Factors to Consider

1
Factors to Consider

• EHR Implementation
• Workflow Improvement

2
Getting Started

• Visioning
• Goals and Benefits
• Readiness Assessment
• Survey Attitudes
• Needs Assessment (address pain points in
  processes)
• Infrastructure Assessment
• Process Mapping
• Current state present processes
• What can be aided by EHR?
• Timeframe

3
Migration Path vs. Implementation Plan

• Migration Path
• Illustrates overall applications, technology
  operations
• Establishes vision and benefits
• Often develops in phases
• Consider infrastructure improvement and PM system
  in light of the migration path to EHR
• Implementation Plan (Project Plan)
• Detailed Steps
• May identify pilots or phases (pdsa)

4
Family Physician Workflow

• The flow of patients entering the office
  getting their needs met within the office
  environment
• The flow of patient information within the office
  environment, whether the patient is present or
  not. This includes clinical, social, and billing
  information

5
Initial Steps

• Establish a project team
• Designate a project manager
• Involve members from all functional areas
• Define present workflow and processes
• Identify the benefits of HIT
• Develop a vision of selected benefits and
  possible process improvement
• Prioritize (low investment, high impact first)

6
Training is the Key

• Obtain sufficient training resources for the
  project
• Schedule sufficient time for staff to fully train
• (Reduced revenues from lost productivity due
  to incomplete training is much more costly than
  scheduled training time)
• Develop in-house experts champions
• Consider on-going consultation and training for
  more complete adoption and workflow improvement
  (i.e. custom templates process identification
  and improvement)

7
Available Tools

• PM/EHR (given)
• Must be integrated
• Single PM/EHR database choices available
• Interoperable sharing data with other systems
• PCs
• Moderate cost
• Infrastructure requirements (cabling power
  wireless space work station location)
• Capable multiple programs and functions
• Acceptable use and security considerations
• Stationary (One needed for every workstation)

8
Available Tools

• Laptops
• Capable multiple application
• Portable (multiple venues, home, off-site care)
• Costly, but fewer may be required
• Weighty
• Power/Operation Issues (battery life docking
  stations etc.)
• Prone to damage, theft
• Possible security issues (encryption, acceptable
  use)

9
Available Tools

• Thin client technology
• Less capable
• More secure, centrally administered
• Stationary
• Needed in each exam room and at each work station
• Less costly
• Lower maintenance and longer life
• More economical for multiple deployments

10
Available Tools

• Wireless network
• Provides mobility
• Security considerations
• Some reliability issues
• Web-based network
• Highly mobile (anywhere, anytime)
• Off site service delivery (home, on-call, home
  visits, community services)
• Disaster recovery capability

11
Available Tools

• Fax
• Reliable, end user familiarity (i.e. pharmacy,
  referral physician)
• e-Fax First step toward pharmacy specialist
  interface
• Scanners
• Convert paper documents to electronic images
• Useful for input of outside paper input
• Care must be taken in selection of material
• Care must be taken in document management

12
Available Tools

• Interfaces
• PM EHR
• Dental Management System (DMS)
• Behavioral Health Management System (BHMS)
• Laboratories
• Pharmacy systems (internal or external)
• Specialists
• Hospitals, EDs
• Messaging
• EHR, Outlook

13
Connectivity - Starters

• Integration with PMS - a given
• Lab Connectivity
• Major labs provide HL7 interfaces
• EHR must be interoperable/accept discreet data
• Orders bar coding result input
• Pharmaceutical orders (options)
• Print for patient
• Fax to pharmacy
• Connect to pharmacy system feedback?
• Automated dispenser interface label maker

14
Initial Considerations

• Conversion
• Demographics
• Document scanning management (extent)
• Paper from Outside
• Scanning vs. Discreet Data

15
Initial Considerations (cont.)

• Prescribing
• Print in office
• e-Fax to pharmacy
• Interface with pharmacy system
• Reporting (i.e. registry data clinical measures
  UDS etc.)
• Is system capable? Custom programming? Options?
• Specialized templates?
• Integrated templates? (workflow implications)

16
Initial Considerations

• Internal messaging
• Map process changes
• Complete protocol
• Unintended consequences
• Patient scheduling
• Flows to provider in EHR
• Clinical personnel use of scheduler?

17
Initial Considerations

• Clinical Decision Support System (CDSS)
• Source of its rules?
• Extent to which it is utilized? (Integrated?
  Reference?)
• Determine impact on quality/workflow
• Establish process for approving changes in rules
• Device integration with local area network (LAN)
• Degree of integration with external clinical
  input (PACS, hospital device results, discharge
  information)

18
Process Example

• Clinic system with 7 large sites central
  laboratory (paper system)
• Workflow initially paper, copies of order to
  patient nurse (chart, tickler file)
• Patient takes order to lab (wait time, possible
  query)
• Patient has specimen taken (processing,
  documentation and reporting time)
• Patient returns to clinic ( do not)
• Patient must be worked in to schedule
  (disruption)

19
Example (cont.)

• Scheduler, nurse and provider are engaged to
  modify schedule
• Nurse checks for faxed result (hopefully
  arrives)
• Chart is chased found. Note and result are
  attached
• Patient is roomed and seen by provider treated
• Progress note is entered in chart, any orders
  written and distributed
• Chart is returned to chart room (hopefully)

20
Example (Cont.)

• Process improvement 1 (location improvement)
• Clinic decides to improve patient flow by
  establishing satellite labs at each clinic site
  trains nurses (med techs maintain standards)
• Results improved turn around patient
  satisfaction and compliance orders and results
  are still on paper
• Schedule continues to be disrupted
• Paper chart, document management, filing
  continues

21
Example (Cont.)

• Additional improvement 2 (LAN and EHR interface)
• Clinic takes additional step of using new testing
  technology to move multiple testing devices in to
  each exam room (i.e. Hb A1c) connected directly
  to the LAN, and interfaces with EHR
• Results Tests are completed in the exam room
  quickly at the point of care
• results are available in minutes discrete data
  interacts with the CDSS to advise provider,
  contributing to improved QI
• Provider completes full course of diagnosis
  treatment in a single encounter and within the
  allocated schedule.
• Patient and provider satisfaction markedly
  improved