What to Consider Before Implementing Health

Information Technology

Jerri Hiniker, RN, BSN, CPEHRProgram Manager

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Stratis Health Stratis Health is a non-profit organization

that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facility improvement for people and communities.

• Under federal contract, Stratis Health serves as Minnesota’s Medicare Quality Improvement Organization (QIO).

• Stratis Health is also involved in other state and national projects funded through government contracts, foundation and corporate grants, and health systems.

• www.stratishealth.org

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Regional Extension and Assistance Center for HIT (REACH)

• Project of Key Health Alliance: Stratis Health, National Rural Health Resource Center, and The College of St. Scholastica – Strong track record of success in HIT and EHR

technical assistance and support • Working in close cooperation with:

– North Dakota Health Care Review, Inc. (NDHCRI)– University of ND, Center for Rural Health

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Today’s Goals

• Learn how to access, modify and apply HIT tools for your organization

• Identify opportunities to utilize the HIT toolkit resources to improve care

• Formalize a process for adopting technology in your organization

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HIT TOOLKITS: BACKGROUND

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HIT vs. EHR

• Health Information Technology (HIT): a general concept that describes the technology that supports management of health information for many purposes

• Electronic Health Record (EHR): a specific system of applications and other elements that capture data from multiple sources for clinical decision support at the point of care wherever that may occur including promotion of health and wellness

Softwarethat directscomputerdevices

People to supportand usesystems

Policythat drivesadoption ofsystems

Hardwarethat enablessystem use

Processthat helpsachieveresults

Copyright © 2009, Margret\A Consulting, LLC. Used with permission of author.

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EHR vs. EMR• Electronic Medical Record (EMR) sometimes refers

to:– Physician office EHR

– Hospital document imaging system

– Non-interoperable record of health-related information

• EHR is term used by:– Federal government

– Institute of Medicine (IOM)

– Health Level Seven (HL7) • Primary organization to develop interoperability in health care information

systems; adopts the term EHR system

– Certification Commission for Healthcare Information Technology

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EHR• Encompasses broader view of a health record moving

from notion of a location for keeping track of patient care events to a resource with enhanced utility

• Provides longitudinal (i.e., lifelong) access to events that may have influenced a person’s health. Virtual core of a health care delivery system information infrastructure

• Merely automating the form, content, and procedures of current resident/patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs

Institute of Medicine, Computer-based Patient Record: An Essential Technology for Health Care, 1991, 1997

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EHR and Health Care Reform

• Includes patient demographic and clinical health information

• Has capacity to:– Exchange electronic health information with and

integrate such information from other sources

– Capture and query information relevant to health care quality

– Provide clinical decision support

– Support physician order entry

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Key HIT Priorities• Coordination

– Exchange key clinical information among providers and patient-authorized entities electronically (HIE)

– Summary care record for every transition in care– Medication reconciliation– Rx fill status notification

• Population– Electronically submit/received data to/from immunization registry– Electronic syndromic surveillance data/reportable lab results to

public health; receive public health alerts• Privacy

– Compliance with HIPAA Privacy and Security Rules• Conduct or update a security risk assessment

– Compliance with fair data sharing practices (Nationwide Privacy and Security Framework)

– Provide summarized or de-identified data for population/public health reporting and research were appropriate

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Health Information Exchange (HIE)

• Very strong interest in accessing and exchanging health information in all health care settings

• Specific areas of need: – Medication reconciliation and organization– Health history and information organization and access– EHR connections– Cross-setting connections (e.g., clinic to nursing home)

• Potential barriers to HIE success: – Lack of capital resources, specifically in some settings– Lack of knowledge/understanding about HIE

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THE HIT TOOLKITS: TOOLS YOU CAN USE

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HIT Toolkits

• Purpose of the toolkits

• Instructions for use

• Types of tools

• Tool structure

• Parts of the toolkits

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Purpose of Toolkits

• Kick start your HIT and EHR planning

• Formalize the process

• Reduce your cost

• Serves as surrogate staff

• Achieve your HIT and EHR goals

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Instructions for Use:Your Dashboard

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Types of Tools• Recorded Webinar sessions

– Short (15-20 minute) educational tools• Walk through use of key tools• Introduce key topics for your HIT team, EHR steering

committee, staff• Stimulate team discussion

• Survey forms, checklists, comparisons, charts, tip sheets, interview tools, rating forms, other tools

