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EHR Business Process Improvements

EHR Business Process Improvements. CDR S. Miles Rudd, MD EHR Clinical Champion Warm Springs Health & Wellness Center Warm Springs, OR. Serves 3,900 tribal and 2,500 non-tribal members. 55,400 patient visits a year for all services. 17,600 patient visits per year for medical providers.

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EHR Business Process Improvements

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  1. EHR Business Process Improvements CDR S. Miles Rudd, MD EHR Clinical Champion Warm Springs Health & Wellness Center Warm Springs, OR

  2. Serves 3,900 tribal and 2,500 non-tribal members. 55,400 patient visits a year for all services. 17,600 patient visits per year for medical providers. 52,300 pharmacy visits per year Warm Springs Health and Wellness Center

  3. Warm Springs Staff • 5 full-time/1 part-time Family Physicians • 4 Nurse Practitioners ( 2 with Diabetes Program, 1 Women’s Health, 1 Urgent Care) • 1 Podiatrist • 4 Dentist (1 Pediatric Dentist) • 1 Optometrist • 8 RN’s, 3 PHN’s, 1 MCH nurse, 1 LPN, 3 NA • 2 Nutritionist

  4. IHS-EHR Implementation • Clinician driven • Confirmed Leadership Support • Tribal Endorsement • Area Office Support • Patient Awareness • VHA Support

  5. Clinical Applications Coordinator (CAC) • Most critical person for the success of the entire process. • Coordinates implementation • Provides EHR user support • Provides/coordinates training for users • Customizes software • Assists in solving workflow issues

  6. Clinical Applications Coordinator • Interpersonal skills • Proactive and helpful nature • Management /leadership skills • Working knowledge of facility processes • Computer skills • Clinical /RPMS background

  7. IHS-EHR Facility Planning • Identify equipment/network needs • Upgrade RPMS applications • EHR Configuration • design notes, quick orders, process changes • Develop strategy for implementation • Training, Training, Training • Morale Support

  8. “You want me to do what?”

  9. Planning for IHS-EHR- First Steps • EHR Implementation Team • Multidisciplinary Team • Clinical Application Coordinator (CAC) • Clinical Champion (Provider) • Nursing • Health Information Services • Information Technology • Administration/Executive Leadership • Pharmacy • Lab/Radiology • Diabetes Program

  10. EHR Implementation Team Roles • Identify and define policies and procedures • Address staffing and scheduling during transition • Provide peer training & marketing • Monitor and execute Implementation Plan • Design and approve templates, menus, and order lists.

  11. EHR Implementation Team Meetings • Monthly meetings initially • Assignment of responsibilities with report back to Team • Meetings became more frequent as implementation date approached. • Daily meetings during implementation • Facilitate communication • Troubleshoot problems • Mini-trainings

  12. VHA Site Visit • Team members went for site visit at Portland VA Medical Center • Hands-on training on CPRS • Discipline specific shadowing • Provided major benefits in conceptualizing the EHR, understanding implementation, and looking at practice flow and redesign.

  13. Practice Redesign • Our group had done previous work to look at practice redesign. • Improve clinical efficiency • Decrease waste • Improve access and provision of care • EHR Implementation gave us an opportunity to incorporate these redesign measures.

  14. What does clinical redesign have to do with the IHS-EHR? DON’T AUTOMATE WASTE! Scenario: Many practices are considering using an electronic medical record (EMR) or other electronic devices, systems, or software. Result: The technology is added into inefficient work processes resulting in more expensive, automated waste. Lesson: Technology alone does not solve efficiency problems- it is a tool, not a solution.

  15. What Are We Trying to Maximize? • Use of personnel • Use of time • Use of skills • Use of materials • Use of space • Use of money • Use of data To meet the needs of our patients

  16. Clinic Redesign- Prior Steps • Created Same Day Appointment System • Assigned Designated Provider • Created Nurse/Provider Teams • Analyzed Patient Population • Analyzed Services Provided (Top Diagnoses, Top Appointments) • Analyzed Staff Activity, Roles, Scope of Practice

  17. Practice Blueprint

  18. Clinic Redesign for IHS-EHR • Redefined roles for nurses aides, nurses, and physicians. • We want to make sure that everyone is working up to their capacity. • Need to unload our providers from work that someone else can complete. • Providers had new responsibilities for order entry and coding. • FUTURE- We want to redefine the role of our medical receptionist.

