Preparing for Outpatient CPOE

As the many pressures for CPOE (Computer-based Provider Order Entry) increase, consideration and planning are critical to build an implementation plan for success. As physicians are asked to take on additional administrative duties, we recognize the importance of optimizing the CPOE process as much as possible. Regarding Provider order entry, many are challenged to replicate the speed of the paper world.

Below is a subset of items to consider.
Optimize, optimize, optimize

1. Optimize, optimize, optimize
2. Know your system set-up options and build considerations backwards and forwards
   Involve physicians in the build process
3. Providers should be asked to provide the details that only they know: nothing else
4. Develop consistent naming convention for ease of use
5. Order sets to allow grouped tests to be ordered efficiently
6. Favorites to ease selection
7. Problem based ordering to ease selection
8. Explore opportunities to transfer other “work” in the EHR to non-providers prior to or as
9. part of the implementation to off-set any addition work
10. Build a solid, effective training program
11. Don’t take short cuts on coaching and support

Managing Change with EHRs

Everyday there are requests to update or change something in your EHR. This can be something as simple as updating a CPT-4 code, updating a user’s name, to updating an enterprise level setting that effects all users. These changes can be subtle to massive, and cause workflow changes, to system downtime, to complete EHR collapse. Either way these changes have an effect on your organization and need to be controlled. This posting will deal with some fundamental processes your organization can put into place to make sure that updates/changes are done in an organized and manageable way.The saying, “..too many cooks in the kitchen…” is also an issue beyond the scope of physical changes.

Most organizations have a large team of EHR analysts that support, implement and train just around the EHR. With so many hands with the ability to make changes (and the lack of some EHRs to lock down specific admin areas) anyone could change anything at any time, and this could have drastic consequences for the organization as a whole. As a reminder, a large percent of organizations forget that EHRs, in most regards, have a direct impact on all operations of the fundamental business core of medical organizations, from everything a clinician does (employee satisfaction, efficiency), to billing (finance), and to patient outcomes (patient satisfaction). More or less, the nervous system that leads to the hands, the feet and the head of the organization.

In the above, we can see that there are areas of concern. We will break these down to the following categories: Level of Change, When to Change and Who Changes. In terms of the above concerns, an organization should create a process diagram with regards to time requirements and number of users affected, along with the above categories.

An example would be:
Specific User Preferences – Level 1 – Time: 10mins
Level 1: Basic changes an analyst can make, and if below 1 hour they can do the change without approval, but must bring to bi-weekly team change control meeting and have one team member review before implementing into live.

Adding an order a specific physician wants in the system – Level 3 – Time: 1 Hours
Level 3: A basic change but one that requires approval from a manager since this order will be visible to all users. Once complete in test bring to the bi-weekly team change control meeting and have one team member review prior to implementing into live.

A new upgrade is available for the EHR
Level 5: A massive change to the system. This will require the approval of the EHR Steering Committee plus the EHR director and will take 90+ hours to implement. In this example, we can see that there are several levels of change that this fictitious organization has created. There are simple changes that are a level 1 and some that are a level 5 that require not just a director’s approval but the steering committee approval before implemented. A diagram could look like this:



Steps an organization could put in place to create a change control process are as followed:
-Form layers of approval, ex. Analyst, Team Lead, Manager, Director, Medical Sponsor, Steering Committee
-Require that all changes go through change control process, no free for all on ANY changes in your EHR
-Create levels of change, i.e. have a specific/general understanding of the impact of a possible change could have (# hours, # of users effected)
-Create a diagram that is clear for your team to understand the process
-Inform all users there is a change control process to keep the system stable (some users may not understand why their request cannot be done right there and then)
(May also require sign off from site managers for any requests that are made (helps prevent a free for all of requests from users))
-Form a bi-weekly or other schedule to have your entire team meet for 10-60 minutes to attend the change control meeting (Do not rush change, if you do bad things will happen eventually)
-Make sure that you set the standard that large changes need to be done off hours (This will help prevent downtime for users or fixes)
-Have a communication plan setup so that your users are always informed of their requests, even if denied (this will help them have faith in your system)
-Make sure everything has been done in test and approved/reviewed by the correct people

It is very tempting to just make changes on the fly. At first you will feel that you had no choice and if you didn’t make the changes, your users would stop using the system or even go over your head to get what they want. But, with the a change control process (signed off by your steering committee) you will be doing your users a better service by making sure things are done correctly and keeping the system stable for all.

