Ambulatory andAcute CareImplementation BiographiesSteven L FritzNovember 2012

Acute Care Hospital Implementations

South Nassau Communities Hospital

Meaningful Use and enterprise data modeling. Allscripts was a green field (new) implementation encompassing acute care, ambulatory EMR, and Emergency Department solutions.

Responsible for the development of the tactical planning to install the full Allscripts application suite. The engagement was accomplished in one phase.

The initiative targeted the primary hospital functions. Additionally the emergency department was included to provide a seamless information patch into the hospital. The entire group of ambulatory clinics were deployed and integrated into the enterprise solution. AllScripts EMR utilized at the MOB and Clinic level including independent practices with admitting privileges – Allscripts MyWay (a.k.a. Aprima). Access to the data repository hosted by the Long Island Patient Information Exchange (LIPIX) was made available to the provider community.

Significant workflow analysis was required to support the new applications and business objectives of the executive management team.

Continuum Health Partners

Meaningful Use, Multiple version catch ups, Patient Safety Initiatives, and enterprise data modeling all culminated in this full scale project. The largest GE Healthcare Centricity Enterprise implantation in North America.

Responsible for the development of the strategic and tactical planning to upgrade the GE Centricity Enterprise application from 4.x to 6.7. Four distinct phases guided the management of the initiative.

Phase ones target was to develop a technical environment that would endure jumping three version of the GE application. Primarily to provide a platform where meaningful use features and functions of the application could be launched. De-customize the current implementation into one where GE’s professional support team could take ownership of the core. Seamlessly integrating AllScripts EHR utilized at the MOB and Clinic level, into the Hospital solutions.

Phase two provided an enterprise view of the care and accounting transactions as the corporation managed its portfolio of applications, and their individual twilight and transformation agendas and timelines. Fully engaging a PMO approach towards the GE implementation.

Phase three implemented a disaster recovery, downtime, and business continuity environment. Utilizing real-time transaction capture and cloning technology, co-location infrastructure, downtime procedures datasets and training, and rigorous SLA, Performance monitoring, and predictive stress analysis.

Phase four provided a sound set of interface standards to enable device integration directly into the patient MPI. Middleware remodeling, traffic management, time-of-day peak analysis, coupled with nightly process scheduling provided a well communicated base of expectations.

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University Physician Associates

The Centricity Initiative was coordinated with the deployment of AllScripts Enterprise EHR

Using a pilot deployment model the endeavor accomplished three objectives. First was the re-deployment of the core practice management function of the GE Centricity application. Customizations established an unstable support environment. Executive management was realigned to support a closer adherence to an out-of-the-box configuration.

Second was the implementation of additional modules to allow better account controls such as the Bad Debt systems. Revenue Cycle management processes in concert with data mining and business intelligence dashboards (via Cognos) provided Line of Business and executive tool sets.

Lastly was the development of a rollout / deployment framework to meet merger & acquisition and internal expansion strategies. Long term technology growth forecasts became reliable, predictable, and achievable.

The 80 ambulatory clinics were re-deployed within the 12 month timeline

Working interactively and collaboratively with the AllScripts Enterprise HER team, the collective team worked synergistically to achieve reduced implementation costs and resources, lower projected sustaining support requirements and an enterprise view of records data as they meet meaningful use targets.

Dignity Healthcare (p.k.a Catholic Healthcare West)

The Centricity Initiative was managed in three phases.

Phase One:Implement the EWS environment – 1.1. Transitioning to the Web involved extensive regression testing and a light amount of process workflow remodeling. Most of this work centered on the development of an enterprise workspace. I architected one workplace for each role to minimize the customizations needed in security plus. Permissions to scripts, screens, HTBs, VTBs, and functions were encapsulated in one secure place. Exceptions were held to a minimum and provided a cleaner support platform.

The rollout was divided into front office and back office. Prior to real-world performance metrics and to allow the deferral of training, the back office staff remained on the character cell system until phase three.

Screen flow customizations were kept to a minimum to provide for a cleaner set of regression tests for phases two and three.

Implement the PCM system 1.2. The Payer Contract Module focused on the six core payers representing 80% of the revenue stream. The remaining twenty payers were added at a slower pace – three months. The fee schedule updates were changed from manual entry to updates using GE’s semi-automatic service.

The catalyst for implementing PCM was the CFO’s desire to have more tools and controls on reimbursement rules and timelines. We went from 85 days to the sub-50 range in three months.

