Performance Improvement within an EHR (Electronic Health Record) Launch
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Transcript of Performance Improvement within an EHR (Electronic Health Record) Launch
Performance Improvement within an EHR (Electronic Health Record)
Launch
WCBF Lean Six Sigma Healthcare SummitMay 2011
Louis C. Rhodes
Purpose: Introduce basic principles of an EHR launch and how Lean-Six Sigma experts can contribute to its success
Learning objectives:• Describe HITECH Act and EHR related impact• Identify key concepts associated with EHR
implementation• Describe points at which Lean-Six Sigma experts
can support EHR design and launch
Purpose and Learning Objectives
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• The HITECH Act mandate that health care entities must implement EHR's by 2015 or face monetary penalties in the form of reductions in Medicare reimbursements.
• What is “meaningful use of electronic health records”?
• The role of Lean Six Sigma in the EHR deployment process
• Crucial decisions that result in successful EHR adoption and avoidance of expensive EHR mistakes
Key Questions/Issues
3
• Administrator, New York University (Department of Obstetrics and Gynecology)
• Graduate of United States Military Academy (BS Management – Engineering) and Xavier University (MBA)
• General Electric Certified Black Belt and Master Black Belt in Six Sigma and Lean
• Eleven years experience in Six Sigma, Lean, and Change Management roles:
• Two years chemical industry (Millennium Chemicals)
• Four years in healthcare equipment and service delivery (GE Healthcare)
• Five years academic healthcare (USF Health and NYU School of Medicine)
• Expertise in curriculum development and skills transfer to clients
Lou Rhodes, MBA, MBB
4
• Agenda:• HITECH Act provisions• EHR implementation considerations• EHR implementation at USF Health
• Ground rules:• Informal environment• Maintain speed• Limit cell phone use• Anything else?
• As a group, describe expectations for this session.
Agenda, Ground Rules, and Expectations
5
HITECH Act Provisions
6
• Health Information Technology for Economic and Clinical Health Act
• Part of the American Recovery and Reinvestment Act of 2009
• $17B allocated for incentives for EHR implementation
• Major provisions:• Incentives and penalties• “Certified” EHR Systems• “Meaningful use” of EHR
HITECH Act Provisions*
7* - From HHS.gov
• Physician: Medicare (per Medicaid (per
Implementation in: eligible professional) eligible professional)
• ≤2012 $44K (5 year payout) $64K (6 year payout)
• 2013 $39K (4 year payout) $64K (6 year payout)
• 2014 $24K (3 year payout) $64K (6 year payout)
• 2015 - $64K (6 year payout)
• 2016 Payment adjustment $64K (6 year payout)
• ≥2017 Payment adjustment -
Incentives and Penalties*
8* - From HHS.gov
• Hospital: Medicare (base Medicaid (base
Implementation in: incentive) incentive)
• ≤2013 $2M $2M
• 2014 ≤$2M $2M
• 2015 ≤$2M; Payment adj. $2M
• 2016 Payment adjustment $2M
• ≥2017 Payment adjustment -
• Assures purchasers and users that EHR system will meet requirements for:• Technological capability• Functionality• Security
• For certification, EHR system must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB).
Certified EHR Systems*
9* - From HHS.gov
• EHR must be adopted, implemented, or upgraded.
• Show use of certified EHR technology that can be measured significantly in quality and in quantity:
• Use of certified EHR in meaningful manner (i.e. - e-prescribing)
• Electronic exchange of health information to improve quality of health care
• Submit clinical quality and other measures
• Demonstrating “meaningful use”:
• Professional:
• 3 core and 3 additional clinical quality measures
• 15 core and 5 of 10 meaningful use objectives
• Hospital:
• 15 clinical quality measures
• 14 core and 5 of 10 meaningful use objectives
Meaningful Use*
10* - From HHS.gov
• Strengthens civil and criminal enforcement of HIPAA:
• Four categories of violations that reflect increasing levels of culpability;
• Four corresponding tiers of penalty amounts that significantly increase the minimum penalty amount for each violation; and
• A maximum penalty amount of $1.5 million for all violations of an identical provision.