EHR Resource Planning (5) – Disseminating Project Plans and Building Custom Reports

Disseminating and building custom project plan reports is the fifth blog in the multi-blog series on estimating resources for an electronic health record (EHR) project. The first blog, Introduction, describes the basis for these blogs and the series of blogs that will follow. The second blog, Defining Resources, discuses how to create the tasks and designate the resources roles assigned to the task in a resource assignment matrix (RAM). The third blog, Estimating Task Work and Duration, explains how to use the RAM created in blog two, estimate work and duration for each task. The forth blog Resource Calendar and Task Relationships talks about how to assigning calendars and tasks relationships to the project plan. The fifth and last blog in this series will cover the challenges of disseminating a project plan and how to build custom reports with Microsoft Project and Office

At this point you have defined the project tasks, assigned resources, estimated work effort and duration and linked the appropriate tasks together. The project is ready to move forward and it is time to disseminate the project plan. There are several challenges when disseminating a project plan to a large team of resources and stake holders. The first challenge you might run into is that the entire team may not own a copy of the project management software to view the project plan. Second, it is likely that many resources have never worked with the project management software and will not have the skill set to use it efficiently or effectively. The third challenge is versioning the project to ensure that the latest version contains all the updates from the entire team and no updates are lost.

Let’s examine each challenge one at a time. The first challenge is the entire team might not have a means to view the project plan. It is common for organizations to only purchase project management software licenses for those that manage projects. In this case, I would suggest using a Microsoft Office application such as Excel. Excel is a very good alternative because most resources will have this software and are familiar with how it works. To minimize the amount of effort it will take to copy the project information into Excel, create a view in Microsoft project just for the exporting of tasks. For example, create a view in the project plan that contains the following columns: Task Name, Start Date, Finish Date, % Complete and Resources. Next, copy the tasks from Project and paste into an Excel spreadsheet. You will notice is that the formatting does not copy over from Project to Excel and you lose the bolding of the summary tasks. In order to quickly format the tasks in Excel I wrote a macro to format the Excel spreadsheet. This will format the Excel spreadsheet and highlight and bold the summary tasks making it very easy to read.

The solution for the first challenge goes hand and hand with the solution for the second challenge, export the project plan to Excel. However, since we just don’t want to give all the resources a long list of all the tasks that mirrors the project plan you will want to filter the report and break it down to make it more meaningful. I would recommend creating three filters in Project: tasks due this week (filter criteria: all tasks where % complete is < 100 and Finish Date is <= to Friday’s Date), tasks due next week (filter criteria: all tasks where % complete is < 100 and Finish Date is <= to next Friday’s Date), tasks due in next two weeks (filter criteria: all tasks where % complete is < 100 and start date is between Monday of current week and Friday of next week). Run these filters on your project plan view created for Excel outputs, cut and paste the tasks into Excel and run the formatting macro. It’s really that simple. You are now able to disseminate information that is buried in a project plan that most resource don’t know even exists. Every project manager’s nightmare is to open up the “latest version” of the project plan to realize it is not the current version. I have a couple suggestions to help minimize the chances of this situation from occurring. My first suggestion is to not share the project plan, own the project plan and make sure you are the only one that can make updates. All updates go through the project manager. This will help eliminate other resources from overwriting your updates. If you must share the project plan I would suggest using some sort of versioning application that keeps multiple versions of the file. I have used SharePoint and it works really well because you can track the version history and can always roll back to a previous version of the file if needed. This was the fifth and final blog of this series. If you have any questions or would like more information regarding project plans, custom reports, or custom marco development please feel free to please contact us at information@projectnavigation.com or 610-590-0336.

Meaningful Use Planning Requirments

Strategic plans are essential to achieve Meaningful Use (MU) for Hospitals and Eligible Providers. While the AMA/AOA and other groups continue to discuss challenges with meeting MU criteria, the countdown has started. Strategic plans need to include estimates for the triple constraints which are timeline, resources and budget. Many strategic plans are inaccurate because of the lack of correlation between constraints. The act of planning establishes assumptions for each constraint which creates a quality triangle and correlation. When assumptions change in one constraint the other constraints are impacted and the quality triangle is skewed.

Currently, manual updates to mediums such as Excel, Visio or Microsoft Project are required as well as input from stakeholders on assumptions while trying to recall over multiple meetings the correlation between constraints. This process is inefficient and leads to inaccurate strategic plans. Our Triple Constraint Tool enables the real-time manipulation of the project timeline, budget and resources while maintaining the correlation between all three. Assumptions may be manipulated for each constraint and modeled in different scenarios so that organizations can determine the pros and cons of each approach and select the best strategic plan for the organization.

