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Planning for the Successful Deployment of an Electronic Medical Record

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Title: Planning for the Successful Deployment of an Electronic Medical Record


1
Planning for the Successful Deployment of an
Electronic Medical Record
  • George Mason University
  • College of Health and Human Services

James L. Oakes, Jr., Principal Health Care
Information Consultants LLC joakes_at_hcicllc.com
2
James L. Oakes
  • Thirty years in healthcare information systems
    and management engineering
  • Extensive experience as an operating manager,
    vendor executive, and consultant
  • Specializes in helping healthcare providers plan
    and optimize use of information resources,
    systems, and technology to improve clinical,
    operational, and financial outcomes
  • Worked with return on investment methodologies
    and analysis for over 25 years and pioneered the
    use of healthcare-specific economic analysis of
    healthcare information technology, including
    financial, clinical, and decision support
  • Developed and deployed healthcare value-based
    planning methodology for healthcare now adopted
    at a 600 bed regional medical center, a
    nationally known pediatric referral center, etc.
  • Served as interim Chief Information Officer in 3
    healthcare institutions in financial or
    operational turnarounds and provided CIO level
    leadership assistance and development in 12
    others
  • Assisted in the development of a business case
    and pilot methodology for a community-wide health
    information exchange initiative (HIE) and
    currently working on planning and implementation
    options for a statewide HIE
  • Co-authored the recently released book, Return on
    Investment for Healthcare Maximizing the Value
    of Healthcare Information Technology (HIMSS 2003
    book of the year) and advocates the development
    of a disciplined business case for technology
    investments
  • Appeared on the Hospital Satellite Network and
    spoken at numerous professional conferences,
    including CPRI, HFMA and HIMSS on such issues as
    effective governance, value realization, and
    strategy alignment
  • Holds a Bachelor of Industrial Engineering and a
    Master of Industrial Management

3
  • The Press Cant Tell You What to Think, but They
    Can Tell You What to Think About
  • John Naisbitt

4
HIMSS 18th Annual Leadership Survey
5
Life in the 21st Century
6
Health Care Technology in the 21st Century
  • Still predominately paper based
  • Systems not interoperable
  • Slow, expensive implementations
  • Increasing public pressure to do something
  • Continuing economic pressures

7
Terms Defined
  • EMR
  • EHR
  • CPOE
  • IHE
  • HIE
  • RHIO
  • EIEIO

8
Why was the casualty rate so high in the civil
war?
9
State of the Industry - Reality
  • Successful CPOE implementations are still rare
  • Fully functioning EMRs are at least as rare
  • Much of the information in the record will
    continue to be paper-based for years to come
  • A failure can cost the CIO his or her job
  • Failure to act can cost his or her job

10
Less than 4 of US Hospitals Using CPOE
The yellow bar represents the number of hospitals
verified in 2003
11
1.3-1.8 US Hospitals w/MDs Entering gt50 Orders
IP Average 54 MDs entering orders, with a very
small percent (1.3-1.8) entering gt50 of the
orders
12
HIMSS 18th Annual Leadership Survey
13
HIMSS 18th Annual Leadership Survey
14
HIMSS 18th Annual Leadership Survey
15
15
16
IT Strategy Alignment
17
IT Planning Process
The process used to develop the plan is comprised
of nine phases, with each phase building from
the information gathered in the previous phase.
18
(No Transcript)
19
The planning process includes an assessment of
the current state and defining a future state.
The resulting gap analysis laid the foundation
for the recommended IS strategies and tactical
plans.
Current State
Common Themes/Interviews
Current MIS Environment Analysis
IT Attributes Exercise
Strategies Tactical Plans
Gaps
Future State
EMR Adoption Model
IS Vision
Operating Principles
IT Attributes Exercise
Davies Award Winners Analysis
IS Goals
20
For Example
  • A metropolitan community hospital
  • Full service medical/surgical
  • Busy emergency services
  • Competitive environment
  • Battle for market share

21
Mission Statement and Vision
  • Mission Statement
  • We are a not-for-profit healthcare provider
    guided by the needs of our patients and
    community.  We distinguish ourselves through
    service and clinical excellence, affiliations
    with the XXX and YYY, and state-of-the-art
    technology and facilities.  We are committed to
    continuous improvement and appropriate use of
    resources.  We create an environment that
    encourages the success and fulfillment of our
    physicians, staff, and volunteers.
  • Vision
  • ZZZ Hospital Healthcare System will set the
    standard for excellence in healthcare in the
    metropolitan region.  Through our affiliations,
    we aspire to provide world-class patient care,
    technology, and clinical research.

