Planning for Successful EHR Deployment

1. Planning for the Successful Deployment of an Electronic Medical Record George Mason University College of Health and Human Services James L. Oakes, Jr., Principal Health Care Information Consultants LLC joakes@hcicllc.com Health Care Information Consultants, LLC

2. James L. Oakes • Thirty years in healthcare information systems and management engineering • Extensive experience as an operating manager, vendor executive, and consultant • Specializes in helping healthcare providers plan and optimize use of information resources, systems, and technology to improve clinical, operational, and financial outcomes • Worked with return on investment methodologies and analysis for over 25 years and pioneered the use of healthcare-specific economic analysis of healthcare information technology, including financial, clinical, and decision support • Developed and deployed healthcare value-based planning methodology for healthcare now adopted at a 600 bed regional medical center, a nationally known pediatric referral center, etc. • Served as interim Chief Information Officer in 3 healthcare institutions in financial or operational turnarounds and provided CIO level leadership assistance and development in 12+ others • Assisted in the development of a business case and pilot methodology for a community-wide health information exchange initiative (HIE) and currently working on planning and implementation options for a statewide HIE • Co-authored the recently released book, Return on Investment for Healthcare: Maximizing the Value of Healthcare Information Technology (HIMSS 2003 book of the year) and advocates the development of a disciplined business case for technology investments • Appeared on the Hospital Satellite Network and spoken at numerous professional conferences, including CPRI, HFMA and HIMSS on such issues as effective governance, value realization, and strategy alignment • Holds a Bachelor of Industrial Engineering and a Master of Industrial Management Health Care Information Consultants, LLC

3. “The Press Can’t Tell You What to Think, but They Can Tell You What to Think About…” John Naisbitt Health Care Information Consultants, LLC

4. HIMSS 18th Annual Leadership Survey Health Care Information Consultants, LLC

5. Life in the 21st Century Health Care Information Consultants, LLC

6. Health Care Technology in the 21st Century • Still predominately paper based • Systems not interoperable • Slow, expensive implementations • Increasing public pressure to “do something” • Continuing economic pressures Health Care Information Consultants, LLC

7. Terms Defined • EMR • EHR • CPOE • IHE • HIE • RHIO • EIEIO Health Care Information Consultants, LLC

8. Why was the casualty rate so high in the civil war? Health Care Information Consultants, LLC

9. State of the Industry - Reality • Successful CPOE implementations are still rare • Fully functioning EMRs are at least as rare • Much of the information in the record will continue to be paper-based for years to come • A failure can cost the CIO his or her job • Failure to act can cost his or her job Health Care Information Consultants, LLC

10. Less than 4% of US Hospitals Using CPOE The yellow bar represents the number of hospitals verified in 2003 Health Care Information Consultants, LLC

11. 1.3-1.8% US Hospitals w/MD’s Entering >50% Orders IP Average: 54% MD’s entering orders, with a very small percent (1.3-1.8%) entering >50% of the orders Health Care Information Consultants, LLC

12. HIMSS 18th Annual Leadership Survey Health Care Information Consultants, LLC

13. HIMSS 18th Annual Leadership Survey Health Care Information Consultants, LLC

14. HIMSS 18th Annual Leadership Survey Health Care Information Consultants, LLC

15. 15 Health Care Information Consultants, LLC

16. IT Strategy Alignment Future Competitive Advantage Short Term Increased Effectiveness Increased Efficiency Today Cost of Doing Business Necessary Evil Health Care Information Consultants, LLC

17. Phase 9 Prepare Program Action Plan/ Tactical Plan Phase 8 Prepare IS Strategic Plan Phase 7 ROI Analysis Phase 6 Develop Gap Analysis and IT Strategies and Initiatives Phase 5 Perform Current Environment Analysis Phase 4 Define Future State Phase 3 Conduct Needs Assessment Phase 2 Confirm Business Vision and Strategies Phase 1 Organize Project IT Planning Process The process used to develop the plan is comprised of nine phases, with each phase “building” from the information gathered in the previous phase. Health Care Information Consultants, LLC

