Margret Amatayakul,MBA, RHIA, CPEHR, CPHIE, CPHIT, CHPS, FHIMSS

Margret\A Consulting, LLCHealth IT Certification, LLC

Steven S. Lazarus, PhD, CPEHR, CPHIE, CPHIT, FHIMSS

Boundary Information GroupHealth IT Certification, LLC

October 5, 2010 –

2:30 pm

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• Business process consultant focusing on electronic health records, and electronic transactions between organizations

• Former positions with MGMA, University of Denver, Dartmouth College

• Active leader in the Workgroup for Electronic Data Interchange (WEDI)

• Speaker and author (two books on HIPAA Security and one on electronic health records)

• Recipient of the HIMSS 2006 Book of the Year Award

• Recipient of Vision and Leadership Award as WEDI Chairman, WEDI Corporate Leadership Award, and WEDI Distinguished Service Awards

• Consultant to CAQH CORE Project• HIPAA Expert Witness

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Strategic IT business process planningROI/benefits realizationProject management andoversightWorkflow redesignEducation and trainingVendor selection andenhanced use of vendor productsFacilitate collaborationsamong organizations toshare/exchange health care informationEHR and RHIO training and facilitation

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Strategic HIT planningEHR migration pathHIE developmentCompliance assessmentsWork flow redesignVendor selectionProduct/market analysisPolicies and proceduresTraining and educationExpert witness

Independent consultant focusing on:◦

EHR readiness, planning, selection, implementation, workflow and process redesign, and quality improvement

◦

HIPAA/HITECH privacy and security risk assessments for covered entities and business associates

Adjunct faculty, College of St. Scholastica, Masters in Health InformaticsFormer positions with CPRI, AHIMA, University of Illinois, Eye & Ear InfirmaryActive participant in standards development, HIMSS; speaker and authorCo-founder and board of examiners, Health IT Certification, LLC

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Begins long before an EHR product is selected

It begins with an understanding that:

◦◦

An EHR is not about automating the paper chart,An EHR is not about automating the paper chart,

◦◦

It is about automating and using information for It is about automating and using information for health care quality and efficiencyhealth care quality and efficiency

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Nature of ChangePhysician EngagementPlanning for ImplementationFilling Vendor GapsUse No EHR Before Its TimeEHR at the Point of CareFollow Up, Celebrate, Correct Course, Feedback

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In the paper world, physicians ◦

Observe the patient

◦

Interview the patient

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Examine the patient

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Assess findings◦

Order diagnostic studies

Record a Record a summary of summary of aboveabove

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Confirm diagnosis

◦

Plan treatmentRecord a Record a summary of summary of aboveabove

In the electronic world, we ask physicians to:◦

Observe patient and record findings

◦

Interview and examine patient following a pre-

defined template

◦

Assess findings and order diagnostic studies with guidance from clinical decision support

◦

Confirm diagnosis and plan treatment, using professional judgment, with guidance from clinical decision support

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Often no “patient story”

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Establish expectation that physicians will participate in EHR project to fully understand it

Engage physicians in discussions of EHR pros and cons, asking them for suggestions on how to capitalize on advantages and mitigate disadvantagesGive physicians specific tasks, such as pre-loading patient data, provide support and feedback, and don’t “cave”

Engage physicians early and often in EHR projectAsk physicians to perform specific tasks throughout the EHR “project,” e.g., Compare the templates in these products, or Review and sign off on your order sets

Establish a culture of trustAsk for their input on changes to workflow – such as using other staff at the top of their credential to ease the data entry burdenDo what you promise, or explain why you can’tShow them not just how to use the system, but their results

“My colleagues understand EHR at the intellectual level,but not at the intestinal level.”

