Transcript Ambulatory EHR Implementation at UCSF Medical Center
Ambulatory EHR Implementation at UCSF Medical Center
Brian Herrick, M.D.
July 18 th , 2008 Slide Recognition to Russ Cucina M.D., William Hersh M.D., Angelina Chang, and Kathy Lehto
Outline
Implementation resources Implementation lessons from the literature Implementation chasm UCSF Medical Center EHR implementation
Choosing EHR (Adler, 2005)
Identify decision makers in a practice Clarify goals Write a Request for Proposal (RFP) Review proposals to narrow the field Vendor demonstrations Check references Rank the vendors Site visits Select finalist Solidify organizational commitment Negotiate contract
Resources
eHealth Initiative EHR Master Quotation Guide (2005): Guide for obtaining vendor quotes EMR Guide for Small and Mid-Sized Practices (2006): Detailed implementation guide for smaller practices DOQ-IT University (elearning.qualitynet.org): Free on-line courses developed by Centers for Medicare and Medicaid Services (CMS)
Resources
AAFP resource: http://www.centerforhit.org/ ACP resource: http://www.acponline.org/running_practce/technol ogy/ehr/roadmap/ AAP resource: http://www.aapcocit.org/ Agency for Healthcare Research and Quality website
Implementation Guidelines and Lessons
HIMSS CEO Survival guide AAFP EHR Pilot Project
HIMSS Ambulatory Paperless Clinics (2007)
Project management must include – Development of scanning/abstracting policy – Create shared need in practice – Analyze workflow – Develop implementation plan – Facilitate third-party interfaces – Template development – Training
CEO Survival Guide to EHR Systems (2006)
Develop a vision for Patient Care Understand environmental factors affecting EHR systems Become aware of the supports available for EHR system planning, acquisition, and implementation: ONCHIT, DOQ-IT, Medicare QIOs, AHRQ, AAFP, CCHIT Develop an EHR system organizational strategy Identify clinical champions
CEO Survival Guide to EHR Systems (2006) cont.
Communication Implement work process transformations Develop training plans Develop capital and operating budgets to support acquisition, implementation, and ongoing management Select the application Implementation: Incorporate EHR systems into clinical and administrative operations Prepare for the future: PHRs, RHIO/IHE
Brief Report of the AAFP’s EHR Pilot Project: Key Learnings from Six Small Family Practices (2005)
Keys to success: 1. Building a Community of Learners 2. Planning/re-designing practice workflows 3. Starting with “Easy Wins” 4. Connectivity increases the value of an EHR i.e. pharmacies, labs Barriers: 1. Partial implementation 2. Variability among medical practice and physician styles 3. The lack of structured data entry
Implementation Chasm (Lorenzi 2008)
Design
Systems must be customized to accommodate the activities of workers and the workers must also change their practices Examples at UCSF MC: Vital Sign Capture and UCare Note Writer
Vital Sign Capture
Tablet or PC Wireless or hard wired Dynamap with Temp, HR, BP, and O2 Sat Importation to the EHR flow sheet
UCare Note Writer
UCSF developed web application for clinical documentation.
UCNW acquires patient context and other data from the EHR to import into the document Other design features.