18. FSLHC FSLHC Strategy Strategy Strategy Market Drivers Business & Clinical Initiatives Business Drivers Business and Business and Directs Clinical Initiatives Clinical Initiatives Support Information Technology Information Technology IT Strategy Strategy & Portfolio St rategy & Portfolio IT Tactical Plan IT Projects IT Projects Health Care Information Consultants, LLC

19. The planning process includes an assessment of the current state and defining a future state. The resulting gap analysis laid the foundation for the recommended IS strategies and tactical plans. Current State Common Themes/Interviews Current MIS Environment Analysis IT Attributes Exercise Strategies Tactical Plans Gaps Future State EMR Adoption Model IS Vision Operating Principles IT Attributes Exercise Davies Award Winners Analysis IS Goals Health Care Information Consultants, LLC

20. For Example… • A metropolitan community hospital • Full service medical/surgical • Busy emergency services • Competitive environment • Battle for market share Health Care Information Consultants, LLC

21. Mission Statement and Vision • Mission Statement • We are a not-for-profit healthcare provider guided by the needs of our patients and community.  We distinguish ourselves through service and clinical excellence, affiliations with the XXX and YYY, and state-of-the-art technology and facilities.  We are committed to continuous improvement and appropriate use of resources.  We create an environment that encourages the success and fulfillment of our physicians, staff, and volunteers. • Vision • ZZZ Hospital Healthcare System will set the standard for excellence in healthcare in the metropolitan region.  Through our affiliations, we aspire to provide world-class patient care, technology, and clinical research. Health Care Information Consultants, LLC

22. Business and Market Drivers • Development of services based on community need, market position, competitors’ positions, margin, recruitment, etc. • Continuing shift from acute care to outpatient services • Development of alternate physician practice models: • Based on locale and structure of local health care market, and market forces (e.g. Number of practices, practice size, strengths and weaknesses of local hospitals, patient demographics, etc.) • Objective of changing flow of patients and delivery of healthcare services • Combat particular physician shortages • Organizational alliances and partnership models • Increasing expenditures (faster than general rate of inflation) • State regulated revenues (70% regulated, 30% negotiated) and other regulatory requirements Health Care Information Consultants, LLC

23. Business and Market Drivers • Emphasis on quality, safety, expense control • Focus on shortage of professional staff such as RNs and other clinical technicians • Continuing capital constraints • Consumer awareness, patient satisfaction, customer service • Need for readily available clinical information • Emphasis on Return on Investment (and more recently “Value”) as part of purchasing decision • “Balanced scorecard” including non-financial (quantitative and qualitative) and financial measures Health Care Information Consultants, LLC

24. Key Strategies • Demonstrate flexibility by promoting patient care and physician strategies: • Traditional acute care • Off campus services and joint services • Increased focus on physician practices • Develop stronger relationships with physicians and tie physicians into the organization • Make it an easy place for physicians to practice; “Endear physicians” and improve MD satisfaction • Demonstrated successes: • Hospital-based physicians including Hospitals, Intensivists, Radiologists, Emergency Medicine, Anesthesiologists, etc. • Specialty Care Medical Group • Differentiate through program development where expertise and base exist • Orthopedics (Joint program has doubled in volume since its inception) • Trauma (County trauma center) • Neurology and Neurosurgery (NIH protocol) • Oncology (Focus on differentiation strategies) • Open Heart Surgery Health Care Information Consultants, LLC

25. Key Strategies • Stabilize existing outpatient programs and partnerships and capitalize on new programs/partnerships/alignments • Focus on quality and patient care • Improve in State, JCAHO and other regulatory measures • Advance existing and conduct new internal process improvement initiatives • Medication reconciliation • Patient throughput and turnaround • ED to inpatient • ICU to non-critical care units • Recent implementation of observation status • Improve patient satisfaction Health Care Information Consultants, LLC

26. Key Strategies • Continue to develop human resource strategies to address personnel shortages and retain talent • Recruitment • Benefits and compensation • Recognition and reward • “Make ZZZ an easy place to work” • Improve employee satisfaction • Improve financial position • Grow volumes • Stabilize existing outpatient programs • Advance partnering opportunities (e.g. XXX • Promote image of “smaller community hospital doing big hospital things” • Cross between smaller hospital and high tech • Increase awareness of community outreach programs • Continue development and execute campus enhancement program Health Care Information Consultants, LLC

