Electronic Medical Records: Implementation and Beyond

(1)

Electronic Medical Records:

Implementation and Beyond

William M. Keane, MD

Chief Medical Officer, Jefferson University Physicians

Bruce A. Metz, PhD

Chief Information Officer, Thomas Jefferson University

John Ogunkeye

(2)

Agenda

I. Jefferson University Physicians Background

II. EMR Project Overview

III. Keys Steps and Critical Success Factors

A. Project Organization and Governance

B. Clinical Transformation

C. Physician Adoption

D. System Roll-out

IV. Primary Challenges and Lessons Learned

To-date

(3)

Jefferson University Physicians

Background

• A clinical enterprise that supports the academic mission of Thomas

Jefferson University, a leading academic medical center in

Philadelphia, PA

–

Responsible for patient care

–

Work closely with Thomas Jefferson University Hospital, our

partner hospital

• 485 Faculty in 17 Clinical Departments

• 230,000 Active Patients

• 412,000 Ambulatory Encounters

• $220 Million in Revenue

• 25,000 Admissions to Primary Hospital

• 16,600 TJUH Surgical Cases at Primary Hospital

• Practice Activities (22 hospitals & 44 Ambulatory Sites)

aka:

JUP

(4)

• Complex Operations

• Multiple sites

• Challenging External

Environment

Jefferson University Physicians

Background

(5)

Jefferson University Physicians

Background

Patient A Inpatient Stay Ancillary Service JUP Practice X Patient A Patient A JUP Practice Y Patient A

“Islands” of information

Integrated

practice profile

and “whole

system”

approach not

matched by

integrated clinical

information

systems

(6)

Jefferson University Physicians

Background

Institutional Goals

• Patient Centric Environment

• Preferred Employer

• Patient, Physician and Staff

Satisfaction

• Fiscal Stability

Patient Mandate

“Develop a plan to ensure that our patients experience in

our clinical enterprise is operationally excellent from their

first contact with Jefferson, across our sites and settings

and continuing after/between episodes of care.”

Jefferson Clinical Planning Patient Experience Committee September, 2005

(7)

Context for a JUP EMR Strategy

Quality is a Strategic Priority for JUP

Enhance Patient Care

Delivery Processes

“Patient Centric Care”

“Unmanaged”

Care Delivery Process

“Managed”

Care Delivery Process

Heightened

Regulatory Environment +

Waning Patient Satisfaction =

Greater Exposure for Risk and Liability

“Manual” Practice Environment + Informed Patient = Patient/Physician/Staff Disaffection

B

u

s

I

n

e

s

Meet Organizational Goals

Respond to External

Imperatives

Market Reputation + Increased Competition =

Threat to Business Model

P

r

o

c

e

s

R

e

n

g

I

n

e

r

I

n

g

(8)

Long-term Vision: Phased Integration

of the Islands of Information

Jefferson

Patient A

TJUH Ancillary Service JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice JUP Practice Other Practice Volunteer Practice TJUH Inpatient

Jefferson

Patient A

TJUH Inpatient TJUH Ancillary Service Other Practice JUP Practice Volunteer Practice Ancillary TJUH Volunteer & Other Practice JUP Group Practice Jefferson Patient A

(9)

Long-term Vision: A “Wired” Practice

Physician at Home Broadband Router with Firewall and VPN Wireless Access Point EMR/PM Application Wireless Access Point EMR/PM Application Internet Internet JUP Practice B Volunteer Faculty Personal Computer Wireless Access Point CCR Data CCR Data Patient Demographics Patient Insurance Medications Allergies Lab Results Dictated Reports Vital Signs DX and CPT codes Patient Demographics Patient Insurance Medications Allergies

Health Maintenance Alerts Lab Results Dictated Reports Vital Signs DX and CPT codes JUP Practice A Personal Computer Personal Computer TJUH TJUH

(10)

