Electronic Medical Records and Systems Integration

1. Electronic Medical Records and Systems Integration

2. Today's Event Sponsored by: Emdeon Practice Services helps practices meet the challenges of healthcare with innovative solutions, including electronic health records, encounter documentation, document and image management, and wireless and Internet connectivity. For more information: Call: 877.WEBMD.01 Visit: www.webmdps.com Visit Emdeon's Virtual Trade Show exhibit at: hdm.unisfair.com/prd.jsp?booth_id=13

3. Robecca Quammen As President and CEO of The Quammen Group, Robecca is an accomplished senior executive in healthcare information systems, combining extensive healthcare administration, software vendor, and consulting practice experience. She has over 25 years experience in healthcare to include business development, sales, strategic and tactical planning, operations and organizational development, product development and delivery and emerging healthcare initiatives. With a career history and reputation for superior quality business solutions and customer service, Robecca has held senior management positions for large healthcare delivery organizations, the nation’s largest healthcare software vendor, and a large private healthcare consultancy. Most recently she founded The Quammen Group as a full-service healthcare consulting firm specializing in business planning and development, strategic planning, large-scale software and hardware implementation, software acquisition, outsourcing, and organizational development.

4. Do We Have an Electronic Medical Record Yet?

5. Today’s Presentation • Systems integration issues that arise when adopting an EMR • Hospitals dealing with integrating legacy systems with new systems, with departmental systems etc. • Stitching together EMR and Practice Management software at a clinic and then connecting them to the hospital data • Data Security challenges, single sign-on, etc. • The role of technology and standards in creating interoperability and data sharing across systems • ESPECIALLY lessons learned on key hurdles and practical strategies that work...

6. Defining an EMR • Automation of current paper chart • Repository of financial and clinical data • Easily accessed, reviewed, updated • Concurrent and retrospective use • Clinicians • Physicians • Support personnel • By-product of data gathered in HIS, CIS, and PM/EMR systems

7. Attending Physician • Nursing • Consulting Physician(s) • Respiratory Care • Case Management • Nutritional Services • Risk Management • IV Team • Patient Financial Services • Infection Control • Wound Management • Pastoral Care • Clinical Process Improvement • Cardiology • PT/OT/Speech • Others ELECTRONIC PATIENT DATA BARRIERS: • Access • Availability • Acceptance • Integration EMR Focus on All Care Providers

8. Easier Said Than Done • This frequently elusive metaphor for the traditional paper chart has been challenging to accomplish in every clinical setting, primarily due to • Cost and availability of solutions • Impact on the clinician workflow/practice • Implementation • Integration with Existing and Planned Solutions

9. EMR - The Balancing Act Financial & Operational Results Competitive Market Pressures Capital & Operational Funding Physician Affinity Heightened Demand for Solutions Multiple Unique User Demands Clinical Reporting Demands Impatience for Solutions Cost Access Security Standards & Tools Integration & Interoperability

10. Why is Integration So Important? EMR Adoption is a topic that transcends the collection, storage, reporting, and transmittal of data. EMR Adoption is a broad topic that encompasses…… Business Practice Systems People

11. Inherent Challenges for EMR Adoption People Systems • Legacy Vs. New • Availability • Best of Breed • Vendor Strategies • Integration • Interoperability • Devices/Mobility • Portals/Single Sign-on • Big Picture • Culture • Integration vs. Functionality • Individual Motivation • Personnel Cost • Fear of Computerization Business Practice • Clear Vision and Priorities • Strategic Plan • Work Flows • Process vs. Task Orientation • Data Ownership • Access and Security • Patience and Time Compromise Compromise Compromise

12. Where Does your EMR Journey Begin? Departmental Systems Impacting Care Process (Emergency, Pharmacy) Departmental/Multi-Disciplinary Systems (Rehab, Respiratory, Surgery, etc.) Specialty Documentation (Critical Care and Women/Children’s) Advanced Clinical Documentation (workflow, rules) Physician Practice Management and EMR Systems E-signature for Physician Signature of Medical Records Results Repository Made Available to Remote and Mobile User Orders/Results Upgrade/Replacement in preparation for CPOE or to Create Integration with Planned Clinical Documentation Projects Legacy Laboratory and Radiology Systems (upgrade or replace?)

