Implementing an Electronic Medical Record

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Implementing an Electronic Medical Record

• Strategic and Operational Considerations

Brian Anderson, MD Allina Hospitals and
Clinics Colorado HIMSS January 13 , 2006
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Five Big Questions
Do you have an organizational strategy? Do you
have a plan for the strategy? Do you have the
right stuff in the plan? Do you have the
resources to work the plan? Do you have a way to
measure your progress?
If the answer to any of the above is NO, Do Not
Pass Go
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Caveat

• HIT implementation is a forcing function
• You make the invisible visible, the informal
  formal, the independent collaborative,
• and change is profound (for better or worse..)

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Integrated Clinical Architecture
Enterprise Vendor
Various Vendors
Lab vendor
Undefined
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Integrated RCS Architecture
Enterprise Scheduling
In Out (Common) Registration
Passive STAR ADT
Ambulatory Registration
Acute Registration
Insurance Verification
Acute Orders
Ambulatory Orders
Clinical Ancillary
Integrated Partner
EMPI
AMR Vendor (s)
Ambulatory Charging
Acute Charging
Undefined
HCFA 1500 Billing
UB92 Billing
Patient Billing Collections
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Interface Complexity Single Integrated Option
EMPI
Enterprise Registration
Integrated Enterprise Vendor
Enterprise Scheduling
Hospital Orders CDS
Patient Accounting
Clinic Orders CDS
Hospital Documentation
Diagnostic Imaging
Clinical Repository
Diagnostic Monitoring
Physician Patient Portals
Radiology
Laboratory
ED
Clinic Documentation
Surgery
Other Hospital Departmental Applications
IP Pharmacy
Transcription, Medical Records, Document Imaging
Clinical Data Warehouse
Revenue Cycle
Undefined Vendor
Other
High Complexity Interface
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Implementation Sequence
Pilot
Design Build Validate
Rapid Design
Train
Linked AMC Track
(Linked Affiliate Track)
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Allinas Integrated Vision
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The Donabedian Model

• Structure Process Outcome

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Allinas Goal Best outcomes, at lowest cost of
production, with zero defects
By providing care that is highly accessible,
highly reliable, promotes healing
interactions and meets the 6 aims of the IOM
Enabled by health information technology
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Clinical Vision Development
Conceptual Model of Healthcare Services Delivery
1. We begin by describing a
2. We consider the drivers

• Clinical
• Business
• Operational
• Environmental

Ideal Future State
3. We then describe an
4. We identify the information system
requirements for the ideal state
Integrated Vision A description of Healthcare
Services Delivery enabled by Information
Technology
5. We articulate an
6. We derive, store, retrieve, analyze,
disseminate
Process Measures
Outcome Measures Clinical, Functional,
Satisfaction,Safety, Cost
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Clinical Vision DevelopmentConceptual Model
The Universal Journey
Patient in Need
Orientation / Information
Access to Care
Follow-up and Continuation of Care
Assessment
Treatment
Two 3-hour clinical visioning sessions were held.
There was no conceptual disagreement on the care
model regardless of facility.
Adapted from Mohr, Batalden and Nelson
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Care Experience
Business Processes
Clinical Processes
Information / Orientation
Access to Care
Assessment
Treatment
Follow-up / Continuation
Process Measures
Outcome Measures
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• Patients, families, and caregivers have
  information that enables them to navigate the
  system.

• Activities include
• Provide access to provider directory (include
  provider bio)
• Provide information about payer
  coverage/participating specialists (benefits
  structure and management)
• Provide facility information / directions
• Identify referral network resource availability
• Support orientation/education for patients
  (provider information, patient routing, view
  outcomes and cost data)
• Provide interactive self-assessments/self-triage
  (may tie into self-scheduling)
• Provide access to community-wide information
  (patient-specific)
• Respond to patient inquiries provide two-way
  communication

The list does not include all the information /
orientation activities possible, but represents
the majority.
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RCS Vision

• One stop scheduling and registration
• Collection of patient financial and clinical
  information is done once
• Patient eligibility and financial obligation is
  known up front
• Charging is driven by documentation at point of
  care
• Easily understandable accurate bill
• Immediate answers to patient financial inquiries

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• The system design principles serve as minimum
  standards upon which to develop future clinical
  processes

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Guiding PrinciplesBest of Breed vs. Integrated
system decisions
Best of Breed

