Carilion Health System: Large Scale Ambulatory EMR Implementation

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Carilion Health System Large Scale Ambulatory
EMR Implementation

• Brent Lambert, M.D.
• Carilion Health System

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EMR

• 15 of Virginia physicians use an EMR

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Carilion Physician Operations

• Carilion Medical Group /- 190 phys.
• Carilion Medical Center /- 90 phys.
• Carilion Emergency Svs. /- 50 phys.
• Total Physicians Employed 330

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CMG Physician Characteristics
2003
1999
1994
2004
2005

• 117 Family Pract.
• 29 Internal Med
• 16 General Sur
• 12 OB-GYNs
• 8 Pediatricians
• 2 Cardiologists
• 4 Neurosurgeons
• 1 Vascular Surg
• 1 Dermatologist
• 1 GYN-Onc
• 1 Pulmonologist
• 1 Gastro.

• 61 60 65 71
  71
• 15 15 14
  20 29
• 8 10 7
• 6 8 6
  5
• 4 4 4
  4
• 1 2 1
• 2 1 1
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158 Phys 54 Loc
24 Phys 9 Loc
171 Phys 61 Loc
188 Phys 62 Loc
193 Phys 64 Loc
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About CMG

• Practices from Woodstock to Wytheville on I-81
  down to Galax and Martinsville on the NC Border.
• Electronic Medical Records in use since 1999
  one record per patient regardless of the location
  of care.
• Single patient financial record regardless of the
  location of care.
• Greater than 600,000 patient records
• 950,000 patient visits a year.

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Ambulatory EMR

• Carilion Medical Group began the role out of
  their ambulatory EMR in March 1999.
• Completed the initial rollout about 2 years later.

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Carilion Medical Groups Experience with EMR

• Started the EMR project in 1998
• First practice to transition from a standard
  paper record to EMR was in March of 1999
• Initial roll out complete in 2002
• No new paper in 2002
• Interfaces from
• practice management system
• reference lab
• radiology reports
• ED records, hospital transcriptions
• document imaging system

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CMGs Challenges

• Database vs. Document Storage
• Minimum usage standards
• Current Problem List
• Current Medication List
• Current Allergy List
• Immunizations
• Takes more time initially
• Learn new application
• Working in 2 worlds
• For most of our physicians it took 9-12 months
  to get back to baseline production.

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CMGs Challenges

• Integration
• Lab both reference and office
• Radiology
• Practice Management
• Transcribed Documents
• ED Reports (from another EMR)
• Document Imaging
• Standard Vocabulary
• Development of standards and clinical content
• Determine what clinical standards to follow
• Development of clinical content with clinical
  decision support tools
• Out of the box the clinical content is very
  basic and clinical decision support is nearly
  nonexistent

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Carilion Medical Group Board

• CMG board made decision to use an EMR
• Board elected by physicians in group and consists
  mostly of physicians
• Board made it clear that EMR was not optional

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EMR Selection

• Board appointed a committee to select an EMR
• Selection committee was made up mostly of
  physicians that were not on the board
• Made several site visits where EMR was used
• Selected Logician by Medicalogic

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Vendor Issues

• Medicalogic privately held company
• IPO
• Bankrupt
• General Electric

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Pilot Site Chosen

• Before final decision to move forward, the EMR
  was piloted
• Pilot site went live and used EMR for about 6
  months before any other sites went live
• Pilot site used to fine tune project plan and
  scope
• Pilot site used to define and refine rollout plan

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Key Project Decisions

• Single database over a WAN
• 100 thin clients
• Device in every exam room
• Limit printers as much as possible
• Interfaces priority

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Rollout Begins

• Order of rollout defined
• Each site had the option to opt out once and move
  to end of list
• Once an opt out site was reached for the second
  time they could not opt out
• 21 week schedule for kickoff to go live
• Site
• Training staff
• IS application staff
• Network Services

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Chart Preload

• Sites encouraged to preload problems,
  medications, and allergies
• Sites free to preload other information
• of charts preloaded very important in success
  at go-live

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Interfaces

• Practice Management System
• Reference Labs
• In-house labs
• Radiology Reports
• Hospital Transcription
• ED Reports

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Enhancements

• Faxing
• Electronic prescription transmission
• Required visit to Virginia State Board of
  Pharmacy
• Still not allowed by DEA for scheduled
  medications
• Document Imaging
• Dinamap

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Provider Decision Support

• Out of the Box
• Medication interaction
• Allergies
• Developed
• Diabetes
• Anticoagulation
• Immunization Reminders
• Mammogram Reminders
• Congestive Heart Failure
• Ob Care

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Diabetic Notification
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Diabetic Assessment
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Initial Anti-Coagulation Form
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A-C Treatment Sched.
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A-C Follow Up Form
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A-C Results

• We think that through standardization of dosing
  we will ultimately improve results for patients
  across a large population.
• Physicians and nursing staff like the
  documentation aids and efficiency

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Consider Mammogram
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Needs Mammogram
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Visit Assessment
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Customization

• Both good and bad
• Out of the Box our EMR is very generic
• EMR allows considerable customization
• Learning curve to customize is long and difficult
• Limited outside sources for EMR content

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Future of Carilion EMR

• More decision support
• Orders with out bound interfaces
• Lab
• Radiology
• Practice Management System
• Reporting

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Lessons Learned

• Difficult and painful process but worth the
  effort for most
• Provider productivity decreases (may not be all
  due to EMR)
• At 18 months encounter/provider/workday down by
  1.8
• At 30 months down by 0.4
• Few providers would ever choose to go back
• We believe that patient care improves!

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Keys to Success

• Total Commitment at the top
• Physician leadership
• Develop in-house skills
• Development/customization team leaders must have
  clinical background