Implementing an Electronic Medical Record

System at OK Care Hospital

Medical Informatics 404-DL

Fall 2009

Group 5Tammy Gray, Beena Joy, Emad Osman, Joseph Ryan, Natalie Schwartz

PROJECT OVERVIEW

To implement a fully integrated patient-centered EMR in a 250

bed medical surgical hospital

• Institutional Goals

– To improve the quality of patient care

– To improve patient outcomes

– To improve patient safety

– To improve organizational efficiency and productivity

– To effect cost reduction

– To improve service and satisfaction to our patients, providers,

and staff

HOSPITAL SYSTEM

OVERVIEW

• General Medical Floors

– 155 beds, 5 floors, 15 double

and 1 single occupancy rooms/

floor

• General Surgical Floors

– 60 beds, 2 floors, 15 double

occupancy rooms/ floor

• Medical ICU/ CCU

– 16 beds

• Medical Step-Down Unit

– 6 beds

• Surgical ICU

– 8 beds

• Surgical Step-Down Unit

– 5 beds

• Labor and Delivery Unit

• Operating Rooms and Delivery

Suites

• Emergency Department

– 15 beds

• Pharmacy Department

• Laboratory Department

• Radiology Department

• Outpatient Clinic

• 300 staff physicians

– Voluntary & hospital-employed

STRATEGIC PLAN: CURRENT STATE

CURRENT SOFTWARE

ADT/ PATIENT REGISTRATION

Siemens

PACS

GE Healthcare

CURRENT HARDWARE

• Terminals in the Admitting Department, Patient Registration, Emergency Department, Billing Department, Pharmacy, Laboratory, Radiology, Outpatient Center

• Terminals at each central nursing station

• 2 terminals at each central nursing station (retrieval)

• 6 terminals in radiology dept. for retrieval and MD reading

STRATEGIC PLAN: FUTURE STATE

ACTIVE, PATIENT-CENTERED EMR

COMPONENTS AND FUNCTIONALITY:

Health care information and data- “anytime, anywhere access”

Full Integration of test results and management- laboratory, PACS

CPOE and e-prescribing

Barcode-enabled point of care- medication administration

Decision-Support systems- evidence-based standards of care

Electronic communication/ connectivity- E-mail, Intranet, Internet

Clinical Reporting- Accrediting agencies, insurance, audits

Clinical Research and Trials

Chronic Disease Management (includes Case Mgt.)

Data-Mining

Fully integrated with ADT and Patient Registration Systems

Other administrative processes- insurance verification, pre-authorizations

STRATEGIC PLAN: FUTURE STATE

ACTIVE, PATIENT-CENTERED EMR

CPOE: Improved patient outcomes

• Reduction in medical errors

• Reduction in adverse drug events

• Improved adherence to clinical protocols

• Decision-support tools- alerts, reminders, call-backs

Cost savings• Reduction in medication errors and adverse events prevent

unnecessary hospital days, reduced liability

• More cost-effective choice of medications

Improved Revenue• Improved accuracy and timely billing

• Increased transaction processing rates

• Reduced LOS

• Improved compliance with core measurements

NEEDS ASSESSMENT (1)

Strong commitment from senior level healthcare administrators

Physician Champion- passionate, respected, strong communication skills, strong leadership ties to medical community

Provider buy-in and adequate representation in the design and implementation of the system

Strong and committed leadership from major hospital departments

Search for qualified vendors- vet organizational and financial stability, track record for service and response, pricing, upgrades, system expandability

Formalize a contract with selected vendor(s)

Develop a business plan- define capital and operating costs, costs of upgrades, organizational financing, government stimulus funding, ROI

Identify the sources of data and systems that need to be integrated

Identify storage space, electrical requirements (power, shielding, ventilation), physical space of clinical and IT activities, present and future capacity

NEEDS ASSESSMENT (2)

Determine information system architecture- integrated platforms and IT infrastructure (servers, operating systems, networks)

Develop solid and reliable administrative, physical, and technical safeguards for 24/7- 365 days/year operability

Solid disaster recovery plan

Human resources analysis

Create a strong and dedicated IT Team, including a CIO, CTO, CSO, CMIO, CNO, system analysts, programmers, database administrators, network administrator, telecommunications specialist, in-house IT staff to establish connections, load and test applications, troubleshoot, staff help desk, training, upgrades

