achieving “meaningful use”: 10 keys to a...

Achieving “Meaningful Use”: 10 Keys to a Successful EHR

Install & Adoption

November 4th, 2010Larry Garber M.D., Medical Director for Informatics

Fallon Clinic/SAFEHealth

Larry Garber, MD • Internist - Fallon Clinic x 24yrs

•Medical Director for Informatics x 12 years

P i i l I ti t f•Principle Investigator for a $1.5M AHRQ grant for SAFEHealth, an “Opt-In” consent federated HIE currently live in MA

•Vice Chair, MAeHC

•Member of MA State HIE Workgroup

•300+ provider multi-specialty group practice •30 specialties, including Occ Med & Behav Med•23 sites in central Massachusetts •200 000 patients with over 1 Million visits/year•200,000 patients with over 1 Million visits/year•Not-for-profit•At financial risk for 60% of our patients•Not affiliated with any hospitals

2001-3 2004 2005 2006 2007Vendor SelectDecisionInitial PlanningContract Signed

Our 7-Year Journey:

Contract SignedTech InfrastructureTeam Training Design – DBVs DevelopmentPractice Mgmt ImplementationClinical EHR Implementation

Phase II Phase IIIPhase IV

2011 2012 2013 2014 2015 2016

Implementation Never Really Ends

Regulatory Changes

Interface Maintenance

Optimization

Upgrades

10 Keys to a Successful EHR

Install & AdoptionInstall & Adoption

10 Keys to a Successful EHR• Early establishment of champions• Selection of the right vendors• Exceptional project leadership

kfl d i• Workflow redesign• Minimal disruption at the sites• Effective training and support• Specialty and user-specific tools • Alignment of incentives• Extensive communication• Monitoring metrics for success



Establish Champions Early• Identify, fund and train physician and

nurse champions• Involve as many people as practical o e as a y peop e as p act ca

during each step, from the very inception• Determine need for EHR at all levels

• 17 site meeting with >half of MD’s + staff• 7 Town Meetings attended by 25% of staff• Senior Management enumerated benefits

Expected Financial Benefits

Expected Financial Benefits

Expected results Industry experience

5% reduction in laboratory testing that was duplicate or inappropriate

0 – 13%

5% reduction in radiology testing that was duplicate or inappropriate

5 – 20%

Other Likely Financial Benefits

p pp p

0.5 FTE’s of order entry and telephone message delivery staff refocused or reduced per 10 providers

NA

50% reduction in preventable serious adverse drug events

10 – 70%

7.5% higher E&M coding levels for increased reimbursement and improved capitation negotiations due to improved documentation

10 – 35%

Estimated 10-year total benefit: $ 44.4 Million

Other EHR Benefits

• Benefits for which financial savings are likely to be achieved – but which are harder to quantify

• Benefits that will markedly improve staff and patient satisfaction and the overall quality and safety of care we provide

Establish Champions Early

• Select EHR vendor using all levels of organization

Di f MD’ ff (ACE)• Diverse team of MD’s + staff (ACE)• Management team (HITEC)• Board approval

• Focused campaign to engage Board members and all of medical leadership• 1 on 1 and group meetings with ALL leaders

Establish Champions Early

• Identify “Superusers” for each role• Providers• Nurses• MAs• Check-in/check-out staff

• Involve managers and “real users” from a broad array of practice settings and specialties during “design” sessions


Workflow redesign• Workflow redesign• Minimal disruption at the sites• Effective training and support• Specialty and user-specific tools • Alignment of incentives• Extensive communication• Monitoring metrics for success

EHR vendor selection process• HITEC developed RFP with 140 functional

requirements

• RFP was sent to 5 EHR market leaders• RFP was sent to 5 EHR market leaders

• 3 finalists selected and demoed their products to ACE committee

• Site visits, User Group meetings, reference checks, KLAS, ROI analysis, technical and financial due diligence were performed on finalists

Don’t be Penny Wise & Pound Foolish• 75-85% of an EHR project cost is fixed,

independent of software vendor• PC Workstations, Servers, Networks• Database licensesDatabase licenses• Other systems (e.g. Document Imaging)• Interfaces/mapping/vocabularies• Workflow analysis and system/template build• Training/Support• Drop in productivity/revenue

