The Electronic Medical Record at Carilion Clinic

1. TheElectronic Medical Record at Carilion Clinic

2. Tools for building the Clinic • Plan • Leadership • Board Governance • Physicians • Standards • Infrastructure • Integrated Electronic Medical Record

3. Same look and feel inpatient and outpatient Ability to share records across the enterprise True continuum of care delivery with a single record Universal view of problems/medications/allergies Patients are not repeatedly asked the same questions Facilitates patient access through our system Higher patient satisfaction Better clinical outcomes An Integrated Electronic Medical Record (EMR)

4. Electronic Clinical Tools at Carilion • 1990 Radiology Management – Siemens • 1990 Pharmacy – Siemens • 1992 Cardiology – GE Muse • 1999 Ambulatory EMR – Logician • 2000 Emergency Department – EDIS • 2000 OR – ORMIS • 2001 PACS – AGFA • 2003 Bed Scheduling – TeleTracking • 2003 Transcription - MedQuist • 2004 Medication Authentication – Siemens • 2005 Acute EMR – CPSI

5. Carilion’s Commitment to Clinical Technology • Operating:75th percentile among peers • Capital: 95th percentile among peers

6. Clinical Technology at Carilion Technology US 50th Percentile Time

7. The Challenge Integration Technology US 50th Percentile Time

8. Carilion Clinic Today is Best of Breed EMERGENCY DEPARTMENT Roanoke Memorial Franklin Memorial New River Valley Giles Memorial Bedford Memorial Stonewall Jackson Wellsoft EDIS CPSI Alignment within applications

9. Carilion Clinic Today is Best of Breed Orders Management Siemens Invision EMERGENCY DEPARTMENT Siemens Soarian Siemens RMS AGFA PACS Radiology Roanoke Memorial Franklin Memorial New River Valley Giles Memorial Bedford Memorial Siemens MAK Pyxis Siemens Pharmacy Pharmacy Cardiology GE Muse Stonewall Jackson OR GE ORMIS ED Wellsoft EDIS Wellsoft EDIS CPSI Document Imaging AMS Sovera Portal Medicity Alignment within applications Alignment across applications

10. Imaging ED Primary Care Pharmacy OR Lab Inpatient Care

14. Total Interfaces: 509

15. The Challenge Integration of Patient Information Technology US 50th Percentile Time

17. Benefits of an Integrated EMR • Patient Safety • Checks for conflicts • “Hard Stops” for safety • Common Allergies List • Common Medication List

18. Imaging ED Primary Care Pharmacy OR Lab Inpatient Care

19. Benefits of an Integrated EMR • Patient Safety • Conflict checking • “Hard Stops” for safety • Common Allergies List • Common Medication List • Reduce Variation and Improve Quality • Paper orders – order sets • Protocols management • Standardized Formulary • “Soft Stops” for Best Medical Practices

20. Benefits of an Integrated EMR • Patient Safety • Conflict checking • “Hard Stops” for safety • Common Allergies List • Common Medication List • Reduce Variation and Improve Quality • Paper orders – order sets • Protocols management • Standardized Formulary • “Soft Stops” for Best Medical Practices • Reduce Overutilization • CT Head • Creatinine

21. Benefits of an Integrated EMR • Patient Safety • Conflict checking • “Hard Stops” for safety • Common Allergies List • Common Medication List • Reduce Variation and Improve Quality • Paper orders – order sets • Protocols management • Standardized Formulary • “Soft Stops” for Best Practices • Reduce Overutilization • CT Chest • Creatinine • Facilitate Research • Standardize data fields • Create searchable data • Support the Research Institute

24. Benefits of an Integrated EMR • Patient Safety • Conflict checking • “Hard Stops” for safety • Common Allergies List • Common Medication List • Reduce Variation and Improve Quality • Paper orders – order sets • Protocols management • Standardized Formulary • “Soft Stops” for Best Practices • Reduce Overutilization • CT Chest • Creatinine • Facilitate Research • Standardize data fields • Create searchable data • Support the Research Institute • Improved Practice • Coordinated Referrals • Coordinated Scheduling

25. Experiences of other Hospitals post Integrated EMR Implementation • Radiology turnaround time reduced • Pharmacist interventions reduced by 50% • Duplicate ancillary tests reduced by 48% • Number of delays in administering medication has fallen by 70% • Omitted administration of drugs reduced by 20% • Test results for mammograms take one day, down from as long as three weeks • New medication procedures can be introduced in hours

26. Carilion’s EMR Selection Process • Fast – Four Months • Broad – Due diligence on four systems • Deep – Participation of more than 300 Carilion employees • All hospitals • All therapies • All administrative and support services • Thorough – More than eight site visits

