000.00
50,000 $
25,000.00
$
6,559,220.00 $ 2,442,922.00
Projected Savings
$ 4,116,298.00
ROI 2
Day to Day Actions
Current
After Implementation
Medication to Patients (Hours)
5.28
1.51
Order Entry of Radiology to Completion of Procedure (Hours)
7:37
4:21
Length of Stay
30.4% Reduction
Lab (from Order to Completion)
Chemistry Tests
48.9% Decrease
Urinalysis
41.6% Decrease
Microbiology
40.6% decrease
Serious Medication Errors
55% decrease
Preventable Medication Errors (PME)
17% decrease
Cost per PME
$ 4,600.00
Average PME Cost for 300 Bed
$1.2 Million
$
41,000
Medication Decision support could identify up to beneficial changes in treatment
Repayments to payers for non-compliant documentation or ineligible services
996,000.00
$25,000.00
$
387.00
Admissions/registration Patient Satisfaction
63%
80%
Overall Patient Satisfaction
75%
80%
Physician Satisfaction
73%
80%
Staff Satisfaction
69%
78%
Physician Patient Load
Net Savings Over a Five year Period
Increase 4-8
$2.5 to $5 million
Implementation Costs
Hardware
Servers
Tablets 400 @ 1500
Computer Stations 25 * 500
Installation (wifi, routers, wiring, etc)
Yearly Maintance 15%
Cost
$
$
$
$
$
50,000.00
600,000.00
12,500.00
30,000.00
103,875.00
Analyst 4 @ 75,000
Director 1 @ 80,000
Consultant Fees
Cost
$
$
$
300,000.00
80,000.00
100,000.00
Interfaces
License Fee 400 @ 15000
Cost
$
$
50,000.00
6,000,000.00
Personal
Software
Implementation Cost
Yearly Cost
$
$
6,742,500.00
583,875.00
Five Year Project
$15,000,000.00
$10,000,000.00
$5,000,000.00
No EHR
Costs
Savings from EMR
$Year
$(5,000,000.00)
$(10,000,000.00)
Facility Implementation
Physician Engagement
Engaging the Clinical Staff
Leadership Support & Collaboration
Real-time Training
Phasing Plan
PHASE 1
Clinical
Foundation
Clinical Viewer
• EMR
• Results Reviewing
HIM / Doc Imaging
Surgery
• Surgery
Pharmacy
• Pharmacy
• Alerts – ADE,
Prevention Alerts
Medication Profile
• Medication
Reconciliation
PHASE 2
Clinical
Enhancement
Patient Care
• Orders Management
• Nursing
Documentation
• Ancillary
Documentation
• eMAR
• Interactive View for
ICU
ED
• ED Tracking Board
and Triage
• Physican
Documentation (ED)
• CPOE for ED
Care of the Patient in
the Physician
Office
7 YEARS
5
Years
PHASE 3
Outcomes
Optimization
CPOE
• Evidence-Based
Alerts at Provider
Order
Nursing Care Plans
Advanced
Laboratory
• Laboratory POC
Solutions
Surgery Expansion
• Anesthesia
The Importance Of Decision Making
Major
Impact
High
Level
Decisions
Clinical Systems Steering Committee (CSSC)
What will be done? Who will do it?
~ 10% of decisions
Moderate
Impact
Mid Level Decisions
~ 25% of decisions
Clinical Standards Committee (CSC)
Physician Advisory Council (PACo)
How will it be done?
Subject Matter Experts (SME)
Less
Impact
Detailed Decisions
~ 65% of decisions
Design the details
Timeline
2010
2011
2012
2013
2014
2015
Design/Build P# 1
Rollout
Design/Build P# 2
Rollout
Design/Build P# 3
Rollout
Phase 1 - 19 Months Design and Build
Phase 2 - 24 Months Design and Build
Go / No Go Decision
Phase 3 - 14 Months Design and Build
Timeline
2010
Q4
Q1
Q2
Q3
2011
Q4
Q1
Q2
2012
Q3
Q4
Plan
Current
State
Assessment
Future
State
Design
Proof of
Concept Build
& Validation
Integration
Testing
Production
Build, Validate
Conversion Prep
Refine &
Validate
Training
Validation and Sign Off Steps
Go / No-go Decision
Facility
Rollout
Q1
Q2
Q3
Q4
Change Adoption Curve
SUSTAIN
“Make It Stick”
7. Don’t Let Up
8. Create a New Culture
ENGAGE
“Make It Happen”
4. Communicate for Buy-In
5. Empower/Enable Others to Act
6. Create Short-Term Wins
PREPARE
“Set the Stage & Decide What to
Do”
1. Create a Sense of Urgency
2. Pull Together the Guiding Team
3. Develop the Change Vision and Strategy
Reference: Our Iceberg Is Melting.
