•  David Shulan, MS, MD, FAAAAI

Make sure the hardware and software is ready

•  Before you or your colleagues are subjected to an EMR. •  Make sure your hardware and networking is ready.

•  Make it as stress free as possible for the user. •  Even minor delays in the system can be aggravating.

•  Make sure the software is set up as advantageously as possible.

•  Do you have plans for proper PROMPT support? •  Do you have “disaster” plans.

Leadership •  Who is going to lead the project? “Champions” •  Practice manager •  Physician •  Nurse •  Outside consultant

Goals

•  Determine what you want to accomplish in the short term and what you wish to do in the long term.

•  Make your goals achievable. •  Be prepared for changes in goals and timelines based

on unforeseen circumstances.

THE ACRONYM

•  Everything

•  Merits

•  Reconsideration

Workflow redesign •  New technology often offers better solutions to

old problems. •  They way we did it for 20 years may not be the

best. •  Do not carry inefficient work flows into the new

system. •  After EHR implementation expect to make

further changes. And changes, and changes.

Preparing for EMR-Expectations •  It is not going to be perfect from the beginning. •  It will get closer to perfection over time but expect an

ongoing process. •  The EMR may do some actions in a way that is

alien to you. •  Adjust EMR •  Adjust your work flows.

•  You may find that you implement parts of the EMR over time. Big Bang vs Incremental

•  Initially you will be less productive. Plan for it.

Assign Responsibility

•  Select individuals or groups to complete task. •  Have them “own” their tasks. •  But be ready to give advice.

•  Identify those who need additional training. •  Identify individuals who are reluctant for the

change and use their skills if possible to bring them into the process.

Planning •  There will be some in your staff who may not be able

to make the change. •  What roles do people have today? •  What roles will they have after implementation? •  Plan for contingencies.

•  Murphy’s Law •  Interfaces are claimed to be compatible

•  Which version of HL7? •  Different systems often do not share data easily.

Planning for EMR

•  Plan an implementation schedule •  Be flexible •  Decide on what features to implement at the

beginning or at all. •  How to get existing patients into the system.

•  Repopulate or add over time. •  Adjust schedules to accommodate training and

implementation.

Planning for EMR

•  Templates •  No pre-made templates will work the way you are

used to working. •  You will need to adapt them and expect to continually

improve upon them. •  It may not be possible to do your full HPI on templates

alone. •  If you need frequent text input, a tablet PC may not be

ideal.

PLANNING FOR EMR!

Templates vs Free text •  Templates can give slightly stilted reports. •  It is often easier to use free text to give a report

in the manner you are accustomed to, but does not give you data that is reportable. But this is beginning to change.

•  Well set up templates can allow for quick easy documentation.

•  CMS is looking for some elements of free text.

Input method •  Pure point and click (most systems are overly

click intensive). •  Pure text. •  Combination of both point and click and text

input. •  For text: •  Typing •  Dictation •  Voice recognition

Security and privacy

•  You will be required to set up security and privacy protocols. •  For staff •  For patients •  For sending records out.

•  You will need to maintain security updates on your system.

IMPLEMENTATION

•  Train, train, train •  Consider timing of “go live” •  Evaluate, re-design, re-educate

•  The process is continual!

IMPACT OF EMR ADOPTION: SURVIVE THEN THRIVE

•  “Stages” •  Excitement •  Apprehension •  Success with frustration •  Demonstrated improvement •  Wouldn’t do without

Switching EHRs

Switching EHRs 1.  May need to switch due to:

a.  Vendor sold or out of business b.  Vendor not able to meet your needs. c.  Costly upgrades. d.  Local market compatibility.

2.  Musts a.  Make sure as much of your previous data can be transferred. b.  Rebuild templates. c.  Hardware compatibility. d.  Plan on “test runs” converting data. e.  You may need to”clean up”transferred data.