13. Where Is your EMR Journey Taking You? • Paperless or Partial Paperless System • Population of a Data Warehouse for Clinical Reporting • Comprehensive Clinical Decision Support (Rules, Workflow) • Integration of Solutions for Continuum of Care • Complete Remote Access for Physicians and Clinicians • Complete or Partial Nurse Documentation • Integration of IT with BioMed • Multidisciplinary Charting • Clinically Driven Revenue Cycle

14. Common Hurdles Along the Journey • COST - EMR Systems are Expensive to Implement and Support • LEGACY SYSTEMS – Integrate, Displace, Replace • INTEGRATION - Best of Breed/Disparate/Closed Systems • DATA SHARING & Interoperability – Information Available As Needed • STANDARDIZATION - Adoption of Nomenclature/Data Dictionary • ACCESS – Device Strategy, Mobility, Remote • SECURITY – Network, Application, Single Sign-On • DATA INTEGRITY – Who Owns It? • WORKFLOW – Enhance It, Don’t Break It! • TRAINING – Of Just About Everyone – What Works?

15. So, How Are We Doing? Efforts have been arduous, lengthy, and expensive, but effective EMR Adoption is within reach when completed as a series of initiatives.

16. Real World Experiences #1 • Goal: Provide an Online Medication Administration Record (MAR) • 1800+ bed integrated delivery system with multiple campuses and outreach clinics • Orders/results/repository in place with clinical documentation system implementation underway • MAR integration between HIS (third party) and RX (in-house developed) • Vendor usage of record format that did not 100% comply with HL7 standards, resulting in a significant amount of custom code in the interface • Complex nature of medications compounded the issue • Change management becomes critical to insure systems are in sync • Outcome: Through integration, this organization was able to accomplish its goal. Change management continues to be critical to the success of this initiative.

17. Orders Results Pharmacy (MAR) • Documentation • Assessments • I & O • Progress Notes • Vital Signs Alerts and Reminders Electronic Medical Record Care Protocols Brand X Brand X Brand X Brand X Brand X Brand X Brand X Real World Experiences #1 CLINICAL DOCUMENTATION PROJECT FUNCTIONS PRODUCTS KEY: Proposed Phase I Proposed Phase II

18. Existing Products #1 Registration/ADT/Results/Orders/Order Status Update/Master Files Repository FINANCE CIS MRI RECEIVABLES ADT/Orders/Order Status Update/Charges/Master Files Pharmacy RADIOLOGY RESPIRATORY Pharmacy Pharmacy Registration/ADT/Orders/OSU Lab Financial/ Clinical Data Registration/ADT/ Orders/OSU Results Add-on Orders/OSU/Results Financial Data Registration/ADT/ Add-on Orders/ OSU/Charges/Results Reporting INTEGRATION ENGINE Dietary Registration/ADT/Orders/OSU Clin. Dec. Support Other Systems Scheduling LEDGEND Registration/ADT Drug Dispenser Registration/ADT Registration/ADT/Orders/Results Bi-directional data flow PACS Charges Registration/ADT/Lab Results Registration/ADT/Lab Orders/ Radiology Results ER System Ambulatory Unidirectional data flow Transcribed Results

19. before after Impact of Integration on the MAR

20. Real World Experiences #2 • Goal: To Provide Cardiology Functionality to a New Specialty Facility • Primary organization has implemented a third party clinical orders/results/documentation system • Specialty (cardiology) organization selected a different third party vendor for their Cardiology Information System • Lack of outbound charting records from specialty system effectively isolating data to that system • Necessitated printing of record to transfer with patient • Investigating CCOW single sign on utilizing industry available products • Outcome: This organization accomplished the goals of the specialty area but did not provide a solution that meets the organizational requirements for having access to clinical data by anyone who needs it. They will be faced with manual solutions such as chart printing until they determine a method to populate a central EMR with integrated or scanned data from the specialty system. Additionally they are facing a common user issue in the need to allow single sign-on to multiple systems and are attempting to solve that problem with technology.