Workflow Analysis- determine # and location of workstations, space requirements, re-design of work areas

Identify training staff and provide dedicated training time

Develop a practical timeline for implementation across the hospital

CRITICAL NEED:IT ALIGNMENT AND STRATEGIC PLANNING

Ensure a strong and clear alignment

between IT decisions/ investments and

the hospital’s overall strategies, goals,

and objectives

Use IT to support the momentum of the

hospital’s vision, not to create the vision

Strong senior leadership and understanding

of the benefits and limitations of the IT

initiatives to achieving organizational goals

Strong IT governance

CRITICAL NEED:PHYSICIAN BUY-IN

WE NEED TO MAKE THE

PHYSICIANS PART OF THE

SOLUTION,

NOT PART

OF THE PROBLEM !!!

Need to Convince Physicians of the

Personal Value of a Hospital EMR

Physician complaints:

“My handwriting is legible”

“None of my patients have had medication errors”

“Why do I need to change my practice to benefit the hospital ?”

Time for classroom or one-on-one training not reimbursed

Learning curve (may be steep for older MD’s)

Cost of installing office technology for hospital linkage

difficult in current economy and reimbursement

environment

Problems remembering multiple or single UserID’s/

Passwords

Need benefits to outweigh MD complaints:

Remote access to hospitalized patient data

Can track their patients across the hospital

Can use CPOE from any site- within the hospital/ office

No more searching/ waiting for charts to enter notes

(e.g. chart is being used for nursing rounds, by case

manager, or another MD; taken off the floor for testing)

Reduction in medication errors and physician liability

Increased patient satisfaction with more integrated

hospital services and efficiency

Can sign discharge summaries and operative reports

from their offices

Improved patient billing services- fewer complaints

Must align the value of a hospital EMR with the value to physician practices !!!

PROJECT STEERING COMMITTEE

Project Sponsor: CIO

Physician Champion: CMO

Physician Advisory Subcommittee:Chairmen, Departments of Medicine, Surgery, Ob/Gyn, Laboratory, Radiology, Emergency Room

Respected representatives of the full-time and voluntary medical staff must be involved from the ground up and at every key decision point!

Nursing Champion: CNO

Nursing Advisory Subcommittee:Nursing Supervisor, Nurse Manager (Medicine, Surgery, ER, L&D, OR)

Director: Quality Improvement

Director: Billing Department

Director: Admitting Department

Director: Risk Management

Director: Medical Records Department

Project Manager: Consultant/IT Liaison

IT Advisory Subcommittee

PROJECT STEERING COMMITTEE

Each department representative within the steering committee must:

Perform a Stakeholder Analysis of their department

Develop a list of CTQ’s (“Critical to Quality”)

Perform a Workflow Analysis of their development

Become the project champion for that area

Stakeholder SWOT Analysis

Short Term

Long Term

Threat Opportunity

↑ Patient safety events

↓ Satisfaction of MDs, patients,

and staff

↑ continued delayed treatment

↑ potential in LOS

Meet strategic goals

Meet/exceed customer

expectations more often

↓ errors, delays in treatment

and LOS

↑ bed availability

Loss of patients/business

↓ reputation and credibility

Possible ↑ in liability,

susceptibility to litigation

Financial impact resulting in ↓ $$

Enhanced patient outcomes

↑ business

↑ community reputation

SOFTWARE SPECIFICATIONS

RFI - VENDOR SELECTION CRITERIA

VENDOR SELECTION

REQUIREMENTS

MEDICAL STAFF PERSPECTIVE:

CPOE capable– Usability

– User-friendly GUI

– Order placing is intuitive (includes e-prescribing)

– Buttons, dials, links, etc., are logically placed

– Minimum number of mouse clicks per function

– Information display is useful and not confusing (“no wall of numbers”)

– Specialty modules in development

– Private practice connectivity

– Customizable order sets

Voice recognition integration

Decision support capable– Alerts appear in summary to reduce fatigue

– Linkage to citations

Value added– Improves safety

– Enhances, not hinders, productivity and efficiency

VENDOR SELECTION

REQUIREMENTS

ADMINISTRATION AND NURSING ADMINISTRATION PERSPECTIVE:

Willing to partner and grow with us-”scalability”