22
Business and Market Drivers
  • Development of services based on community need,
    market position, competitors positions, margin,
    recruitment, etc.
  • Continuing shift from acute care to outpatient
    services
  • Development of alternate physician practice
    models
  • Based on locale and structure of local health
    care market, and market forces (e.g. Number of
    practices, practice size, strengths and
    weaknesses of local hospitals, patient
    demographics, etc.)
  • Objective of changing flow of patients and
    delivery of healthcare services
  • Combat particular physician shortages
  • Organizational alliances and partnership models
  • Increasing expenditures (faster than general rate
    of inflation)
  • State regulated revenues (70 regulated, 30
    negotiated) and other regulatory requirements

23
Business and Market Drivers
  • Emphasis on quality, safety, expense control
  • Focus on shortage of professional staff such as
    RNs and other clinical technicians
  • Continuing capital constraints
  • Consumer awareness, patient satisfaction,
    customer service
  • Need for readily available clinical information
  • Emphasis on Return on Investment (and more
    recently Value) as part of purchasing decision
  • Balanced scorecard including non-financial
    (quantitative and qualitative) and financial
    measures

24
Key Strategies
  • Demonstrate flexibility by promoting patient care
    and physician strategies
  • Traditional acute care
  • Off campus services and joint services
  • Increased focus on physician practices
  • Develop stronger relationships with physicians
    and tie physicians into the organization
  • Make it an easy place for physicians to practice
    Endear physicians and improve MD satisfaction
  • Demonstrated successes
  • Hospital-based physicians including Hospitals,
    Intensivists, Radiologists, Emergency Medicine,
    Anesthesiologists, etc.
  • Specialty Care Medical Group
  • Differentiate through program development where
    expertise and base exist
  • Orthopedics (Joint program has doubled in volume
    since its inception)
  • Trauma (County trauma center)
  • Neurology and Neurosurgery (NIH protocol)
  • Oncology (Focus on differentiation strategies)
  • Open Heart Surgery

25
Key Strategies
  • Stabilize existing outpatient programs and
    partnerships and capitalize on new
    programs/partnerships/alignments
  • Focus on quality and patient care
  • Improve in State, JCAHO and other regulatory
    measures
  • Advance existing and conduct new internal process
    improvement initiatives
  • Medication reconciliation
  • Patient throughput and turnaround
  • ED to inpatient
  • ICU to non-critical care units
  • Recent implementation of observation status
  • Improve patient satisfaction

26
Key Strategies
  • Continue to develop human resource strategies to
    address personnel shortages and retain talent
  • Recruitment
  • Benefits and compensation
  • Recognition and reward
  • Make ZZZ an easy place to work
  • Improve employee satisfaction
  • Improve financial position
  • Grow volumes
  • Stabilize existing outpatient programs
  • Advance partnering opportunities (e.g. XXX
  • Promote image of smaller community hospital
    doing big hospital things
  • Cross between smaller hospital and high tech
  • Increase awareness of community outreach programs
  • Continue development and execute campus
    enhancement program

27
Start where you are..
  • Understand and document current environment
  • Consider all applications
  • Be prepared for surprises