Strategic Business Drivers

• Improve Workflow Efficiency

• Eliminate Medical Errors

• Improve Patient Satisfaction

• Improve Faculty/Staff Satisfaction

• Improve Community Image

• Improve Patient Safety and the Quality of Care for Patients

• Standardize Patient Care Delivery Process

• Enable Instant Access to Information

• EMR System Selection in 2005; Project Kickoff in 2006

(11)

Source: Partners Health Care experience based on 2500 patients and providers. “Cost and Benefit Analysis for electronic medical records in primary care.” The American Journal of Medicine 2003;114:397-403

Summary of EMR Benefits

Decreased Billing Errors Increased Billing Capture Radiology Savings Lab Savings Drug Savings Adverse Drug Events Prevention Transcription Savings Chart Pull Savings 15% 14% 13% 5% 5% 15% 29% 4%

(12)

Return on Investment Benchmarks

1_{Mark Leavitt, Medical Director of HIMSS,}

2005 DOQ-IT Presentation

Hard Dollar Benefits

Industry 1 Capture lost charges 1% - 5% revenue gain Reduce defensive down coding 5% - 11% revenue gain Reduce claims denials and delays 15 - 30 day A/R speedup Increase preventive and management services 5% revenue gain

Reduce transcription $5k - $15k/yr costs cut

Stretch Dollar Benefits

Increase physician productivity 0% - 15% revenue gain Staff efficiency 0% - 15% cost reduction Reduced chart pulls $5/pull or $6k/yr/MD Reduce cost of paper chart materials $1-5/pt or $1k/yr/MD Reduce costs of chart storage and archiving $1k/yr per physician

JUP ROI Analysis 1% revenue gain

1% revenue gain

15-30 day A/R speedup Not included in analysis $6,404k/yr costs cut

Not included in analysis 7% cost reduction

$2.59/pull or $3,617/yr/MD $1.20-3.60/pt

(13)

EMR Project Review:

Implementation Plan Key Components

• Implementation budgeted at approximately $18.0M

• Wave 1: Organizational and System Readiness

• Wave 2: Implementation of TouchWorks Modules and Supporting

Interfaces

• Wave 3: Go Live and Roll-Out

• Transition to Steady State

(14)

MILESTONE O C T 1 N O V 2 D E C 3 J A N 4 S E P 1 2 O C T 1 3 N O V 1 4 F E B 5 M A R 6 A P R 7 M A Y 8 J U N 9 J U L 1 0 A U G 1 1 F E B 1 7 M A R 1 8 A P R 1 9 D E C 1 5 J A N 1 6 M A Y 2 0 J U N E 2 1 J U L Y 2 2 A U G 2 3 S E P 2 4 O C T 2 5 N O V 2 6 A U G .. 3 5 S E P 3 6 2006 2007 2008-09 MONTH

Change Management and Communication WAVE 1

• Process Redesign and Standardization

• Project Organization and Mobilization

• Project Team Space Acquisition

• Hardware Procurement and Installation of Network (Server side)

• Client Device Procurement and Rollout

WAVE 2

• Introduction to Touchworks Training and Interface Training

• Future State Design and Documentation (Best Practice)

• Design and Develop Full EMR and Interfaces

• Interface Delivery and Remediation

• Note Design and Development

• Integrated Testing, Fit Gap Analysis and Rapid Redesign

• Steering Committee Sign-off

• Simulation

WAVE 3

• Deliver Alpha Site

• Rollout Beta Site

• General Rollout

• Rollout Closeout

Implementation Timeline

(15)

Critical Planning Items

• Project Definition

–

Not

an Information Technology Project

–

Cultural Transformation leveraging technology

• Workflow Redesign

• Training, Behavior

• Decision Making

–

Quick turnaround on decisions

• Financial implications

–

Integration with current leadership making structure

• Minimize redundancy

–

Focus on what is in the best interest of the patient

• Time Commitment

–

Physicians

• Dedicated effort

»

Compensation/Incentive

–

Administrators (all levels)