Phase I time line – 4 months from launch through transition to production.

Phase Two:Upgrade to version 4. This phase required an extensive study of the as-is configuration. A clean up and simplification sub-project was initiated to lower the regression test failure rates.

Ninety percent of the testing issues were associated with the GE applications functionality between 3 and 4. We found several compatibility problems which were resolved by GE.

The use of a third party forms printing company required the upgrade of one ancillary system – Global Works.

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Phase Three:Implement ETM 3.1. The Task Management system was chosen to provide for a singular control prompter. Extensive analysis of as-is workflow and manual task management provided the foundation to the dictionary and configuration work of this module. The complexity of other enterprise applications in this clinical environment made interfaces (20+) a key success factor. This project came on the heels of the implementation of the AllScripts TouchWorks EMR solution. Data flows between 8 major applications, and the core MPI, Enterprise Index (EI) provided measurable ROI from ETM. Well managed tasks provided very swift drops out of TES into BAR. Organized rejection /denial workflows were controlled my ETM.

Implement AVM 3.2. The Visit Management system was integral to the changes in the company’s practice management structure. With 22 clinics using the Centricity application, patient visits and scheduling became a critical control point. To meet the objectives of acquisition and expansion plans without a parallel expansion of IT infrastructure, AVM and ETM were crucial.

Module InventoryAP BAR BAR-NPI BAR-PCM DBMS EDIEDI-BAR EDI-MCA EDI-NPI EDI-270/271 ICWEB MCAPCS Security+ TES EWS PCM ATMETM

Sub System Inventory for SHClaims/Rcpt Open Referrals Statements Interfaces

Medtronic Corporation – MiniMed Division - Durable Medical Equipment

The Centricity Initiative was an application replacement and operations remodel project

Design the DME module. The insulin pump division of a DME company - embarked on an initiative creating a new module for GE Centricity. The Durable Medical Equipment (DME) module was surrounded by the full suite of Centricity modules, including Informatics. At the core of the system is the TES module controlled by ETM. A complete interface-based coupling of Centricity and SAP was design, build, and deployed. My team of interface and applications experts completed this endeavor.

The business objective was to provide a seamless, single sourced, order-to-cash solution across the entire organization.

In addition to complex design and configuration of the Centricity system, sophisticated data transport systems were required. This diagram illustrates the application landscape upon which the DME module was rooted.

Module InventoryAP BAR DBMS DME * ETM EWS MCAPCS Security+ TES

Sub System InventoryClaims/Rcpt Open Referrals Statements Informatics Interfaces

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* Durable Medical Equipment (DME)

Module details

DMEThe Order-To-Cash initiative at Medtronic led to the creation of a new module for the Centricity

application suite. Durable Medical Equipment (DME). A deep understand of the functionality and architectural core of Centricity (p.k.a. IDX, FlowCast) was required to engineer this system. The general description of this module is that it provided for the sale of equipment to patients. Prospecting, sales, manufacturing, warranties, returns, upgrades, continuation of therapy, and shipping logistics are all business functions of this module. One extension to the DME module is the recurring pharmaceutical products module. The automated replenishment of consumables to the end user. Ties to the SAP ERM system provides a closed-loop supply chain. One additional extension provided a web portal for customer based order placement and management tools.

Informatics (BI, Data Warehouse)A key component of the DME Centricity implementation was the ability to implement management tools

that measured against the business realization metrics. Two extensions were implemented to broaden the use of Business Intelligence (BI) data. First was the

integration of Business Objects resident in the Data Warehouse. The cubes were remodeled to change from the data mart in SAP, to the databases in Centricity. Second was the implementation of the full Cognos application. The limited Cognos provided by GE too narrowly focused on GE data. With several other enterprise applications in use, a broader data pool was required.

ETMSH as well as DME focused on the functionality of task management. A great deal of configuration

through dictionaries was completed. In the revenue cycle arena; claims to contract to payment to reconciliation to GL posting required sophisticated workflow analysis.

AVMWith a number of clinical locations in the greater Sacramento area, managing provider schedules, cross

facility appointments, and complex patient-payer-guarantor relationships, AVM play a key role in achieving a good economy-of-scale with the scheduling and reception staffs.

EDIThe EDI module played a key role at SH in building interface data models. Eligibility and claims

management assisted in the revenue cycle.