Has an ongoing plan for moving us from A to B

– Accepts accountability for assisting the organization in the re-

engineering of all workflows

– Education plan includes ongoing support

Demonstrated implementation satisfaction with other like organizations

High level dashboard report capability for key indicators linked to

strategic goals

Evidence that vendor’s EMR acquisition results in the improved patient

outcomes and cost savings over time

Reporting is turn-key and non-proprietary

VENDOR SELECTION

REQUIREMENTS

NURSING STAFF PERSPECTIVE:

Workflow promotes optimal face time with patients and real time

documentation

GUI is intuitive and views customizable by user preference

Terminology is dynamic

Medication barcoding is integrated

VENDOR SELECTION

REQUIREMENTS

PHARMACY PERSPECTIVE:

Medications and dosages are discreet fields

Smooth transition of orders from ER to inpatient

Alerts with decision support

Requires justification

– Alert overrides

– Non-formulary meds

Reporting is turn-key

CPOE

e-Prescribing

e-MAR

VENDOR SELECTION

REQUIREMENTS

QUALITY PERSPECTIVE:

Core Measures abstraction is automated

Reporting is turn-key

– All data are reportable and easily accessed through ODBC

connection

– Proprietary tools are not required

Links with Laboratory, PACS, Pharmacy, both internal and

external

VENDOR SELECTION

REQUIREMENTS

INFORMATION TECHNOLOGY PERSPECTIVE:

• Full integration with all other disparate clinical & non-clinical

systems within the organization

• Scalable

• Roll-based access

• Audit trails

BUDGET

RETURN ON INVESTMENT

Current Key Costs

Medical Records One Year

Salary & Benefits for Medical Records $ 70,000.00

# of Medical Records Staff 30

Chart Creation Cost $ 2.00

# of Charts Created a Year 10% of Patients

# of new patient a physician sees 220

Cost of Chart Storage $ 2,000,000.00

Clinician Costs

Rx Pads $ 77,220.00

# of Physicians 300

Transcription Costs $ 1,000,000.00

Other

Coding Errors/Missing Charges $ 1,200,000.00

Billing Turn Around Time 4 weeks

Misc Office Expenses 50,000

Cost Per Year $ 6,559,220.00

Return On Investment (ROI)

Current Key Costs

Medical Records One Year

Percent

Savings Current After Saving

Salary & Benefits for Medical Records 70,000.00$ 43% 2,100,000.00$ 1,197,000.00$

# of Medical Records Staff 30

Chart Creation Cost 2.00$ 90% 132,000.00$ 13,200.00$

# of Charts Created a Year 10% of Patients

# of new patient a physician sees 220

Cost of Chart Storage 2,000,000.00$ 75% 2,000,000.00$ 500,000.00$

Clinician Costs One Year

Percent

Savings Current After Saving

Rx Pads 77,220.00$ 90% 77,220.00$ 7,722.00$

# of Physicians 300

Transcription Costs 1,000,000.00$ 90% 1,000,000.00$ 100,000.00$

Other One Year

Percent

Savings Current After Saving

Coding Errors/Missing Charges 1,200,000.00$ 50% 1,200,000.00$ 600,000.00$

Billing Turn Around Time 4 weeks 1 week

Misc Office Expenses 50,000 50% 50,000 25,000.00$

Cost Per Year 6,559,220.00$ 6,559,220.00$ 2,442,922.00$

Projected Savings 4,116,298.00$

ROI 2

Day to Day Actions Current After Implementation

Medication to Patients (Hours) 5.28 1.51

Order Entry of Radiology to Completion of Procedure (Hours) 7:37 4:21

Length of Stay 30.4% Reduction

Lab (from Order to Completion)

Chemistry Tests 48.9% Decrease

Urinalysis 41.6% Decrease

Microbiology 40.6% decrease

Serious Medication Errors 55% decrease

Preventable Medication Errors (PME) 17% decrease

Cost per PME $ 4,600.00

Average PME Cost for 300 Bed $1.2 Million $ 996,000.00

Medication Decision support could identify up to beneficial changes in treatment 41,000

Repayments to payers for non-compliant documentation or ineligible services $25,000.00 $ 387.00