• Specialty lead

(16)

Critical Success Factors

• Strong Executive Sponsorship

• Effective Governance

• Extensive Change Management (Clinical

Transformation)

• Deep Physician Involvement

• Tight Project Management (Tasks and Budget)

• Comprehensive Training, Support and

Communication

All tied together by a structured,

strategic approach

(17)

JUP Management Committee PR OJEC T EXEC U TIVE C OU N C IL B U D GET IN FR A STR U C TU R E TEA M C LIN IC A L TR A N SFOR MA TION GR OU P ‘GO- LIVE’ TEA M PR OJEC T STEER IN G C OMMITTEE C LIN IC A L A D VISOR Y TEA M D ESIGN & B U ILD TEA M Q/ A R ISK MA N A GEMEN T PR OJEC T D IR EC TOR PR OJEC T C OOR D PMO PMO PH YSIC IA N A D VISOR Y GR OU P VEN D OR OVER SIGH T C OMMITTEE C OMMU N IC ATION S EXEC U TIVE SPON SOR S E LE CT COMMIT T E E OF T HE JUP BOARD

Project Organization and

Governance

(18)

Project Organization and

Governance (continued)

JUP Management Committee PROJECT EXECUTIVE COUNCIL BUDGET TEAM

IT TEAM CLINICAL TRANS _TEAM PROJECT STEERING COMMITTEE CLINICAL ADVISORY TEAM DESIGN & BUILD TEAM Q/A RISK MANAGEMENT PROJECT DIRECTOR PROJECT COORD PMO PMO PHYSICIAN ADVISORY GROUP VENDOR ADVISORY COMMITTEE COMMUNICATIONS EXECUTIVE SPONSOR EMR TASK FORCE OF THE JUP BOARD TESTING TEAM OTHER TEAMS PROJECT SPONSORS

Project Accountability Pods

Clinical Departments Medical Specialties Surgical Specialties Primary Care Phys. Lead (2) Admin. Lead (1) Phys Lead (3) Admin. Lead (2) Hospital Based Phys. Lead (3) Admin. Lead (1) Phys. Lead (2) Admin. Lead (1) Com mun icat ion Flow Com munic ation F_low

(19)

Available functionality will be leveraged to enhance the patient experience with JUP.

Patient Services

A primary driver for all decisions regarding the JUP EMR will be to ensure safe patient care.

Patient Safety

A primary driver for decisions regarding the JUP EMR will be to ensure the delivery of quality patient care.

Quality

The JUP EMR will be universally adopted and will be used as designed.

EMR Adoption

Decisions regarding the JUP EMR will be made within the JUP governance structure that supports both enterprise-wide and multi-specialty perspectives, while sustaining the academic and research missions of the University. The decision process will be transparent and have clearly delineated lines of communication.

Decision Making

The JUP EMR will be designed and implemented in a fashion that permits ongoing evaluation and standardization of quality of care rendered by each provider.

Evaluation and Demonstration of Quality

Patient satisfaction is a primary focus of JUP.

Patient Satisfaction

Description Principle

(20)

The JUP EMR implementation will maintain a financial focus and facilitate achievement of the ROI.

Economic Impact

Alignment of process and systems will promote the ideal patient experience and enable long term integration.

Campus

Collaboration

Practice productivity related to the JUP EMR “go live” is expected to decrease transiently and there will be a plan to minimize its impact.

Go Live

Productivity

The goal and commitment is to high system availability.

System Availability

The JUP EMR will be designed to improve operational efficiency and promote patient safety and clinical excellence.

Operational Efficiency

The JUP EMR project requires a collaborative communication strategy supported by a communication team with representation from all

stakeholder groups.

Communications

Clinical information, using the Allscripts library content, will be defined and managed within the JUP EMR governance.

Clinical Content

The JUP EMR will support care collaboration across JUP, TJUH and external organizations.