21. Real World Experiences #3 • Goal: To Provide Specific Departmental Functionality to the Respiratory Department with Emphasis on Charging and Work Scheduling • Third party clinical orders/results/documentation • Purchased and implemented specialty niche respiratory system • Lack of outbound charting records from specialty niche respiratory system, effectively isolating data • Necessitated printing of record to transfer with patient • Interdisciplinary care charting was not accomplished • Outcome: By permitting a departmental solution to be purchased and implemented to solve the specific problems of the respiratory department, this organization has lost significant opportunity to meet regulatory guidelines for interdisciplinary charting and to insure that all care givers have access to the complete patient experience as they are performing their specific functions.

22. Real World Experiences #4 • Goal: To Provide a Comprehensive EMR Solution in a Small Community-Based Facility in Which Funding was Challenging • Purchased a single source solution for all departmental and nursing functions and a third party specialty ER system • Chose to implement the comprehensive solution in three distinct phases over several years • Phase 1 included the population of a repository for local and remote access by physicians and care givers • Phase 2 introduced Medical Records, Pharmacy and Radiology functionality with a sub-phase to introduce an ER system • Phase 3 will introduce clinical documentation • Outcome: This organization knew its limitations with funding and staff to support multiple systems from multiple vendors and chose to purchase and implement a single source solution for departmental, advanced clinical and electronic medical record functions. They faced competitive pressures in their community to retain ER physicians and consequently purchased a niche ER system to meet their requirements. They chose to implement in relatively small increments to provide functionality and benefit to end users at various milestones.

23. ADT ADT Real World Experiences #4 Current State (2004) Legacy HIS/CIS Rad/Orders/Rx PA/Payroll/HR/ADT ERP MM/GL Medical Records Coding ADT ICD9 (tape) ICD9 (tape) ADT Charges Drug Dispensing Charges Results Orders Integration Engine OR Scheduling Orders Results Charges ADT (Orders) Results ADT ADT LAB EKG TV

24. Clinical Data Repository ADT ADT Real World Experiences #4 Phase 1 Transcription Transcription MR Coding Legacy HIS/CIS Rad/Orders/Rx PA/Payroll/HR/ADT ERP MM/GL ADT ADT Transcription (RAD Results) Transcription ICD9 (tape) ICD9 (tape) Orders (statuses) Integration Engine Drug Dispensing ADT ADT Results (text/discrete) Charges Charges Results Orders Orders (statuses) Results (Text/discrete) Integration Engine Transcription ADT Results (text/discrete) Orders (statuses) OR Scheduling Orders Results Charges ADT (Orders) Results ADT ADT LAB EKG TV

25. ED System Example Second Phase #4 Legacy HIS/CIS Rad/Orders/Rx PA/Payroll/HR/ADT ERP MM/GL Transcription Phase 2 Orders w/ statuses Results (Rad) ADT Open Engine Results (RT/ECG) Orders (w/statuses) Orders - Results Charges Clinical Data Repository ADT Integration Engine Results (Text/discrete) Order Statuses ADT Clinical Data (text) Orders EKG Lab Results (text/discrete) Results (ECG) Orders - Results Charges ADT MDI (TPR/BP) Physician Billing LAB Physician Billing Medical Devices

26. Home or Office Clinical Data Repository Hospital Sample Information Flow Diagram #4 Cardiology Registration Laboratory Radiology Orders w/statues Results Demographics Visit History Orders w/statues Results Orders w/statues Results Respiratory Therapy Medical Records Orders w/statues Results H & Ps · Op Reports Discharge Summaries EEGs