Admissions/registration Patient Satisfaction 63% 80%

Overall Patient Satisfaction 75% 80%

Physician Satisfaction 73% 80%

Staff Satisfaction 69% 78%

Physician Patient Load Increase 4-8

Net Savings Over a Five year Period $2.5 to $5 million

Implementation Costs

Hardware Cost

Servers 50,000.00$

Tablets 400 @ 1500 600,000.00$

Computer Stations 25 * 500 12,500.00$

Installation (wifi, routers, wiring, etc) 30,000.00$

Yearly Maintance 15% 103,875.00$

Personal Cost

Analyst 4 @ 75,000 300,000.00$

Director 1 @ 80,000 80,000.00$

Consultant Fees 100,000.00$

Software Cost

Interfaces 50,000.00$

License Fee 400 @ 15000 6,000,000.00$

Implementation Cost 6,742,500.00$

Yearly Cost 583,875.00$

Five Year Project

$(10,000,000.00)

$(5,000,000.00)

$-

$5,000,000.00

$10,000,000.00

$15,000,000.00

Year

No EHR

Costs

Savings from EMR

Physician Engagement Leadership Support & Collaboration

Engaging the Clinical Staff Real-time Training

Facility Implementation

Clinical Viewer

• EMR

• Results Reviewing

HIM / Doc Imaging

Surgery

• Surgery

Pharmacy

• Pharmacy

• Alerts – ADE, Prevention Alerts

Medication Profile

• Medication Reconciliation

Patient Care

• Orders Management

• Nursing

Documentation

• Ancillary

Documentation

• eMAR

• Interactive View for

ICU

ED

• ED Tracking Board and Triage

• PhysicanDocumentation (ED)

• CPOE for ED

Care of the Patient in the Physician Office

CPOE

• Evidence-Based Alerts at Provider Order

Nursing Care Plans

Advanced Laboratory

• Laboratory POC Solutions

Surgery Expansion

• Anesthesia

PHASE 1

Clinical Foundation

PHASE 2Clinical

Enhancement

PHASE 3Outcomes

Optimization

Phasing Plan

7 YEARS5 Years

The Importance Of Decision Making

MajorImpact

ModerateImpact

Less Impact

Mid Level Decisions

HighLevelDecisions

Detailed Decisions

~ 25% of decisions

~ 10% of decisions

~ 65% of decisions

How will it be done?

Design the details

What will be done? Who will do it?

Clinical Systems Steering Committee (CSSC)

Clinical Standards Committee (CSC)

Physician Advisory Council (PACo)

Subject Matter Experts (SME)

Timeline

Design/Build P# 3

2010 20122011 20142013 2015

Design/Build P# 2

Phase 1 - 19 Months Design and Build Phase 3 - 14 Months Design and Build

Phase 2 - 24 Months Design and Build

Go / No Go Decision

Design/Build P# 1

Rollout

Rollout

Rollout

Timeline

20112010 2012

Validation and Sign Off Steps Go / No-go Decision

Plan

Facility Rollout

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

CurrentState

Assessment

FutureState

Design

Proof of Concept Build& Validation

Training

Refine & Validate

Production Build, Validate

Conversion Prep

Integration Testing

Reference: Our Iceberg Is Melting.

Eight Step Process for Successful Change.

Author, John Kotter, 2006. Page 130-131.

PREPARE

“Set the Stage & Decide What to

Do”1. Create a Sense of Urgency

2. Pull Together the Guiding Team

3. Develop the Change Vision and Strategy

ENGAGE

“Make It Happen”

4. Communicate for Buy-In

5. Empower/Enable Others to Act

6. Create Short-Term Wins

SUSTAIN

“Make It Stick”

7. Don’t Let Up

8. Create a New Culture

Change Adoption Curve

Critical Success Factors

• These critical success factors apply to all areas impacted by the project.

Critical Success Factor Measurement Process

The project is completed on budget. Project expenses are monitored and tracked to stay

within budget. This is a multi-year project and will be

measured on an annual basis.

The process solutions identified in the project

scope were implemented in each of the facilities

according to the plan.

Validation of new care delivery processes activated

in each facility based on the final scope document

and/or governance approval.

Project milestone dates and deliverables were

achieved with less than 10% variance.

Track and manage project plan dates and

deliverables as defined in the approved project plan

baseline. Baseline date to be determined. 90% of

the Phase II teams meet all milestone dates and

deliverables.

Current state analysis completed and signed off.

Future state analysis completed and signed off 45

days prior to the first activation.

Require signatures from department teams

interviewed for current state.