Care Collaboration

Description Principle

Project Guiding Principles

(continued)

(21)

Project Branding

(22)

Organizational Transformation

Transforming the Workforce Physician Integration Clinical Process Optimization Leveraging Technology Sustainable Change

Periodic Review of Metrics that Measure, Monitor Benefit Realization for Processes

Standardization, efficiency and utilization optimization

in care delivery and administrative process

Provider engagement in the development, adoption, acceptance

and accountability for care delivery processes

Achieving change through communication, Governance/leadership,

knowledge

Management while focusing on organizational culture Merging of technology and

operational processes to achieve value and intelligence for clinical

care delivery

Modified from Healthlink Approach to Process Redesign & Clinical Transformation

(23)

• Healthlink/IBM served as Clinical Transformation (BPR) vendor

• Healthlink Engagement Results – Part I

– Detailed current state analysis for representative practices:

• Otolaryngology

• Family Medicine

• Obstetrics and Gynecology

• Internal Medicine

• Cardiology

• Surgery

• Healthlink Engagement Results – Part II

– Detailed Future State Design

• Based on Best Practices

• Scope included:

» Appointment Scheduling

» Orders

» Patient Encounter documentation

» Dictation

» Prescription Renewals

» Patient Intake

» Medical Records

» Charges

Clinical Transformation Initiative

(24)

• Road Map to the Future State

–

Each practice will identify the ‘gap’ between their current work flows and

the desired future state workflows

–

JUP Clinical Analysts conduct focus group sessions with each practice

to develop their future state road map.

–

JUP Clinical Analysts provide on-going oversight of the implementation

of the road map(s)

–

Future state planning is complete for:

• Family Medicine

• Otolaryngology

–

Future state planning is in process for:

• Ob/Gyn

• Cardiology

Clinical Transformation Initiative

(continued)

(25)

• As part of the clinical transformation effort two practices were selected to

pilot a ‘hard copy’ medical records outsourcing solution – Family Medicine

and Otolaryngology.

–

Otolaryngology has a very efficient medical records process

–

Family Medicine was extremely challenged

• Family Medicine, by its nature, is a magnet for medical record documents. As

a result they could no longer adequately manage their patient medical

records.

• Working with the EMR Clinical Analysts, JUP Operations and the EMR Project

Director, the Family Medicine practice re-engineered their approach to

medical records management including:

–

Scanning of clinically medical record documents

–

Abstracting medication lists and allergies and entering them into

the ‘pre live’ EMR system

–

Outsourcing all of the medical records functions

Clinical Transformation Initiative:

The Family Medicine Experience

(26)

Physician Adoption:

Dealing with Change

• The EMR makes me look like I don’t know what to do in front of my

patients and colleagues.

• Don’t tell me how to practice medicine!

• You don’t understand how I do my job.

• You are shifting the work from the staff to me.

• My productivity will suffer and thus my compensation could be

negatively impacted.

• This will adversely change my relationship with the patient.

• The organization gets all the benefit while I get more work.

• This is going take a lot more of my time.

There is the ever-present issue of

securing wide-spread physician

(27)

Physician Adoption Plan:

Major Components

• Lead Project Conceptualization

–

Planning committees led by physicians

• Physician Champions/Advocates

–

“Messiahs” spreading the gospel

• Project Guiding Principles

–

Signed off by physicians

–

Decisions track to guiding principles

• Assign Physicians to Specialty Groups

–

Clinical content

–

Physician workflow design teams

–

Computer device demonstrations

(28)

Physician Adoption Issues:

Physician Roles

• Appointed a Physician Champion (50 % Effort)

–

Reports to JUP Medical Director (Executive Sponsor)

–

Practice plan covered effort associated direct and indirect

costs)

–

Housed in EMR Project Office

–

Works “shoulder to shoulder” with Project Director

• Appointed 3 Physician Advocates (~10% Effort each)

–

Practice plan covered effort associated direct and indirect

costs)

(29)

• Provides leadership, mentoring and guidance to colleagues

• Provides ongoing communication to peers and other staff

–

Goals, objectives and project benefits

–

Link between EMR project and other JUP initiatives

• Serves as subject matter expert

–

Current and future state, clinical workflows

• Serves on appropriate advisory groups

• Serves as a liaison to and from the practices, operations,

project teams and the organization’s leadership

• Serves as an active participant in clinical transformation

activities and provides advice, recommendations and guidance

Physician Adoption Issues:

Physician Advocate Role

(30)

• Value

- Do the physicians see the value of the EMR?

