IHS - EHRIndian Health Service - Electronic Health Record Fort Defiance Indian Hospital
Presenters • Arlinda Bilagody MT • Jacqueline Jones ITS • Rhonda Nelson DPM • Charles Schmitt MD • Kelley Simms PharmD • Lynda Von Bibra RN
Overview • Introduction • Visit demonstration • Implementation • Hospital Tour • Lunch • Departmental Presentations • Quality improvement and lessons learned • Other projects
Fort Defiance • Started EHR August 2004 • 122323 EHR Notes written (4/3/5) • Hospital User Population =21152 to 24851 in past 3 years
Outpatient now on EHR: Eye Clinic Podiatry Well Child Peds OB-Gyn Adult Appt Walk-In Clinic Orthopedics Surgery ENT Elder Assessment Elder Assessment Working on: Inpatient Emergency Dept. Ft. Defiance Indian Hospital
RPMS • Resource Patient Management System (RPMS) as the database for patient information. • Developed in the 1970s • The Patient Care Component (PCC) and the Indian Health Service Electronic Health Record (EHR) are tools to enable the entry of patient data into the database. • PCC developed in the 1980s • A number of packages have been added to improve the functionality of the RPMS system.
Case Management RCIS Surgery PCC Data Entry Behavioral Health System Elder Care PCC Patient Database Patient Registration Dental Women’s Health Laboratory Emergency Room Immunization Public Health Nursing Radiology Pharmacy CHR Appointment System
Case Management RCIS Surgery PCC Data Entry Behavioral Health System Elder Care PCC Patient Database Patient Registration Dental Women’s Health Laboratory Emergency Room Immunization Public Health Nursing Radiology Pharmacy CHR Appointment System EHR
EHR Visit Demonstration C Schmitt
New Terms • Gooey • Kack • …
New Terminology POE – Provider Order Entry CAC – Clinical Application Coordinator GUI – Graphical User Interface OE/RR – Order Entry/Results Reporting PIMS – Patient Information Management System TIU – Text Integration Utilities Server side applications – roll and scroll; back end applications CPRS – Computerized Patient Record System VueCentric Framework VISTA – Veterans Health Information System & Technology Architecture
Leadership, Commitment, Buy-in • Confirmed Leadership support • Tribal Endorsement • Area Office Support • Patient Awareness • Clinician driven
Force Analysis What factors will encourage EHR implementation? What EHR implementation barriers exist?
Hire a CAC • The incumbent is responsible for the implementation and support of multi-service software packages that automate the capture of clinical encounter information and its subsequent retrieval. The application coordinator manages the customization of the site parameters and addresses integration issues with other software packages. The incumbent assists in the implementation of new software products obtained by the facility that cover these functions. • Analyzes and evaluates processes related to information flow and serves as liaison between service lines concerning these processes…Assists staff in the efficient use of the current software. • Provides training to clinical staff … emphasizes timeliness, accuracy, security and the importance of these functions on every other clinical application. Coordinates classes with IRM training section and serves as backup for basic training classes. • Incumbent promotes an awareness of the importance of data validity and data security and coordinates efforts to correct deficiencies and errors that occur in the electronic record..,provide secondary support on related software modules…
Develop training plan for CAC http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=OITTrainingLinks • Recommended Training for CAC & Implementation Team: • Basic Site Manager • Fileman • PCC Outputs • Lab Package • Radiology Package • Preparing Pharmacy for EHR • Advanced EHR trainings • Site Visit to EHR site
Implementation Team • Clinical Champions from each discipline (Lab,RN, RPh,MD,etc) • Administration/Executive Leadership • Information Technology • Include Area IRM representation • Clinical Application Coordinator
Implementation Team Roles • Identify and define Policies and Procedures • Address staffing and scheduling during transition • Peer Training & Marketing • Monitor and Execute Implementation Plan • Design and Approve templates, menus, and ordering lists for E.H.R.
Hardware • Evaluate current hardware needs • Evaluate network needs • Begin procurement process for hardware • Hire additional IT staff if necessary • Install new equipment and test it before using
Upgrade Hardware/Infrastructure • RPMS server • Training server • Network • Lab Interface Upgrade • Workstation Access - Everywhere • Backup Power
Computers and Printers • computers (desktops/tablets/laptops) • in the outpatient clinics and medical staff offices. • computers were purchased for EHR • Costs approximately • of the new computers in the outpatient clinic • Remainder were distributed to medical staff, replaced outdated systems, or placed in areas that were not previously using computers. • There are printers in the Indian Hospital, of which are located in the outpatient clinics.
Costs • Estimated Equipment cost: $430,358 • Comptime: 1,820 hrs • Training: $2,163.36 • Personnel • CAC / two Assistants • Contractor: $7,100 (97 hrs) • Help w/ drug file cleanup
RPMS "Point-of-Service" packages • Assure packages are being used correctly before going to EHR • Immunization 8.0 • Women's Health • Diabetes Management • Behavioral Health System v3.0 • Behavioral Health GUI • Dental • Case Management • Implement or assure correct usage to appropriately capture required data.