• Sample job descriptions, policies and procedures, request for proposal, other model documents

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Tool Structure• Purpose

– Each tool begins with a brief statement of purpose

• Instructions for Use– Many tools include specific instructions for use– Some tools are more informative than interactive and may not need

instructions for use

• Notes and illustrations– Some tools include notes to define terms, diagram a concept, or

provide references

• Tool – Microsoft Word, PowerPoint, or Excel– Modifiable

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Purpose and Instructions for Use

Statement of Purpose

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Resources and References

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Examples and Illustrations

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Tools in Excel

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THE HIT TOOLKITS: USING THE TOOLS

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Model for Adopting Interoperable Electronic Health Records(Source: Minnesota E-Health Initiative)

Assess

Plan InteroperateReadiness

Effective Use

Implement

Select

Achievement of

2015 Mandate

Continuum

of EHRAdoption

Adopt Exchange

Utilize

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Parts of the Toolkit: Adopt

• Tools to help you assess, plan for, and select HIT and EHR– readiness assessments– project management aids – goal setting tools – instructions on current workflow and process mapping– support for understanding the HIT marketplace, issuing

a request for proposal, and conducting due diligence for selection and contract negotiation

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Adopt - Assess• How to use the toolkit (Handout, PPT, Webinar)

• HIT Governance

• Vision and Strategic Planning for HIT (Handout, PPT, Webinar)

• Communication Plan

• HIT Attitudes Assessment

• Computer Skills Survey

• Total Cost of Ownership/Return on Investment Analysis

• IT Staffing Inventory

• IT System Inventory

• HIT Security Risk Analysis and Controls Assessment

• Contingency Plan Assessment

• Application Interface Inventory

• Financing Resources

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Communication• Communicate

– Early– Often– To all– In many ways

• Communication– Removes fear factor– Generates ideas– Gains buy-in– Achieves results

• Plan for Communication– Or it will be forgotten

Stakeholders:• Board of Directors

• Physicians

• Administrators

• Clinical leads

• All staff

• Patients

• Payers

• Insurers

• Employers

• Others

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Communication Plan

EHRProgress

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Reviewing Your Readiness

• Readiness Assessment report

• Attitudes and Skills Survey

• IT inventory and IT staffing

• Financial assessment

• Interpret results and assess your specific needs

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Readiness Assessment Report• Interviews with facility leaders and physicians• Assesses readiness in 8 different areas

–  Pre-work in selecting an EHR – Understanding of associated costs–  EHR expenditures and benefits (finances and financing)–  Commitment of administration leadership – Physician support– Use of technology– IT infrastructure and support – Benefits/expectations

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Attitudes Survey

*

*

Risk Area: Where Red +

Yellow > 40%

Risk Area: Where Red + Yellow > 40%

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Computer Skills Survey

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Financial Assessment

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Adopt - Plan

• HIT Steering Committee

• Meetings, Agendas, and Minutes

• Clinical IT Leadership

• Project Management

• Project Manager Job Description

• Goal Setting

• Change Management

• Workflow and Process Redesign (Handouts, PPT, Webinar)

• Chart Conversion Planning

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HIT/EHR Steering Committee• Physician leader• Other physician representatives, including

– Champions– Curmudgeons

• Representatives from:– Nursing– Administration– Business office– IT

• Project manager

Use as applicable:• Board liaison• CFO• Procurement specialist• Legal counsel• EHR consultant• External contract negotiator

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Project Management• Ensure readiness

– Provide for EHR education– Assess readiness – Facilitate identifying goals, critical

success factors, assumptions, risks, & obstacles

• Organize the effort– Facilitate formation of EHR steering

committee – Develop job descriptions for new &

changed positions– Plan communications– Document project tasks

• Initiate change management– Oversee process mapping– Identify EHR functional

requirements– Coordinate technical requirements– Plan chart conversion

• Coordinate vendor selection– Support code of conduct– Aid in surveying marketplace & narrowing

field of candidates– Coordinate RFI/RFP issuance, response,

& evaluation– Coordinate due diligence activities– Assist in identifying financing/ROI

• Coordinate implementation– Establish progress reporting system– Maintain issues log problem-escalation– Install change control process– Harmonize project plan w/vendor’s – Develop turnover strategy– Monitor task completion– Develop & oversee training plan– Develop & oversee test plan– Support system build– Plan & manage go live

