Roadmap to Success in a Rural Local Health Department

1. Roadmap to Success in a Rural Local Health Department Deb McCullough DNP, RN, FNP Gordon Mattimoe RN, MSN, FNP 6/5/2013

3. Steps to Select EHR • conducted a needs assessment • Staff • FTEs: 2 FNPs, 3 RNs, and 5 clerical • Contract: MD, 2 NPs • Health services • Public health • Primary health care • Family planning • Immunizations • STD/HIV/TB

4. Steps to Select EHR • Funding sources • County • DSHS grants • Medicaid/CHIP/WHP/Medicare • Billing • Electronic immunization, family planning, Medicare • Special needs • communicate with DSHS when possible • immunization inventory, billing, and upload to ImmTrac

5. Who is an Eligible Professional under the Medicare EHR Incentive Program? • Eligible professionals under the Medicare EHR Incentive Program include: • Doctor of medicine or osteopathy • Doctor of dental surgery or dental medicine • Doctor of podiatry • Doctor of optometry • Chiropractor

6. Who is an Eligible Professional under the Medicaid EHR Incentive Program? • Eligible professionals under the Medicaid EHR Incentive Program include: • Physicians (primarily doctors of medicine and doctors of osteopathy) • Nurse practitioner • Certified nurse-midwife • Dentist • Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant. • To qualify for an incentive payment under the Medicaid EHR Incentive Program, an eligible professional must meet one of the following criteria: • Have a minimum 30% Medicaid patient volume* • Have a minimum 20% Medicaid patient volume, and is a pediatrician* • Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals • * Children's Health Insurance Program (CHIP) patients do not count toward the Medicaid patient volume criteria.

7. Steps to Select EHR • Workflow analysis • Organizations’ current structure • Paper appointment, medical record, and billing • Workflow progression • Patient flow • Documented patient and staff activities from check-in to check-out • Changed clinic set-up and processes

8. ACHD Workflow Analysis

9. Workflow Analysis with EHR

10. Steps to Select EHR • Hosted (Cloud computing) vs onsite system • ease of use; • immediate availability of software updates; reduced start-up expenses; • vendor provided system redundancy, back-up, privacy and security;7 and the LHDs limited IT support and expertise. • The limitations of a hosted EHR system • Internet connectivity and potential downtime

11. Steps to Select EHR • Evaluated multiple vendors for meeting meaningful use and national certification regulatory requirements

12. Staff Expectations • Decrease medication errors • Provide a better mechanism for updating the medication list • Eliminate physician’s handwriting issues • Reminders to patients per patient preference for preventive/ follow up care • Improve preventive care services provided and compliance with clinical guidelines • Meet national EHR goals • Meet meaningful use and clinical decision support (CDS) criteria • Reduce administrative and reporting burden • Retrieve files and sort medical records • Gather and help analyze data • Improve prescription process, patient safety, and workflow management • Conduct clinical quality improvement (QI) research • Provide clinical decision support (CDS) • Enhance practice management (integrate scheduling, billing, and coding)

13. Steps to Select EHR • Involved staff in EHR selection and implementation • EHR demonstrations • 3 online ( WTHIT REC) • I onsite demonstration (LHD with eCW)

14. Successful EHR Implementation • People skills (leadership, communication, and training) • Articulate vision • Actively involve staff and MD in pre-implementation planning phase • Example of non-participation in EHR selection

15. Organizing Framework • Step 1: learn basics of EHR • Step 2: conduct workflow analysis, compare paper and EHR processes, identify EHR champions • Step 3: determine appropriate EHR based on budget and work flow needs, purchase EHR. • Step 4: implementation phase – changing from paper to electronic

16. Implementation Steps • Formed a team to complete the 15-week pre-implementation tasks • Recruited based on job descriptions and potential contribution to the team • Met weekly answering these questions • What did we accomplish? • What are the next steps? • List things to do? • What went well? • What didn’t work? • Team determined criteria for successful EHR implementation

17. ACHD Criteria for Successful Implementation • Live with an EHR by October 1, 2011. • Eliminates paper charting and generates minimal paper forms to add to the EHR. • Uses the EHR to its best capacity as determined by reassessing and streamlining workflow processes. • Meets the Stage 1 meaningful use criteria by November, 2012. • January 22, 2013.

