Running head: FINAL PROJECT 1

Information Systems Management

LDR 620

Final Project

Thea Picklesimer

Siena Height University

November 1, 2013

FINAL PROJECT 2

OVERVIEW

The Beaches Clinic is replacing the paper medical record with a fully electronic record.

Beaches Clinic is a highly regarded practice. 32 specialty services are offered by 180 physicians.

This practice views patient care, research and education as the intertwined components of its

mission. The clinic has experienced steady growth since the first patient walked through the

doors during 1986.

Currently, 160,000 office visits are conducted, annually. Part of the success, of the clinic,

is based on guidance, given to the patients, to navigate through the gauntlet of healthcare

offerings. A Primary Care Physician, (PCP) is assigned to every patient. The care of the patient

is orchestrated by the assigned provider. Specialist are partners in the practice. The healthcare

needs, of the patient, can be met at the clinic.

Referrals to specialist are placed, by the PCP’s, as needed. Diagnostic and therapeutic

services are offered within the clinic facility. A local hospital, Prima Care Hospital, is the tertiary

care choice. The physicians of The Beaches Clinic have admitting privileges through their

affiliation, with Prima Care. A process improvement will be achieved once the Clinic and the

hospital are linked by a common electronic medical record, (EMR). Patient information will be

accessible by both facilities.

Paper patient records within the clinic and hospital often used multiply resources to travel

from one point to another. Approximately 330 desk attendants’ tracks records, file loose sheets,

gather and transport records to the various locations. Once the patient’s visit is complete loose

sheets are filed and the record is complete another group of assistants take over, the management

of the paper record.

FINAL PROJECT 3

The completion assistants are charged with assessment of the record for completion.

During the final analysis, forms are accessed for the presence of the required signature and

necessary reports to complete the encounter and close the record. The failure to complete the

required paper work requires many people hours. Time is spent tracking down the signer and the

needed reports, to close the record. This is a labor intensive process. Even with the considerable

amount of people resources, to produce a complete and closed record, six months is not unheard

of to complete and close the patient record.

Once the electronic medical record is functional healthcare providers will access the same

record at the clinic or within the hospital. A paper chart is subject to the loss of documentation.

Paper can be lost in the transit from one site to another. The electronic medical record will house

all documentation digitally. The medical record will be completed more quickly. Having

complete information increases patient safety. Parts of the patient’s medical story are not left out,

related to the chart not being completed.

Discussions to implement an electronic record began during 1992. Representatives from

the Clinic and the affiliated hospital formed a steering committee to begin building the

specifications for an EMR to be submitted for a request for information, (ROI) and a request for

purchase, (RFP). The specifications developed were congruent with the mission for both

facilities.

An information systems vendor to provide a robust product was sought. Three vendors

were courted. No one vendor could provide the desired product, to Beaches. One vendor

impressed the steering committee. The impressive vendor implemented a laboratory system, the

hospital. The vendor did not have experience, in the field of, developing an electronic medical

record. The strength of the company was in laboratory systems and clinical data repository. The

FINAL PROJECT 4

vendor offered to act as a consultant to guide the hospital, through the selection process, of an

electronic medical record. The steering committee agreed to partner with the vendor.

The vendor began planning the implementation. An imaging vendor was suggested, as

the vendor of choice. The design plan included scanning handwritten notes, from 1992 forward,

into a digital format. Personnel were hired to scan the documents. Additional systems were

bought in for dictation and transcription work flow. As the project grew in size an expanded

steering committee was formed. The charge, of the committee, included the task of determining

how to best implement the creation of the EMR and pilot the system. A hospital unit was

selected for the implementation. It was decided to allow the physicians to use the paper medical

record while training to use the EMR.

Pilot program started on a floor with three specialty services, (should have focused on a

unit with only one service or one specialty service. The patients were seen elsewhere in the

hospital. Therefore, dual documentation was being maintained. The steering committee knew the

dual documentation would be in place for two years. The paper record serves as the legal record

in the event of downtime.

