Choosing and Implementing an Electronic Nursing Information System in a Home Health Organization

1

Choosing and ImplementingChoosing and Implementingan Electronic Nursing Information Systeman Electronic Nursing Information System

in a Home Health Organizationin a Home Health Organization

Michael Lees, M.D.Michael Lees, M.D.

OHSU BMI 512OHSU BMI 512

Winter 2008Winter 2008

2

Why convert to an electronic nursing information system?

“Making strides in the clinical documentation process can result in significantly faster billing and more complete reimbursement for Healthcare facilities…To maximize reimbursement, a facility’s clinical documentation must be fast, accurate, and thorough.” (Rehm 2007 p. 8)

A Guideline for Implementing an electronic

Nursing Information System (NIS)

3

Purpose of the Project:

To implement an electronic Nursing Information System to show measurable improvement in the quality of patient care as reflected in standard quality indicators and to improve reimbursement from third party payers by:

1. Improving Accuracy of Documentation

2. Improving Completeness of Documentation

3. Decreasing Time to Finish Documentation

Choosing a vendor and Implementation of a electronic NIS

4

One project managers who manages the teamExecutive support and sponsorshipObjectives are well definedProject is on time and budgetTeam commitment and cohesivenessNo conflicts with other projects or resourcesThe project is fun

Traits of a successful project

(Brady 2000)

5

System Implementation Strategy (Brady 2000, p35)

4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a

request for proposal

5Review the RFPs and narrow the

field

6Attend vendor

demonstrations

8Rank the vendors

9Conduct site visits

10Select a finalist

11Solidify

organizational commitment

12Negotiate a

contract

Adler 2005

An Overview of the Scope of the Project

6


4Selecting the RFP

recipients

7Check

references

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

1Identify your decision makers.

7

All stakeholders need to be represented at all stages of planning and preparing for the eventual use of the NIS {Nurses, Physical Therapists, Occupational Therapists, Social Workers, Administration, Clerical Workers} (Fullerton 2006)

“This individual has to be willing to put in a lot of extra, typically uncompensated, hours doing research and management tasks.” (Adler 2005 p2)

The Clinical Champion

8


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.


field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

3Write a


22Clarify your goalsClarify your goals

9

Organization requirementsAccess to patient data from remote sitesImprove legibility of notesImprove ease of completing required formsReduce time and resources (paper, toner) from printing copies of patient information for each providerImprove communication between home heath agents and the referral sourcesIncorporation of decision support e.g. number of visits for a particular diagnosis or triage during intake for potentially needed services•Use coded data input as much as practical Easier review and evaluation of the records by administration•Interface with billing•Decrease number of incomplete charts •Decrease number of missing files

Provider requirementsPrint patient education materials at the point of care as neededObtain electronic signature and print signed patient documentsAutomated input of vitals signs directly from the machineElectronic capture of audio and video- stethoscope, wounds•Forms are always available at the point-of-care (Reduced need for providers to drive to the office to get forms)•Electronic checklist reminding user of missing or incomplete forms before the record is submitted•Patient’s health care information is readily available•Fax or email requests for orders from the patient’s home to the physician of record

Security requirements•Secure logon- user name/password in conjunction with fingerprint scanner•Finger print scanner may be used for patient identification as well•Thin client technology- no data to be stored on the portable device in the event of theft or loss

Consider the expected results from and requirementsfor a Nursing Information System

10

Referral Source (Hospital, physician’s office)

Intake- Obtains and records Demographics, Diagnosis, Orders Obtain H&P, Consultations, Operative notes, Lab and test results, Discharge summary for the main chart

Review of intake data

AppropriateReferral

Referral denied and referral source notified

Referral accepted and sent to scheduler for assignment based on territory and service

Scheduler sends voice mail to appropriate providers

Primary Service- Opens Case

Providers gather required documents and supplies from office

Secondary service- Start of care

Shadow chart created at home office for filing of loose papers

Providers gather copies of medical records obtained at intake

Provider drives to home office ***

Provider attempts to verify orders with referring source if unclear

Yes

No

Provider gathers required and appropriate clinical information during evaluation of the patient

Provider drives to patient’s location

Information recorded on proper forms- may occur at the point-of-contact or later in the day