• Also:
• Strikes the previous bar on the imposition of penalties if the covered entity did not know and with the exercise of reasonable diligence would not have known of the violation (such violations are now punishable under the lowest tier of penalties); and
• Provides a prohibition on the imposition of penalties for any violation that is corrected within a 30-day time period, as long as the violation was not due to willful neglect.
Security Provisions*
11* - From HHS.gov
• Restricts selection to approved vendors• Offers incentives for early adopters (and
penalties for late adopters)• Increases penalties associated with security
breaches and data management risks• Requires investment in quality information
collection processes and security protocols
Impact on EHR Implementation
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EHR Implementation Considerations
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EHR Advantages andDisadvantages
14
Advantages• Reduction of errors
(information transfer, cross-checks)
• Data mining capacity
• Decision support for streamlined workflows
• Immediate information availability
• Single record (for hospital or practice)
• Potential mobility (?)
Disadvantages• Initial investment (software,
hardware, internal staff, consultants)
• Ongoing support costs (internal staff, hardware, upgrades)
• Transition friction
• Data entry time
EHR Promoters and Inhibitors
15
Promoters• Change readiness
• Physician engagement
• Regulatory requirements
• Planning and preparation
• Adequate support availability
Inhibitors• Lack of incentives
• Impact on productivity and efficiency
• Lack of standardization
• Cost of transition
• Changes to workflow
Interactions and Trade-offs
Transition Friction and Inefficiency
16
1.Slow acceptance and efficiency improvement
2.Fast acceptance and efficiency improvement
• Physician engagement
• Workflow development
• Support mechanisms
3.Efficiency improvement and leverage
• Template set-up
• Tablet use
• Dictation software
• Further workflow improvements
Eff
icie
ncy
Time
Implementation
20-30%22
11
33
Integration
17
• EHR enters as an technology initiative
• Leverage of the EHR occurs through improved processes
• Adoption and utilization of the EHR occurs through people
• All are needed for successful implementation and return on investment
People Process
Technology
EHR
Leveraging Patient Data
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• Patient EHR:
• Continuity and availability of information
• Hospital workflows:
• Application of clinical rule-sets
• Triggers for orders and actions
• Data Mining:
• Ease of case review and comparison
• Discrete data availability
Patient Electronic
Health Record
Hospital Workflows
Data Mining (Education
and Research)
Data
Data
EHR Implementation at USF Health
19
• Mission: To improve life by improving health through partnership, research, education and healthcare
• 3,500 team members of educators, staff, physicians, researchers
• Over 420 physicians, 135 allied health, and 70 nurse practitioners
• 2 new out-patient buildings with imaging and an ambulatory surgery center
• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay• $350 million enterprise
USF Health Overview
20
USF Health: EHR Timeline
2006 2007 2008 2009
21
• Vendor selection
• Planning
• Workflow development
• IT platform upgrades
• Initial go-live• Rolling
department go-lives
• Continued department go-lives
• v11 upgrade
• Workflow improvements
• Tablet roll-out
Initial investment
22
Workflow Design: Deployment of New Technology or Facility
Create Future State
Identify Workflow
Develop Organization
Build Specifications
• Collect voice of customer
• Describe future state
• Identify design principles
Operational Mechanisms: Interdisciplinary Executive Team and Workflow Design Teams with change management skills
• Map current process
• Build future process maps
• Identify gaps/ constraints and needed actions
• Conduct walk-through
• Identify tasks and assign to positions
• Create organizational structure
• Build job descriptions
• Map layout
• Identify technology requirements
• Develop protocols/ policies
22
23
• Fully e-enabled scheduling and check-in:
• Ability to schedule appointments, check-in, pay co-pay (or balances), and input health status information
• Check-in ticket print-out and streamlined on-site process
• All patient care occurs in exam rooms:
