performance improvement within an ehr (electronic health record) launch
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Performance Improvement within an EHR (El t i H lth R d)EHR (Electronic Health Record)
Launch
WCBF Lean Six Sigma Healthcare SummitMay 2011
Louis C. Rhodes
Purpose and Learning Objectives
Purpose: Introduce basic principles of an EHR
p g j
Purpose: Introduce basic principles of an EHR launch and how Lean-Six Sigma experts can contribute to its success
Learning objectives:• Describe HITECH Act and EHR related impactp• Identify key concepts associated with EHR
implementation• Describe points at which Lean-Six Sigma experts
can support EHR design and launch
2
Key Questions/Issues
• The HITECH Act mandate that health care
y Q
The HITECH Act mandate that health care entities must implement EHR's by 2015 or face monetary penalties in the form of reductions in Medicare reimbursements.
• What is “meaningful use of electronic health records”?
• The role of Lean Six Sigma in the EHR d l tdeployment process
• Crucial decisions that result in successful EHR adoption and a oidance of e pensi e EHRadoption and avoidance of expensive EHR mistakes
3
Lou Rhodes, MBA, MBB
• Administrator, New York University (Department of Obstetrics and
, ,
Gynecology)• Graduate of United States Military Academy (BS Management –
Engineering) and Xavier University (MBA)• General Electric Certified Black Belt and Master Black Belt in Six
Sigma and Lean• Eleven years experience in Six Sigma Lean and ChangeEleven years experience in Six Sigma, Lean, and Change
Management roles:• Two years chemical industry (Millennium Chemicals)
Four years in healthcare equipment and service delivery (GE• Four years in healthcare equipment and service delivery (GE Healthcare)
• Five years academic healthcare (USF Health and NYU School of Medicine)Medicine)
• Expertise in curriculum development and skills transfer to clients4
Agenda, Ground Rules, and E t ti• Agenda:
Expectationsg
• HITECH Act provisions• EHR implementation considerations• EHR implementation at USF Health
• Ground rules:• Informal environment• Maintain speed• Limit cell phone use• Limit cell phone use• Anything else?
• As a group describe expectations for this sessionAs a group, describe expectations for this session.
5
HITECH Act ProvisionsHITECH Act Provisions
6
HITECH Act Provisions*
• Health Information Technology for Economic and
HITECH Act Provisions
Health Information Technology for Economic and Clinical Health Act
• Part of the American Recovery and yReinvestment Act of 2009
• $17B allocated for incentives for EHR implementation
• Major provisions:• Incentives and penalties• “Certified” EHR Systems• “Meaningful use” of EHR
7* - From HHS.gov
Incentives and Penalties*• Physician: Medicare (per Medicaid (per
Implementation in: eligible professional) eligible professional)
Incentives and Penalties
Implementation in: eligible professional) eligible professional)• ≤2012 $44K (5 year payout) $64K (6 year payout)• 2013 $39K (4 year payout) $64K (6 year payout)• 2014 $24K (3 year payout) $64K (6 year payout)• 2014 $24K (3 year payout) $64K (6 year payout)• 2015 - $64K (6 year payout)• 2016 Payment adjustment $64K (6 year payout)• ≥2017 Payment adjustment -
• Hospital: Medicare (base Medicaid (base Implementation in: incentive) incentive)
• ≤2013 $2M $2M• 2014 ≤$2M $2M• 2015 ≤$2M; Payment adj. $2M
8* - From HHS.gov
$ ; y j $• 2016 Payment adjustment $2M• ≥2017 Payment adjustment -
Certified EHR Systems*
• Assures purchasers and users that EHR system will meet
Certified EHR Systems
p yrequirements for:• Technological capability• Functionality• SecurityFor certification EHR s stem m st be tested and certified• For certification, EHR system must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB).
9* - From HHS.gov
Meaningful Use*
• EHR must be adopted, implemented, or upgraded.
Meaningful Use
• Show use of certified EHR technology that can be measured significantly in quality and in quantity:• Use of certified EHR in meaningful manner (i.e. - e-prescribing)Use of certified EHR in meaningful manner (i.e. e prescribing)• Electronic exchange of health information to improve quality of
health care • Submit clinical quality and other measures• Submit clinical quality and other measures
• Demonstrating “meaningful use”:• Professional:
• 3 core and 3 additional clinical quality measures• 15 core and 5 of 10 meaningful use objectives
• Hospital:Hospital:• 15 clinical quality measures• 14 core and 5 of 10 meaningful use objectives 10
* - From HHS.gov
Security Provisions*
• Strengthens civil and criminal enforcement of HIPAA:
Security Provisions
• Four categories of violations that reflect increasing levels of culpability;
• Four corresponding tiers of penalty amounts that significantlyFour corresponding tiers of penalty amounts that significantly increase the minimum penalty amount for each violation; and
• A maximum penalty amount of $1.5 million for all violations of an identical provisionidentical provision.