28
Current Information Systems Environment
Application Portfolio
ACCESS
REVENUE
CLINICAL
Billing AR
Electronic Claims Submission
Order Entry
Results Reporting
Clinical Data Repository
Patient Assessments
ADT
Registration
Electronic Claims Scrubber
Collections Management
Electronic Payment Posting
Eligibility
Enterprise Scheduling
MD Clinical Document- tation
Care Plans/ Pathways
Clinical Decision Support
Interdisciplinary ClinDoc
Medical Necessity
Denial Tracking
Document Imaging
CPOE
EMPI
Physician Access
ANCILLARY/DEPARTMENTAL
Med Admin (barcoding)
Emergency Department
ED PhysicianDocumentation
Medication Dispensing
General Ledger
Accounts Payable
ENTERPRISE RESOURCE PLANNING
Pharmacy
Laboratory
Radiology
PACS
Surgery
Anesthesiology
Cost Accounting
Time Attendance
Fixed Assets
Budgeting/ Forecasting
Pathology
Microbiology
Blood Bank
ICU
Rehab (PT, OT, Sp)
EKG (Muse)
Payroll
Human Resources
Executive Support
Materials Management
Help Desk
Case Management
Quality Improvement
Infection Control
Disease Management
Cardiology
Facilities Maintenance
Decision Support
Security
Incident Reporting
ADE Surveillance
Utilization Review
Dietary
Transport
Endoscopy
Coding
HIM
Abstracting
Chart Management
Dictation Transcription
Report Writing
Tumor Registry
Physician Credentialing
Employee Education
Radiation Oncology
Employee Health
GSI PACS (being replaced)
Fund Raising
Call Center
Nurse Call System
Trauma Registry
Medical Library
Core Vendor Other Vendors Not Automated
Staff Scheduling
Partially Automated
29
Todays Information Flow
Patient/ Family View Organization
View Process View Technology View
Admit
Allergies
Blood Panel
Progress Note
Insurance Authorization
Medications
30
Develop a vision for the future.
  • Phase in applications in a logical manner
  • If moving towards a core vendor strategy, phase
    in as contracts expire
  • Look for quick wins along the way
  • Recognize that users must see continuing benefits
    to support a long term plan
  • Be prepared to adapt plan as circumstances
    dictate
  • Communicate, communicate, communicate!

31
One Organizations Portfolio Leading to CPOE
CPOE
18 Months
Problem
Care Plans
Lists
9 Months
Common
Integrated
Nursing
Today
Order
Monitors
Assessments
Sets
Outpatient
Document
Electronic
Vital Signs
Online
Assessments
Imaging
Signature
I/Os
MAR
Electronic
Operating
Clinical
Case
100
Medical
EKG
Room
Alerts
Mgmt.
Codified
Necessity
Results
Mgmt.
Physician
Online Results
Ad
-
HOC
Dictation/
Bar Code
Scheduling
Remote
Reporting
Transcription
Access
Universal
Integrated
Patient
Order
Patient
Home
Radiology
LAB
Pharmacy
Demographics
Management
ID
Health
32
Tomorrows Information Flow
Patient/ Family View Organization
View Process View Technology View
Allergies
Admit
Blood Panel
Progress Notes
Medications
Insurance Authorization
33
Single View of Virtual Patient Record
Physician Office
Patients
Long Term Care
33
34
Legend
Electronic Medical Record
Sequenced or Simultaneous Installations
System yet to be Installed
Patient-Centric Information Systems February 2007
Web-based Viewable Results
Computerized Provider Order Entry
System Operational
Orange Indicates FY 08 Emphasis
Integrated Patient Monitors (OB, ICU, ER,
Telemetry)
Web-based Physician Remote Access
Electronic Scheduling
Installed Quadramed Product Planned Quadramed
Product
Picture Archiving Communication System
(PACS) McKesson HMI
Care Plans Problem Lists
Outpatient Assessments
Clinical Alerts
Online Medication Administration Record
Electronic EKG Results Pyramis
Electronic Signature Quantim e-Sig
Document Imaging/Storage EDM
ED Documentation Tracking T-System EV
Nursing Assessments
Vital Signs I/O
OB QS Sentinel
Management Ad-HOC Reporting Crystal Reports
Dictation/ Transcription Precyse Solutions
HealthNotes, SpeechQ
Case Management MIDAS
Utilization Review MIDAS
OR Management ORSOS
Materials Management Dimension21
Patient Registration Affinity Reg NTierprise Home
Works, Mestamed
Order Mgt. Viewable Results Common Order
Sets Order Mgmt
Pathology MediSolutions AP
RadiologyRMS
Lab Medilab
Pharmacy Affinity Pharmacy Etreby
Clinics/Ambulatory /Physician NTierprise
PM HealthmaticsEMR
Home Health Homeworks
Transitional Care AccuCare
Home Medical Equipment MestaMed
Coding Quantim Coding Homeworks
Medical Record Management Affinity MRI, MRA,
MRC
Medical Necessity Caremedic LMRP
Billing Collections Affinity, SSI, Medifax
MestaMed, Homeworks, Medware, Zirmed
The FOUNDATION REQUIRED to make these components
into a Fully Functional Electronic Medical Record
includes the following
1. Business Continuity Plans that provide for
Redundant Storage and Communications to ensure
constant availability of the systems 2. An
adequate number of appropriate user devices
connected to a Robust Infrastructure that
provides data that is shared (interfaced or
integrated) across the continuum of care 3.
Common Identification of the Patient across the
continuum of care 4. Adequate Technical Support
to ensure continuous operation.
35
Things to keep in mind.
  • You cant do everything at once
  • Not all applications need to be state-of-the-art
  • Paper will always be with us
  • Value is in the mind of the beholder
  • You must decide how far out on the bleeding
    edge your institution wants to be
  • A well implemented system is more valuable than a
    snazzy one that is poorly implemented