Eight Step Process for Successful Change.
Author, John Kotter, 2006. Page 130-131.
Critical Success Factors
• These critical success factors apply to all areas impacted by the project.
Critical Success Factor
Measurement Process
The project is completed on budget.
Project expenses are monitored and tracked to stay
within budget. This is a multi-year project and will be
measured on an annual basis.
The process solutions identified in the project
scope were implemented in each of the facilities
according to the plan.
Validation of new care delivery processes activated
in each facility based on the final scope document
and/or governance approval.
Project milestone dates and deliverables were
achieved with less than 10% variance.
Track and manage project plan dates and
deliverables as defined in the approved project plan
baseline. Baseline date to be determined. 90% of
the Phase II teams meet all milestone dates and
deliverables.
Current state analysis completed and signed off.
Require signatures from department teams
interviewed for current state.
Require signatures from members of the Clinical
Standards Committee for future state design.
Future state analysis completed and signed off 45
days prior to the first activation.
“Proof of Concept” demonstrated through a partial
system build to validate the future state workflow
and system functionality with approval from the
appropriate stakeholders.
Require signatures from SMEs and Clinical
Standards Committee for future state workflows and
partial build.
Critical Success Factors
Critical Success Factor
Measurement Process
System functionality was adequately tested to
identify and resolve software and workflow
issues prior to conversion.
Corporate compliance will audit integration testing
and provide feedback.
Training team received design documentation
and new care delivery workflows with adequate
lead time to prepare training and competency
testing programs.
Training materials, scenarios and policies were
available for training of staff.
Appropriate staff attended training prior to
activation (only those with excused absence
from appropriate director will be allowed to take
training at a later time).
Training attendance tracked to ensure at least 95%
of appropriate staff attended training.
Staff members who attended training passed
competency test.
Training competency scores tracked to ensure at
least 98% of staff pass competency test with score
80% or higher.
The "C" suite at each facility participated in the
facility preparation and conversion activities.
Participation in facility preparation meetings and
support of new care delivery processes.
Project Standards
Rules of Engagement – Key criteria that must
be met to support the project’s success
Defining a Project – What specifically is a
project … and what is not a project
Tools – The tools that are used to
manage projects and document project
activity
Project Roles and Responsibilities –
What is expected of participating team
members
Project Governance/Organization
Structure – Identification of Teams
within the project
Customer Responsibilities – What is
needed from the customer to maximize
success
Project Levels and Complexities –
Identification of the levels of complexities
and how each is treated in terms of
documentation, communication, and
involvement
Project Documentation – Standard
documentation naming conventions and
storage locations
Communication Management – Standard
methods and styles of communication
designed to provide consistency for the
teams and customers
Meeting Management – Establishes standard
meetings and updates with efficient
Planning, Facilitating, and Documenting
Vendor Management – Defines how to manage
vendors and service professionals; includes
contracts, Corporate Compliance, and
standardized Change Management
Risk Management – Defines how project risks
are identified, managed, and mitigated
Project Organization
CEO
Chief Medical
Informatics
Officer
CIO
Physician
Executive
Clinical
Transformation
VP
EMR Director
(Nursing)
PM Integration
EMR Director
(Ancillary)
Technical
Project Mgr.
PM Testing
PM Interfaces
Vendor
Executive
EMR Governance Structure
Board of
Trustees
Quality
Committee
Office of the
President
EMR Executive
Oversight
Board
Clinical
Systems
Steering
Committee
EMR Project
Steering
Committee
Physician
Advisory
Council
Clinical
Standards
Committee
EDUCATION , TRAINING &
COMMUNICATION
STRATEGY
• By Beena
Joy, RN BSN
Summary of Recommendations
• Approval to solicit RFI
• Approval to distribute RFPs based on vendor responses
• Support organizational efforts to improve care and safety,
streamline processes, increase satisfaction, and decrease costs
and waste through EMR implementation
• Play an integral role in changing our reputation and our name
from “OK Care Hospital” to “Exceptional Care Hospital”
Questions?
EMR EDUCATION & TRAINING
http://www.medicalpracticetrends.com/2008/10/26/training-staff/
Communication Slides
http://accustatemr.com/In%20The%20News/Articles/Essential%20People%20Skills%20for%20EHR%20Im
plementation%20Success.pdf
http://archive.healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_890717_0_0_18/EHR%20Com
munication%20Plan.pdf