Import of Vital Signs from UCare
- range calculation over last 24-hour
Import of Lab Results from UCare
- last 24 hours of basic labs - structured visual representations
Save draft within Note Writer
Publish “Preliminary” Note (resident)
Publish “Preliminary” Note (resident)
Publish “Final” Note (attending)
- resident and attending notes as one unified note
Required Fields
note cannot be published to UCare without them Service Chiefs may define resident and attending requirements
“Copy-forward” controls
Service Chiefs may forbid or permit carry-forward of information day to day
Template Development by Service Chiefs
- web-based template design - changes can be made real-time
Template Development by Service Chiefs
- web-based template design - changes can be made real-time
Template Development by Service Chiefs
- web-based template design - changes can be made real-time
Template Development by Service Chiefs
- web-based template design - changes can be made real-time
DNU Abbreviation Correction
Clinician writes a note containing DNU abbreviations
DNU Abbreviation Correction
Note Writer guides clinician through correcting abbreviations
DNU Abbreviation Correction
On sending the note to UCare, UCare Note Writer takes clinician through a dialog to correct DNU abbreviations Clinician’s choices • accept automatic fixes • manually fix Submitting the note to UCare with the DNU Abbreviations in place is not an option and is prevented
Implementation Chasm (Lorenzi 2008)
Management
Capacity for change Context of change
Vendors have limited knowledge of both capacity and context, therefore it is important to organizations take responsibility for these issues
Organization
Operational-organizational issues: downtimes, workflow changes, help desk, perception of IT department not listening to or being disconnected from the operational needs
Assessment
Organizational readiness, assessing the immediate context for implementation, evaluating the implementation in formative and summative manners
UCSF Ambulatory EHR Pilot Implementation
Pilot of Ambulatory administrative functionality to 6 practices in a variety of specialties Functionality Deployed: – Viewing labs, reports, radiology, inpatient documentation, outpatient transcription – Patient tracking – Vital sign capture – Documentation of Point of Care Testing
EMR Ambulatory User Survey
Summary and Results: April 2008
UCSF Medical Center CIS Department
Ambulatory Team
April 24, 2008
Goals of Assessment
What functions are being utilized?
Who is using the functions and where are they using them?
What are some of the hurdles?
Users wish list?
Respond to concerns, questions, and gap in knowledge
INTRODUCTION
EMR Ambulatory User Survey
April 2008 Results
The EMR Ambulatory Planning Committee (APC) and Clinical Information Systems (CIS) Department sponsored a user survey to solicit feedback from UCSF Medical Center physicians and staff utilizing EMR in the ambulatory setting. An email request for participation was sent to all ambulatory practices that have engaged in the planning and/or completion of a EMR installation. This is the first survey taken since launching EMR Ambulatory. Questions were developed by the APC and CIS Department and captured using a a web-based tool, www.SurveyMonkey.com
. The survey was open from April 7-21, 2008. Users were informed that their feedback would only be shared with the APC and CIS Department. Survey results would be summarized at the department level so that individual names can be kept confidential. This presentation summarizes the responses received. Data has been corrected for general user errors. All free text comments have been retained. Any questions regarding the survey can be addressed by the CIS Department – Ambulatory Team.
SUMMARY: DETAILS
Survey Demographics
Roles Represented Other *, 11% Practice Manager, 4% Nurse Practitioners, 11% Nurses, 15% Back Office, 19% Front Office, 9% Physicians, 31%
Approximately 375 users received the survey request – 98 responses received, a 26% response rate – Physicians were the highest responders to the survey – Back Office staff includes a range of users 26 practices received the survey request – Practices represent those which the CIS-Ambulatory Team has worked with to date – Predominant practices which responded include: Lakeshore Family Medicine OB/GYN practices Pediatric practices Vascular Surgery * : Other Category represents users who identified themselves by a staff role that was not a role type provided in the survey. Many are licensed staff. Some of these roles may be considered back office staff, however, the users do not identify themselves as such in the survey.
SUMMARY: OVERVIEW
Overview
Positive feedback on being surveyed – Significant response rate across roles – “Step in right direction” Strong desire to go chartless across organization – Actively using EMR – A sense of “waiting” for functionality and enterprise-wide use – EMR has high potential, however, lacks robust functionality – Many suggestions for improvement received Continued dependency on STOR – Desire to eliminate need for two systems – Desire for better user interface in EMR Many system hurdles deter greater use of EMR – Data retrieval is quicker in STOR due to perceived EMR system limitations (slow login) – More accurate user information could be captured after system hurdles are resolved
SUMMARY: DETAILS
Response Summary: Physicians
Most physicians who responded reside in primary care (Family practice, OB/GYN, Pediatrics practices). Their hurdles and wish list indicate a desire for functionality that would increase efficiency and that they have seen as standard practice in other healthcare institutions.
