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Ambulatory EHR Implementation at UCSF Medical Center. Brian Herrick, M.D. July 18 th , 2008 Slide Recognition to Russ Cucina M.D., William Hersh M.D., Angelina Chang, and Kathy Lehto. Outline. Implementation resources Implementation lessons from the literature Implementation chasm

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Ambulatory EHR Implementation at UCSF Medical Center

Brian Herrick, M.D.

July 18th, 2008

Slide Recognition to Russ Cucina M.D., William Hersh M.D., Angelina Chang, and Kathy Lehto


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Outline

  • Implementation resources

  • Implementation lessons from the literature

  • Implementation chasm

  • UCSF Medical Center EHR implementation


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Choosing EHR (Adler, 2005)

  • Identify decision makers in a practice

  • Clarify goals

  • Write a Request for Proposal (RFP)

  • Review proposals to narrow the field

  • Vendor demonstrations

  • Check references

  • Rank the vendors

  • Site visits

  • Select finalist

  • Solidify organizational commitment

  • Negotiate contract


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Resources

  • eHealth Initiative EHR Master Quotation Guide (2005): Guide for obtaining vendor quotes

  • EMR Guide for Small and Mid-Sized Practices (2006): Detailed implementation guide for smaller practices

  • DOQ-IT University (elearning.qualitynet.org): Free on-line courses developed by Centers for Medicare and Medicaid Services (CMS)


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Resources

AAFP resource:

http://www.centerforhit.org/

ACP resource:

http://www.acponline.org/running_practce/technology/ehr/roadmap/

AAP resource:

http://www.aapcocit.org/

Agency for Healthcare Research and Quality website


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Implementation Guidelines and Lessons

  • HIMSS

  • CEO Survival guide

  • AAFP EHR Pilot Project


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HIMSS Ambulatory Paperless Clinics (2007)

  • Project management must include

    • Development of scanning/abstracting policy

    • Create shared need in practice

    • Analyze workflow

    • Develop implementation plan

    • Facilitate third-party interfaces

    • Template development

    • Training


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CEO Survival Guide to EHR Systems (2006)

  • Develop a vision for Patient Care

  • Understand environmental factors affecting EHR systems

  • Become aware of the supports available for EHR system planning, acquisition, and implementation: ONCHIT, DOQ-IT, Medicare QIOs, AHRQ, AAFP, CCHIT

  • Develop an EHR system organizational strategy

  • Identify clinical champions


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CEO Survival Guide to EHR Systems (2006) cont.

  • Communication

  • Implement work process transformations

  • Develop training plans

  • Develop capital and operating budgets to support acquisition, implementation, and ongoing management

  • Select the application

  • Implementation: Incorporate EHR systems into clinical and administrative operations

  • Prepare for the future: PHRs, RHIO/IHE


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Brief Report of the AAFP’s EHR Pilot Project: Key Learnings from Six Small Family Practices (2005)

Keys to success:

  • 1. Building a Community of Learners

  • 2. Planning/re-designing practice workflows

  • 3. Starting with “Easy Wins”

  • 4. Connectivity increases the value of an EHR i.e. pharmacies, labs

    Barriers:

  • 1. Partial implementation

  • 2. Variability among medical practice and physician styles

  • 3. The lack of structured data entry


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Implementation Chasm (Lorenzi 2008) Learnings from Six Small Family Practices (2005)


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Design Learnings from Six Small Family Practices (2005)

  • Systems must be customized to accommodate the activities of workers and the workers must also change their practices

  • Examples at UCSF MC: Vital Sign Capture and UCare Note Writer


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Vital Sign Capture Learnings from Six Small Family Practices (2005)

  • Tablet or PC

  • Wireless or hard wired

  • Dynamap with Temp, HR, BP, and O2 Sat

  • Importation to the EHR flow sheet


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UCare Note Writer Learnings from Six Small Family Practices (2005)

  • UCSF developed web application for clinical documentation.

  • UCNW acquires patient context and other data from the EHR to import into the document

  • Other design features.