Robert McDonald, MD, P.S. Rudie Clinic, Duluth, MN7

Develop your own, highly detailed project plan, with start and end times and specific resource assignmentsConduct a vendor gap analysis – what will the vendor do and what must you doCarefully design new workflows and processes and trace their performance with physician-nurse teams. Ensure that the EHR has been thoroughly tested. Train just in time, one-on-one, and in “rehearsal” mode (physicians learn by “show one; do one”)Provide at-the-elbow support until productivity is back to parObtain feedback in as many ways as possibleCelebrate success and correct course as needed

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Most vendors:◦

Do not address, or address well, workflow and process redesign◦

Do not perform sufficient testing; often relying upon training time to “catch”

issues, and not seeing

“load”

issues because they occur after go-live◦

Under-estimate time required to build and test interfaces; and often create incomplete interfaces◦

Do not provide “clinically-relevant”

support for new

users of EHR (e.g., do you find “breast cancer” under A, B, or C?)

◦

Do not follow up to aid in optimization

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An incomplete implementation of an EHR is worse than paper*!◦

Workarounds created because users think they are “quicker”

actually create extra steps and put patient

care at risk◦

Hybrid record situation creates potential for duplication of effort and error states◦

Partial use of EHR allows new users to slip into bad habits that are difficult to break◦

Incomplete implementations create confusion and lack of trust in new users that may not be recoverable in the future

* Casalino, LP, et al. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results, Archives of Internal Medicine, June 22, 2009.

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Individuals who have little or no experience using a computer are much more conscious of personal shortcomings in their use than their patients or team membersPhysicians have great fear of showing any weakness or hesitancy in front of their patients or others Physicians are very reluctant to provide their patients access to information that might reveal any uncertaintyPhysicians only trust themselves and the familiar

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Health care decisions often require reasoning under high degrees of certaintyComplex care is increasingly provided in a time- and resource-pressured environment because of need to contain costs and stay on par with reimbursementEHRs are often designed to mimic existing paper-based forms and processes – because that is familiar, but these provide little support for cognitive tasks of knowledge workersConsumer empowerment is a growing trend, with evidence that an engaged patient is a more compliant patientWe live in a digital age, where even the elderly are using computers or value caregiver use of computers on their behalf

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Evaluate workflows◦

One size does not fit all

Draw a physical layout of exam room, patient room, or other area were EHR will be usedConsider devices: desktops, notebooks, tablets, WOWs all have their placePlan to engage the patient in use of EHRRehearse using the EHR at the POC

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Is more than how the chart movesWorkflow improvement should focus on how you use informationFor example, when do you want to see preventive screening reminders?◦

On the appointment scheduling screen◦

At the time the nurse opens the chart for check-in◦

At the time the physician opens the chart◦

When the physician gets to the assessment and plan◦

Some or all of the above, depending on the screening

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Do you have the physical infrastructure to support use?◦

Where will you put what kinds of devices –

at A, B, or C:◦

How will you share data with the patient?

◦

How will you demonstrate value, security?

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How do keep devices clean? ◦

Can you move the WOW through the door?

Where will you charge the WOW?◦

Do your patients have access to a computer at home for HIE?

A

B

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C

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Introduce the new EHR.State you are logging in.

Position yourself (without your back to the patient)

Engage the patient in your use of the EHR

Show the patient trend lines, drawings, etc.

Tell the patient what you are doing and their findings

Log off. Encourage patient to use the clinicalsummary for ongoing care

Copyright Copyright ©© 2010, Margret2010, Margret\\A Consulting, LLCA Consulting, LLC16

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Margret Amatayakul, MBA, RHIA, CPEHR, CPHIE, CPHIT, CHPS, FHIMSS

President, Margret\A Consulting, LLCCo-Founder, Health IT Certification, LLCwww.margret-a.commargret@margret-a.com(847) 895-3386

Steven S. Lazarus, PhD, CPEHR, CPHIE, CPHIT, FHIMSSPresident, Boundary Information GroupCo-Founder, Health IT Certification, LLCwww.boundary.netwww.healthitcertification.comsslazarus@boundary.net(303) 488-9911 (office)(303) 809-9337 (cell

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