EHR Business Process Improvements

CDR S. Miles Rudd, MDEHR Clinical ChampionWarm Springs Health & Wellness CenterWarm Springs, OR

Warm Springs Health and Wellness Center

• Serves 3,900 tribal and 2,500 non-tribal members.

• 55,400 patient visits a year for all services.

• 17,600 patient visits per year for medical providers.

• 52,300 pharmacy visits per year

Warm Springs Staff

• 5 full-time/1 part-time Family Physicians• 4 Nurse Practitioners ( 2 with Diabetes Program,

1 Women’s Health, 1 Urgent Care)• 1 Podiatrist• 4 Dentist (1 Pediatric Dentist)• 1 Optometrist• 8 RN’s, 3 PHN’s, 1 MCH nurse, 1 LPN, 3 NA• 2 Nutritionist

IHS-EHR Implementation

• Clinician driven• Confirmed Leadership Support• Tribal Endorsement• Area Office Support• Patient Awareness• VHA Support

Clinical Applications Coordinator (CAC)

• Most critical person for the success of the entire process.

• Coordinates implementation

• Provides EHR user support

• Provides/coordinates training for users

• Customizes software

• Assists in solving workflow issues

Clinical Applications Coordinator

• Interpersonal skills

• Proactive and helpful nature

• Management /leadership skills

• Working knowledge of facility processes

• Computer skills

• Clinical /RPMS background

• Identify equipment/network needs

• Upgrade RPMS applications

• EHR Configuration– design notes, quick orders, process changes

• Develop strategy for implementation

• Training, Training, Training

• Morale Support

IHS-EHR Facility Planning

“You want me to do what?”

Planning for IHS-EHR- First Steps

• EHR Implementation Team– Multidisciplinary Team

• Clinical Application Coordinator (CAC)• Clinical Champion (Provider)• Nursing• Health Information Services• Information Technology• Administration/Executive Leadership• Pharmacy• Lab/Radiology• Diabetes Program

EHR Implementation Team Roles

– Identify and define policies and procedures – Address staffing and scheduling during

transition– Provide peer training & marketing– Monitor and execute Implementation Plan– Design and approve templates, menus, and

order lists.

EHR Implementation Team Meetings

• Monthly meetings initially– Assignment of responsibilities with report back

to Team

• Meetings became more frequent as implementation date approached.

• Daily meetings during implementation– Facilitate communication– Troubleshoot problems– Mini-trainings

VHA Site Visit

• Team members went for site visit at Portland VA Medical Center– Hands-on training on CPRS– Discipline specific shadowing

• Provided major benefits in conceptualizing the EHR, understanding implementation, and looking at practice flow and redesign.

Practice Redesign

• Our group had done previous work to look at practice redesign.– Improve clinical efficiency– Decrease waste– Improve access and provision of care

• EHR Implementation gave us an opportunity to incorporate these redesign measures.

What does clinical redesign have to do with the IHS-EHR?

DON’T AUTOMATE WASTE!

Scenario: Many practices are considering using an electronic medical record (EMR) or other electronic devices, systems, or software.

Result: The technology is added into inefficient work processes resulting in more expensive, automated waste.

Lesson: Technology alone does not solve efficiency problems- it is a tool, not a solution.

What Are We Trying to Maximize?

• Use of personnel

• Use of time

• Use of skills

• Use of materials

• Use of space

• Use of money

• Use of data

To meet the needs of our patients

Clinic Redesign- Prior Steps

• Created Same Day Appointment System

• Assigned Designated Provider

• Created Nurse/Provider Teams

• Analyzed Patient Population

• Analyzed Services Provided (Top Diagnoses, Top Appointments)

• Analyzed Staff Activity, Roles, Scope of Practice

Practice Blueprint

Clinic Redesign for IHS-EHR

• Redefined roles for nurses aides, nurses, and physicians.– We want to make sure that everyone is

working up to their capacity.– Need to unload our providers from work that

someone else can complete.– Providers had new responsibilities for order

entry and coding.– FUTURE- We want to redefine the role of our

medical receptionist.

Super-Users

• Clinical Super Users (RN, Lab, DM, MD)– Training– Templates– Peer Support

• Pharmacy Super User– Medication Quick Orders– Adverse Reaction Tracking System setup– Training on medication orders– Pharmacy 7 duties

Infrastructure Upgrade

• RPMS server upgrade

• Network upgrade

• Wireless network

• Lab Interface Upgrade

• Computers in all Exam Rooms

• Backup Power

Hardware Preparations

Phase I: – Setup and maintain a training and “live” server– Backup RPMS server– Additional computers/tablets/laptops

• PHNs, Dental, Exam Rooms, Everywhere

Phase II: – Upgrade wireless network– Implement Vista Imaging /Scanning System

• To eliminate paper documents

– Dental Imaging– Pharmacy Signature Pad

Software Preparations

• Package upgrades to RPMS

– Radiology– Text Integration Utility (TIU)– Adverse Reaction Tracking– Pharmacy 7– Scheduling (PIMS)– Pharmacy Inpatient Suite– Behavioral Health– Cache– Numerous RPMS patches