36
Understand Your Institutions Risk Profile
Traditional Technology Adoption Curve
37
No Longer Supported Last Generation State of the Art Leading Edge Emerging from the Lab In the Lab

Number of Installations
Pharmacy
Radiology
Automated Pathways
EKG
Lab
EMR
RFID
Billing
Physician Office Management
PACS
AI
Voice Activated Systems
Budgeting
Credentialing
Time
38
Differing Views of Value
Business View
Information View
Process View
Application View
Technology View
39
Hospital Automation Levels for of Operating
Budget
40
Return on Investment is Essential
The Economic Value Pathway
  • Measurements have focused on tactical items, but
    should also focus on strategic goals. Broaden
    your focus Can technology contribute to the
    bottom line?

41
Before After Daily Printing
Before
After
42
Sample Cost Data
43
Evolution to Clinical Transformation
Process/Technology Maturity
Value Creation
44
Tactical Plan (EMR)
45
Tactical Plan (Non-clinical)
46
Tactical Plan (Services)
47
Tactical Plan (Technical Infrastructure)
48
Tactical Plan (Governance)
49
Tactical Plan (Information Use/Workflow)
50
Tactical Plan (Culture/Organization)
51
A few words about governance
  • Good governance wont guarantee a successful
    project, but
  • Poor governance will almost certainly doom a
    project

52
Governance Defined
  • Exercising authority or control over the
    decision to utilize resources in the pursuit of
    organizational objectives or strategies.

53
IT Governance Goals
  • Create a fast, flexible and effective process
  • Strategically align decision-making and
    accountability
  • Be selective and apply the best thinking within
    the organization so not all decisions are sent
    through governance
  • Measure IT performance and value

54
IT Governance Fits Into Overall Enterprise
Governance
Enterprise Governance
  • IT Governance is an organized framework of roles,
    responsibilities, policies methods used to
    guide, direct manage IT resources
  • IT Governance is an extension of Enterprise
    Governance, not an island function delegated to
    IT department
  • Effective IT Governance requires executive-level
    involvement participation by stakeholders

55
ISSC Role
  • Sources of Projects
  • Strategic Business Initiatives
  • IT Vision and Plan
  • Dept Initiated Requests
  • Maintenance Upgrades

CFO CEO input
Requested
ISSC Prioritization Must Have Defer Cancel
Available
Other IT Routine IT Other Strategic
Initiatives CPOE
12 Month IT Plan
Resources Project Plans Project Budgets
  • Executive Sponsors and ISSC Membership
    Responsibilities
  • Set objectives policy
  • Measure performance business value
  • Cascade strategy, policy goals throughout
    organization
  • Facilitate communication
  • Establish clear accountabilities
  • Manage risk
  • Remove barriers
  • Improve processes, organization structure
    knowledge

Ongoing Role
12 Month Project Portfolio
56
Four Ares
  • Value question
  • Understanding of
  • expected benefits
  • Accountability for
  • realization
  • Relevant metrics
  • Benefits realization
  • process

Are we doing the right things?
Are we getting the benefits?
  • Strategic question
  • In line with vision
  • Consistent with
  • business principles
  • Contributing to
  • strategic objectives
  • Architecture question
  • In line with architecture
  • Consistent with principles
  • Consistent with other
  • initiatives

Are we doing them the right way?
Are we getting them done well?
  • Delivery question
  • Management,
  • Delivery, change mgt
  • Resources to deliver
  • Required technology
  • Required capabilities

57
Governance Map
Executive Governance
Executive Council
IS Strategic Governance
Information Systems Steering Committee
IS Management
IT Department Liaisons
Senior Mgmt. Team
IT Operations
Project Teams
IT Staff
58
Areas for Action
  • Systems
  • Governance
  • Services
  • Technical Infrastructure
  • Information Use/Workflow
  • Culture/Organization

59
Technology is just a matter of using the right
wrench to pound in the correct screw
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