CHECKLIST FOR PREPARING FOR IMPLEMENTATION

•  Do you have a clinical lead and an administrative lead for the project? •  Have you appointed a project manager? Does one of the "leads" have the time

and skills to do this or do you need to hire a consultant? •  Have you worked with your team to create a project plan, with tasks, timelines

and a named individual responsible for each task? Is everyone in agreement with this plan, including the vendor?

•  Have you worked with your team to complete a process map for your practice and identify areas for improvement, e.g. where the EMR software will change how you work, where staff have different roles, where information and data flow differently?

http://www.emrtoolkit.ca/view_section.php !

CHECKLIST FOR PREPARING FOR IMPLEMENTATION

•  Have you determined the training requirements for each member of your practice? Do some need to acquire basic computer skills as well as training in the EMR software?

•  Have you identified potential "super users" in the clinical and administrative areas who can help other users become familiar with the software and troubleshoot issues?

•  Have you scheduled dedicated training time and lighter workloads for staff during training and implementation?

http://www.emrtoolkit.ca/view_section.php !

CHECKLIST FOR PREPARING FOR IMPLEMENTATION

•  Have you developed privacy and security policies for your practice? Do all staff understand the policies? Are patients aware of the policies?

•  Have you established system management guidelines and a disaster recovery plan for the practice? Have you worked out implementation details with your vendor(s)?

•  If you are planning on meeting meaningful requirements. Are you prepared?

http://www.emrtoolkit.ca/

ARRA ACT and Meaningful use •  Can I get a financial subsidy for EMR? •  The government will only cover part of your

costs. •  To get money you must meet government

meaningful use rules. •  These rules will increase in stringency from 2011

(stage 1), 2013 (now 2014) (stage 2) to 2015 (now 2016) (stage 3) and likely beyond .

Medicare

•  You can receive up to 75% of gross billing but no more than that listed in the table in the next slide.

•  The e-prescribing incentive is dropped. •  The penalties for not e-prescribing have

begun.

Medicare Physician Payment Incentives (Maximum) !

Note change from schedule:As of December 2013 stage 2 is extended 1 year into 2016 and stage 3 is to begin in 2017.!

Medicaid!

Meaningful Use Stage 1: What we did 1.  Computerized Provider Order Entry (CPOE) 2.  E-Prescribing (eRx) 3.  Report ambulatory clinical quality measures to CMS/States 4.  Implement one clinical decision support rule (we did smoking

cessation) 5. Provide patients with an electronic copy of their health

information, upon request 6.  Provide clinical summaries for patients for each office visit 7.  Drug-drug and drug-allergy interaction checks 8.  Record demographics

15 Core Objectives:!

Meaningful Use Stage 1: What we did 1.  Maintain an up-to-date problem list of current and active

diagnoses 2.  Maintain active medication list 3.  Maintain active medication allergy list 4.  Record and chart changes in vital signs 5.  Record smoking status for patients 13 years or older 6.  Capability to exchange key clinical information among

providers of care 7.  Protect electronic health information

15 Core Objectives:!

Menu Set (choose 5 of 10) 1. *Drug-formulary checks 2. *Incorporate clinical lab test results as structured

data 3. *Generate lists of patients by specific conditions 4. *Send reminders to patients per patient

preference for preventive/follow up care 5.  Provide patients with timely electronic access to

their health information

* For measures we used!

Menu Set (choose 5 of 10) 1. Use certified EHR technology to identify patient-specific

education resources and provide to patient, if appropriate 2. Medication reconciliation 3. Summary of care record for each transition of care/referrals 4. *Capability to submit electronic data to immunization

registries/systems (we linked to the NYS immunization registry)

5.  Capability to provide electronic syndromic surveillance data to public health agencies

* For measures we used!

Clinical Quality Measures (CQM) (3 needed) 1. *Hypertension – Blood Pressure Measurement 2. *Preventive Care and Screening Measure Pair

A.  Tobacco Use Assessment B.  Tobacco Cessation Intervention

3. *Adult Weight Screening and Follow up 4.  Weight Assessment and Counseling for Children and

Adolescents 5. *Preventive Care and Screening

A.  Influenza Immunization for Patients > 50 Years old 6.  Childhood Immunization Status

* For measures we used!