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Import of Vital Signs from Learnings from Six Small Family Practices (2005)UCare

- range calculation over last 24-hour


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Import of Lab Results from UCare Learnings from Six Small Family Practices (2005)

- last 24 hours of basic labs

- structured visual representations


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Save draft within Note Writer Learnings from Six Small Family Practices (2005)


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Publish “Preliminary” Note (resident) Learnings from Six Small Family Practices (2005)


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Publish “Preliminary” Note (resident) Learnings from Six Small Family Practices (2005)


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Publish “Final” Note (attending) Learnings from Six Small Family Practices (2005)

- resident and attending notes as one unified note


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  • Required Fields Learnings from Six Small Family Practices (2005)

  • note cannot be published to UCare without them

  • Service Chiefs may define resident and attending requirements


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“Copy-forward” controls Learnings from Six Small Family Practices (2005)

- Service Chiefs may forbid or permit carry-forward of information day to day


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DNU Abbreviation Correction Learnings from Six Small Family Practices (2005)

  • Clinician writes a note containing DNU abbreviations


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DNU Abbreviation Correction Learnings from Six Small Family Practices (2005)

  • Note Writer guides clinician through correcting abbreviations


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DNU Abbreviation Correction Learnings from Six Small Family Practices (2005)

  • On sending the note to UCare, UCare Note Writer takes clinician through a dialog to correct DNU abbreviations

    • Clinician’s choices

      • accept automatic fixes

      • manually fix

  • Submitting the note to UCare with the DNU Abbreviations in place is not an option and is prevented


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Implementation Chasm (Lorenzi 2008) Learnings from Six Small Family Practices (2005)


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Management Learnings from Six Small Family Practices (2005)

  • Capacity for change

  • Context of change

  • Vendors have limited knowledge of both capacity and context, therefore it is important to organizations take responsibility for these issues


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Organization Learnings from Six Small Family Practices (2005)

  • Operational-organizational issues: downtimes, workflow changes, help desk, perception of IT department not listening to or being disconnected from the operational needs


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Assessment Learnings from Six Small Family Practices (2005)

  • Organizational readiness, assessing the immediate context for implementation, evaluating the implementation in formative and summative manners


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UCSF Ambulatory EHR Pilot Implementation Learnings from Six Small Family Practices (2005)

  • Pilot of Ambulatory administrative functionality to 6 practices in a variety of specialties

  • Functionality Deployed:

    • Viewing labs, reports, radiology, inpatient documentation, outpatient transcription

    • Patient tracking

    • Vital sign capture

    • Documentation of Point of Care Testing


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EMR Ambulatory Learnings from Six Small Family Practices (2005)User Survey

Summary and Results: April 2008

UCSF Medical Center

CIS Department

Ambulatory Team

April 24, 2008


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Goals of Assessment Learnings from Six Small Family Practices (2005)

  • What functions are being utilized?

  • Who is using the functions and where are they using them?

  • What are some of the hurdles?

  • Users wish list?

  • Respond to concerns, questions, and gap in knowledge


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INTRODUCTION Learnings from Six Small Family Practices (2005)

EMR Ambulatory User Survey

April 2008 Results

The EMR Ambulatory Planning Committee (APC) and Clinical Information Systems (CIS) Department sponsored a user survey to solicit feedback from UCSF Medical Center physicians and staff utilizing EMR in the ambulatory setting. An email request for participation was sent to all ambulatory practices that have engaged in the planning and/or completion of a EMR installation.

This is the first survey taken since launching EMR Ambulatory. Questions were developed by the APC and CIS Department and captured using a a web-based tool, www.SurveyMonkey.com. The survey was open from April 7-21, 2008. Users were informed that their feedback would only be shared with the APC and CIS Department. Survey results would be summarized at the department level so that individual names can be kept confidential.

This presentation summarizes the responses received. Data has been corrected for general user errors. All free text comments have been retained. Any questions regarding the survey can be addressed by the CIS Department – Ambulatory Team.