Please contact us today at information@projectnavigation.com to schedule your personal demonstration of this ground breaking tool that will revolutionize strategic planning for EHR and other industry projects.

Personal Health Records (PHR) on the Rise Again

In last several years, the term PHR has risen, fallen and then risen again. What caused the rise in interest in PHRs again? Where is the interest coming from?

 

●      What is a PHR?

●      What functionality can a PHR have?

○      What value does a PHR bring?

●      Can I mix my PHR with my EHR

○      Tethered

○      Not tethered

●      What are the different PHRs out there?

●      Is it part of meeting meaningful use?

 

What is a PHR?

This is a quote taken directly from the CMS website, “In general, a Personal Health Record (PHR) is controlled by the individual, and can be shared with others, including caregivers, family members and providers.  This is different from a provider's electronic health record, which is controlled by the provider just as paper medical records are today.  Ideally, a PHR will have a fairly complete summary of an individual's health and medical history based on data from many sources, including information entered by the individual (allergies, over the counter medications, family history, etc).”[i]  So in summary a PHR is a way for patients to input their own health data and review it. A step closer to the Medical Home concept (also known as Patient-Centered Medical Home[ii])

 

What Functionality can a PHR have?

PHRs can have all different sorts of functionality, just like an EHR. Here is a list of different functionalities that can be found in PHRs currently:

●      Entering Med History

●      Entering Allergies (Med & Environmental)

●      Present Medication Alerts

○      Drug to Drug Reactions

○      Drug Dosage

○      Drug duplications

○      Drug reactions to allergies

●      Entering Past Social History

●      Immunization Records

●      Entering Family History

●      Entering Medical Device information

○      Automatically

○      Manually

●      Scheduling/rescheduling for doctor visits

●      Renewing Medication Requests

●      Send communications to hospital staff

○      Doctor

○      Triage Team

○      Etc

●      Update Demographic information

○      Share data with others

●      Can share with such entities as the Genomix research link

●      Link to Pharmacies to receive up to date medication information

●      Test Results Viewable

●      Access to radiology reports

●      View portions medical chart

 

With this list of possible functionality, we can start to see the value that a PHR can bring. If a patient updates their medication list or has a direct link to the pharmacies that he or she uses, such as CVS, Walgreens, etc their medication lists can update automatically, and in turn, update their med list in their physicians EHR as unverified meds. The physician can then verify the medications at the patient’s next visit. There are multiple values to be found just in this aspect alone: patients have a medication list up to date, physicians have the medication list up to date, clinical intake time decreases with having to type out, find, and entering medications in the EHR. Another aspect that can save time and increase patient health is that if the patient is traveling or has to go to the hospital, they can give access to the ER physician to see all of their PHR data. And/or the patient could wear a PHR bracelet and the physician could use an emergency physician code to get the data if the patient is unconscious.  The patient would have to allow this type of access.
 

Another value adding functionality is the scheduling and rescheduling function that a PHR can offer. This functionality will cut down the amount of calls and work required by the front desk.   Additionally this would also cut down confusion and time delays with patients, with having a single source to find when and where their appointments were.

 

Can I mix my PHR with my EHR

There is a lot of value to be found in a PHR, but that value really only can be amplified when a PHR is linked (tethered) to the physicians EHR/PMS.  Without this link, a PHR is only a tool for a patient to collect and store medical information, which in itself is not a bad thing, but does not bring as much value to the Medical Home concept as a linked PHR. Many EHR vendors offer a PHR that will link to their system however many  of them offer limited integration . Be sure to review the capabilities/functionality before picking a PHR to link with your system.

 

What are the different PHRs out there?

As mentioned there are a number of PHRs out there: below are some examples. 

GoogleHeath - https://www.google.com/health

Microsoft’s HealthVault - http://www.healthvault.com/

Dossia – http://www.dossia.org

MyChart - http://www.epic.com/software-phr.php

Indivo- http://indivohealth.org

MyHealtheVet – (Used by VA) – http://www.health-evet.va.gov

iHealth – http://medfusion.net/ihealthrecord/

 

Is it part of meeting meaningful use?

