• Internet access and e-mail from every workstation and every user account. • Printing from every workstation and every user account. Also test label
printing (if relevant).
• Access to office productivity tools, e.g., word processing and spreadsheet programs, clinical reference tools, etc. for all users who need them.
• Backup and recovery. Verify that the process works as it should and that data restored from a backup is useable.
• Archiving of patient charts when a patient leaves the practice.
• Remote Access. If remote access is provided to permit users to access the EMR system from off-site (e.g., at home or in another clinic location), ensure that it works as planned and that all security protocols are installed and activated. • Wireless network security. If a wireless network is used, ensure security is
properly enabled and that unauthorized devices (computers, messaging devices (e.g., Blackberry, Palm), etc.) cannot view or access the network traffic.
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OntarioMD provides a template for implementation acceptance testing1. This
template can be customized to suit a practice’s goals and requirements.
4.4 System & software user guides
Ensure that the vendors supply good user manuals for both the hardware and software, in either printed or electronic form (preferably both).
User guides for the EMR and any desktop applications (e.g., Microsoft Office®), and basic hardware and networking troubleshooting guides are invaluable to new users and to “super users” supporting others in the practice.
4.5 Accessing support services
Ensure that all staff members are aware of what to do when they have technical problems. For instance, under what circumstances should a user call the vendor’s help line or customer support centre? The practice should consider developing a simple policy for users on a day-to-day basis, such as the following:
“If you have trouble with your EMR, follow these three steps in order:
1. Use the help file: examine the user guides to try to resolve the issue on your own.
2. Consult the on-site “super user” or other IT support, if available. 3. Contact the vendor’s support desk.”
More detailed support policies and procedures should be documented as part of the service level agreement with your vendors.
Service level agreements and the documented escalation procedures can be very general or extremely detailed, but should outline criteria and timelines for support and system performance issues. In addition to outlining basic support procedures, the agreement should also address the steps to be taken in the event of a system failure, response times for routine and ad hoc queries, and response times for problem resolution (network down, machine failure, etc.).
4.6 Data entry, quality, & reporting – implementing best practices
The largest value in using an EMR is not in the data you enter, but in the
information you can retrieve to help improve patient care. Effective EMR use relies on a sound understanding of a few quality principles and core concepts about data:
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• Data types and management – The data collected may be in either or both plain text or structured formats. OntarioMD’s Records Management Guide2 is
a short, content-rich guide that introduces the concepts of data types,
principles of data capture, quality, storage and archiving, and data conversion approaches, including key tips on deciding whether to scan data into the EMR.
• Data mining and reports – Data collected is useful only if it can be retrieved in an efficient manner. Similarly, meaningful reports can be generated only if the data is
accurate and complete.
Understanding data mining and reporting principles helps set the stage for continuous improvement in the practice. Implementing effective clinical decision support at the point of care and managing patient populations (e.g., recalls and alerts, self-audit) is not possible without good quality data. See the Canadian EMR Success Stories (Chapter 6) for examples of “quick wins” with data mining to improve patient care and see the chapter “Optimizing your EMR” for
more details on technology-enabled quality improvement and best practices. Key principles of data quality and coding are:
• Data quality – The GIGO principle: If you put “garbage in”, you will get “garbage out”. In health informatics, definitions of quality data generally refer to data with the following characteristics: it is accurate, complete, relevant, up to date, and accessible when and where it is needed. Consistent data entry and coding practices help to generate quality data, and to ensure that the data in the EMR will be useful.
Without quality data, your ability to use your EMR data to self-audit is impaired and the GIGO principle rules. Self-auditing is particularly useful in ensuring best practices are followed for patient populations with specific health risks, chronic conditions, or comorbidities. For instance, managing diabetes and cardiovascular care is easier if you can consistently identify all
Team members have recognized the
criticality of good data coding and
data entry practices. E.g., one
physician did not code diagnostic
data (ICD9) well. Now that the
practice is using the EMR to
generate comparative reports over
time, and the reports are often
discussed at the weekly meetings, the
physician has seen the impact of
poor coding practices on the data,
and is working to improve coding
habits. The team has also
standardized the way all disciplines
encode diagnoses for alcohol
overuse, and is working on
standardized coding for other high
priority diagnoses. - Central Interior
Native Health Services
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patients in the practice with the conditions, or at risk due to particular characteristics. If inconsistent coding practices are applied, or the data is incomplete, you may miss portions of your patient population when attempting to implement recall programs (e.g., for A1C monitoring, or influenza vaccines for high risk populations).