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Survey Demographics

  • Approximately 375 users received the survey request

    • 98 responses received, a 26% response rate

    • Physicians were the highest responders to the survey

    • Back Office staff includes a range of users

  • 26 practices received the survey request

    • Practices represent those which the CIS-Ambulatory Team has worked with to date

    • Predominant practices which responded include:

      • Lakeshore Family Medicine

      • OB/GYN practices

      • Pediatric practices

      • Vascular Surgery

* : Other Category represents users who identified themselves by a staff role that was not a role type provided in the survey. Many are licensed staff. Some of these roles may be considered back office staff, however, the users do not identify themselves as such in the survey.


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SUMMARY: OVERVIEW Learnings from Six Small Family Practices (2005)

Overview

  • Positive feedback on being surveyed

    • Significant response rate across roles

    • “Step in right direction”

  • Strong desire to go chartless across organization

    • Actively using EMR

    • A sense of “waiting” for functionality and enterprise-wide use

    • EMR has high potential, however, lacks robust functionality

    • Many suggestions for improvement received

  • Continued dependency on STOR

    • Desire to eliminate need for two systems

    • Desire for better user interface in EMR

  • Many system hurdles deter greater use of EMR

    • Data retrieval is quicker in STOR due to perceived EMR system limitations (slow login)

    • More accurate user information could be captured after system hurdles are resolved


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Physicians

Most physicians who responded reside in primary care (Family practice, OB/GYN, Pediatrics practices). Their hurdles and wish list indicate a desire for functionality that would increase efficiency and that they have seen as standard practice in other healthcare institutions.

Usage / Functionality

  • Location Most Used

    • Private Offices, 63.0 %

    • Exam Rooms, 55.6%

    • Back Office, 51.9 %

  • Functionality Most Used

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Results Viewer (Flow sheet, Lab data, etc.)

    • Document Display

  • Functionality Least Used

    • Notes to Self

    • PPD Reports (Custom flow sheet reports)

    • Notes without Visits

Usage / Functionality

Hurdles

  • System (slowness, cumbersome login)

  • Cumbersome access to notes, flow sheets, and reports

  • Primitive note writing

  • Lab data is buried in EMR

Hurdles

Wish List

  • Scanning documents

  • Faxing documents

  • Notes for patient lists, non-visits, phone calls

  • Documentation templates

  • Prenatal records

  • E-mail alerts and reminders

  • Electronic prescriptions

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: NPs

Most nurse practitioners who responded reside in the OB/GYN practices and in Urology-Oncology. They have a strong desire for progress note functionality. However, they may not be aware of the documentation options currently available to them.

Usage / Functionality

  • Location Most Used

    • Private Offices, 72.7 %

    • Exam Rooms, 54.5%

  • Functionality Most Used

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Results Viewer (Flow sheet, Lab data, etc.)

    • Patient Tracking

  • Functionality Least Used

    • Notes to Self

    • PPD Reports (Custom flow sheet reports)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

Usage / Functionality

Hurdles

  • System (slowness, cumbersome login)

  • Need for training

Hurdles

Wish List

  • Progress notes

  • Sending results to providers through EMR

  • Body templates

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Nurses

Nurses who responded represent a range of primary and specialty care practices. Their frequent access to patient data has led to a strong desire for tools that support better documentation and coordination of care. A reliance on printing still exists.

Usage / Functionality

  • Location Most Used

    • Back Offices, 83.3 %

    • Private Offices, 41.7 %

  • Functionality Most Used

    • Results Viewer (Flow sheet, Lab data, etc.)

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Chart Summary View

  • Functionality Least Used

    • PPD Reports (Custom flow sheet reports)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

    • Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation)

Usage / Functionality

Hurdles

  • System (slowness, cumbersome login)

  • Difficulty locating reports

  • Developing patient lists in order to complete patient care follow-up

  • Having complete patient information in one area or system

Hurdles

Wish List

  • Scanning documents

  • Document phone conversations

  • Ability to paste patient's test report to the mercury message

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Front Office

Front office staff who responded commonly need to retrieve patient information for other users. They show a strong desire for consistent use of EMR throughout their practice. As users who access multiple applications, front office staff are proponents for using EMR as the sole repository of patient information.