Location Most Used – – – Private Offices, 63.0 % Exam Rooms, 55.6% Back Office, 51.9 % Functionality Most Used – – Patient Lists (Census, Group, Schedules, Personal Lists) Results Viewer (Flow sheet, Lab data, etc.) – Document Display Functionality Least Used – Notes to Self – – PPD Reports (Custom flow sheet reports) Notes without Visits
System (slowness, cumbersome login) Cumbersome access to notes, flow sheets, and reports Primitive note writing Lab data is buried in EMR
Scanning documents Faxing documents Notes for patient lists, non-visits, phone calls Documentation templates Prenatal records E-mail alerts and reminders Electronic prescriptions
SUMMARY: DETAILS
Response Summary: NPs
Most nurse practitioners who responded reside in the OB/GYN practices and in Urology-Oncology. They have a strong desire for progress note functionality. However, they may not be aware of the documentation options currently available to them.
Location Most Used – – Private Offices, 72.7 % Exam Rooms, 54.5% Functionality Most Used – Patient Lists (Census, Group, Schedules, Personal Lists) – – Results Viewer (Flow sheet, Lab data, etc.) Patient Tracking Functionality Least Used – Notes to Self – PPD Reports (Custom flow sheet reports) – Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)
System (slowness, cumbersome login) Need for training
Progress notes Sending results to providers through EMR Body templates
SUMMARY: DETAILS
Response Summary: Nurses
Nurses who responded represent a range of primary and specialty care practices. Their frequent access to patient data has led to a strong desire for tools that support better documentation and coordination of care. A reliance on printing still exists.
Location Most Used – – Back Offices, 83.3 % Private Offices, 41.7 % Functionality Most Used – Results Viewer (Flow sheet, Lab data, etc.) – – Patient Lists (Census, Group, Schedules, Personal Lists) Chart Summary View Functionality Least Used – PPD Reports (Custom flow sheet reports) – Inbox (Transcriptions requiring signature, documents on hold, inbox coverage) – Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation)
System (slowness, cumbersome login) Difficulty locating reports Developing patient lists in order to complete patient care follow-up Having complete patient information in one area or system
Scanning documents Document phone conversations Ability to paste patient's test report to the mercury message
SUMMARY: DETAILS
Response Summary: Front Office
Front office staff who responded commonly need to retrieve patient information for other users. They show a strong desire for consistent use of EMR throughout their practice. As users who access multiple applications, front office staff are proponents for using EMR as the sole repository of patient information.
Location Most Used – Front Office, 100.0 % Functionality Most Used – – Patient Tracking Patient Lists (Census, Group, Schedules, Personal Lists) – Results Viewer (Flow sheet, Lab data, etc.) Functionality Least Used – – Chart Summary View Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation) – Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)
System (slowness, cumbersome login)
Doctors need to use EMR to look up patient records so that staff can eliminate printing reports from STOR
SUMMARY: DETAILS
Response Summary: Back Office
Back office staff who responded cover a broad range of positions, including administrative and licensed personnel. Hence, they use a variety of EMR functions and have more interaction with non-UCSF organizations. There is also a strong desire for and reliance on printing.
Location Most Used – – Back Offices, 85.7 % Front Office, 50.0 % Functionality Most Used – Patient Lists (Census, Group, Schedules, Personal Lists) – – Patient Tracking Results Viewer (Flow sheet, Lab data, etc.) Functionality Least Used – PPD Reports (Custom flow sheet reports) – Inbox (Transcriptions requiring signature, documents on hold, inbox coverage) – Notes without Visits
System (slowness, access) Unable to print
Scanning documents Faxing documents Input vitals automatically from blood pressure machine to the computer Access between EMR and other applications (Blackberry, PACS)
SUMMARY: DETAILS
Response Summary: Practice Mgrs
Few practice managers responded to the survey. Those who did voiced concern with managing and facilitating process workflow, given the current state of EMR functionality. They offer a broad view of the potential and anticipation EMR brings to a practice.