• Also:• Strikes the previous bar on the imposition of penalties if the covered
entity did not know and with the exercise of reasonable diligenceentity did not know and with the exercise of reasonable diligence would not have known of the violation (such violations are now punishable under the lowest tier of penalties); and Pro ides a prohibition on the imposition of penalties for an iolation• Provides a prohibition on the imposition of penalties for any violation that is corrected within a 30-day time period, as long as the violation was not due to willful neglect. 11
* - From HHS.gov
Impact on EHR Implementation
• Restricts selection to approved vendors
Impact on EHR Implementation
Restricts selection to approved vendors• Offers incentives for early adopters (and
penalties for late adopters)p p )• Increases penalties associated with security
breaches and data management risksg• Requires investment in quality information
collection processes and security protocols
12
EHR Implementation Considerations
13
EHR Advantages andDi d tDisadvantages
Advantages DisadvantagesAdvantages• Reduction of errors
(information transfer,
Disadvantages• Initial investment (software,
hardware, internal staff, cross-checks)
• Data mining capacityD i i t f
consultants)• Ongoing support costs
(internal staff hardware• Decision support for streamlined workflows
• Immediate information
(internal staff, hardware, upgrades)
• Transition frictionImmediate information availability
• Single record (for hospital • Data entry time
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or practice)• Potential mobility (?)
EHR Promoters and InhibitorsEHR Promoters and Inhibitors
Promoters InhibitorsPromoters• Change readiness• Physician engagement
Inhibitors• Lack of incentives• Impact on productivity and y g g
• Regulatory requirements• Planning and preparation
p p yefficiency
• Lack of standardization
• Adequate support availability
• Cost of transition• Changes to workflow
Interactions and Trade-offs
15
Transition Friction and InefficiencyTransition Friction and Inefficiency
1.Slow acceptance and efficiency improvement
2.Fast acceptance and efficiency improvement33• Physician engagement• Workflow development• Support mechanismsen
cy
20-30%22
11
33
• Support mechanisms3.Efficiency improvement
and leverageEffi
cie
Implementation• Template set-up• Tablet use• Dictation software
Time
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• Further workflow improvements
IntegrationIntegration
• EHR enters as an technology initiative
• Leverage of the EHR th hPeople Process occurs through
improved processes• Adoption and
People Process
Adoption and utilization of the EHR occurs through people
Technologypeople
• All are needed for successful
EHR
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implementation and return on investment
Leveraging Patient DataLeveraging Patient Data
• Patient EHR:• Continuity and
availability of information
Patient Electronic
HealthHospital
WorkflowsData
• Hospital workflows:• Application of
clinical rule-sets
Health Record
Workflows
clinical rule sets • Triggers for orders
and actionsData Mining:
Data Mining (Education
• Data Mining:• Ease of case
review and comparison
and Research)
18
comparison• Discrete data
availability
EHR Implementation at USF HealthEHR Implementation at USF Health
19
USF Health Overview
• Mission: To improve life by improving health through
USF Health Overview
p y p g gpartnership, research, education and healthcare
• 3,500 team members of educators, staff, physicians, hresearchers
• Over 420 physicians, 135 allied health, and 70 nurse practitionerspractitioners
• 2 new out-patient buildings with imaging and an ambulatory surgery center
• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay
$350 illi t i• $350 million enterprise
20
USF Health: EHR TimelineUSF Health: EHR Timeline
2006 2007 2008 20092006 2007 2008 2009
• Vendor l ti
• Initial go-live • Continued d t t
• Workflow i tselection
• Planning• Workflow
• Rolling department go-lives
department go-lives
• v11 upgrade
improvements• Tablet roll-out
development• IT platform
upgradespg
Initial investment
21
Workflow Design: Deployment of N T h l F ilitNew Technology or FacilityCreate Future Identify Develop BuildCreate Future
StateIdentify
WorkflowDevelop
OrganizationBuild
Specifications
• Collect voice of c stomer
• Map current process
• Identify tasks and assign to
• Map layoutcustomer
• Describe future stateIdentify design
process• Build future
process maps• Identify gaps/
and assign to positions
• Create organizational
• Identify technology requirements
• Develop• Identify design principles
• Identify gaps/ constraints and needed actions
• Conduct walk-
organizational structure
• Build job descriptions
• Develop protocols/ policies
through
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Operational Mechanisms: Interdisciplinary Executive Team and Workflow Design Teams with change management skills
22
Design Principles
• Fully e-enabled scheduling and check-in:
Design Principles
• Ability to schedule appointments, check-in, pay co-pay (or balances), and input health status information