27. Real World Experiences #5 • Goal: To Provide a Comprehensive EMR Solution in a Community-Based Facility in Which Funding was Challenging and Many Initiatives Were Already Defined and Underway • Faced many projects to upgrade or replace existing functionality before moving forward with advanced clinical functionality • Identified sum total of initiatives required to achieve the desired electronic medical record • Established strategy to guide all purchasing decisions and align organization around key vendors and solutions • Formulated 5 year budget projections to educate the organization on priorities based on funding availability • Gained consensus from organization regarding pending and future EMR initiatives • Outcome: This organization now has a roadmap to guide their information technology activities according to their operational strategic plan for the next 5 years. Annual review and validation of the plan is scheduled. This organization fully understands the implications of their short and long term activities as they relate to deployment of an EMR. Further they understand that the EMR deployment is a series of projects.

28. Strategies for Success: Establish Goals & Objectives • Establish Health System Objective • Completely paperless • Hybrid medical record (part electronic/part paper) • Establish relationships with all ancillary departments and vendors • Future purchases: disparate systems versus integration • Decisions driven from critical data to be available in the EMR based on feedback from advisory groups • Development and adherence to Information Systems Strategic Plan

29. Strategies for Success: Understand Current State • Development of Current State Model • Inventory of all departmental systems • Inventory all existing interfaces • Understand the mix of integrated and disparate systems • Understand the integration limitations with various systems • Evaluate Clinical Workflow • Understand impact of decisions on current and proposed clinical workflow • Patient Movement • Interdisciplinary • Nursing • Physician

30. Strategies for Success: Acquiring Systems • Maintain Focus on Strategic Direction • Unrelenting focus on goals • Executive leadership • Be realistic • Be objective • Be concrete (how & when questions) • Clinician and physician involvement • Seek Outside Advice and Counsel (these decisions are expensive and have huge organizational impact) • Experiences from staff who have worked in other environments • Vendor References • Internet • Consultants

31. Strategies for Success: Disparate Systems • Disparate Systems • Potentially more robust functionality • HL7 Compliance for Interfacing to EMR • Cost of Ownership • Additional Interfaces to support • Additional application support fees • Additional Upgrades

32. Strategies for Success: Integration & Interoperability • Integrated Systems vs. Interoperability • Departmental/user specific functionality • Support and maintenance (impact on technical architecture) • Data availability/sharing • Clinical workflow • Short and long term use of data • Discreet data vs. textual

33. Strategies for Success: Establish Rational Expectations • Establish EMR Timelines • Map out timelines for each project • Overall timeline is driven by labor and financial resources • Start with basics to ensure initial success • ADTs • Laboratory results (discrete and text) • Radiology results (text) • Cardiology results (text) • Respiratory results (discrete) • Documentation (H&Ps, Op Rpts, Discharge Summaries, Consults, etc.)

34. Strategies for Success Summary • Choose an EMR product strategy that offers the greatest potential for success in your particular circumstances • Choose as many modules as possible that are integrated into a suite of products • Carefully choose products that have a strong history of integration with other products • Use disparate system integration as sparingly as possible to accomplish your EMR goals • Leverage a variety of technologies to create visual, functional, and database integration • Gradually phase in the EMR to lessen the impact • Understand that the EMR is a series of projects and initiatives • Take best advantage of available technologies • Group products/modules in a way that allows users to recognize incremental victories and obtain functionality in shorter time frames

35. encompasses much more than the relationship between the physical parts of the system. In Closing, The Successful EMR Adoption Health Outcomes Cost Successful adoption is measured by the user and validated in the meaningful application of data in the care delivery process.

36. Robecca Quammen President/CEO The Quammen Group 1400 S. Orlando Avenue, Suite 204 Winter Park, FL 32789 407-758-3390 (cell) 407-539-2040 (fax) E-mail: becky@quammengroup.com

37. Today's Event Sponsored by: Emdeon Practice Services helps practices meet the challenges of healthcare with innovative solutions, including electronic health records, encounter documentation, document and image management, and wireless and Internet connectivity. For more information: Call: 877.WEBMD.01 Visit: www.webmdps.com Visit Emdeon's Virtual Trade Show exhibit at: hdm.unisfair.com/prd.jsp?booth_id=13