Location Most Used – – Back Office, 100.0 % Private Offices, 100.0 % Functionality Most Used – Patient Tracking – Patient Lists (Census, Group, Schedules, Personal Lists) Functionality Least Used – – Notes to Self Notes without Visit – – – PPD Reports (Custom flow sheet reports) Inbox (Transcriptions requiring signature, documents on hold, inbox coverage) Flow sheet Charting (Vitals, Point of Care Testing, PPD documentation)
System (slowness, access) Need to duplicate work in shadow charts because waiting for future functionality (Note Writer) Current tools do not support workflow documentation
Scanning documents Faxing documents Fully functioning EMR product for Ambulatory Ability for inpatient users to have access outpatient data
SUMMARY: DETAILS
Response Summary: Other
The “Other” role was created after receiving feedback from users early in the collection
process. These users, who did not identify with the available role types, include social workers, specialists, research aides, coordinators, technicians, and supervisors. Their feedback
reflects the experience of retrieving information down stream after patient data has been entered into EMR by others.
Location Most Used – Back Offices, 71.4 % – – Front Office, 42.9 % Private Offices, 42.9 % Functionality Most Used – Patient Lists (Census, Group, Schedules, Personal Lists) – – Patient Tracking Results Viewer (Flow sheet, Lab data, etc.) Functionality Least Used – Notes to Self – PPD Reports (Custom flow sheet reports) – Inbox (Transcriptions requiring signature, documents on hold, inbox coverage)
System (slowness, access) Unable to print Difficulty navigating; Need for training Drilling down to view and write notes
Scanning documents Faxing documents Radiology reports Less drill down to view and write notes Alerts that reduce user error (writing in wrong patient chart, closing without signing)
NEXT STEPS
Next Steps
Coordinate response to system performance-related hurdles with Field Services Address the need for additional training with practices
Determine what wish list items can realistically be offered in the near future
Decide on the frequency of future surveys
Next Steps cont.
Proposed Action: Distribute mass communication to all practices Proposed Action: Schedule training sessions to specific practices Proposed Action: Practice and direct user communication Proposed Action: Contact each user directly
Overarching Issues Timing Out Faxing Scanning Future Functionality & Potential Enhancements Training - All Functions Needed Training - Accessing STOR & Other Applications Specific Action Items for Amb Team Practice See Below: See Below: See Below: See Below: See Below: See Below: Training - Flow chart/Flow sheet Related Training - Notes Related Training - Printing Difficulties Training - Misc.
Slow Login/System Performance See Below: See Below: See Below: See Below: See Below: See Below: Action Item (and any specific comments) Send communication to all practices: A new time-out policy has been created and will be effective by late May 2008. Provide specific information on the new time-out policy to all practices.
Send communication to all practices: This is a newly approved special project. CIS Team will follow-up with practices in Fall 2008.
Send communication to all practices: The IT-CIS Department is developing this as a special project with HIMS. CIS Team will follow-up with practices in Fall 2008.
Include text on which ideas from the survey can be resolved using scanning functionality.
Send communication to all practices: We received many great ideas from the survey. Provide all practices with a sampling of the ideas. They would be considered as future functionality and potential enhancements.
Meet 1-on-1 with practices.
Ask them to consider scheduling general training sessions for these practices.
Meet 1-on-1 with practices.
Determine next steps after training is provided and whether hardware needs to be reassessed.
Meet 1-on-1 with practices Meet 1-on-1 with practices Meet 1-on-1 with practices Meet 1-on-1 with practices Meet 1-0n-1 with practices.
Offer to re-assess their hardware, either for whole practice or for users who need it per survey input.
Send communication to Practice: Slow Log-in may be due to LCJ user interface. Future CEUI should resolve slow system performance issues, reducing time by approximately 15 seconds.
Contact users directly
Conclusion
There are many resources to assist in the selection and implementation of an EHR With an understanding of the management capacity and organizational structure, and with thoughtful technical design and regular assessments, a successful implementation of an EHR can be achieved.