Usage / Functionality

  • Location Most Used

    • Front Office, 100.0 %

  • Functionality Most Used

    • Patient Tracking

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Results Viewer (Flow sheet, Lab data, etc.)

  • Functionality Least Used

    • Chart Summary View

    • Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

Usage / Functionality

Hurdles

  • System (slowness, cumbersome login)

Hurdles

Wish List

  • Doctors need to use EMR to look up patient records so that staff can eliminate printing reports from STOR

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Back Office

Back office staff who responded cover a broad range of positions, including administrative and licensed personnel. Hence, they use a variety of EMR functions and have more interaction with non-UCSF organizations. There is also a strong desire for and reliance on printing.

Usage / Functionality

  • Location Most Used

    • Back Offices, 85.7 %

    • Front Office, 50.0 %

  • Functionality Most Used

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Patient Tracking

    • Results Viewer (Flow sheet, Lab data, etc.)

  • Functionality Least Used

    • PPD Reports (Custom flow sheet reports)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

    • Notes without Visits

Usage / Functionality

Hurdles

  • System (slowness, access)

  • Unable to print

Hurdles

Wish List

  • Scanning documents

  • Faxing documents

  • Input vitals automatically from blood pressure machine to the computer

  • Access between EMR and other applications (Blackberry, PACS)

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Practice Mgrs

Few practice managers responded to the survey. Those who did voiced concern with managing and facilitating process workflow, given the current state of EMR functionality. They offer a broad view of the potential and anticipation EMR brings to a practice.

Usage / Functionality

  • Location Most Used

    • Back Office, 100.0 %

    • Private Offices, 100.0 %

  • Functionality Most Used

    • Patient Tracking

    • Patient Lists (Census, Group, Schedules, Personal Lists)

  • Functionality Least Used

    • Notes to Self

    • Notes without Visit

    • PPD Reports (Custom flow sheet reports)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

    • Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation)

Usage / Functionality

Hurdles

  • System (slowness, access)

  • Need to duplicate work in shadow charts because waiting for future functionality (Note Writer)

  • Current tools do not support workflow documentation

Hurdles

Wish List

  • Scanning documents

  • Faxing documents

  • Fully functioning EMR product for Ambulatory

  • Ability for inpatient users to have access outpatient data

Wish List


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SUMMARY: DETAILS Learnings from Six Small Family Practices (2005)

Response Summary: Other

The “Other” role was created after receiving feedback from users early in the collection process. These users, who did not identify with the available role types, include social workers, specialists, research aides, coordinators, technicians, and supervisors. Their feedback reflects the experience of retrieving information down stream after patient data has been entered into EMR by others.

Usage / Functionality

  • Location Most Used

    • Back Offices, 71.4 %

    • Front Office, 42.9 %

    • Private Offices, 42.9 %

  • Functionality Most Used

    • Patient Lists (Census, Group, Schedules, Personal Lists)

    • Patient Tracking

    • Results Viewer (Flow sheet, Lab data, etc.)

  • Functionality Least Used

    • Notes to Self

    • PPD Reports (Custom flow sheet reports)

    • Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)

Usage / Functionality

Hurdles

  • System (slowness, access)

  • Unable to print

  • Difficulty navigating; Need for training

  • Drilling down to view and write notes

Hurdles

Wish List

  • Scanning documents

  • Faxing documents

  • Radiology reports

  • Less drill down to view and write notes

  • Alerts that reduce user error (writing in wrong patient chart, closing without signing)

Wish List


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NEXT STEPS Learnings from Six Small Family Practices (2005)

Next Steps

  • Coordinate response to system performance-related hurdles with Field Services

  • Address the need for additional training with practices

  • Determine what wish list items can realistically be offered in the near future

  • Decide on the frequency of future surveys


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Next Steps cont. Learnings from Six Small Family Practices (2005)


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Conclusion Learnings from Six Small Family Practices (2005)

  • There are many resources to assist in the selection and implementation of an EHR

  • With an understanding of the management capacity and organizational structure, and with thoughtful technical design and regular assessments, a successful implementation of an EHR can be achieved.


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