Additional Set of CQMs (3 of 38)

Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies

PQRS (formerly PQRI)

43 !http://www.acponline.org/running_practice/payment_coding/pqrs/pqrswizard_presentation.pdf!

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html!

Should You own your hardware ?

Client server

•  Definition: Client/Server describes the relationship between two computer programs in which one program, the client, makes a service request from another program, the server, which fulfills the request.

Client Server

•  Client server model diagram •  source: http://www.javaworld.com/javaworld/jw-10-2001/jw-1019-jxta.html

Game Changers

•  High speed internet makes connections with remote servers practical and common. •  The computing power can be at a remote location or

multiple locations. •  Virtualization has brought computing power at a

much lower cost (for hardware).

Virtualization • With availability of more advanced processors

running multiple cores, it is possible and now very common to have one server running multiple virtual servers on the same hardware. If one virtual server has a software problem, it becomes relatively easy to switch to another virtual server. One can have virtual servers residing in multiple locations to provide redundancy should hardware/environmental failure at one location.

Virtualization (A non medical example)

•  At home I can run through a virtualization program, run Windows (several versions) and the Mac operating system at the same time. I can make a copy of the virtual machine. So if one version of windows gets corrupted, I can restore quickly the second copy.

Desktop Virtualization •  Basically has the program running on a remote server

and the user interacts on a virtual desktop. •  The device that you use to access the system, does

not need to have much in the way of computing power.

•  No data resides on the computer, laptop, tablet, or thin client. •  Example our office, the VA, and local medical center use

Citrix to access servers via multiple kinds of devices. •  One can access the virtual machines via PC, MAC, Linux,

tablets and even smartphones.

Application Service Provider •  The ASP owns and operates a software application. •  The ASP owns, operates and maintains the servers that run

the application. The ASP also employs the people needed to maintain the application.

•  The ASP makes the application available to customers everywhere via the Internet, either in a browser or through some sort of "thin client." The EHR data resides on a central server not the end user computer.

•  The ASP usually provides the needed software, security updates.

•  The ASP bills for the application either on a per-use basis or on a monthly/annual fee basis.

Client server vs ASP •  It is like owning a vehicle versus leasing. •  Up front cost will be higher with the client server

model. •  With a client server or virtual variations you will need

to personally or hire a service to maintain your equipment.

•  You will need to run your own backups. •  You will need to maintain some redundancy of

hardware to avoid failures. (RAID servers and/or virtual servers)

Client server vs ASP •  While the upfront can cost is higher, long term

costs could be less, if you have the expertise. •  You buy the software then only pay for maintenance. •  Computer hardware continually becomes less

expensive and more powerful. •  With a web based system you are dependent

on the internet and its speed. •  A client server system in you office will usually

be faster.

Client server Advantages vs ASP

•  You will not be shut down if there is an internet outage with a client server model. •  This can usually be avoided by using redundant

internet providers. •  You have control of you data. •  A large local medical practice lost some data due to

human error with their ASP system. Human error can occur with any system.

Client server VS ASP •  Client server systems are turning into virtual

environments. •  The difference is now becoming who owns and

maintains the servers.

ASP Advantages •  Lower up front costs. •  You do not need worry about maintaining hardware,

latest security updates. •  As improved high speed internet has become

available, in most instances the speed is good. •  Redundant internet providers can add to reliability. •  Allows you to concentrate on using versus

maintaining your EMR. •  Note that the complexity of of systems is increasing.

Questions on both

•  Who owns your data •  “free EHRs” may mine the data you put in. •  Look at your EMR contract, a system that you paid for

and installed in your office could be a data mining source for your vendor.

•  Hardware costs have dropped but not the cost and complexity of maintaining these systems. •  There is a lack of good trained personnel to manage

these systems.

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