27. The Slippery Slope

28. Scope • Acute EMR – CCMC (but not Pharmacy) • Acute EMR – CCMC and CNRVMC (but not pharmacy) • Pharmacy and Acute EMR – CCMC and CNRVMC (but not ED) • ED, Pharmacy, Acute EMR – CCMC and CNRVMC (but definitely not Ambulatory EMR) • Ambulatory EMR, ED, Pharmacy, Acute EMR – CMC, CNRVMC, CGMH, CFMH (but not CPSI sites) • Ambulatory EMR, ED, Pharmacy, Acute EMR – All Hospitals and practices • Ambulatory EMR, ED, Pharmacy, Acute EMR, EMPI – All Hospitals and practices • Ambulatory EMR, ED, Pharmacy, Acute EMR, EMPI, Registration – All Hospitals and practices (but not scheduling or billing) • Ambulatory EMR, ED, Pharmacy, Acute EMR, EMPI, Scheduling – All Hospitals and practices (but not billing) • Ambulatory EMR, ED, Pharmacy, Acute EMR, EMPI, Scheduling, Billing, Registration – All Hospitals and practices

29. Scope (but not lab)

30. Clinical Information System Evaluation Process On Site Demos By 4 Vendors Selected Two Vendors Evanston, IL (Vendor 1) 1st Vendor 1 Contract Call Contract Signature Cleveland Clinic (Vendor 1) Vendor 1 Corporate Visit Baystate, MA (Vendor 2) Somerset, NJ (Vendor 2) Vendor 2 Deep Dive Began Selection Vendor 1 Deep Dive Vendor 2 Corporate Visit Vendor 1 Selection 2 8 – 15 26 4 5 11 13 16 17 18 26 1 23 August September October November December

31. Magic Quadrant for North American Enterprise CPR 2006 Source: Gartner December 2005

32. Selection Preference Summary Vendor 2 Vendor 1 PHYSICIANS NURSING PHARMACY ED THERAPIES HIM IT INFORMATICS

33. MAK

34. INTEGRATED EMR

35. Carilion Clinical Application Integration INTEGRATED EMR Technology Time 2007 2008 2009 2010

36. Immediate Benefits – Carilion Clinic • All physicians have immediate access to a patient’s entire record • From any location • Standardization of order sets • Best practice adoption • Tracking referral patterns

37. Accomplishments to-date • Created and trained 125-person EMR team • Built physician practice content and training • Converted 9 years of Centricity records to new system • 780,000 patient records • 43 million data fields

40. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care

41. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care 2/20 Daleville 3/26 Blue Ridge 4/2 Vinton 4/9 North Roanoke 4/16 Colonial Avenue 4/16 Urgent Care Roanoke 4/30 Crystal Spring 5/7 Northwest 5/14 Southeast 5/21 Roanoke Salem 5/28 Brambleton

42. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care RMH Clinics Peds Surgery Specialty OB / Gyn

43. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care RMH Clinics Peds Surgery Specialty OB / Gyn NRV Area Practices Franklin Area Practices Giles, Lexington, Bedford Practices

44. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care RMH Clinics Peds Surgery Specialty OB / Gyn RMH Peds CPOE All CPOE NRV Area Practices CNRVMC All CPOE Franklin Area Practices CFMH Giles, Lexington, Bedford Practices CGMH CSJH BMH

45. Practice 1 Go-live February 20, 2008

46. 2008 2009 2010 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M Roanoke Primary Care RMH Clinics Peds Surgery Specialty OB / Gyn RMH Peds CPOE All CPOE NRV Area Practices July 26 CNRVMC All CPOE Franklin Area Practices CFMH Giles, Lexington, Bedford Practices CGMH CSJH BMH

47. Roanoke Memorial Go-Live July 26, 2008 159 Inpatient Order Sets being built Trained Staff 5,000 clinical, financial, and administrative staff More than 1,000 classes Installed more than 500 new computers Created command center

48. Physician Training eLearning – Self paced Classroom – Two 4 Hour Sessions Simulation Sandbox – Practice on own Findings – Leadership first is significant to ensuring compliance – Physicians who spend more time in preparation are most effective Day 1

49. Go-Live at Roanoke Memorial 10/18/08 CPOE Pediatrics 11/18/08 CPOE All 5/5 – 5/16 Train Physician Leaders 7/26/08 CRMH Go-Live 5/26 – 7/19 Train All Physicians March April May June July August September October November 7/14 – 7/18 Dress Rehearsal

50. Carilion Clinic Technology Capital $30 M $20 M $10 M 0 * * - Total budgeted capital spend for new EMR is $65.8 M