Provider drives to home office to submit forms to be filed in the patient’s chart

Provider attempts to contact referring physician if a change in patient condition or if plan of care needs to be modified

Completed chart on file

Provider responsible for missing or incomplete forms drives to home office to correct the deficiency

Chart reviewed for completeness

Providers check voice mail

Provider checks voice mail and learns of deficiency

Provider responsible for missing or incomplete forms is sent voice mail

Missing or incomplete forms present

Billing claims submitted from completed chart

11


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals


field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

33Write a request for proposalWrite a request for proposal

12

REQUEST FOR PROPOSAL (RFP) OUTLINE

A request for proposal that follows an outline like the one below will tell prospective vendors what they need to know about your practice to provide you with useful information about their products, and it will help to ensure that the responses you receive can be more easily compared.

I. Cover letterII. Introduction and selection processIII. Background information about your practice

a. Size and locationb. Current practice management system and any EHRsc. Current computer hardwared. Current network information

IV. Your practice's desired EHR functionality (prioritized)V. Vendor information

a. Company historyb. Number of employees (separate numbers for sales, support, research

and development, and management)c. Financial statementsd. History of their EHR producte. List of all current EHR users and list of users similar to your practice in

size and type (including how long they've been using the software and, ideally, what version they're using currently)

VI. Product descriptiona. How it performs the functions described in section IVb. Other functions it performsc. Product brochures, etc.d. Software versions and release dates

VII. Hardware and network requirementsVIII. Customer maintenance and supportIX. Vendor training X. Implementation planXI. Interface history and capabilitiesXII. Proposed costs and payment scheduleXIII. Warranties

XIV. Sample contract

http://www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.printerview.html

http://www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.printerview.html

13


7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

44Selecting the RFP recipientsSelecting the RFP recipients

14

1. Literature, trade shows, and Internet search; 2. Initial site reference calls and visits secured through informal networking or a literature search; 3. Development of a request for information (RFI); 4. market analysis; 5. Development of a request for proposals (RFP); 6. Initial product demonstrations; 7. Development of vendor and product requirements against which the various products can be compared and scored; 8. Reference calls; site visits to organizations that have experience with the product, talking with both information technology personnel and end users.

Where to find prospective Nursing Information Vendors

Rosebaugh (2004 p232)

15


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a


6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

55Review the RFPs and narrow the fieldReview the RFPs and narrow the field

16

1. http://www.rheumatology.org/products/coding/03emr_ack.asp

2. http://www.himss.org 3. http://www.elmr-electronic-medical-records-emr.com

4. http://www.medrecinst.com/conferences/tepr/index.asp

5. http://www.centerforhit.org

Adler (2005)

Resources for evaluation of electronic health records systems

http://www.rheumatology.org/products/coding/03emr_ack.asp

http://www.himss.org/

http://www.elmr-electronic-medical-records-emr.com/

17


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

66Attend vendor demonstrationsAttend vendor demonstrations

18

EHR DEMONSTRATION RATING FORM You can download a PDF version of this form.

http://www.aafp.org/fpm/20050200/55howt.html#box_b

76 year old female discharged from hospital after exacerbation of congestive heart failure. History of diabetes, hypertension, coronary artery disease status post drug eluting stents, ischemic cardiomyopathy, and atrial fibrillation.

Medications include metoprolol xl 50mg once daily, coumadin 5mg once daily, lisinopril 20mg twice daily, insulin 70/30 30 units before the morning meal and 20 units before the evening meal, clopidogrel 75mg once daily, furosemide 80mg once in the morning

19

Background

How many physicians/nurse practitioners/physician assistants are in your group?

How many office sites do you have?

What year did you go live?

What practice management software do you use?

How many interfaces do you have with the EHR?

Provider usage

What percent of your providers use the EHR?

What functions do most/all of your providers use?

Do your providers still dictate?

What has been the most frustrating thing about the EHR for the providers?

What has been the best thing?

How much individual physician customization is there?

Are you happy with the templates? Were they pre-loaded? How do they get modified?

Have you saved money? Have you broken even?

Does electronic prescribing work?

Does e-faxing work?

How have patients responded to the system?