Dr. Nikki Shaw’s, Computerization and Going Paperless in Canadian Primary
Health Care (Chapter 11)3 provides an overview of data quality and a sample
of the benefits gained by mining your EMR data to improve patient health outcomes.
• Data entry – Agree on a common approach to data entry and coding among all members of the practice and ensure that all members of the practice team follow this approach. Data entry best practices rely on consistency and codified data. Aspects of data entry include:
o What to record? How much detail? What do you need to know to support
patient care?
o How to record it? Structured data, such as standard templates,
terminology and dictionaries, and code sets are strongly recommended rather than free text data entry. However, free text is still valuable for letter writing, referrals, and some clinical notes.
o Who is to record it – Direct data entry (the clinician, at the point of care) or indirect data entry (a medical office assistant or transcriptionist)? o When is it to be recorded – During the patient encounter or afterward? o What codes should be used – How will the practice team agree on
common terminology and code sets for all patients in the practice? For problem lists? For medication lists?
Dr. Nikki Shaw’s, Computerization and Going Paperless in Canadian
Primary Care (Chapter 10)4 provides an overview of data entry guidelines
and tips.
To scan or not to scan – Records are still being created in many formats such as fax, hardcopy, and non-standardized electronic message formats. Integrating these records into an EMR system can be a complex and time consuming process. A common solution is to scan paper documents into the EMR. Scanning creates an electronic image of the original document which is linked to the patient record. However, this image will not add clinical value to the EMR unless a user (e.g., a
Data coding and quality standards
are set with input from all members
of the team: clerical (scanners,
stenos, billing staff), and clinical
staff (physicians and nurses). -
Haig Clinic
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scanning clerk, Medical Office Assistant (MOA), or clinician) takes the time to index the picture by manually inputting key clinical data about the document
(description of the test, results, values, etc.), and attaching that to the patient record along with the image.
Use caution scanning! If you cannot derive structured data which will allow you to use the scanned document in a data query or report, it will have little value in the EMR. See the Canadian EMR Success Stories (Chapter 6) and Going Paperless in
Canadian Primary Health Care, pages 89-905 for more details.
4.7 Maintaining your EMR
Staying current with user training, system maintenance, and upgrades ensures that the EMR will be more likely to continue to meet your needs. These items should be addressed as part of your service level agreements with vendors.
Alberta’s POSP has released a series of documents addressing system and data management on an ongoing basis (see Further Reading for this chapter). They identify the core content areas for service level agreements, and provide suggestions for best practices related to data management, archiving, disaster recovery planning, and related systems management activities.
More system maintenance, backup, archiving, and security principles are discussed in “Preparing for Implementation”, under the section on “What new policies and procedures do you need to consider.”
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All Tools & Further Reading references below are consolidated in the on-line version of the Toolkit at: http://www.emrtoolkit.ca/resources.php.
References are available in the language of the author.
4.8 Tools
1 Implementation Acceptance Testing
http://www.ontariomdtsp.ca/Includes/docs/InstAT.doc
A guide to help verify that all components in the “Scope of Work” are completed and working the way they were designed and contracted to work (from OntarioMD).
2 Records Management Guide
http://www.ontariomdtsp.ca/Includes/docs/RecMan.doc A guide to identifying the goals and objectives for moving from paper-based to electronic medical records. Describes the different types of data that can exist in an electronic medical record and explains the implications of using different data types – includes templates (from OntarioMD).
3 Overview of data quality and a sample of the benefits gained
http://www.emrtoolkit.ca/files/nshawdataqualityoverview.pdf Reproduced with permission from Computerization and Going
Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by
Radcliffe Publishing, 2004.