Training of the physicians testing the EMR was started. Training guides and reference

manuals were developed by the vendor. The physicians testing the system seemed pleased with

the EMR. Yet, the paper medical record remained in use. Some used the EMR more than

others. The pilot was deemed successful by the steering committee. NO formal evaluation of the

system was completed. As the roll out began physician’s verbalized frustration with the time it

took to use the system. Productivity, of the physicians was impacted. The new system interfered

with their ability to see as many patients as they did prior to the system implementation.

FINAL PROJECT 5

The clinic exam rooms were not fully assessed for placement of the computer terminals.

Physicians found it difficult to look patients in the eye. They were instead focused on the

computer screen and looking for information.

By 1996 the electronic version was being used. No one could any longer use the paper

medical record.

CULTURE

We know from the case study presented by White and Wakefield (1998) The Beaches

Clinic was “built on the premise that serving the whole patient is of paramount importance.” The

process of the system installation did not include any patient or employee focus groups. Seymour

(2004) describes a focus group by adding background for the reader she stated, “Focus groups

techniques—also called “focused group discussions” or “user groups” were developed after

World War II to evaluate audience response to radio programs. A focus group is a qualitative

research process designed to elicit opinions, attitudes, beliefs and perceptions from individuals to

gain insights and information about a specific topic”.

Focus groups should have been in the master plan. Feedback from the groups would have

revealed various opinions and may have enhanced the implementation of the electronic record.

Even if negativity was present, among the members of the group, toward the electronic medical

record, a positive outcome would have been found by listening to their input and assessing the

organizational culture. No formal cultural assessment was completed.

The Beaches Clinic and PrimaCare Hospital each had independent organizational

cultures. The electronic medical record blended two cultures. Yet, the assessment of the cultures

was skipped. The culture appears to be physician oriented. The structure of the steering

committee was physician driven. If this is a true reflection of the culture a physician champion

FINAL PROJECT 6

should have been identified, prior to the RFP development. A physician champion was needed to

rally the physicians and communicate the changes to the medical record to the peer group.

However, the champion must hold a position of authority and be respected by his or her peer

group.

As Kotter (2012) discussed, “A powerful person at the top, or a large enough group from

anywhere in the organization, decides the old ways are not working, figures out a change vision,

starts acting differently, and enlists others to act differently. If the new actions produce better

results, if the results are communicated and celebrated, and if they are not killed off by the old

culture fighting its rear-guard action, new norms will form and new shared values will grow”.

The transition path, to the electronic record, could have been more smoothly paved by having the

support of a physician champion. Communication and gaining buy-in, (from all employees) was

needed for the electronic medical record to be successful.

TOOLS FOR SUCCESS:

As with any purchasing project a RFP, (request for purchase) must be developed.

Specifications are detailed with expectations, deliverables, on-going support, and maintenance.

The RFP must be a solid document. Vendors formulate their bids based on the specifications,

submitted. People analyzing the RFP, once it is returned, must have an eye for detail and

knowledge of the actual product the vendor has offered, as an answer to the specifications.

The RFP is critical to have a legal understanding of the product requested, terms of

support, and if the product answers the need of the organization within the budget Specifications

for an electronic medical record were identified during the request from purchase process, (RFP).

No vendor could deliver the expected specifications, as requested. This was a missed opportunity

by the steering committee. The case study points out the committee realized they did not have an

FINAL PROJECT 7

in-house technical expert to build the system. This statement implies, to the reader, a technical

expert was needed to help navigate the non-technical decision makers through the process.

If an organization is without expert, from within, seek one from outside of the

organization. The organization was headed in the right direction. The steering committee

understood they needed the assistance of a consultant. The down fall was selecting a vendor, as

the consultant. The vendor could not provide the specifications the organization desired. The

vendor suddenly became the expert in electronic medical records. This vendor had experience in

clinical data repository to integrate patient data. The vendor offered to help the clinic assess other

systems that would work well with their data repository system.

