Implementing an Electronic Health Records System in Corrections

1. Implementing an Electronic Health Records System in Corrections By George Wells Tom Donahue

2. In the Beginning • $1.2 million from Medical Cost Reduction • Provide health care services to an increasing inmate population in the face of annual industry medical inflation rates of 17% for health care in general and 22% for pharmaceuticals. ( source: Arlen Group Employee Benefits). • 15-year old Unix Pharmacy Application • Multiple Paper Records • Dental • Medical • Mental Health • Optometry • Substance Abuse

3. Problems with old Process • Appointment scheduling. • Cross-discipline coordination. • Duplicate information. • On-call care provider did not have inmate chart. • Hand written chart entries. • Unable to identify trends/similarities. • Chart entries not always timely. • Non-standard terminology. • Lack of chart integration across disciplines. • Pharmacy application was inefficient.

4. Requirements • New Pharmacy system needed. • Electronic Health Records to replace reliance on paper records. • Enhanced communication across all health services disciplines. • Electronic interfaces with medical equipment. • Telemedicine capability. • Color GUI body, dental, and eye charts. • Support Windows 2000/XP, MS SQL, and MS Office 2000 and 2003. • Comply with Federal healthcare regulations such as HIPAA and provide available accurate info. • Standardize clinical protocols in all NDCS facilities to improve medical record documentation.

5. Requirements • Active and Archived Searchable Databases. • Retain records as active for 5 years after discharge; then move to archive database. • Medical Terminology Dictionary. • Application security based on user profile. • Interface with Corrections Tracking System, Substance Abuse Treatment Program, Medical Surveillance Database, Medcom’s Laboratory Information System, and Mug Shot Database. • ODBC and ADO/OLE DB Compliant.

6. Requirements • Support NTFS and Active Directory. • HIPAA Compliant. • Permanent record of chart entries. • Maintain security log of all user activity. • Handle 4,500 initial records and 15% annual growth. • Support XML meta data interchange standard. • Extended use of drop down menus and WYSIWYG. • Import/export data to/from SPSS, SAS, MS Office.

7. Requirements • Chart Sharing concepts with Patient Flow • Electronic Forms Management • Medication and Pharmacy Management • Employ the Inmate ID Card to bring up the correct chart. • State Statute requires NDCS to provide inmates health care that is equal to what is available in the local community. • Enhance fiscal management and data reporting.

8. Revised Requirements • Reduced interfaces to just CTS and Mug Shot databases. • Eliminated interfaces to medical instruments.

9. Vendor Selection • Selection team comprised of business and technical staff. • Three qualified vendors. • Lowest price vendor also highest technical score. • Contract signed July 2005. • Start date was August 24, 2005. • Site setup/“Live” Testing May 15-June 2, 2006. • Test Evaluation and Review May 22-26, 2006. • NDCS-wide “Go Live” June 12-14, 2006. • Final Review and Acceptance July 17-28, 2006.

10. Implementation Challenges • Additional network infrastructure needed. • Care providers needed to access charts of inmates at all locations. • Standardize Health Services processes/forms. • IT support staff overloaded; no new FTEs. • 3 desktop support, 4 network/server support, 1 database programmer, 2 help desk, and IT manager. • 1200+ PCs, 200 laptops, 43 servers, 650+ printers, 25 scanners, and 30 digital cameras. • 20 locations across Nebraska.

11. Obstacles Overcome • Word 2000 different than 2003. • Windows 2000 Pro support reduced by Microsoft; needed to upgrade PCs to XP Pro. • Database Architecture altered to fit NDCS need. • Contracted with the Office of the CIO for staffing assistance. • Employed tablet PCs with docking stations in office areas in lieu of networked PCs in the exam rooms. • Scan bar code on inmate ID card to bring up correct chart.

12. Obstacles Overcome • Obtained additional funds to support purchase of additional Tablets and PCs for staff efficiency. • Trained Super Users first, Key Personnel, and finally all other staff by discipline. • Change from vendor’s on-site Project Manager to one located at vendor’s corporate office mid-implementation.

13. Architecture QuickMed - WA OCC/ CCC-O DEC/ LCC Central Office Pharmacy/ CCC-L NCCW NCYF WEC TSCI NSP Spare

14. Lessons Learned • Reissue of RFP came at a cost; reduced time to implement system. • Keep vendor and implementation teams focused on requirements and timeline took more effort than planned. • Don’t try to do more than one major implementation at a time; we had three! • Don’t fool yourself to believe that everything that could go wrong has been planned for.

15. Lessons Learned • Realistic Time Frame • Communication Challenges • Integrate the delivery of health care services seamlessly across the department’ s multiple facilities and health care disciplines. • The electronic health record will require significant IT Support both during and post implementation

16. Delivery Enhancements • Significantly improved medical record quality - legibility and completeness with substantial reduction in provider, nurse and administrative clerk time dedicated to charting, filing, and searching for medical record documentation. • Improved performance in all steps in managing medications. • Continuity of care will be enhanced. An average offender is moved every few years to a different facility approximately 58% are on medication of some kind; continuity of care will be affected when provider-patient relationship is interrupted. • Paper records can be misplaced and lost.

17. Enhancements continued • Providers and nurses now spend approximately 40% of time charting encounters and patient episodes. Medical Records charting accounts for 50% of overtime charged by medical staff. With an EHR cost will decrease if managed properly. • Accuracy and timeliness of management reporting will improve. Reporting systems are only as good as the data entered. Electronic Health Record system supports data entry processes concurrent with workflow and incorporates standards ensuring the quality and timeliness of management reports.

18. Questions?