4 Overview of data entry guidelines
http://www.emrtoolkit.ca/files/nshawChapter10datarecording.pdf Reproduced with permission from Computerization and Going
Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by
Radcliffe Publishing, 2004.
5 Deriving structured data and adding clinical value.
http://www.emrtoolkit.ca/files/nshawdataqualityoverview.pdf Reproduced with permission from Computerization and Going
Paperless in Canadian Primary Care, Dr. Nicola T. Shaw. Published by
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4.9 Further reading
• Kick-off Meeting – Project Checklist (POSP facilitated): http://www.posp.ab.ca/files/KOM-Project-Checklist.doc
• CMA – A Physician’s Guide to Implementing Electronic Medical Records: http://www.cma.ca/
• Critical Care for Your Electronic Data:
http://www.posp.ab.ca/files/CriticalCareforyourElectronicData.pdf • System Management Guidelines:
http://www.posp.ab.ca/files/SystemManagementGuidelines.pdf • System Management Guidelines Custodian’s Summary:
http://www.posp.ab.ca/files/CustodiansSummary.pdf
4.10 Chapter 4 checklist
Checklist for Implementation & Maintenance
Have all users received training per the training plan? Is the EMR installed per the Scope of Work requirements?
Is the electronic-to-electronic data conversion/migration complete? Is paper-to-electronic data conversion underway? Have a strategy and timelines been developed and have all members of the practice team agreed to them?
Have the acceptance criteria as defined in the contract with the vendor (based on the Scope of Work) been met, signed off, and have you moved to an operational support agreement with your vendor?
Have you verified that your backup processes are working correctly and verified the data?
Have you been following your system management plan to ensure all desktops, servers, and related peripherals (e.g., printers) are up to date with their operating systems, security patches, antivirus and application software?
Are you aware of planned upgrades to your EMR software? Have you agreed with your team on criteria for deciding whether to and when to implement them?
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4.11 User notes
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Chapter 5
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Practice efficiency & ongoing improvement
Contents
At a Glance ... 70 5.1 Post-implementation reviews (PIRs): evaluating the EMR ... 71 5.2 Data sharing & interoperability... 72 5.3 Quality improvement
(QI)
... 73 5.4 Looking ahead... 75 Tools & Resources ... 77 5.5 Tools... 78 5.6 Further reading... 79 5.7 Chapter 5 checklist ... 80 5.8 User notes ... 8170
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At a Glance
Realizing and maintaining the optimal benefits of an EMR requires measuring how the system has changed the practice and regular re-evaluation of the system.
1. Regular practice assessments (e.g., post-implementation reviews and reassessments of the practice’s needs) help to determine: the impact of the EMR; whether it’s meeting the practice’s requirements; opportunities for improvement; and ways to measure the impact of new changes within the practice.
2. System-to-system interoperability (e.g., for electronic receipt of lab results, e-Prescribing, and exchanging patient data between EMRs) is the “next generation” of value for primary
health care providers with EMRs. Without good interoperability, scanning and manual data entry costs and the lack of consistently structured data formats between systems undermine the value of an EMR – it limits a health care
provider’s ability to intelligently
mine the data for clinical decision support and proactive care planning. 3. A practical quality improvement approach can help practices to identify
short and long term goals, and to test ways to use the EMR to meet them.
EMRs open the door to trying other
changes in our practice. For
instance, we’ve implemented
‘advanced access’ scheduling, and
could not have tracked “3rd next
available appointments” without
the EMR. - Dr. Paul Murray
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5.1 Post-implementation reviews (PIRs): evaluating the EMR
Both the practice’s needs and the EMR system may change over time, so regular evaluation and re-evaluation of the system, practice goals, and priorities will help to ensure you continue to get the most from the EMR.
The purpose of a post-implementation review is to assess the degree to which the practice’s goals and requirements have been met and thus assess the value of the EMR.