18. Meaningful Use Certificate

19. Implementation Steps • Reviewed equipment and technical requirements • Workflow needs and space requirements • Computer on wheels in each clinic room, staff can face patient, or use computer where needed in the clinic

20. Implementation Steps • Reviewed processes, conducted workflow analyses, and established redesign strategies. • For example, to avoid transitioning ACHD’s dysfunctional Medicaid Texas Health Steps (THS) paper process to an electronic format, the staff redesigned and streamlined the documentation.

21. Staff Training • Attended Crossroads Conference 2011 • Meaningful use, patient safety, • , e-Prescribing, medication reconciliation, and CPOE • 4 day vendor training • Demonstrations and hands-on practice time for front office, RN, provider, and billing staff. • End of day meeting to address clinic policy questions and identify how-to questions • eCW assigned ACHD a strategic account manager and access to online chat for how-to-questions

22. Lessons Learned • Encourage and promote continual improvement and workflow redesign

23. PDSA Cycle

24. Clinical Decision Support (CDS) • Systems provide tools to deliver intelligently filtered, appropriately timed, and actionable information to patients or clinicians.

25. Promote Continual Improvement • Immunizations • Didn’t understand how all the components (EHR, billing, inventory) worked together.

26. Inventory and Billing

27. Billing

28. Inventory and Billing

29. Order Sets

30. CDS/Alerts

31. Documentation in EHR

32. Work Flow

33. Workflow • Interface with ImmTrac • EHR interface with the statewide immunization registry (ImmTrac) is not automatic. • For more information: http://www.dshs.state.tx.us/immunize/immtrac/attestation.shtm • ACHD is waiting on eCW to set-up the interface.

34. Reminder/Recall • Schedule appointments for the next vaccine • Phone call reminders from the system • Enroll immunization only patients in the patient portal – sends an email and provides access to immunization record • Form letters for appointment missed • For vaccine recall – easy to pull patients who received the vaccine

35. Lessons Learned • EHR facilitated and improved the immunization program’s administrative and clinical processes. • Workflow analysis with all staff increased understanding of the system and individual role within the program. • Adding the vaccine history to the EHR versus scanning records improved provider assessment of vaccine needs at all clinic visits. • Adding CDS influenza and tetanus alerts decreased adult vaccine missed opportunities.

36. Lessons Learned • Adding order sets decreased immunization documentation time. • Scheduling patients for follow-up vaccine visits aided in reminder and recall (phone calls prior to appointment and letters sent to no-shows). • Adding the vaccine record to the patient portal increased patient access to records.

37. Diabetes • Goal: To meet the diabetes standards of care.

38. Diabetes Minimum Practice Recommendations

39. Diabetes Minimum Practice Recommendations

40. Diabetes Minimum Practice Recommendations

41. Diabetes Minimum Practice Recommendations

42. Order Set - Meds

43. Order Set

44. CDS/Alerts

45. CDS/Alerts

46. Flow Sheet

47. Lessons Learned • Determine scanning policy • Scan enough of the chart to avoid pulling paper charts • Adopt standardized nomenclature to access and retrieve the scanned data quickly • Pre-EHR plan laborious and time consuming. • Final policy • HX, medication list, immunization record, past year of progress notes, and lab/x-ray reports

48. Lessons Learned • Decrease patient load post-implementation. • Some processes should model existing paper practices • 1 per hour, took 2 hours for HX • Cumbersome EHR process • Paper HX provided structure • Resolved issue by arranging EHR format to replicate paper HX form

49. Lessons Learned • Repetitively encouraged staff to report EHR problems or write on a flip chart • 6 months after implementation nurses identify EHR issues quickly and strive to redesign to improve efficiency • Eg, lab billing for in-house and referral lab

50. Lessons Learned • New users embrace the EHR more rapidly if it is easy to use and meets their needs • System flexibility is important • Created templates for Texas Health Step visits, family planning physical exam, STD visits, health risk assessment and preventive health education • Blood sugar and waist circumference added to the vital sign section