• Triage, assessment, treatment, and scheduling of appointments occur in the exam room
• Phones and computers in each exam room
• One-stop shopping:
• Referrals and procedures routinely go to USF Health
• System and service level supports high availability of appointments (immediate, space available, scheduled)
• Additional services (x-ray, lab, ancillary) are completed at time of appointment they were identified as a need
Design Principles
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Processes:• Pre-Appointment
• Arrival/Check-in
• Paper Scanning
• Provider Actions
• Other Media Routing
• Patient Visit
• Protocol Driven Test
• CCS Post-Visit
• Academic Secretary Post-Visit
• Point-of-Service Test
• PSR Check-out
• CCC check-out
• Messaging and Tasking
• Results Verification
Processes (continued):• No-Shows/Same Day Cancellations• Nurse/Tech Visit• Correspondence• Provider Actions
Standardization opportunities:• Positions and abbreviations• Greenie Construction• Exam Room Flags• Orders and Routing Options• Provider/Designee Delivery• Test Classification• Internal Referral Appointment Needs
24
Workflow Evaluation: Initial Identification
25
CCS monitors IDX for arrived Patients specific to supported Provider (CCC acts as back-up monitor)
CCS observes arrivalCCS confirms Exam Room availability
Patient moves to Clinical Entry Point
CCS collects Pager and drops into Pager Collection Point inside Clinical Entry Point
CCS collects Greenie and escorts Patient to Exam Room
CCS flags Exam Room “CCS Intake”
CCS identifies appropriate Pager number of arrived Patient and trips Pager
CCS starts AllScripts note
CCS identifies brief Chief Complaint/Reason for Visit and enters data into AllScripts
CCS takes Vitals and enters data into AllScripts
CCS moves to appropriate Clinical Entry Point, greets Patient, and confirms identity
25
Standardized Workflow: PatientVisit
26
Clinical Floor Design and Flow
Floor Guide greets Patient and fast pass checks in, or directs to kiosk or PSRPSR checks-in Patient, receives co-pay, and receives history and releasesPatient selects waiting areaMA accompanies Patient to exam roomMA completes vitals and history; Physician provides care; MA schedules follow-on appointmentsMA escorts Patient to clinic exit and farewells
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USF Health: EHR Timeline
2006 2007 2008 2009
• Vendor selection
• Planning
• Workflow development
• IT platform upgrades
• Initial go-live• Rolling
department go-lives
• Continued department go-lives
• v11 upgrade
• Workflow improvements
• Tablet roll-out
IT Upgrade
Train Design Support
• Install computers/ printers
• Check platforms
• Provide basic training
• Identify specific needs
• Set-up templates
• On-site support
• Transition to phone support
27Implementati
on
Form: Past Medical History
28
Change Aid: Provider Instruction Trifold
29
After Action Review: Issue and Action Plan
30
Data Entry Optimization
Other staff enters data into EHR
Physician types into EHR
Physician uses dictation service
Physician enters data into discrete fields in template
Physician utilizes voice recognition
software
• Good use of staff• Limited potential for transfer of
workload
• Control• Familiarity with process• Poor use of Physician time
• Quick data entry• Dictation cost• Requirement to check dictation
• Quick data entry• Supports ease of research• Requires template set-up and some
standardization
• Quick data entry• Immediate check of dictation• Initial cost and training
• Purchasing:• Select system based on reasonable expectation of need
• Planning:• Create roll-out plan for technology, training, and process actions
• Expect transition friction and temporarily reduce scheduled patient load
• Physicians:• Engage early and often
• Consider a physician champion
• Workflow:• Plan on changes where technology, people, and process intersect
• Consider standardization based on best practices before transition
• Communication:• Provide updates often through multiple channels
Key Learning's: USF Health Transition to EHR
32
• Completion: All entries finished in total at time of service
• Communication: Ease of access to information and appropriately routed
• Compliance: Meets all regulatory requirements
• Quality: Information is of value
The 4C’s of the EHR*
* - Dr. Lennox Hoyte, USF Health CMIO 33
Thank you for your time.
Questions?
34