The organization entered into an agreement with a vendor for a service they were not

seeking with the original RFP. A clinical data repository, (CDR). The organization is now

charged with finding a system to interface smoothly with the CDR. A review of Levy would

have assisted the steering committee to ask more questions of the vendor with the foot in the

door with the CDR. “A software requirement specification describes how a product will work

entirely from the user's (or customer's) perspective. It should care less about implementation. A

technical specification describes the internal implementation of the software. It talks about data

structures, relational database models, choice of programming protocols, and environmental

properties” (2013).

IMPLEMENTATION

A unit was selected for the pilot of the electronic medical record. The unit chosen was

home base to three specialty services. A unit with one specialty should have been the target for

the pilot. The case study discussed the patient movement and the difficult task of the records

moving with them. Dual systems were in use. The paper record needed to remain updated and

FINAL PROJECT 8

exact to the electronic record. The paper record was the official medical record and the only one

sanctioned by state law at that time. The pilot program affected the paper record. Yet, in the pilot

the paper record and the electronic record were maintained and updated to be mirror images of

one another.

Systems were created to assure reports were found in both records, (electronic and

paper). 30 staff was hired to perform the quality checks, (reports in the correct record). This

process continued for two years. Only when the organization believed the paper records and the

electronic record data matched could people breathe a sigh of relief/

The implementation of the electronic medical record lead to additional work flow

enhancements. The paper system is cumbersome. Many resources are needed to keep the flow of

paper moving among the care providers at the clinic. Three systems generated electronic

information. The systems included registration, laboratory and radiology. These stand -alone

systems do not interface to a data warehouse.

Accessibility of the data, and reducing labor costs were paramount to the implementation.

However, the wish to reproduce the paper chart in an electronic form would prove to be a bad

business decision along with a few other seemingly benign decisions. The perfect storm was in

the making.

The pilot rolled on during January 1994. Word spread of the pilot. Many of the Beaches

physicians considered the system a failure, before it was fully implemented. Communication

regarding the system was not wide spread. Much of the work was done in a silo. The physician

members of the steering committee were fully aware of the change from a paper chart to an

electronic medical record. Physicians, throughout the hospital, understood the problems with a

FINAL PROJECT 9

paper medical record. Yet, the physicians had no reason to believe the paper chart would be

phased out and replaced with an electronic system.

PROCESS IMPROVEMENT:

As with any purchasing project a RFP, (request for purchase) must be developed.

Specifications are detailed with expectations, deliverables, on-going support, and maintenance.

The RFP must be a solid document. This is how vendors formulate their bids. People analyzing

the RFP once it is returned must have an eye for detail and knowledge of the actual product the

vendor has submitted.

The RFP is critical to having a legal understanding of what was asked for, what has been

bid and can it meet the needs of the organization within the budget Specifications for an

electronic medical record were identified during the request from purchase process, (RFP). No

vendor could deliver the expected specifications. This was a missed opportunity by the steering

committee.

The case study points out the committee realized they did not have an in-house technical

expert to build the system. From this statement the reader can also ask if they have an in house

technical expert to even help negative the non-technical decision makings through the process. A

wish list can start with dreams. After a while reality must come into the picture. What we want

and what we can live with was not assessed during this process.

If an organization is without expert, from within, seek one from outside of the

organization. The organization was headed in the right direction. The steering committee

understood they needed the assistance of a consultant. The down fall was selecting a vendor, (as

the consultant) an RFP had been sent to. The vendor could not provide the specifications the

FINAL PROJECT 10

organization desired. The vendor suddenly became the expert in electronic medical records. This

vendor has experience in clinical data repository to integrate patient data.

The vendor offered to help the clinic assess other systems that would work well with their

data repository system. Fault #1- The organization has now entered into an agreement with a

vendor for a service they were not seeking with the original RFP. A clinical data repository,

(CDR). The organization is now charged with finding a system to interface smoothly with the

CDR.