27. Start where you are….. • Understand and document current environment • Consider all applications • Be prepared for surprises Health Care Information Consultants, LLC

28. Current Information Systems Environment: Application Portfolio ACCESS Billing AR Electronic Claims Submission REVENUE CLINICAL Order Entry Results Reporting Patient Assessments Clinical Data Repository Registration ADT Electronic Claims Scrubber Collections Management Electronic Payment Posting Eligibility Enterprise Scheduling Care Plans/ Pathways MD Clinical Document- tation Clinical Decision Support Interdisciplinary ClinDoc Medical Necessity Denial Tracking Document Imaging CPOE EMPI Physician Access ANCILLARY/DEPARTMENTAL Med Admin (barcoding) Emergency Department ED PhysicianDocumentation Medication Dispensing General Ledger Accounts Payable ENTERPRISE RESOURCE PLANNING Pharmacy Laboratory PACS Surgery Anesthesiology Radiology Cost Accounting Time & Attendance Budgeting/ Forecasting Fixed Assets Pathology Microbiology Blood Bank Rehab (PT, OT, Sp) ICU EKG (Muse) Materials Management Executive Support Human Resources Payroll Help Desk Quality Improvement Case Management Infection Control Disease Management Cardiology Decision Support Security Facilities Maintenance ADE Surveillance Incident Reporting Utilization Review Dietary Endoscopy Transport HIM Chart Management Coding Abstracting Dictation & Transcription Report Writing Tumor Registry Radiation Oncology Employee Education Physician Credentialing Employee Health GSI PACS (being replaced) Trauma Registry Call Center Nurse Call System Fund Raising Medical Library Core Vendor Other Vendors Not Automated Staff Scheduling Partially Automated Health Care Information Consultants, LLC

29. Today’s Information Flow Patient/ Family View Organization View Process View Technology View Admit Blood Panel Allergies Progress Note Insurance Authorization Medications Health Care Information Consultants, LLC

30. Develop a vision for the future…. • Phase in applications in a logical manner • If moving towards a “core vendor” strategy, phase in as contracts expire • Look for “quick wins” along the way • Recognize that users must see continuing benefits to support a long term plan • Be prepared to adapt plan as circumstances dictate • Communicate, communicate, communicate! Health Care Information Consultants, LLC

31. One Organizations Portfolio – Leading to CPOE CPOE 18 + Months Problem Care Plans Lists 9 Months Common Integrated Nursing Today Order Monitors Assessments Sets Outpatient Document Electronic Vital Signs Online Assessments Imaging Signature I/O’s MAR Electronic Operating Clinical Case 100% Medical EKG Room Alerts Mgmt. Codified Necessity Results Mgmt. Physician Online Results Ad - HOC Dictation/ Bar Code Scheduling Remote Reporting Transcription Access Universal Integrated Patient Order Patient Home Radiology LAB Pharmacy Demographics Management ID Health Health Care Information Consultants, LLC

32. Tomorrow’s Information Flow Patient/ Family View Organization View Process View Technology View Admit Allergies Blood Panel Progress Notes Medications Insurance Authorization Health Care Information Consultants, LLC

33. Single View of Virtual Patient Record Hospital Hospital Physician Office Patients Long Term Care 33 Health Care Information Consultants, LLC