Integrated

• Principle 1
• If a new or enhanced application is requested and
  our integrated vendor provides the functionality,
  we will use the integrated vendors product.
• Allina has chosen a technology strategy based on
  integration.
• All systems/project requests that involve sending
  or receiving data to/from the AMR/RCS product
  should be evaluated against this principle
• We will assume the integrated vendor product will
  be the system of choice unless a strong business
  case can be made in favor of a different solution

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Guiding PrinciplesCore System Design
Business Unit Design
System- Wide Design

• Principle 2
• We will create a core system design that will be
  shared by all business units
• Standardization is key to achieving benefits and
  rapid implementation
• Standardization reduces the cost of support
• Medical technology acquisitions must meet core
  system technical and integration requirements
  unless a cost/benefit analysis supports a
  different decision

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Guiding PrinciplesSoftware Customization
Customized
Standard

• Principle 3
• We will install generally available software
• Customization increases risk and lengthens
  project timelines
• Standard software is highly configurable
• Generally available software will be the solution
  of choice unless a business case demonstrates
  competitive advantage with customization of
  source code
• Customization increases ongoing support
  requirements

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Guiding PrinciplesResource Focus
New Systems
Legacy Systems

• Principle 4
• We will shift the focus of our internal resources
  from support and enhancement of Legacy
  Applications to designing and building the new
  AMR/RCS system.
• Legacy support must be continued for basic
  maintenance activities
• Project and enhancement requests for legacy
  applications must be closely monitored and
  prioritized
• Strategies to backfill support resources to work
  on new applications will be included in the
  implementation plan
• Migrate over time where only required fixes or
  mandated compliance related changes will be made
  to legacy software

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Guiding PrinciplesProject Sponsorship
Operations Project
IS Project

• Principle 5
• Major technology change initiatives with
  significant operational benefit will be owned and
  driven by operational leadership
• Physicians and Executives must play leadership
  roles in order for the implementation to be
  successful.
• Change needs to be supported from the top of the
  organization.
• Governance and decision making structures will be
  put in place to support this principle.
• Leadership will be accountable for sponsorship
  and achievement of expected benefits/outcomes

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Guiding PrinciplesChange Management
Minimal Change Support
Required Change Support

• Principle 6
• We will understand work process and change
  management implications of technology
  improvements, and provide the necessary support
  to effectively manage change.
• Employees and providers who will be affected will
  be informed about and represented in the process
  and content design efforts, as well as
  implementation efforts
• Training will occur as technology and process
  changes are introduced to assure necessary skills
  are exhibited
• Job requirements and organizations staffing will
  be evaluated to ensure timely workforce
  transition planning
• Organized labor commitments will be anticipated
  and honored

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Decision Rights
Decision_________________________________
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Excellian Governance and Guidance
Board Oversight
Steering Team
Executive SponsorCMO
Project VP

• Physician
• Quality Patient Safety
• Communications
• Pharmacy
• Compliance
• Patient Management
• Workforce
• Nursing
• etc

Advisory Groups
Program Management Team
RCS Sponsors
Benefits Director
IS
Workforce Director
Clinical Sponsors
Allina Program Director
Vendor Program Director
Consultant Program Director
Implementation Planning Teams
Clinical Benefits Planning
RCS Teams
Clinical Teams
Technology/ Architecture Team
Vendor Team
RCS Benefits Planning
Site Teams/Managers
Roll Out Teams
Integration Team
Training Teams
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Physicians
Project Management Team
Optimization team
Physician Advisory Team
Decision Support
CMO
Executive sponsor
Hospitals
Clinics
System Champions
Site Champions 2-4 hrs/wk ramp up at
site implementation
4 metro 7 regional
AMC Hospital based
Clinical documentation Orders ED
Clinical Documentation Orders
Design Consultants
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Clinical Vision DevelopmentClinical Leaders Team
Role Develop the clinical vision and provide
clinician input for the requirements to support
the vision

• Invited Membership
• Physicians
• Nurses
• Executive Clinical Leaders
• Quality Improvement Specialists
• Therapists

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Excellian Advisory Group Structure
Advisory Teams
Project Teams
Physician
Board Oversight
Detail Advisory
Rev Cycle
Project Mgmnt Team
Steering Team
Hospital Pt Care
Clinic Pt Care
Decision Review and Approval
Oversight and Resolution
Design Decisions
Design Input
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Clinical Benefits Planning Organization
Steering Team
Project Management Team
Clinical Benefits Planning Team

