Achieving Meaningful Use : 10 Keys to a Successful EHR Install & Adoption

Transcription

1 Achieving Meaningful Use : 10 Keys to a Successful EHR Install & Adoption November 4 th, 2010 Larry Garber M.D., Medical Director for Informatics Fallon Clinic/SAFEHealth Larry Garber, MD Internist - Fallon Clinic x 24yrs Medical Director for Informatics x 12 years Pi Principle i Investigator t for a $1.5M AHRQ grant for SAFEHealth, an Opt-In consent federated HIE currently live in MA Vice Chair, MAeHC Member of MA State HIE Workgroup 300+ provider multi-specialty group practice 30 specialties, including Occ Med & Behav Med 23 sites in central Massachusetts patients with over 1 Million visits/year 200,000 patients with over 1 Million visits/year Not-for-profit At financial risk for 60% of our patients Not affiliated with any hospitals

2 Our 7-Year Journey: Vendor Select Decision Initial Planning Contract Signed Tech Infrastructure Team Training Design DBVs Development Practice Mgmt Implementation Clinical EHR Implementation Phase II Phase III Phase IV Implementation Never Really Ends Regulatory Changes Interface Maintenance Optimization Upgrades Keys to a Successful EHR Install & Adoption

3 10 Keys to a Successful EHR 10 Keys to a Successful EHR Establish Champions Early Identify, fund and train physician and nurse champions Involve as many people as practical o e as a y peop e as p act ca during each step, from the very inception Determine need for EHR at all levels 17 site meeting with >half of MD s + staff 7 Town Meetings attended by 25% of staff Senior Management enumerated benefits

4 Expected Financial Benefits Expected Financial Benefits

5 Other Likely Financial Benefits Expected results 5% reduction in laboratory testing that was duplicate or inappropriate 5% reduction in radiology testing that was duplicate or inappropriate p 0.5 FTE s of order entry and telephone message delivery staff refocused or reduced per 10 providers 50% reduction in preventable serious adverse drug events 7.5% higher E&M coding levels for increased reimbursement and improved capitation negotiations due to improved documentation Estimated 10-year total benefit: Industry experience 0 13% 5 20% NA 10 70% 10 35% $ 44.4 Million Other EHR Benefits Benefits for which financial savings are likely to be achieved but which are harder to quantify Benefits that will markedly improve staff and patient satisfaction and the overall quality and safety of care we provide Establish Champions Early Select EHR vendor using all levels of organization Diverse team of MD s + staff (ACE) Management team (HITEC) Board approval Focused campaign to engage Board members and all of medical leadership 1 on 1 and group meetings with ALL leaders

6 Establish Champions Early Identify Superusers for each role Providers Nurses MAs Check-in/check-out staff Involve managers and real users from a broad array of practice settings and specialties during design sessions 10 Keys to a Successful EHR EHR vendor selection process HITEC developed RFP with 140 functional requirements RFP was sent to 5 EHR market leaders 3 finalists selected and demoed their products to ACE committee Site visits, User Group meetings, reference checks, KLAS, ROI analysis, technical and financial due diligence were performed on finalists

7 Don t be Penny Wise & Pound Foolish 75-85% of an EHR project cost is fixed, independent of software vendor PC Workstations, Servers, Networks Database licenses Other systems (e.g. Document Imaging) Interfaces/mapping/vocabularies Workflow analysis and system/template build Training/Support Drop in productivity/revenue Cheapest to most expensive EHR will only change total cost by 5-10% Ergonomic Exam rooms Prepare for the worst System Fault Tolerance Redundant Servers Redundant Networks Redundant Networks Business Continuity Access Nightly downloads of scheduled patients to local PCs with UPS Disaster Recovery site Downtime procedures and supplies

8 10 Keys to a Successful EHR Exceptional Project Leadership C level ownership Steering Committee active ownership from operations, clinical and finance MD committee (EARs) PCP s and specialists actively involved in decisions Issues and decision escalation process, alternatives with pros and cons Financial management, budget and benefits Exceptional Project Leadership Project Team with clear roles, leadership, and Project Management support Hands on Project Director, relationships with Operations Strong team members (recruit the best, external and internal) Physician and Nurse Champions active members of implementation team EHR certification of implementation team 65 MD content experts to help with build

9 Exceptional Project Leadership Detailed project plan/resource assignments Status Reports Scope management Risks/Issues/Decisions Log Daily Issue Resolution Meetings during crunch time (including business owners) 10 Keys to a Successful EHR Workflow Redesign Lean theory training sessions for the multidisciplinary practice team Document and evaluate current workflows and physical plant Identify issues and opportunities Brainstorming sessions to resolve issues and improve processes Document resultant value-stream mapping in Excel and Visio Update policies and procedures

10 10 Keys to a Successful EHR Minimal Disruption at the Sites Phased implementation Maximal increments of change that don t interrupt operations Gives time to become proficient i with skills before taking on new tasks at next phase Data conversion from the paper chart that doesn t involve physicians or staff Doesn t take time away from busy MD s and staff No juggling paper and EHR charts in exam room Speech recognition software Easiest documentation tool to learn Phased EHR Implementation 1. Practice Management (Registration/Scheduling/Billing) 2 Clinical Results Repository 2. Clinical Results Repository 3. Paperless Telephone Messaging and Prescribing 4. Computerized Physician Order Entry/Documentation/Billing in Exam Room