DBMSMany reports and data pulls were extracted using the DMBS module. The sustaining support team in

collaboration with the project teams cataloged and fine-tuned the report library.

MPI (EI)I was on the MPI consul for SH. I have a deep knowledge of clean-up initiatives. I’ve implemented

sophisticated patient registration and check-in systems to reduce duplicates, errors, and John Doe’s.

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Ambulatory EMR/EHR ImplementationsClient: Community Hospital (450 bed) and Ambulatory Practices – New York

Sponsors: Ambulatory DO Chief VP of HIM & EMR Chief Information Officer Vice President of Clinical Care Physician Advisory Group

Project SubManagers: Hospital Practice Management EMR deployment manager Behavioral Health Director Physician Billing DirectorDesktop deployment and management Level 2/3 sustaining operations support manager

Primary Objective: Deployment for the Allscripts Enterprise EHR solution across the enterprises ambulatory practices

Secondary Objectives: Develop a model implementation of EHR at three sites Collaborate with the inpatient deployment of Allscripts Eclipsys Create a deployment / rollout model for independent PC’s on Long

Island Develop forms management and workflow interaction department Document all charge and claim systems

Budget: $30M. Rollout modeling, Training curriculum development, Helpdesk support planning, Infrastructure upgrade and deployment (Practice sites, LAN, Desktop)

Timeline – 13 Months: Enterprise deployment planning, layered in two phases, Go-live and 30 day fine-tuning, Transition to production, sustaining support.

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Staff Levels: Strategic planning: 3 Tactical planning: 4 Deployment and training planning: 4 Deployment: 6 Transition to sustaining support: 6 FTE SME headcount – front-end and back-end: 14

The data interchange complex was redesigned from its prior state (shown below) to an enterprise view (not shown). This allowed for lowered error log management requirements and corrective activities.

The institution utilized a semi-centralized billing landscape. The prior state (shown below) was re-engineered to a streamlined, scalable, resilient, and optimized CBO. The benefits realization and return on investment was achieved by lowering the manual processing, adding fail-over to electronic transfer engines, and enterprise standards for structure and timing. Built-in rejection analytics provided self-learning re-submission process management

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Client: Practice Healthcare Organization – Suburban Philadelphia Pennsylvania

Sponsors: Office of the CIOEnterprise Applications Manager

Project SubManagers: Data Center DirectorPractice ManagementPractice Administration DirectorDesktop deployment and management Level 2/3 sustaining operations support manager

Primary Objective: Strategic and tactical planning for the enterprise rollout of the Siemens NextGen EHR solution across the 120 ambulatory practices and clinics for Practice Healthcare Organization

Secondary Objectives: Study the pilot implementation of the NextGen EHR at three practices Research the enterprise deployment of the NextGen practice management Create a deployment / rollout model for enterprise wide utilization

Budget: $10M. Rollout modeling, Training curriculum development, Helpdesk support planning, Infrastructure upgrade and deployment (Practice sites, LAN, Desktop)

Timeline - 3Months: Enterprise deployment planning, layered in four groups, Go-live and 30 day fine-tuning, Transition to production, sustaining support Service Level Agreement management.

Staff Levels: Strategic planning: 2Tactical planning: 6Deployment and training planning: 4 Deployment: 25 Transition to sustaining support: 4 FTE SME headcount – front-end and back-end: 2

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Client: Clinical Healthcare Organization – Sacramento California Region

Sponsors: Scott W. – OCIO Sue H. – CFODag J. – COO

Executive Team: Mark M. – Site ExecutiveDr. L. S. – Hospital physician consultant Dr. M. K. – Foundation physician consultant

Project Sub Managers: Loretta S. – Practice Management – Workflow reengineering Jeff E. – Interface and integration management Mike W. – Desktop deployment and management Randy B. – Regional Server Farm management Joe F. – Server Farm management Ryan M. – Regional LAN / WAN management Patricia A. – Level 2 sustaining operations support manager

Trisha R. – Level 2 sustaining supportEduardo A. – Level 2 sustaining support

Primary Objective: Implement the AllScripts TouchWorks EMR solution across the 22 ambulatory clinics for the Clinical Healthcare Organization in the Greater Sacramento region

Secondary Objectives: Link the clinical data to 5 hospitals via the regional MPI database Develop a disaster recovery / fail over strategic plan Create and deploy a user interface integrating all front end systems Engineer an enterprise data model through the middleware ELT toolset Create a deployment / rollout model for enterprise wide utilization