• Benefits Director
• Consultant Lead
• Allina clinical analyst
• Allina financial analyst

• Physician
• Nursing
• Pharmacy
• HIM

Clinical Benefits Advisory
Subject Matter Experts (SMEs)
Operational Leadership

• Clinical leadership
• Metro operational leadership
• Regional operational leadership
• AMC operational leadership

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Implementation PlanningClinicals
AMR
Planning
Team
MD
Advisory
Group
Clinical
Physician
Clinical
Medication
HIM
Radiology
Orders
Decision
OR
Portal
Doc.
Mgmt
Support
IP
OP
IP
OP
IP
OP
IP
OP
IP
OP
IP
OP
IP
OP

• Physician
• Linkage Team

• HIM Reps

• Nursing Reps
• CIS Analysts
• MDs/Providers
• Ancillaries
• Charge Services

• Pharmacy Reps
• Nursing Reps
• Pharmacy
• Analysts
• MDs
• Ancillaries

• Care Improvement
• Quality

• Nursing Reps
• CIS Analysts
• MDs/Providers
• Ancillaries
• Charge Services

• OR Reps

• Radiology Reps
• RIS Analysts
• Charge Services

Team Participants

• Remote
• Access
• Comm-
• unication

• Chart Deficiency
• Chart Tracking
• Transcription
• Document
• Imaging

• Pharmacy-based orders
• Dispensing
• Compounding
• Titrated IVs
• Weight and age-based protocols
• Electronic MAR
• Alerts

• Reporting
• Clinical
• Indicators
• Data Mining

• Boarding
• Anes
• Documentation
• Charging
• PACU
• Materials

• Physician
• Nursing
• Ancillaries
• Flowsheets
• Progress Notes
• Growth Charts
• Immunization Record
• Problem List

• Scheduling
• Film Tracking
• Dictation
• Transcription

• Provider Orders
• Nursing Orders
• Ancillary Orders
• Order Communication
• Protocol Management
• Orders-based
• Rules and Alerts

Functional Focus
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Implementation PlanningRevenue Cycle
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Example Implementation Organization - OpTime
OpTime Team Leads
Product Design Teams
OR Process Design Team
Scheduling/Case Entry
Membership TBD
All site representation
Preference Cards
All site representation
Materials/Supplies/Charging
All site representation
Log Entry/Intra-op
All site representation
Reporting
All site representation
Site Team Leads
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Benefits Levels of Measurement
When? Last year (2002) What? Use Allina
volumes, rely on published literature to estimate
current process and future improvement
amounts Why? Define benefit categories,
estimate benefit amounts
Level One
When? This year (2003) What? Measure Allina
processes, estimate future improve-ment amounts
(literature), identify process improvements Why?
Validate benefit amounts, define change
mechanisms, create integrated implementation
plans, set budgets
Level Two
When? Immediately before go-live
(2004-2006) What? Update Allina volumes and
process measurements, target specific process
improvements Why? Set specific process targets
and operational metrics
Level Three
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AMR Benefits

• Unexplained Practice Variation
• Adverse Drug Events
• Drug Costs
• Radiology/Laboratory Test Costs
• Clinical Documentation Costs
• Ordering Costs
• Chart Management Costs
• Reimbursement

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RCS Benefits

• Reduced Denials
• Improved Information Flow
• Coordination of Patient Scheduling
• Higher Collection Ratios
• New Sources of Patient Revenue
• Enhanced Management of Payor Contracts
• Productivity / Staffing Costs

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Clinical Decision Support - Knowledge Domains

• Educational Materials
• Patient and Family
• Caregivers
• Rules and Alerts and Protocols
• Laboratory
• Pharmacy
• Health Maintenance
• Preventive Services
• Clinical Knowledge Tools
• Order Sets
• Care Plans
• Medication Protocols
• Resource Links
• Internal External
• Documentation
• Structured
• Automated (e.g., physiological monitoring)

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Flight Checklist

• Clear strategic direction
• Compelling vision
• Guiding principles
• Decision rights
• Guidance systems
• Highly effective communication
• Operational ownership
• Strong engagement
• Appropriate metrics

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Particular Pitfalls

• Scope creep
• Pace and sequence
• Overdesign
• Feedback gaps
• Builders testing
• Safety
• Privacy and security
• Post go-live support
• Human factors
• Fatigue

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Building as you go..Checklist for todays and
future flights

• Decision support
• Scope and version control
• Training and support innovations