With meaningful use coming into play, we need to know where a PHR fits.  According to the 2011 Objectives[iii] (listed on the Meaningful Use Matrix):

 

The goal is to electronically capture in coded format, and to report health information and to use that information to track key clinical conditions

●      Provide patients with electronic copy of- or electronic access to- clinical information (including lab results, problem list, medication lists, allergies) per patient preference (e.g., through PHR) [OP, IP]

 

With that stated, a PHR is required by 2011 to meet ‘meaningful use’.

 

In closing, it is clear that a PHR will be part of your HIT role out either to meet meaningful use and/or to bring value to both patients and your organization. In upcoming blogs we will discuss PHRs in more detail, and perhaps provide comparative analysis..

 

 

[i] http://www.cms.gov/PerHealthRecords/

[ii] http://www.medicalhomeinfo.org/

[iii]http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11113_872719_0_0_18/Meaningful%20Use%20Matrix.pdf

 

Meaningful Use

How should Organizations define the budget, resources and timeline to achieve meaningful use criteria and quality for stimulus payments? Physicians with Electronic Health Records (EHR) that can show “meaningful use” in 2011 are eligible for $44,000 over 5 years through Medicare and $65,000 over 6 years through Medicaid. The Centers for Medicare and Medicaid Services (CMS) published the revised meaningful use criteria on January 13, 2010. An overwhelming amount of public comment has been provided in regards to the criteria not being achievable and unrealistic for the timeframe. The Government does not intend for every healthcare organization to achieve the meaningful use payments because there would be budget deficits similar to the cash for clunkers program in 2009. The challenging meaningful use criteria will motivate a large percentage of early adopters and those already in the implementation process. These early adopters will likely receive the payments, as they should, while those organizations that did not take the risk prior to ARRA may be able to qualify in a future stage or just avoid penalties. Regardless of the state of the organization there are 3 essential management tools that must be in place to achieve meaningful use in every organization. These tools include a visual timeline, a resource matrix and a meaningful use dashboard.

1. Visual Timeline
The visual timeline is typically created in Excel or in other software applications. The Excel worksheet is typically configured with calendar months on top and applications down the left side with merged cells that represent duration for implementation projects, upgrades and integration projects. We recommend adding bold lines vertically corresponding to the calendar months with each meaningful use stage. The objective of the visual timeline is to provide a visual representation of the program to be implemented to meet each stage for stimulus payments.

2. Resource Matrix
The resource matrix should be combined with the visual timeline. In order for the timeline to be achievable, resources must be procured to complete the work. Resource effort should be estimated to match the duration in the visual timeline. The cost of the resource may also be added which will be a key input into budgeting for meaningful use.

3. Meaningful Use Dashboard
The third tool is a dashboard with meaningful use criteria by stage to track whether the metric has been achieved and calculates an organization’s percentage of completion by stage. The dashboard provides an executive review of progress to these strategic initiatives and planning for metrics that are at risk of not being achieved.

Whether the organization is already live or just beginning the journey, these tools are essential for an accurate timeline, budget, resources and dashboard to achieve meaningful use. For more information regarding these tools and approach please contact us at information@projectnavigation.com or 610-590-0336.

Training Strategies for Minimizing Impact to Physician Productivity:

The training experience is one of many critical components that help determine the level of success of migrating to an EHR. A poor training experience can leave a provider confused, frustrated and less willing to embrace the change thrust upon him. When looking at training impact on productivity of providers alone, there are several items worth considering:

1. How to maximize classroom time

a. Strong facilitator and trainer

b. Workflow and role based training with real scenarios

c. Confirm room and training devices are ready prior to the start of the training session

d. Clearly communicate location, parking, training session start and end times

2. Communication prior to training session

a. Basic understanding of the project

b. The Vision

c. Realistic Expectations

d. Phasing

e. Reasons for Change

f. Online tutorials

3. Consider offering training during non peak patient hours

a. Early Morning

b. Early Evening

c. Weekends

4. Understand the level of complexity of the material and scope of change

a. Allot appropriate amount of training time given the specific software and functionality being introduced - If a session only needs to be 60 minutes, don’t schedule 3 hours as well the reverse

b. Avoid spending too much time on components that are relatively intuitive, and focus on those items that are significantly changing critical to daily workflow

5. Schedule sessions close to when the EHR will get used in a live setting

6. Expect that coaches will be necessary the first few days that providers use the new system and processes

As part of the overall training experience, classroom time away from patients must be well spent. Along with many other components, well planned training will help minimize impact to Physician productivity during the initial implementation of an EHR.