  19. Super-Users • Clinical Super Users (RN, Lab, DM, MD) • Training • Templates • Peer Support • Pharmacy Super User • Medication Quick Orders • Adverse Reaction Tracking System setup • Training on medication orders • Pharmacy 7 duties

  20. Infrastructure Upgrade • RPMS server upgrade • Network upgrade • Wireless network • Lab Interface Upgrade • Computers in all Exam Rooms • Backup Power

  21. Hardware Preparations Phase I: • Setup and maintain a training and “live” server • Backup RPMS server • Additional computers/tablets/laptops • PHNs, Dental, Exam Rooms, Everywhere Phase II: • Upgrade wireless network • Implement Vista Imaging /Scanning System • To eliminate paper documents • Dental Imaging • Pharmacy Signature Pad

  22. Software Preparations • Package upgrades to RPMS • Radiology • Text Integration Utility (TIU) • Adverse Reaction Tracking • Pharmacy 7 • Scheduling (PIMS) • Pharmacy Inpatient Suite • Behavioral Health • Cache • Numerous RPMS patches

  23. Major Software Updates • Pharmacy Upgrade to version 7 (March 7) • Required several days to prepare drug files • Utilized Portland VHA pharmacist to assist • Worked overtime and weekends to get ready • Major process changes for pharmacists • Implemented the Pharmacy Allergy and Adverse Reaction Tracking System: • All of the allergies that have been entered into PCC had to be manually entered into the new tracking system and verified by a pharmacist

  24. Major Software Updates • Implement the new scheduling package (PIMS) • This software was substantially different than the old version of scheduling and required facility wide training • Checking in patient using the scheduling package

  25. IHS-EHR Configuration • Design templates • Design Menus and Quick Orders • Medications, Lab Tests, Radiology, Nursing • Define consults • Pick lists and Superbills • Note Titles • User Setup (keys) • Parameters • Print Formats

  26. Staff Orientation • Staff Training: • CPRS Training Module presented at staff meetings • Pharmacy Training Module: • Available on Warm Springs Web Site • Mandatory for all pharmacy staff • CPRS Training Module: • Interactive training posted on Warm Springs Web Site • Mandatory for providers • Mary Hager Demo • Portland VHA visit and hands on training

  27. Mock Patient • Mock patients walked through a visit • Valuable exercise • Identified training needs of staff in new roles. • Clarified issues about hardware needs. • Identified issues about queuing. • Validated new patient flow plan.

  28. Pre-Implementation Training • 2 hour training for everyone on VIEWING patient data in EHR • Site Manager and Superuser training at VHA eHealth University (Camp CPRS) • EHR test system loaded on all user’s computers • Newsletters, web updates, meeting updates

  29. Training – Go Live Week • 4 hours training outside of clinic responsibilities • Departmental trainings • Use knowledgeable trainers • One-on-one training • Competency checklists

  30. Going Live • Intense CAC and IT support • Make appropriate scheduling adjustments • Daily debriefings…. • Procedural questions • Technical issues • Training

  31. Medical Records Process • Chart pulls • Note and orders filing in paper chart • Printing and filing chart copies • Batch printing • Release Of Information • Outside consults and reports • Scanning • Receiving reports in electronic format • Incorrect entries

  32. PCC Coding Issues • Coding done from daily lists of visits • No hard copy to code from • Daily Error Reports • No POV, E&M Code, Activity Time • ICD Coding By Providers • Duplicate Visit Creation

  33. Business Office Issues • Services Pick List development, installation, and training • Missing E&M codes • No hard copy to work with • EHR notes are legible • Great opportunity for improved provider documentation & increase billing/collections

  34. Hospital Issues • Providers work at a community hospital 15 miles from clinic. • Recurrent problems noted over the years. • Patients seen in hospital with no access to clinic notes (Did have RPMS access via modem) • Patient follow-up in clinic with no notes. • Billing delays due to delay in receiving documentation. • Billing delays due to delay in completion/receiving hospital superbill.

  35. Hospital Issues • Created a new process for hospital workflow • Established network access points in major areas of hospital. • Providers utilized laptops and linked to clinic using Virtual Practice Network (VPN) and Terminal Services Client • Notes, POV, and Superbill completed in EHR • Notes copied to Word document and printed on blank hospital Progress Note form.

  36. Pharmacy • Outside prescription orders • Printing pharmacy service copies for orders • Refill and New prescriptions aren’t always grouped • DEA requirements for controlled substances • Schedule II drugs require handwritten signature • How to incorporate pharmacy patient signature log • Pharmacy requirement for completed/signed notes

  37. Miscellaneous Issues • Relax provider schedules during first weeks of implementation • Productivity issues while learning • How to handle flowsheets in EHR • How to get reference lab results in EHR • Standardization of Note titles • Specialty clinic providers

  38. Miscellaneous Policies/Procedures • Transition for people not using EHR yet • Use of personal templates • Template approval process • Note content standards • Use of chat and broadcast functions • Documenting missing PCC elements in EHR • Surgical history, colonscopy, refusals, mammogram • Check in process • Lab justification

  39. Template approval process Required form elements Plan that notes be able to stand on their own if printed. This is intended that pertinent information related to the visit be a part of the templates. Name Date of Visit Clinic Encounter History Personal History/GPRA Exam Diagnosis/POV Plan Education Refusals Signature Template Approval Process

  40. Template Approval Process • Needs: Patient education templates for adults, GPRA, DM standards • “###” symbols used around information needed to be entered by data entry Procedures for new forms • Deploy new forms in “Test” folder on the Live EHR • EHR Team give e-concurrence of the form prior to deployment

  41. Questions?

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