11 Historical Data Conversion Electronic (from legacy repository QuickChart) Manual Abstraction Document Imaging (scanning) QuickChart Database # of Years # of Records Prescriptions Million Lab Million Imaging 14 2 Million Notes Million Visits Million Total 95 Million QuickChart Database (cont d) Immunizations, Health Maintenance, Disease Management 15 years Allergies 10 years EKGs 15 years Future Lab and Visit appointments 1 year

12 QuickChart & EHR Data Sources Fallon Clinic transcribed visit notes Fallon Clinic transcribed imaging reports Reference lab results Inbound interfaces from a home health agency and 5 hospitals (lab, imaging, notes), including SAFEHealth.org Health Information Exchange (HIE) currently Live in Central Massachusetts Patients give opt-in consent to exchange clinical data only between specific organizations where patient receives care No central clinical repository. Data flows from EHR to EHR. Developed with $1.5 Million AHRQ Grant Sustainability is enabled by low operating expenses resulting from internally developed software and no RHIO QuickChart & EHR Data Sources Direct entry into QuickChart (allergies, telephone messages) Fallon Clinic billing FCHP claims

13 At-risk claims data fed to clinic Hospitals Solo MD s FCHP Ref Lab Imaging Centers PBM Fallon Clinic Billing and Claims data FCHP Claims medication list and fill hx FCHP and Fallon Clinic claims/billing: Immunizations Health Maintenance Dates (e.g. Mammo, Colonoscopy, CPE, etc ) Disease Management Dates (e.g. HA1c, Retinal Exam, Smoking status, etc ) Past Medical Hx (filtered for chronic & signif. dxs) Past Surgical Hx (filtered for significant procedures) Visit Hx (OV/CPE, Consult, ER, Hospital, SNF/LTC) How Much to Convert Much passion surrounding this topic Issues Clinical value Research value Cost of storage Time for conversion Performance impact on live system We decided to convert everything

14 Conversion Planning Make a drawing of all of your current data stores and where they are going to appear in EHR Identify the interfaces to use Include the future state of how interfaces will flow in the live environment This is NOT for the faint of heart! 41 42

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16 Manually Abstracting Paper Chart Allergies Family History Growth chart data Problem Lists Document Imaging (Scanning) Multidisciplinary clinical team defined what to scan (type and how far back) Handwritten notes (e.g. Pediatric CPEs) Graphical results (e.g. PFTs, audiogram) Outside reports (e.g. consultants, MRIs) Indexing is critical for finding in EHR Patient Level (10 types, e.g. Advance Directive) Visit Level (20 types, e.g. Outside consults) Procedure Level (150 types, e.g. MRI of Breast) Speech Recognition EHR s documentation tools are very powerful and useful, however Take a long time to learn all of the tools Hard to document HPI & Medical Decision Making Used Dragon Naturally Speaking Medical Study showed higher quality notes and increased physician satisfaction with documentation & EHR Hybrid notes are most efficient Notes signed in EHR improved 4 days 45 mins Average increase of 8 minutes/day/md Saves $7,000/MD/year

17 10 Keys to a Successful EHR Effective Training and Support Recent college grads trainers optimizers Mandatory just-in-time training Hands-on training, 1 computer per user User-specific classes Job class (MD, nurse, MA, checkin/checkout) Specialty Proficiency testing LEVEL video on exam room computer physician patient interactions (with permission o Kaiser Permanente) Mandatory dress rehearsal Effective Training and Support Go-live support by trainers for 2 weeks All-staff site meetings 1-on-1 circle-backs Documentation summits Optimization team Live lunches

18 10 Keys to a Successful EHR Specialty & User-Specific Tools Need to balance user needs with: Bandwidth to build/maintain content for everyone Quality and design consistency standards Specialty-specific ordering and documentation tools System-wide and specialty preference lists User-specific preference lists and some documentation tools (SmartPhrases) 10 Keys to a Successful EHR

19 Alignment of Incentives Food/beverages at all training classes CME/CEU credits for all training classes MD financial compensation for drop in productivity 50% x 1 week, 25% x 2 weeks 90% of visits completed and billed cleanly within 48 hours, during the fourth month after go-live of final phase MD Productivity another customer Avg wrvus per MD EMR Jan '04 Mar '04 May '04 Jul '04 Sep '04 Nov '04 Jan '05 Mar '05 May '05 Jul '05 Fallon Productivity All Sites Visits/hr Week (3 = go live)

20 Fallon Productivity - One MD Keys to a Successful EHR Extensive Communication Many presentations, early and often, with Senior Management involvement Monthly Managers Meeting update Status reporting, EHR vendor & internal Demonstrations tailored to the audience, repeat, interaction FAQ to clarify details of vision & scope All-staff kick off have some fun

21 9/19/ Extensive Communication Newsletters EHR Plan-It, written by business owners for business owners Tech-Know Tips, written by MD for MD s Feedback directly through implementation team/trainers and Help Desk Surveys Before and after Involve MDs and staff lets them know that you re listening 10 Keys to a Successful EHR

22 Monitoring metrics for success Metrics team identified >150 measures Revenue Operations and Finance Clinical Operations Clinical Quality/Safety Customer Service Human Resources Information Technology Monitoring metrics for success Metrics classified according to value for evaluation: High, Medium, Low Metrics classified according to cost of data gathering: High, Medium, Low Low cost Metrics are currently captured Medium cost Additional reporting is required High cost A grant or special project is needed Measure high-value, low/medium-cost Summary Achieve success with: kfl d i

23 Questions?