A review of Levy would have assisted the steering committee to ask more questions of

the vendor with the foot in the door with the CDR. “A software requirement specification

describes how a product will work entirely from the user's (or customer's) perspective. It should

care less about implementation. A technical specification describes the internal implementation

of the software. It talks about data structures, relational database models, choice of programming

protocols, and environmental properties” (2013).

STRENTGHS:

An EMR allows a health care provider to access the information from any linked

computer terminal. Gone are the days of waiting for a chart to be called up and delivered to the

physical location of the patient. In this case study, (White and Wakefield 1998) the physicians

had the ability to access the medical records, electronically, at the clinic or the hospital. Records

were more complete, if not fully completed, as compared to the paper chart.

Missing information was a large problem with the paper charts. Additionally, if forms

were not completed or signed a department of people were assigned to capture the signatures to

be able to close out a chart. An electronic record can offer a “forced field” to demand a signature

FINAL PROJECT 11

before the next step can be processed. Therefore, reducing the need for personnel to be employed

to “chase down forms to be signed by the provider.

The electronic medical record allows the patient chart to be updated and completed more

quickly. By having updated records patient safety is enhanced. Sensmeier (2011) defines

Clinical Transformation as, “This involves assessing and continually improving the way patient

care is delivered at all levels in a care delivery organization. It occurs when an organization

rejects existing practice patterns that deliver inefficient or less effective results and embraces a

common goal of patient safety, clinical outcomes and quality care through process redesign and

IT implementation. By effectively blending people, processes and technology, clinical

transformation occurs across facilities, departments and clinical fields of expertise”.

Patient appointments can be scheduled at the time of check out and a reminder printed for

the patient at that time

Charts in the paper system often took six months to complete and close out. Until the

chart was closed billing could not be processed. An open paper chart equaled delays and perhaps

even lost revenue.

Query for research data is less time intensive as compared to a paper records. Electronic

medical records can be searched on for diagnosis codes, and key word phrases. Extraction of

data from a paper chart is a manual time intensive process. Quality Management is enhanced

with the use of an electronic medical record. Diagnosis codes and key phrase searches reveal

infections based on dates and even units. The data can be used to along with root cause analysis

to determine the underlying problem and seek a resolution. CQI is the model individuals and

teams use to improve existing processes systematically throughout the organization and in the

design and implementation of new processes. A few of the healthcare projects involving CQI at

FINAL PROJECT 12

my employer are patient safety goal center. A few focus on the reduction of infection

rates, falls, pressure ulcers and so on. All of these projects started with a concern and a goal for

improvement. CQI can be applied to any situation in healthcare or outside of healthcare. Quality

Improvement (CQI) is a quality management process that encourages all health care team

members to continuously ask the questions, “How are we doing?” and “Can we do it better?”

(Edwards, 2008). The interaction is simply to evaluate and ask how we can improve.

The need to fax, copy or even mail patient records is eliminated when hospitals and

clinics are linked by an enterprise wide system.

Reduction of clerical personnel involved in record movement and record retrieval. Once

the paper record was phased out personnel to track the loose sheets and other paper seeking

activities were not needed. Doing more with less saves financial resources.

  Additional cost reductions projected as system performance improves.  

WEAKNESSES

One red flag was present out of the gate. A vendor was selected to act as a consultant and

manage the implementation of the electronic record. The vendor had zero experience in the

development or implementation of an electronic record. The vendor’s strength was in a lab

system and data warehousing.

A consultant with a strong background in implementation of electronic medical records

was needed. The implementation team needed to be filled with personnel from inside the

organization. Folks on the inside can help with finding resources and answering other questions

an outsider cannot answer. Certainly, a consultant can help with the project management and

workflow process. However, a consultant should not be charged with the sole responsibility, (or

given the power) to make independent decisions on behalf of the organization.

FINAL PROJECT 13

The case study touched on the subject of the paper record being the only official record in

the eyes of the State. The case study does not advise the reader of the additional concerns

regarding the official paper record. However, the reader can surmise this is the rationale for the

dual documentation. The electronic medical record and the paper record mirrored one another.