Major Software Updates

• Pharmacy Upgrade to version 7 (March 7)– Required several days to prepare drug files – Utilized Portland VHA pharmacist to assist– Worked overtime and weekends to get ready– Major process changes for pharmacists

• Implemented the Pharmacy Allergy and Adverse Reaction Tracking System:– All of the allergies that have been entered into PCC

had to be manually entered into the new tracking system and verified by a pharmacist

Major Software Updates

• Implement the new scheduling package (PIMS)– This software was substantially different than

the old version of scheduling and required facility wide training

– Checking in patient using the scheduling package

IHS-EHR Configuration

• Design templates • Design Menus and Quick Orders

– Medications, Lab Tests, Radiology, Nursing

• Define consults• Pick lists and Superbills• Note Titles• User Setup (keys)• Parameters• Print Formats

Staff Orientation

• Staff Training:– CPRS Training Module presented at staff meetings– Pharmacy Training Module:

• Available on Warm Springs Web Site• Mandatory for all pharmacy staff

– CPRS Training Module: • Interactive training posted on Warm Springs Web Site• Mandatory for providers

– Mary Hager Demo– Portland VHA visit and hands on training

Mock Patient

• Mock patients walked through a visit

• Valuable exercise– Identified training needs of staff in new roles.– Clarified issues about hardware needs.– Identified issues about queuing.– Validated new patient flow plan.

Pre-Implementation Training

• 2 hour training for everyone on VIEWING patient data in EHR

• Site Manager and Superuser training at VHA eHealth University (Camp CPRS)

• EHR test system loaded on all user’s computers

• Newsletters, web updates, meeting updates

Training – Go Live Week

• 4 hours training outside of clinic responsibilities

• Departmental trainings

• Use knowledgeable trainers

• One-on-one training

• Competency checklists

Going Live

• Intense CAC and IT support• Make appropriate scheduling adjustments• Daily debriefings….

– Procedural questions– Technical issues– Training

Medical Records Process

• Chart pulls• Note and orders filing in paper chart• Printing and filing chart copies

– Batch printing• Release Of Information• Outside consults and reports

– Scanning– Receiving reports in electronic format

• Incorrect entries

PCC Coding Issues

• Coding done from daily lists of visits• No hard copy to code from• Daily Error Reports• No POV, E&M Code, Activity Time• ICD Coding By Providers• Duplicate Visit Creation

Business Office Issues

• Services Pick List development, installation, and training

• Missing E&M codes• No hard copy to work with• EHR notes are legible• Great opportunity for improved provider

documentation & increase billing/collections

Hospital Issues

• Providers work at a community hospital 15 miles from clinic.

• Recurrent problems noted over the years.– Patients seen in hospital with no access to clinic

notes (Did have RPMS access via modem) – Patient follow-up in clinic with no notes.– Billing delays due to delay in receiving

documentation.– Billing delays due to delay in completion/receiving

hospital superbill.

Hospital Issues

• Created a new process for hospital workflow– Established network access points in major

areas of hospital.– Providers utilized laptops and linked to clinic

using Virtual Practice Network (VPN) and Terminal Services Client

– Notes, POV, and Superbill completed in EHR– Notes copied to Word document and printed

on blank hospital Progress Note form.

Pharmacy

• Outside prescription orders• Printing pharmacy service copies for orders• Refill and New prescriptions aren’t always grouped• DEA requirements for controlled substances

– Schedule II drugs require handwritten signature

• How to incorporate pharmacy patient signature log• Pharmacy requirement for completed/signed notes

Miscellaneous Issues

• Relax provider schedules during first weeks of implementation

• Productivity issues while learning• How to handle flowsheets in EHR• How to get reference lab results in EHR • Standardization of Note titles• Specialty clinic providers

Miscellaneous Policies/Procedures

• Transition for people not using EHR yet• Use of personal templates• Template approval process• Note content standards• Use of chat and broadcast functions• Documenting missing PCC elements in EHR

– Surgical history, colonscopy, refusals, mammogram

• Check in process• Lab justification

Template Approval Process

• Template approval process• Required form elements

– Plan that notes be able to stand on their own if printed. This is intended that pertinent information related to the visit be a part of the templates.

• Name• Date of Visit• Clinic Encounter• History• Personal History/GPRA

• Exam• Diagnosis/POV• Plan• Education• Refusals• Signature

Template Approval Process

• Needs: Patient education templates for adults, GPRA, DM standards

• “###” symbols used around information needed to be entered by data entry

Procedures for new forms• Deploy new forms in “Test” folder on the Live

EHR• EHR Team give e-concurrence of the form prior

to deployment

Questions?