Can your physicians access the system from home? How do they do this?

Implementation & hardware

Did the implementation go smoothly? How long did it take?

Do you have a wide area network (WAN)? How much bandwidth is used?

Was the EHR preloaded with CPT and ICD-9 codes? Was it preloaded with formularies?

What hardware do the physicians use? What hardware do the medical assistants use?

If you are using a wireless network, how well does it work?

How much of the paper chart did you scan or input into the EHR? How did you do it?

Do you still use paper? If paperless, how long did that take?

Training & support

How long does it take a physician to become fully trained/efficient in using the EHR?

How long does it take a medical assistant to be trained?

What kind of support system did you set up for the EHR? How many full-time support people are required?

Have you been happy with the upgrades and support?

Do you have an EHR committee? An IT medical director? Are physician “champions” involved in the maintenance, training and upgrading of your EHR?

Satisfaction

Would you buy this system again?

What would you do differently? System Implementation Strategy (Brady 2000, p35)

4Selecting the RFP

recipients

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

77Check referencesCheck references

20


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

88Rank the vendorsRank the vendors

Vendor 2

Vendor 3

Vendor 1

1 3

Vendor 2

XXXXX 3

Vendor 3

XXXXX XXXXX

21


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors

10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

99Conduct site visitsConduct site visits

22


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


11Solidify


1010Select a finalistSelect a finalist

12Negotiate a

contract

Adler 2005

23


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

12Negotiate a

contract

1111Solidify organizational commitmentSolidify organizational commitment

Adler 2005

24


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


1212Negotiate a contractNegotiate a contract

Adler 2005

What is duration of contract

What occurs when contract ends

What role will the vendor have

Request that the vendor’s source code be placed in escrow

Clarify circumstances of access to the code

Consider using a lawyer with software contract experience

25


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

Roll out the new system

26


4Selecting the RFP

recipients

7Check

references

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005


1Identify your

decision makers.

27


4Selecting the RFP

recipients

7Check

references

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005


1Identify your

decision makers.

28

Choosing and implementing a Nursing Information System to convert a paper-based patient record to an electronic one is a time consuming task.

Methodically working through the process is important to the ultimate success of the project.

Having the right people involved to not only to help select but also to promote the system is a proven benefit. (Fullerton 2006)

“To thrive, a home care agency must see automation as an opportunity…” (Rosebaugh 2004 p. 228)

Closing Thoughts


4Selecting the RFP

recipients

7Check

references

1Identify your

decision makers.

2Clarify your goals

3Write a



field

6Attend vendor

demonstrations

8Rank the vendors


10Select a finalist

11Solidify


12Negotiate a

contract

Adler 2005

29

References:(Adler 2005) Kenneth G. Adler, MD, MMM, How to select an Electronic Health Record System, Family Practice Management, February 2005 Vol.12, No2 http://www.aafp.org/fpm/20050200/55howt.html

(Baron 2005) Richard J. Baron, M.D., Electronic Health Records: Just around the Corner? Or Over the Cliff? Ann Inter Med. 2005:143:222-226

(Brady 2000) Maureen Brady, RN, MBA (2000) Clinical Informatics Chicago, IL Healthcare Information and Management Systems Society

(Fullerton 2006) Cliff Fullerton, MD, Lessons learned from pilot site implementation of an ambulatory electronic health record Proc (Bayl Univ Med Cent) 2006; 19:303-310

(Rehm 2007) Christopher Rehm, MD, Making Billing Strides by Improving Clinical Documentation For The Record June 11, 2007 Vol. 19 No. 12 P. 8http://www.fortherecordmag.com/archives/ftr_06112007p8.shtml (Rowley 2005) Robert Rowley, MD, Practicing Without Paper Charts: One Clinic’s Experience Family Practice Management, February 2005

(Rosebaugh 2004) David L. Rosebaugh, BS, MURP Getting Ready for the Software in Your Future Home Health Care Management & Practice / April 2004 / Volume 16, Number 3, 228-234 DOI: 10.1177/1084822303259877http://hhc.sagepub.com.liboff.ohsu.edu/cgi/reprint/16/3/228

Documents

Choosing and Implementing an Electronic Nursing Information System in a Home Health Organization