PIRs are not intended to be “one time” events. They provide an opportunity to assess what works, what doesn’t, and to determine the best means to address any outstanding issues. The first review should be held within one month of becoming fully operational. All members of the project team should be included: the practice team, vendors, and any health region support staff who participated. The same meeting “ground rules” (see NHS “Working with groups”1) as you used during
project planning should apply.
PIRs can and should be conducted regularly, e.g., 1, 3, 6, and 12 months post- implementation, and every 6-12 months subsequently. Regular review and reassessment of the EMR, and its fit with the practice goals and objectives, will help you continue to maximize the value from your investment in the technology. Sample questions for consideration in a PIR include:
• Was the EMR implemented on time? • Was it on budget?
• Does it meet your needs, as documented in the Scope of Work and the contract with the vendor(s)?
• Did the Scope of Work and vendor contract(s), as written, effectively document the clinic’s requirements?
• Does the EMR meet staff’s expectations? If not, why not?
• Are all health care providers and administrative staff using the EMR? If not, why not?
• Are all health care providers and administrative staff using all features of the software which are relevant to their jobs?
• Are all paper charts archived? If not, what timeframe has been set to complete this work?
• Are health care providers coding problem lists consistently? Have standards been set for the level of detail to capture for data entry/data coding?
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• Has the EMR improved patient care? If so, how? • Has the EMR improved patient safety? If so, how?
• Does the EMR save any time for health care providers? If so, how: o Charting?
o Billing?
o Prescription writing/renewal? o Referrals/letter writing?
o Assessing lab results? (e.g., out of range values? trends over time?) o Monitoring rule-based recall/guideline-based care processes – e.g., how
many diabetes patients have had their A1C measured within the past 3-6 months?
o Identifying high risk patient populations (e.g., patients eligible for/requiring annual flu vaccines)?
o Drug recall? o Other areas?
• Does the EMR save any time for administrative staff? If so, how: o Billing?
o Scheduling? o Referrals? o Patient recall? o Other areas?
• Is additional training required for any health care providers or staff?
The results from a PIR research project2 have been compiled in a formal study. The
results demonstrate the increasing value of an EMR over time.
5.2 Data sharing & interoperability
To maximize the utility of your EMR, you need to be able to share data – with other providers participating in the care of your patients, with other health care facilities (e.g., labs, hospitals, pharmacies, public health organizations), with government agencies (e.g., billing), and with patients themselves.
All patient data is not available in a single information system, and health care providers are situated in many different practice settings, facilities and
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organizations, all of which use different information systems – or none at all, relying on paper-based charting. Consequently, sharing patient data, and, more basically, obtaining a complete view of a patient’s health record, usually requires system-to-system interoperability.
Interoperability relies on the development and implementation of standard data definitions (for data format and content) and information exchange infrastructure (e.g., system architecture), to allow different systems to communicate with one another.
In jurisdictions with EMR standards or vendor accreditation programs, the
interoperability requirements for EMR vendors are often predefined. In early EMR planning stages, this may help to identify a short-list of vendors who are
prequalified to meet your interoperability requirements.
Standards for facilitating data sharing are under development at all levels (national, provincial, and regional). Investment in the national “electronic health record” and eHealth is escalating, and the emphasis on vendor “compliance” with interoperability standards is increasing.
This is a rapidly changing and evolving environment – in order to be positioned to maximize the interoperability of your EMR, confirm if your jurisdiction (region, province or territory) has established any formal or informal interoperability standards which may influence your EMR choice (see Appendices for regional contacts, and a list of related questions to ask your jurisdiction). Also, engage in regular discussions with your EMR vendor, and your jurisdiction, to see what new opportunities for improved patient care may arise through new interoperability standards.
5.3 Quality improvement (QI)
Quality improvement relies on good data. An EMR can support improved patient care and practice management by enabling measurement of improvement through high-quality data. The “Assessing your Practice: Green Book”3 provides guidelines
to assist practices to collect quality data and information. Maximizing the benefits of an EMR requires strict adherence to rules regarding the types and amount of data collected and how it is maintained. This set of “best practices” is crucial to providing consistent levels of patient care.