Understanding How to Customize Your Product and Redesign Your Workflow

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• Understanding How to Customize Your Product and
  Redesign Your Workflow
• Charles B Wang
• Community Health Center
• Thomas Tsang, MD, MPH
• Chief Medical Officer

Promoting HIT Adoption in the HRSA Community
Success Through Collaboration November 5-7, 2007
in Crystal City, VA
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Agenda

• Introduction
• Pre-Implementation Plan
• Team Design
• Implementation
• QA

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Charles B. Wang Community Health Center-
Demographic Overview-

• Established in 1971
• 96 of patients use language other than English
• Location
• 3 sites in Manhattan
• 1 site in Queens
• Payor mix
• 70 Medicaid, Medicare, Managed Medicare
  Products
• 28 uninsured
• 2 commercial insurance plan
• Patients served in 2006 gt40,000
• Number of visits in 2006 gt140,000

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Introduction

• Combined number of active medical records
  approx. 35,000 records
• Daily, approx. 800 paper charts were pulled at
  all three sites.
• Over 700 referrals/month in Adult Primary Care

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CBWCHC Mission for EMR

• Implement an EMR system that will electronically
  document, support, and transform the Centers
  patient data to improve the clinical quality of
  care and the healthcare delivery process.

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CBWCHCs Vision for EMR

• Improve Quality of Patient Care
• Track disease processes
• Perform outcomes analysis
• Provide clinical decision support at the time of
  intervention
• Allow immediate access to aggregate data for
  analysis
• Empower Patient
• Collaborative relationship
• Empower Staff
• Integrate multiple dimensions
• Decision support
• Enhance communications

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EMR project - Goals

• Patient encounter documentation
• Access review test results and clinical
  documents
• Integrate Clinical Pathway to practice
• Provide guidelines and health maintenance
  reminders on disease prevention
• E-Rx with interaction checking
• Enhanced pt education at the time of encounter
• Better utilization of data for outcome analysis
  and QA process
• Instant, appropriate, enterprise-wide access

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EMR Organizational Leadership
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EMR Implementation Team

• Core Team-charged with overall project management
• Design Team- provider champion, nursing champion,
  receptionist champion, CI, charged with mapping
  out pre-EMR workflows
• Training - CI team
• Pre-load coordination-
• Template design
• Report

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Standardization vs. Customization

• We decided templates would be uniform within a
  specialty across sites
• Resources dedicated to customize out of the box
  templates for each specialty but not for each
  site
• Assessed need for data reporting for grants and
  programs
• Did templates support other patient flows?

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Variation of Care

• Variation of care variation of quality
• Well documented in literature for over 30 years
  in cardiothoracic surgeries, care of acute MIs,
  asthma care
• Decreasing variation, increase standardization
  will ultimately improve quality

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Pre-Implementation

• Design team worked internally mapping out all
  flows- defined through job functions
• Nursing, referral staff/case manager, social
  work, front desk work flows
• Each champion tasked to come up with patient flow
  AND non-patient workflows
• Re-designed with efficiencies
• Core team translated new work flows into EMR
  templates

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Process Redesign

• Design eliminates irrelevant or duplicate
  documentation and redundant processes
• Design supports clinical data collected from
  other systems, which are captured by an interface
  whenever reasonable
• Patient data is standardize throughout the
  patient record
• Patient safety is a primary design requirement

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Phone-note before Re-engineering
Call Medical Records for chart
Need Chart
YES
Phone MD in back
Phone question requires MD intervention
MD responds to message
NO
YES
Urgent
YES
NO
Write question in message book
Call Medical Records for chart
NO
-Patients name -Tel -Sign/date/time
Leave chart, phone note for MD in back
PSR answers question over phone
MD responds to message
Chart returned to Medical Records
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PHONE NOTE after re-engineering
MD access the chart immediately in EMR
Need Chart
YES
Phone MD in back
Phone question requires MD intervention
MD responds to message
NO
YES
Urgent
YES
NO
Type information in phone note
Route to MD in EMR
NO
-Patients name -Tel -Sign/date/time
MD responds to flag
PSR answers question over phone
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Challenges

• Multi-site differences and balancing
  standardization goal
• 30 years of operational history changed in 1 year
• When to stop customization
• Resources-human capital, financial
• Process may exacerbate differences in sites

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Overcoming barriers

• Leadership
• Champions drive the process at the unit level
• Super users to take ownership of processes and
  support changes
• Open communication- meetings, meetings and more
  meetings
• Show efficacy and increased efficiency from first
  implemented unit

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Instant EHR Benefit

• Reliable documented clinical communication staff
  communication, documenting phone notes, referral,
  etc
• Mobility of patient records
• Patient level data is retained and validated from
  encounter to encounter
• Culture change of standardization Quality
  assurance

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Current ROI

• Outcomes data generated for
• Obesity in Pediatrics
• DM Review (A1C, LDL, Microalbumin, Eye exam)
• Womens Health and Mens Health Outcomes Review
• Geriatric Care Review
• Depression in Mental Health (PHQ3 and PHQ9)
• Public reporting to NYCDOH
• Child Immunization Registry
• Communicable diseases

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Future

• Collaborate with other CHCs
• Share knowledge of template designs
• Share workflows
• Create users groups