• Cheapest to most expensive EHR will only change total cost by 5-10%

Ergonomic Exam rooms

Prepare for the worst• System Fault Tolerance

• Redundant Servers• Redundant NetworksRedundant Networks

• Business Continuity Access• Nightly downloads of scheduled patients

to local PCs with UPS• Disaster Recovery site

• Downtime procedures and supplies



Exceptional Project Leadership• “C” level ownership

• Steering Committee – active ownership from operations, clinical and finance

• MD committee (EARs) – PCP’s and specialists actively involved in decisions

• Issues and decision escalation process, alternatives with pros and cons

• Financial management, budget and benefits

Exceptional Project Leadership• Project Team with clear roles, leadership, and Project

Management support• Hands on Project Director, relationships with

Operations

• Strong team members (recruit the best, external and internal)

• Physician and Nurse Champions active members of implementation team

• EHR certification of implementation team

• 65 MD content experts to help with build

Exceptional Project Leadership• Detailed project plan/Resource assignments

• Status Reports

• Scope management• Scope management

• Risks/Issues/Decisions Log

• Daily Issue Resolution Meetings during crunch time (including business owners)

10 Keys to a Successful EHR• Early establishment of champions• Selection of the right vendors• Exceptional project leadership• Workflow redesign• Minimal disruption at the sites• Effective training and support• Specialty and user-specific tools • Alignment of incentives• Extensive communication• Monitoring metrics for success

Workflow Redesign• Lean theory training sessions for the

multidisciplinary practice team• Document and evaluate current workflows Document and evaluate current workflows

and physical plant• Identify issues and opportunities• Brainstorming sessions to resolve issues and

improve processes• Document resultant value-stream mapping in

Excel and Visio• Update policies and procedures


Minimal Disruption at the Sites• Phased implementation

• Maximal increments of change that don’t interrupt operationsGi ti t b fi i t ith kill b f • Gives time to become proficient with skills before taking on new tasks at next phase

• Data conversion from the paper chart that doesn’t involve physicians or staff• Doesn’t take time away from busy MD’s and staff• No juggling paper and EHR charts in exam room

• Speech recognition software• Easiest documentation tool to learn

Phased EHR Implementation

1. Practice Management (Registration/Scheduling/Billing)

2 Clinical Results Repository2. Clinical Results Repository3. Paperless Telephone Messaging and

Prescribing4. Computerized Physician Order

Entry/Documentation/Billing in Exam Room

Historical Data Conversion

• Electronic (from legacy repository –QuickChart)

• Manual Abstraction• Document Imaging (scanning)

QuickChart Database

# of Years # of Records

Prescriptions 22 32 Million

Lab 16 30 Million

Imaging 14 2 Million

Notes 14 11 Million

Visits 15 20 Million

Total 95 Million

QuickChart Database (cont’d)

• Immunizations, Health Maintenance, Disease Management – 15 years

• Allergies – 10 years• EKGs – 15 years• Future Lab and Visit appointments –

1 year

QuickChart & EHR Data Sources

• Fallon Clinic transcribed visit notes• Fallon Clinic transcribed imaging

treports• Reference lab results• Inbound interfaces from a home

health agency and 5 hospitals (lab, imaging, notes), including SAFEHealth.org

• Health Information Exchange (HIE) currently Live in Central Massachusetts

• Patients give “opt-in” consent to exchange clinical data only between specific y porganizations where patient receives care

• No central clinical repository. Data flows from EHR to EHR.

• Developed with $1.5 Million AHRQ Grant• Sustainability is enabled by low operating

expenses resulting from internally developed software and no RHIO

QuickChart & EHR Data Sources

• Direct entry into QuickChart(allergies, telephone messages)

• Fallon Clinic billing• FCHP claims

At-risk claims data fed to clinic

S l R f

Hospitals

SoloMD’s

ImagingCenters PBM

RefLab

FCHP

FallonClinic

• FCHP Claims medication list and fill hx• FCHP and Fallon Clinic claims/billing:

• Immunizations

Billing and Claims data

• Health Maintenance Dates (e.g. Mammo, Colonoscopy, CPE, etc…)

• Disease Management Dates (e.g. HA1c, Retinal Exam, Smoking status, etc…)

• Past Medical Hx (filtered for chronic & signif. dxs)• Past Surgical Hx (filtered for significant procedures)• Visit Hx (OV/CPE, Consult, ER, Hospital, SNF/LTC)

How Much to Convert• Much passion surrounding this topic• Issues

• Clinical valueClinical value• Research value• Cost of storage• Time for conversion• Performance impact on live system

• We decided to convert everything

Conversion Planning

• Make a drawing of all of your current data stores and where they are going to appear in EHRare going to appear in EHR

• Identify the interfaces to use• Include the future state of how

interfaces will flow in the live environment

• This is NOT for the faint of heart!