• Coordinate ongoing maintenance & benefits realization

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Job Description

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Project Plan

• Start early to manage tasks

• Manage scope and timeline

• Control “implementation”

• Harmonize “installation” component with vendor

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EHR Goals• Access data• Improve quality of care• Enhance patient safety• Support health maintenance, preventive care, and

wellness • Increase productivity • Reduce hassle factors/improve satisfaction for

clinicians, consumers, and caregivers • Support revenue enhancement• Support predictive modeling and contribute to

development of evidence-based health care guidance• Maintain patient confidentiality and exchange data

securely among all key stakeholders

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Getting Specific (Patient Safety)• “We want to improve patient safety”

– Great, but will physicians? – Use EHR at point of care?– To reduce potential medication errors as

evidenced by no reportable ADEs, and fewer than 2 anecdotes of near misses per month?

– Using a drug reference tool or comprehensive e-prescribing system?

– Within 12 months of EHR implementation?

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Goal Analysis

• Are these goals?

• Are they sufficiently measurable?

• What will it take to achieve such access?

• Does the timeline seem appropriate?

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Achieving the GoalStep 1. Gain consensus on guideline to help achieve

better outcomes

Step 2. Identify data needed: last procedure/test date, where performed, results; document performance, results, & provider ID, or referral, or instructions to patient

Step 3. Test data collection using a structured paper form, if desired/applicable

Step 4. Incorporate into EHR as an alert, prompt, &/or template

Step 5. Establish measurement scheme (e.g., query database monthly, report by provider, report by results, monitor progress via quarterly QA)

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Workflow and Process Redesign• Process mapping is the task of describing the

nature of the tasks associated with each process– Processes are tasks performed

• For EHR, processes are how data is collected and processed into information and how knowledge is applied to the information

– Workflow is the sequence in which the tasks are performed

• Process mapping should identify all the detailed steps, in sequence, as well as the supporting forms and/or reports that are currently used or generated in order to ensure all current data collection and information generation processes are identified

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Process Mapping Steps1. Identify processes to map; define process

boundaries2. Define process elements: inputs, outputs, tasks,

participants – focus on information flow and use3. Brainstorm to ensure all tasks are identified, identify

critical tasks, those that don’t belong4. Arrange tasks in sequence, alternative paths5. Identify at what points errors, delays, communication

breakdowns, or repetition or rework occurs 6. Use process mapping to collect all forms and reports

to be automated7. Once current process is mapped, analyze and

describe revised processes

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Identify Processes and Boundaries

• Process mapping should get to a very specific level of detail

• Too big a process becomes tedious, and usually involves too many people

• Map processes that are typically separate from one another; e.g., medication ordering may or may not always follow medical history taking

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Define Process Elements• Map information flows• Ensure all inputs and outputs are identified

– Paper: sources of data, forms, reports– Electronic: systems, templates, displays

• Identify all tasks, including those performed mentally (e.g., “Have I checked whether the patient is allergic to the active ingredient in this drug?” is a process that can’t be seen, but is critical to medication ordering process)

• Even though processes on data and flow of information are being mapped, capture who is responsible for each process

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Brainstorm to Refine Tasks

• Are these all the tasks?

• Are some tasks performed only occasionally? Are they included? What triggers their performance?

• Are some tasks performed by others, but part of this process? Include them.

• Are there some tasks identified that really are not a part of this process, but a part of another process? Exclude them.

• What tasks are critical? That is, if not performed, the process is meaningless.

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Collect Forms and Reports• Identify all forms, their versions, where used,

by whom, under what circumstances– Evaluate whether forms are currently entirely

completed and accurate– Compare similar forms for differences, understand

the differences, and map them

• Identify all reports, their versions, who generates them, when, under what circumstances, who uses them– Determine whether all reports are actually needed

and used

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Analyze and Describe Revisions

• Bottlenecks

• Sources of delay

• Rework due to errors

• Role ambiguity

• Duplications

• Unnecessary steps

• Cycle time

• Lack of adherence to standards

• Lack of information

• Lack of quality controls

Send politics &personal preferences out the door

Always getto root cause

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Process Improvement• Build cohesive teams of individuals who actually

perform the process and orient team members on purpose of process improvement

• Select tools and instruct team members on process improvement methodology

• Map current processes that are impacted by EHR, commonly performed, critical to clinical care

• Leave bias and blame at the door, you want to identify workarounds and issues

• Avoid identifying opportunities for improvement prior to completely mapping current processes

