Carilion Health System: Large Scale Ambulatory EMR Implementation

Brent Lambert, M.D.Carilion Health System

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EMR

~15% of Virginia physicians use an EMR

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Carilion Physician Operations

• Carilion Medical Group +/- 190 phys.• Carilion Medical Center +/- 90 phys.• Carilion Emergency Svs. +/- 50 phys.• Total Physicians Employed 330

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CMG Physician Characteristics

• 117 Family Pract.• 29 Internal Med• 16 General Sur• 12 OB-GYNs• 8 Pediatricians• 2 Cardiologists• 4 Neurosurgeons• 1 Vascular Surg• 1 Dermatologist• 1 GYN-Onc• 1 Pulmonologist• 1 Gastro.

61% 60% 65% 71% 71%

15% 15% 14% 20% 29% 8% 10% 7% 6% 8% 6% 5% 4% 4% 4% 4% 1% 2% 1% 2% 1% 1% <1% <1% <1% <1% <1% <1% <1% <1% <1% <1%

2003 1999 1994

158 Phys54 Loc

24 Phys9 Loc

171 Phys61 Loc

2004

188 Phys62 Loc

2005

193 Phys 64 Loc

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About CMG

• Practices from Woodstock to Wytheville on I-81 & down to Galax and Martinsville on the NC Border.

• Electronic Medical Records in use since 1999 – one record per patient regardless of the location of care.

• Single patient financial record regardless of the location of care.

• Greater than 600,000 patient records• 950,000 patient visits a year.

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Ambulatory EMR

• Carilion Medical Group began the role out of their ambulatory EMR in March 1999.

• Completed the initial rollout about 2 years later.

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Carilion Medical Group’s Experience with EMR

• Started the EMR project in 1998• First practice to transition from a standard paper record to

EMR was in March of 1999• Initial roll out complete in 2002• “No new paper” in 2002• Interfaces from:

– practice management system– reference lab– radiology reports– ED records, hospital transcriptions– document imaging system

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CMG’s Challenges

• Database vs. Document Storage• Minimum usage standards

– Current Problem List– Current Medication List– Current Allergy List– Immunizations

• Takes more time initially– Learn new application– Working in 2 worlds

For most of our physicians it took 9-12 months to get back to baseline production.

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CMG’s Challenges

• Integration– Lab – both reference and office– Radiology– Practice Management– Transcribed Documents– ED Reports (from another EMR)– Document Imaging

• Standard Vocabulary• Development of standards and clinical content

– Determine what clinical standards to follow– Development of clinical content with clinical decision support tools

• “Out of the box” the clinical content is very basic and clinical decision support is nearly nonexistent

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Carilion Medical Group Board

• CMG board made decision to use an EMR• Board elected by physicians in group and consists mostly of

physicians• Board made it clear that EMR was not optional

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EMR Selection

• Board appointed a committee to select an EMR• Selection committee was made up mostly of physicians that

were not on the board• Made several site visits where EMR was used• Selected Logician by Medicalogic

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Vendor Issues

• Medicalogic – privately held company• IPO• Bankrupt• General Electric

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Pilot Site Chosen

• Before final decision to move forward, the EMR was piloted• Pilot site went live and used EMR for about 6 months before

any other sites went live• Pilot site used to fine tune project plan and scope• Pilot site used to define and refine rollout plan

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Key Project Decisions

• Single database over a WAN• 100% thin clients• Device in every exam room• Limit printers as much as possible• Interfaces priority

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Rollout Begins

• Order of rollout defined– Each site had the option to opt out once and move to end of

list– Once an opt out site was reached for the second time they

could not opt out• 21 week schedule for “kickoff” to “go live”

– Site– Training staff– IS application staff– Network Services

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Chart Preload

• Sites encouraged to “preload” problems, medications, and allergies

• Sites free to preload other information• % of charts preloaded very important in success at go-live

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Interfaces

• Practice Management System• Reference Labs• In-house labs• Radiology Reports• Hospital Transcription• ED Reports

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Enhancements

• Faxing– Electronic prescription transmission

• Required visit to Virginia State Board of Pharmacy• Still not allowed by DEA for scheduled medications

• Document Imaging• Dinamap

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Provider Decision Support

• “Out of the Box”– Medication interaction– Allergies

• Developed– Diabetes– Anticoagulation– Immunization Reminders– Mammogram Reminders– Congestive Heart Failure– Ob Care

Diabetic Notification

Diabetic Assessment

Initial Anti-Coagulation Form

A-C Treatment Sched.

A-C Follow Up Form

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A-C Results

• We think that through standardization of dosing we will ultimately improve results for patients across a large population.

• Physicians and nursing staff like the documentation aids and efficiency

Consider Mammogram

Needs Mammogram

Visit Assessment

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Customization

• Both good and bad– “Out of the Box” our EMR is very generic– EMR allows considerable customization– Learning curve to customize is long and difficult– Limited outside sources for EMR content

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Future of Carilion EMR

• More decision support• Orders with out bound interfaces

– Lab– Radiology– Practice Management System

• Reporting

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Lessons Learned

• Difficult and painful process – but worth the effort for most• Provider productivity decreases (may not be all due to EMR)

– At 18 months encounter/provider/workday down by 1.8– At 30 months down by 0.4

• Few providers would ever choose to go back• We believe that patient care improves!

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Keys to Success

• Total Commitment at the top• Physician leadership• Develop “in-house” skills• Development/customization team leaders must have clinical

background