41

42

43

44

Manually Abstracting Paper Chart

• Allergies• Family History• Family History• Growth chart data• Problem Lists

Document Imaging (Scanning)• Multidisciplinary clinical team defined what to scan

(type and how far back)• Handwritten notes (e.g. Pediatric CPEs)• Graphical results (e.g. PFTs, audiogram)• Outside reports (e.g. consultants, MRIs)• Indexing is critical for finding in EHR

• Patient Level (10 types, e.g. Advance Directive)• Visit Level (20 types, e.g. Outside consults)• Procedure Level (150 types, e.g. MRI of Breast)

Speech Recognition• EHR’s documentation tools are very powerful

and useful, however…• Take a long time to learn all of the tools• Hard to document HPI & Medical Decision Making• Hard to document HPI & Medical Decision Making

• Used Dragon Naturally Speaking Medical• Study showed higher quality notes and increased

physician satisfaction with documentation & EHR• Hybrid notes are most efficient• Notes signed in EHR improved 4 days 45 mins• Average increase of 8 minutes/day/MD• Saves $7,000/MD/year


Effective Training and Support• Recent college grads trainers optimizers• Mandatory just-in-time training• Hands-on training, 1 computer per user• User-specific classes

• Job class (MD, nurse, MA, checkin/checkout)• Specialty

• Proficiency testing• LEVEL video on exam room computer

physician patient interactions (with permission oKaiser Permanente)

• Mandatory dress rehearsal

Effective Training and Support• Go-live support by trainers for 2

weeks• All staff site meetings• All-staff site meetings• 1-on-1 circle-backs• Documentation summits• Optimization team• Live lunches


Specialty & User-Specific Tools• Need to balance user needs with:

• Bandwidth to build/maintain content for everyone• Quality and design consistency standardsQ y g y

• Specialty-specific ordering and documentation tools

• System-wide and specialty preference lists• User-specific preference lists and some

documentation tools (SmartPhrases)


Alignment of Incentives• Food/beverages at all training classes• CME/CEU credits for all training classes• MD financial compensation for drop in

productivity• 50% x 1 week, 25% x 2 weeks• 90% of visits completed and billed cleanly within 48

hours, during the fourth month after go-live of final phase

MD Productivity – another customer

Avg wRVUs per MD

375400425

EMR

250275300325350375

Jan '

04

Mar '04

May '0

4

Jul '

04

Sep '0

4

Nov '0

4

Jan '

05

Mar '05

May '0

5

Jul '

05

Fallon Productivity – All Sites

3.003.50

0.000.50

1.001.50

2.002.50

3.00

1 2 3 4 5 6 7 8 9 10 11

Week (3 = go live)

Visi

ts/h

r

Fallon Productivity - One MD

3.5

4

4.5

0

0.5

1

1.5

2

2.5

3

1 2 3 4 5 6 7 8 9 10 11 12 13 14


Extensive Communication• Many presentations, early and often,

with Senior Management involvement• Monthly Managers Meeting update y g g p• Status reporting, EHR vendor & internal• Demonstrations – tailored to the

audience, repeat, interaction• FAQ to clarify details of vision & scope• All-staff kick off – have some fun

9/19/2007 61

Extensive Communication• “Newsletters”

• “EHR Plan-It”, written by business owners for business owners

• “Tech-Know Tips”, written by MD for MD’s

• Feedback directly through implementation team/trainers and Help Desk

• Surveys • Before and after• Involve MDs and staff – lets them know that

you’re listening


Monitoring metrics for success• Metrics team identified >150 measures

• Revenue Operations and Finance• Clinical Operations• Clinical Operations• Clinical Quality/Safety• Customer Service• Human Resources• Information Technology

Monitoring metrics for success• Metrics classified according to value for

evaluation: High, Medium, Low• Metrics classified according to cost of data

th i Hi h M di Lgathering: High, Medium, Low• Low cost – Metrics are currently captured• Medium cost – Additional reporting is required• High cost – A grant or special project is

needed

• Measure high-value, low/medium-cost

Summary – Achieve success with:• Early establishment of champions• Selection of the right vendors• Exceptional project leadership


Questions?

[email protected]

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