• Obtain benchmark data, using statistical charts, to define expectations for change and for use in benefits realization studies

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Process Improvement• Determine the root cause(s) of problems needing

improvement• Identify changes that address the root cause(s), not just

symptoms• Document changes by creating an “improved” process

map • Use new processes to identify:

– EHR functional specifications – Write scenarios for performance requirements– Build out the EHR system, test, and train to achieve

improvements• Incorporate changes into policy and procedure• Test new workflows and processes • Train all on new workflows and processes• Conduct benefits realization and celebrate successful

change/correct course as necessary

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Improve/Automate Process

• Why is it done – is it necessary?

• Why is it done at this location?

• Why is it done at this time?

• Why is it done by this person?

• Why is it done this way?

• What is impact of automation?

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For Clinical Transformation• Always ask, does it always happen this way?

Does it always have to happen this way?– Why not have as much patient data entered as possible

in advance of the hospitalization, then validate it

• Anticipate push back when flows start to differ from today:– Look closely at multiple forms for one purpose– Anticipate “downstream” time savings– Introduce quality checks that improve patient safety,

quality of care– Communication changes must be anticipated and

managed

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Model for Adopting Interoperable Electronic Health Records(Source: Minnesota E-Health Initiative)

Assess

Plan InteroperateReadiness

Effective Use

Implement

Select

Achievement of

2015 Mandate

Continuum

of EHRAdoption

Adopt Exchange

Utilize

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Adopt - Select• HIT Code of Conduct

• Vendor Selection (Handouts, PPT, Webinar)

• Requirements Analysis

• Request for Proposal

• RFP Analysis

• Key Differentiators

• Due Diligence: Demonstration Plan

• Due Diligence: Site Visit Plan

• Due Diligence: Reference Check Plan

• Vendor of Choice

• Contract Checklist

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Utilize - Implement• Project Planning – Word version

• Project Planning – Excel version

• Issues Management

• Workflow and Process Improvement

• Policy and Procedure Checklist

• Forms and Reports Analysis

• Input Device Planning

• System Build

• Change Control

• Clinical Decision Support

• Training Plan

• Testing Plan

• Roll Out Strategies

• Space Planning

• Go-live checklist

• HIT Technical Security Controls

• Implementation Strategies for Assessment Documentation

• Implementation Strategies for EDMS and Hybrid Record Risk Management

• Implementation Strategies for Physician Documentation

• Implementation Strategies for Electronic Medical Administration (E-MAR)

• Ongoing System Maintenance, Administration, and Data Quality

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Utilize – Effective Use• Quality Measurement, Reporting, and Improvement

Resources• HIT Adoption Milestone Results• Monitoring SMART Goal Achievement• Benefits Realization• User Satisfaction• TCO and ROI Assessment

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Exchange – Readiness

• HIE Readiness• HIE Goals and Governance Models• HIE Technology

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Exchange – Interoperate

• HIE Data Stewardship• HIE Interoperability (PPT)• Policy and Procedure for Personal Health

Records (PHR)

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Opportunities for Improvement• EHR adoption and implementation should be part of

an overall strategic plan• Infrastructure needs to be well functioning

– Leadership– Governance– Project Management– Staff buy-in

• Goal setting and measuring benefits throughout the process is vital

• Process map and re-design are essential to successful use

• Effective change management is the cornerstone

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Visit Stratis Health TODAY

www.stratishealth.org/HIT_Toolkit

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Stratis Health:Types of HIT Services

• Readiness Assessments

• Comprehensive EHR Roadmap– Assess, Plan and Select– Implement and Optimize

• Workflow redesign

• Cultural adoption

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Stratis Health:Types of Assistance• Educational sessions

– Conference presentations– Toolkit tutorials

• Formal Learning Collaboratives– Three-four learning sessions – Monthly group or individual consultation

• One-on-one consultations– Monthly consultation

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Resources

• HIMSS, http://www.himss.org – Technology, resources, tools

• AHIMA, http://www.ahima.org/ – Job descriptions, EHR content, legal issues

• Federal Government Health Information Technology Website, http://healthit.hhs.gov

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Thank You!

Contact Information:

Jerri Hiniker, RN, BSN, CPEHR

Email: jhiniker@stratishealth.org

Ph: 952-853-8540

To register or find out more information about REACH

http://khaREACH.org

877-331-8783, ext. 222