Require signatures from members of the Clinical

Standards Committee for future state design.

“Proof of Concept” demonstrated through a partial

system build to validate the future state workflow

and system functionality with approval from the

appropriate stakeholders.

Require signatures from SMEs and Clinical

Standards Committee for future state workflows and

partial build.

Critical Success Factors

Critical Success Factor Measurement Process

System functionality was adequately tested to

identify and resolve software and workflow

issues prior to conversion.

Corporate compliance will audit integration testing

and provide feedback.

Training team received design documentation

and new care delivery workflows with adequate

lead time to prepare training and competency

testing programs.

Training materials, scenarios and policies were

available for training of staff.

Appropriate staff attended training prior to

activation (only those with excused absence

from appropriate director will be allowed to take

training at a later time).

Training attendance tracked to ensure at least 95%

of appropriate staff attended training.

Staff members who attended training passed

competency test.

Training competency scores tracked to ensure at

least 98% of staff pass competency test with score

80% or higher.

The "C" suite at each facility participated in the

facility preparation and conversion activities.

Participation in facility preparation meetings and

support of new care delivery processes.

Project Standards

Rules of Engagement – Key criteria that must

be met to support the project’s success

Defining a Project – What specifically is a project … and what is not a project

Tools – The tools that are used to manage projects and document project activity

Project Roles and Responsibilities –What is expected of participating team members

Project Governance/OrganizationStructure – Identification of Teams within the project

Customer Responsibilities – What is needed from the customer to maximize success

Project Levels and Complexities –Identification of the levels of complexities and how each is treated in terms of documentation, communication, and involvement

Project Documentation – Standard documentation naming conventions and storage locations

Communication Management – Standard methods and styles of communication designed to provide consistency for the teams and customers

Meeting Management – Establishes standard meetings and updates with efficient Planning, Facilitating, and Documenting

Vendor Management – Defines how to manage vendors and service professionals; includes contracts, Corporate Compliance, and standardized Change Management

Risk Management – Defines how project risks are identified, managed, and mitigated

Project Organization

CEO

Chief Medical Informatics

Officer

Physician Executive

CIO

Clinical Transformation

VP

EMR Director (Ancillary)

PM InterfacesPM Testing

EMR Director (Nursing)

PM Integration Technical Project Mgr.

Vendor Executive

EMR Governance Structure

Board of Trustees

Quality Committee

Office of the President

EMR Executive Oversight

Board

Clinical Systems Steering

Committee

EMR Project Steering

Committee

Physician Advisory Council

Clinical Standards Committee

EDUCATION , TRAINING &

COMMUNICATION

STRATEGY

• By Beena

Joy, RN BSN

Summary of Recommendations

• Approval to solicit RFI

• Approval to distribute RFPs based on vendor responses

• Support organizational efforts to improve care and safety,

streamline processes, increase satisfaction, and decrease costs

and waste through EMR implementation

• Play an integral role in changing our reputation and our name

from “OK Care Hospital” to “Exceptional Care Hospital”

Questions?

Facility Implementation1. Reference: Our Iceberg Is Melting.Eight Step Process for Successful Change. Author, John Kotter, 2006.

Page 130-131.

Budget and Return on Investment2. Benchmark Data Source: American Journal of Medicine, April 2003 Issue ($5 Cost per paper chart)

3. Benchmark Data Source: CDC Advance Data Aiugust,2003(1 in 10 visits are new patients)

4. 2/jorg=journal&source=MI&sp=&sid=/N/622195/s014p0029.pdf?issn=

5. http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/Medical_Associates_Ambulatory_PRT

224.pdf

6. Benchmark Data Source: RxSecurityUSA, RxPads.com, FileRx, AmericanSecurity Rx

7. http://www.mdconsult.com/das/article/body/171667657-

2/jorg=journal&source=MI&sp=&sid=/N/622195/s014p0029.pdf?issn=

8. http://www.nuance.com/healthcare/pdf/cs_healthcare_BrigWomens.pdf

EMR Education & Training9. http://www.medicalpracticetrends.com/2008/10/26/training-staff/

Communication 10.http://accustatemr.com/In%20The%20News/Articles/Essential%20People%20Skills%20for%20EHR%20Imple

mentation%20Success.pdf

11.http://archive.healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_890717_0_0_18/EHR%20Communication

%20Plan.pdf