The dual systems were maintained for approximately three years. Maintaining two systems

caused an additional financial strain on the hospital. More personnel were needed and hired to

keep the two systems flowing.

A unit with more than one specialty was selected as the pilot unit. By selecting a unit

with more than one specialty this added to the amount of people requiring training on the system.

Increased financial burden on the organization with additional staff. Quality checks, of

the paper and electronic record, were needed to verify the test results available in both records

for the physicians to view.

Work around solutions to keep the charts up to date, (Imaging of hand written noted in

the electronic record).

Clinic flow was slowed down with the implementation of the electronic medical record.

A project manager or a lead person from the organization would have had the knowledge the

clinic flow would be slowed. The solution to this would have been to reduce the amount of

patients being seen, in the clinic, in the first one to two weeks of the pilot. Such a plan would

have allowed the providers the time they needed to see the patient and to document the patient

encounter without a bottleneck of activity.

At the elbow support was not present, (or at least mentioned in the case study). The

providers had training prior to the pilot go live date. However, additional resources “at the

elbow” of the providers would have assisted the learning and hands on experience. Some

FINAL PROJECT 14

providers may have had a more positive experience and touted the positives of the medical

record. Instead physicians expressed concern about the time it took to use the system as the roll

out progressed.

COMMUNICATION

Design a marketing campaign to inform the end users why a change is needed. Continue

to send out bulletin updates to keep the organization informed.

Schein (2010) discussed eight conditions needed for psychological safety, (change

theory). Following this model may have provided a platform for care providers and other

involved with the electronic medical record to express their concerns, fears and work through

them in a positive manner.

A compelling positive vision

Formal training

Involvement of the learner

Informal training of groups/teams

Practice fields, coaches & feedback

Positive role models

Support Groups

Systems consistent with new way of working

DATA INTEGRITY

The data is only as good as the data input. Medical information must be correct. A life is

at stake. For example, if an allergy is missed and not entered a life threatening situation may

occur.

FINAL PROJECT 15

Data integrity is linked to patient safety. If the information cannot be trusted the care may

lead to errors, harm of a patient and even death.

The case study closed with the following thought, “..The members of the EMR steering

committee are feeling confident that they have helped the clinic make dramatic improvements in

their information system and in the delivery of patient care.” (White and Wakefield 1998). The

steering committee propelled the implementation forward. With more up front planning and a

well thought out implementation plan the process could have been smoother.

As a leader of any project the “what if” question must be considered. By asking and

thinking about the “what if” questions allows for planning and being prepared for situations that

will arise in any process improvement project.

 

FINAL PROJECT 16

REFERENCES

Edwards PJ, et al. maximizing your investment in EHR: Utilizing EHRs to inform continuous

quality improvement. JHIM 2008;22(1):32-7. 

Glandon, G.L., Smaltz, D.H., & Slovensky, D.J. (2008) Information Systems for Healthcare

Management (7th ed.) IL, Chicago Foundation of the American College of Healthcare

Executives.

Kotter, J. (2012). October 25, 2013. Retrieved from:

http://www.forbes.com/sites/johnkotter/2012/09/27/the-key-to-changing-organizational-

culture/

Levy, D. (2013). Software Requirements Specification, (SRS), what you need to know. October

23, 2013. Retrieved from:

http://www.gatherspace.com/static/software_requirement_specification.html

Schein, E. H. (2010). Organizational culture and leadership. A conceptual model of managed

culture change (pp. 299-313).San Francisco, CA: Jossey-Bass.

Seymour, A. (2004). Focus Groups- An Important Tool for Strategic Planning. October 24, 2013.

Retrieved from: http://www.justicesolutions.org/art_pub_focus_groups.pdf

 Sensmeier, J. (2011) October 14, 2013 Retrieved from:

http://www.nursingcenter.com/lnc/journalarticle?Article_ID=1239188

White, A. and Wakefield, G. (1998). Developing an Electronic Medical Record for an Integrated

Physician Office Practice. October 1, 2013. Retrieved from eCollege.