34. Legend Electronic Medical Record System yet to be Installed Sequenced or Simultaneous Installations Patient-Centric Information Systems February 2007 Web-based Viewable Results** Computerized Provider Order Entry** System Operational Orange Indicates FY 08 Emphasis Integrated Patient Monitors** (OB, ICU, ER, Telemetry) Web-based Physician Remote Access** Electronic Scheduling** * Installed Quadramed Product **Planned Quadramed Product Care Plans Problem Lists** Outpatient Assessments** Clinical Alerts** Online Medication Administration Record** Picture Archiving & Communication System (PACS) McKesson HMI Electronic EKG Results Pyramis Electronic Signature** Quantim e-Sig** Document Imaging/Storage EDM* ED Documentation & Tracking T-System EV Nursing Assessments** Vital Signs I/O** OB QS Sentinel Management Ad-HOC Reporting Crystal Reports Dictation/ Transcription Precyse Solutions HealthNotes*, SpeechQ Case Management MIDAS+ Utilization Review MIDAS+ OR Management ORSOS Materials Management Dimension21 Patient Registration Affinity Reg* NTierprise HomeWorks, Mestamed Order Mgt. Viewable Results Common Order Sets Order Mgmt* Pathology MediSolutions AP RadiologyRMS Lab Medilab Pharmacy Affinity Pharmacy* Etreby Clinics/Ambulatory /Physician NTierprise PM HealthmaticsEMR Home Health Homeworks Transitional Care AccuCare Home Medical Equipment MestaMed Coding Quantim Coding* Homeworks Medical Record Management Affinity* MRI*, MRA*, MRC* Medical Necessity Caremedic LMRP Billing & Collections Affinity*, SSI, Medifax MestaMed, Homeworks, Medware, Zirmed TheFOUNDATION REQUIREDto make these components into aFully Functional Electronic Medical Recordincludes the following: 1.Business Continuity Plans that provide for Redundant Storage and Communications to ensure constant availability of the systems 2. An adequate number of appropriate user devices connected to a Robust Infrastructure that provides data that is shared (interfaced or integrated) across the continuum of care 3.Common Identification of the Patientacross the continuum of care 4.Adequate Technical Support to ensure continuous operation. Health Care Information Consultants, LLC

35. Things to keep in mind…. • You can’t do everything at once • Not all applications need to be state-of-the-art • Paper will always be with us • Value is in the mind of the beholder • You must decide how far out on the “bleeding edge” your institution wants to be • A well implemented system is more valuable than a snazzy one that is poorly implemented Health Care Information Consultants, LLC

36. The Healthcare Technology The Healthcare Technology Adoption Life Cycle Adoption Life Cycle Mainstream Mainstream Mainstream Mainstream Early Early Market Market Market Market Market Market Ù Ù Ú Ú Chasm Chasm Skeptics Skeptics Innovators Innovators Pragmatists Pragmatists Conservatives Conservatives Early Adopters Early Adopters Innovators Mainstream Skeptics Understand Your Institution’s Risk Profile Traditional Technology Adoption Curve Health Care Information Consultants, LLC

37. Number of Installations Radiology Pharmacy Automated Pathways EKG Lab EMR RFID Billing Physician Office Management PACS AI Voice Activated Systems Budgeting Credentialing Time Health Care Information Consultants, LLC

38. Differing Views of Value Business View Process View Application View Information View Technology View Health Care Information Consultants, LLC

39. Hospital Automation Levels for % of Operating Budget Health Care Information Consultants, LLC

40. Enterprise Level • Financial Strategy • Marketing Strategy • Business Line Strategy • Customer Service Strategy • Process Level • Work & Process Redesign • Functional/Programmatic Transformation Tactical Level • Incremental Improvement • Automation Benefits (ie, cycle time reduction, FTE reduction, error elimination) $$$ $$ $ Traditional Healthcare Industry ROI Return on Investment is Essential The Economic Value Pathway Measurements have focused on tactical items, but should also focus on strategic goals. Broaden your focus: Can technology contribute to the bottom line? Health Care Information Consultants, LLC

41. Before & After Daily Printing Before After Health Care Information Consultants, LLC

42. Sample Cost Data Health Care Information Consultants, LLC

43. Evolution to Clinical Transformation Clinical Transformation Process Redesign • Doing different things • Cross-organization collaboration • Strategic advantage Process Improvement • Doing things differently • Operational effectiveness • Joint IT & Process Redesign Sketchy Processes Automate Transactions • Doing the same things quicker • Technology install separate from PI • Data overload • Little useful info • Individual heroes Dynamic Partnering Process Automation Info Silos Process/Technology Maturity Value Creation Health Care Information Consultants, LLC

44. Tactical Plan (EMR) Health Care Information Consultants, LLC

45. Tactical Plan (Non-clinical) Health Care Information Consultants, LLC

46. Tactical Plan (Services) Health Care Information Consultants, LLC

47. Tactical Plan (Technical Infrastructure) Health Care Information Consultants, LLC

48. Tactical Plan (Governance) Health Care Information Consultants, LLC

49. Tactical Plan (Information Use/Workflow) Health Care Information Consultants, LLC

50. Tactical Plan (Culture/Organization) Health Care Information Consultants, LLC