Budget: $4.3M. Application Deployment, Workflow development, Rollout modeling, Infrastructure upgrade and deployment (WAN, Storage, Server, Desktop, Scanner)

Timeline - 18Months: Needs analysis, vendor selection, pilot deployment, enterprise deployment planning, layered deployment in 6 groups, Go live and 30 day fine-tuning, Transition to production, operational performance deployment, sustaining support SLA management: Jan 2006 through June 2007

Staff Levels: Needs analysis through vendor selection: 8 Deployment and training planning: 12 Application configuration and interface development (Core): 26 Deployment: 20 Transition to sustaining support: 10 FTE SME headcount – front-end and back-end: 6

Project milestones

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The original needs analysis was performed by the Clinical Healthcare Organization Sacramento management groups. A consul of people created the RFP materials along with the decision analytics for the vendor selection. This process took approximately 6 months.

Following the selection of AllScripts as the vendor, the team transitioned into an application configuration and deployment strategy group. They created a project success matrix to grade the effectiveness of the applications deployment. It was used as the root of the scope management documentation set.

A key success factor of deploying the EMR application across 22 clinics and integrating with 5 hospitals was the technology infrastructure. WAN bandwidth, desktop performance, application monitoring, and storage planning were the basis of the technology infrastructure initiative. This resulted in the deployment of 1500 high performance desktops and 400 document scanners. The LAN was upgraded to a gigabit network. The WAN was upgraded to a 45 mb pipe. Additionally, the server farm processor set was expanded by 11 servers, each averaging 8 processors with 32 gb of memory. Redundancy was provided by wireless and split sub-net management, servicing critical work centers. Two independent WAN providers were acquired for each major hub, one in a dormant state awaiting failure. The primary application servers were set up in a clustered configuration. The Network Attached Storage (NAS) was configured to stay pace with the disk consumption projections – 35gb a week. Monitoring tools to track application, WAN, and server utilization were implemented as part of the original tactical plan.

A model office was established to draw on the subject matter experts within the many diverse operating areas. They made up the core development consultants interfacing with the vendor’s technical team. As a collective, they ensured that the application met the scope criteria. Additionally, they were responsible for the UAT activities and the go-live support group.

Scope management proved to be critical to keep rework to a minimum, timelines manageable, and cost containment possible. There was approximately 15% overruns due to initial requirements oversights. Strong management of vendor performance and sub-contractor utilization allowed the overall budget to stay below the $4.3 cap.

The total inventory of interfaces numbered 22. Merger and acquisition activities while the project was in-flight posed significant challenges, but were met within budget guidelines and delivered on time. Most notably was the purchase of an imaging center which needed to be integrated into the workflows and data movements. This one collection point replaced 5 smaller dissimilar systems. The net impact to the timeline was negligible.

Weaknesses surfaces with the selection of the document scanning equipment. Additional homework could have been performed with regard to the scanning strategy. Initial go-live scanning requirements exceeded equipment failure (Mean Time Between Failure) thresholds. The remedy was to purchase higher capacity,

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better duty-cycle equipment. Long term planning recommended the establishment of scanning centers specifically suited to one-time bulk document management.

Vendor management was important in controlling deliverables and deadlines. With 22 interfaces to be written, HL7 specifications along with custom extensions provided an enterprise view of the data. Extra time was invested to allow simpler future modifications possible. Approximately 30% data growth impacted development. This planed-to-actual was expected, and was represented in the project plan. An enterprise middleware redesign initiative was spawned from this project.

The main lesson learned was the amount of time required for the laboratory integration points. It should have been 300% of the original estimate. Additionally, coordination with a separate server/application upgrade team could have been more transparent. They added 2 man-months of effort but did not affect the AllScripts go-lives.

The total population of providers (concurrent seats) was set at 700. The supporting staff accounted for an additional 1800 people. The benefits realization metrics was to quantify a 30% increase in patient visit counts with no appreciable increase in patient-facing headcount. That was achieved. Additionally, significant intra-clinic data shareability, reduced duplicate MRN creation, and single application integrated records access was accomplished.

A rollout model was authored to act as a new-site deployment kit. The technology and application costs were optimized to approximately 75% of expected. Standards for users, desktops, workflows, and backend turnover allow exceptional return on investment for new clinics, new builds or acquisition. Enterprise data models provided smother data migration plans.

The project plan used to tract the tasks contained 1577 WBS items.

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