• Content

- Is the clinical content of the system complete and useful?

• Functionality

- Is the functionality of the application adequate?

• Navigation

- How easy is it to navigate through the various screens?

• Transaction Efficiency

– How many ‘clicks’ does it take to get to the

required function/information?

• Individual Customization

– Does the application support individual

customization easily?

• Intuitiveness/Thought Flow

– How closely does the flow of the screens

and data match the way physicians can envision working?

• Functionality vs. Ease of Use

– When does the system functionality

impede ease of use?

Physician Adoption Issues:

Key Points to Consider

(31)

EMR Roll-out Schedule

07 07 07 07 08 08 08 08 08 08 08 08 08 08 08 08 09 09 09 09 09 09 09 09 09 09 S O N D J F M A M J J A S O N D J F M A M J J A S O OTO X Fam Med X X Anesthesia Radiology Pathology ED Rad Onc X X X X X X X X X X OB/GYN/JOGA X JIMA/ Hematology X Cardiology X Surgery X Neurology X Neuro -Surgery X Urology X Endocrinology X Pain Center Rheumatology X Pulmonary X Infectious Disease X Nephrology X Sleep Center Primary Care X Rehab X Dermatology X Psych X

(32)

EMR Roll-out Schedule

(continued)

Pre-live Milestones by Practice

190 Days Out 190 Days Out 180 Days Out 180 Days Out 130 Days Out 130 Days Out 120 Days Out 120 Days Out 100 Days Out 100 Days Out 60 Days Out 60 Days Out 30 Days Out 30 Days Out 14 Days Out 14 Days Out 5 Days Out 5 Days Out • • Hardware Hardware • • Selection Selection • • Hardware Hardware Ordered Ordered •

• Network Network ““BuildBuild out out”” • •Scanning/Scanning/ Abstracting Plan Abstracting Plan •

• User Set Up User Set Up •

• Practice Specific Practice Specific Build Out

Build Out

•

• Clinical Content Clinical Content Review, Edited

Review, Edited

and Approved

•

• Scanning and Scanning and Abstracting, Abstracting, Commences Commences • • Interfaces Interfaces Activated Activated •

• End User End User Dictation/ Dictation/ Transcription Transcription Training Training • • Hardware Hardware Deployed Deployed •

• Super User Super User Training

Training

•

• End User End User Training

Training

•

• Final Pre Final Pre ““Go-LiveGo-Live””

Review Review • • Simulation Simulation Testing Testing

(33)

Primary Challenges Going Forward

• Vendor Management and Software Stability

• High Availability IT Infrastructure

• Roll-out Support

• Implementation of New Workflows for the

Practices

• Physician Acceptance

(34)

EMR Data Center Solution:

An Architectural Overview of Major Components

Campus Fiber Network Ring Connecting TJU/H Center City Sites,

Methodist, St. Agnes, 401 Broad St. (TJUH IS Projected Completion

Date of 11/07)

DBSi Data Center Hosting Site Valley Forge, PA

401 Broad St. Carrier Hotel TJU Co-Location Fail-Over Site Sungard Disaster Recovery Site

Internet Links

TJU/TJUH Center City Campus Scott Data Center and Network Core

Locally Connected JUP Practices and Clinics Off-Site JUP Practices

Connected by Remote T1 Circuits, Frame Relay, and Managed Ethernet

Dedicated Data Circuits Connecting Campus Network To Remote JUP Practices Backup DSL Links From