Go Live • Identify go-live clinic or location • Address staff concerns • Identify all affected staff: lab, pharmacy, nursing, radiology, medical records… • Schedule an overview of EHR training • Publicly promote the EHR implementation • Discuss with all parties: hospital, tribal, labor union, etc.
Implementation Strategy • Implementation-Who and When • Everyone at once - one at a time? • Lab ordering , then radiology ordering, then pharmacy ordering, then notes • Bring up one team/dept at a time
Document Plans • Assess risk and effects of initial changes in productivity • Develop contingency plan • Provide area office with a copy of implementation plan
Productivity Expectations • 50% of EHR users felt that they experienced a decrease in productivity after using EHR. • Only 2 users felt that they were unable to see as many patients in a day as they could previously. • Members of the medical staff report seeing about 16-20 patients per day depending upon the clinic they are working in. • One respondent pointed out that they see the same number of patients each day, but must spend an additional hour to do so.
Productivity Long Term Short Term
Our Ambulatory Clinic’s caseload has steadily increase over the past 2 years.
Most of this growth is concentrated in our largest / busiest clinics- hitting record high volumes on EHR.
EHR EHR EHR EHR EHR
What Happens to Clinics When They Get On the EHR ??? It appears that clinics experience a drop in productivity for 1-3 months and then experience a rebound in productivity. Usually the clinics return to volumes above pre-EHR volumes.
Optometry, Pediatrics and Physical Therapy seeing more patients on EHR. Podiatry experiencing decreased demand. Internal Medicine just starting on EHR- experiencing a drop in productivity. OB/Gyn seeing about 10% fewer patients per provider on EHR.
Productivity • Factors that assist EHR users in taking care of patients include: • Medication lists • Historical visit information • POVs • Allergy warnings • Legibility of visit information • Lab history • Graphs • Improved nursing efficiency • Improved patient screening • Quick-orders
Prepare for Installs • Review CAC and User Guides • Coordinate with consultants • Prepare a plan for providing staff with training on new RPMS packages
Ancillary Packages PIMS 5.3 patched to support CPRS v20 Part of EHR suite: Dietetics 5.0 Nursing 4.0 Surgery 3.0 Medicine 2.3 Problem List 2.0 I/O Package 4.0 Vitals 5.0 Scheduling GUI (9/30/04) Vista Imaging v3.0 (Optional) (Requires Radiology 5.0) Pharmacy Package (OE/RR 3.0 Inpatient Pharmacy 5.0, Outpatient Pharmacy 7.0, Consults 3.0) with PSG mods Controlled Substances 3.0, Drug Accountability 3.0, Auto Replenishment 2.3, Pharmacy Benefit Management 3.0, BCMA 2.0 Lab v5.2 p18 TIU v1.0 (requires PIMS 5.3) Electronic Health Record Functionality Radiology v5.0 (requires PIMS 5.3) Pharmacy Data Management- PSS v1 p1 Clinical Queue, Services tab, Provider POV, Health Maintenance (Wellness), Nursing triage, CPT codes, Problem List, Immun. IHS-EHR Graphical User Interface (GUI) Electronic Health Record Update Your Software Site RPMS System Baseline applications: Cache 5.0.12 (FM22, F200 conversion, K8), Laboratory v5.2 p17, Radiology v4.0/4.5 p10, Outpatient Pharmacy v6 p5, Pharmacy Inpatient Suite v4.5, Immunization v8.0 p1, Women’s Health v2 p9, Patient Chart v1.4 p1, Patient Registration v7.0 p4, MAS v5, p8 Current patches of the following: AUT, AUPN, ACPT, AVA, XB; (ER package) - VA Lexicon v2.0 - VA Health Summary v2.7 - Visit Tracking/PCE/ Clinical Reminders (requires PIMS 5.3) PCC Data Entry v2.0 P7 Fileman 22 (1002), HL7 v1.6 p1005, Kernel Toolkit v7.3 p1002, Kernel v8 p1009 - Integrated Billing 2.0 - Auto Info Collection Systems 3.0 - Generic Text Generator 3.0 Kernel 8 (1010), Mailman 7.1 p1004 patched to support CPRS v20
PIMS • Patient Information and Management System • Scheduling • ADT • Security
Work flow/Business Process Analysis • Follow the paper chart from patient registration to the billing office • What processes will change with EHR? • How to keep processes the same with EHR? • What processes will not work with EHR? • How to re-design / work around… • Make sure everyone is on the same page!
Patient Registration Case Mgt Pharmacy Patient Visit PCC Patient Database Lab Radiology Coding Billing Data Entry Key Paper Flow EHR Flow Common Flow