• Check-in ticket print-out and streamlined on-site processCheck in ticket print out and streamlined on site process• All patient care occurs in exam rooms:
• Triage, assessment, treatment, and scheduling of appointments occur in the exam roomoccur in the exam room
• Phones and computers in each exam room• One-stop shopping:
• Referrals and procedures routinely go to USF Health• System and service level supports high availability of
appointments (immediate, space available, scheduled)
23
pp ( , p , )• Additional services (x-ray, lab, ancillary) are completed at time of
appointment they were identified as a need23
Workflow Evaluation: Initial Id tifi tiProcesses: Processes (continued):
Identification
• Pre-Appointment• Arrival/Check-in• Paper Scanning
• No-Shows/Same Day Cancellations• Nurse/Tech Visit• Correspondence
Pro ider Actions• Provider Actions• Other Media Routing• Patient Visit
• Provider Actions
Standardization opportunities:• Positions and abbreviations• Protocol Driven Test
• CCS Post-Visit• Academic Secretary Post-Visit
• Positions and abbreviations• Greenie Construction• Exam Room Flags• Orders and Routing Options
• Point-of-Service Test• PSR Check-out• CCC check-out
g p• Provider/Designee Delivery• Test Classification• Internal Referral Appointment Needs
24
• Messaging and Tasking• Results Verification
24
Standardized Workflow: PatientVi it
CCS monitors IDX for
Visit
arrived Patients specific to supported Provider (CCC acts as back-up monitor)
CCS observes arrival CCS confirms Exam Room availability
Patient moves to Clinical Entry Point
CCS identifies appropriate Pager number of arrived Patient and trips Pager
CCS moves to appropriate Clinical Entry Point, greets Patient, and confirms identity
CCS collects Pager and drops into Pager Collection Point inside
CCS collects Greenie and escorts Patient to Exam CCS flags Exam Room
“CCS Intake”Collection Point inside Clinical Entry Point Room CCS Intake
CCS identifies brief Chief
25CCS starts AllScripts note
CCS identifies brief Chief Complaint/Reason for Visit and enters data into AllScripts
CCS takes Vitals and enters data into AllScripts
25
Clinical Floor Design and FlowClinical Floor Design and Flow
87
6
53
4
Floor Guide greets Patient and fast pass checks in, or directs to kiosk or PSRPSR checks-in Patient, receives co-pay, and receives history and releasesPatient selects waiting areaMA accompanies Patient to exam room
3
4
5
6
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MA accompanies Patient to exam roomMA completes vitals and history; Physician provides care; MA schedules follow-on appointmentsMA escorts Patient to clinic exit and farewells
7
8
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USF Health: EHR TimelineUSF Health: EHR Timeline
2006 2007 2008 20092006 2007 2008 2009
• Vendor l ti
• Initial go-live • Continued d t t
• Workflow i tselection
• Planning• Workflow
• Rolling department go-lives
department go-lives
• v11 upgrade
improvements• Tablet roll-out
development• IT platform
upgradesIT
Upgrade Train Design Supportpg
• Install computers/ printersCheck
• Provide basic training
• Identify specific needsSet up
• On-site support
• Transition to phone• Check
platforms• Set-up
templatesto phone support
27Implementation
Form: Past Medical HistoryForm: Past Medical History
28
Change Aid: Provider Instruction T if ldTrifold
29
After Action Review: Issue and A ti PlAction Plan
30
Data Entry OptimizationData Entry Optimization
Other staff enters • Good use of staffdata into EHR
Physician types i t EHR
• Limited potential for transfer of workload
• ControlFamiliarity with processinto EHR
Physician uses dictation service
• Familiarity with process• Poor use of Physician time• Quick data entry• Dictation costdictation service
Physician enters data into discrete
Dictation cost• Requirement to check dictation
• Quick data entry• Supports ease of researchdata into discrete
fields in template
Physician utilizes
• Supports ease of research• Requires template set-up and some
standardization
• Quick data entryyvoice recognition
software
Quick data entry• Immediate check of dictation• Initial cost and training
Key Learning's: USF Health T iti t EHR• Purchasing:
Transition to EHR
• Select system based on reasonable expectation of need• Planning:
• Create roll-out plan for technology training and process actionsCreate roll out plan for technology, training, and process actions• Expect transition friction and temporarily reduce scheduled patient load
• Physicians:E l d ft• Engage early and often
• Consider a physician champion• Workflow:
• Plan on changes where technology, people, and process intersect• Consider standardization based on best practices before transition
• Communication:• Provide updates often through multiple channels
32
The 4C’s of the EHR*
• Completion: All entries finished in total at
The 4C s of the EHR
Completion: All entries finished in total at time of service
• Communication: Ease of access to• Communication: Ease of access to information and appropriately routedC li M t ll l t• Compliance: Meets all regulatory requirements
• Quality: Information is of value
* - Dr. Lennox Hoyte, USF Health CMIO 33
Thank you for your time.
Questions?
34
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