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Thomas G. Zimmerman, DO, FACOFP, CPHIMS South Nassau Communities Hospital Oceanside, NY
Hospital Demographics 440-bed community hospital in suburb of NYC 1023 Medical Staff 850 Physicians (of which 75 are hospital-employed) 3000 Employees 720 RN’s Dually-Accredited Family Medicine Residency (18) Visiting Residents (OB, Surgery, Peds – total 18) © Thomas Zimmerman, DO, FACOFP, CPHIMS 2
Do your homework!! Thoroughly evaluate the project’s feasibility Preliminary architecture and design specifications “Informed consent” of all stakeholders Consider the financial impact of the project (as well as work-hours involved) Complete EHR, or phased approach Phase 1 – Orders and Results Phase 2 – Clinical Documentation © Thomas Zimmerman, DO, FACOFP, CPHIMS 3
Planning Clarify Project Objectives and Scope Proposed Timeline Cost and Quality objectives Scope of Project Deliverables Verify that all stakeholders agree to these guidelines to avoid confusion, wasted effort or duplication, and/or project failure. © Thomas Zimmerman, DO, FACOFP, CPHIMS 4
Planning Identify a single leader of the project A large steering committee by itself does not allow for personal responsibility and action. CMIO / CIO / VP EMR/HIM should take the lead in monitoring progress and addressing obstacles Steering committee can serve as a resource to the project leader to discuss issues and find solutions © Thomas Zimmerman, DO, FACOFP, CPHIMS 5
Planning Full-Time Project Manager Day to day management, execution, and delivery of the implementation Reports to Project Sponsor / Steering Committee Should have experience with IT implementations © Thomas Zimmerman, DO, FACOFP, CPHIMS 6
Planning Interdisciplinary Implementation Teams Executive Sponsors Department or section leaders Experienced Subject Matter Experts (SME’s) Physicians, IT tech’s, EMR consultants End-users with AND without IT experience Department of Medical Education Residents, students (of all types) © Thomas Zimmerman, DO, FACOFP, CPHIMS 7
Planning Strong Administrative Sponsorship and Involvement Ensures that each implementation team (not just the Steering Committee) has the authority to make decisions that will “stick” Expresses the strong commitment of the hospital for this implementation (to the end-users) Ensures better communication and awareness © Thomas Zimmerman, DO, FACOFP, CPHIMS 8
Planning Core Analyst Team Hire flexible thinkers who have a sense of perspective and a sense of humor – you will need both. Consultants – Caveat Emptor!! Enlist their services judiciously, respect and acknowledge their expertise, but make sure that hospital staff retain ownership of the project Interfaces Lab / Rad / Dietary / Admitting Make sure the time and costs for the development/testing/verification for all of these are appropriately accounted for in negotiations, contract, and scope © Thomas Zimmerman, DO, FACOFP, CPHIMS 10
Identify Risks Technical – interface issues, equipment compatibility issues, delays in upgrades End User Acceptance – resistance to change (computerized physician order entry, medication reconciliation, etc.) Recognize, monitor, and address these risks in a timely manner, and ensure communication between stakeholders (no surprises!) © Thomas Zimmerman, DO, FACOFP, CPHIMS 11
Question the Vendor Don’t accept “it’s hard coded” or “it’s working as intended” Clinicians need to drive the train for patient safety © Thomas Zimmerman, DO, FACOFP, CPHIMS 12
Staffing Concerns Clarify time commitments for staff members involved with the implementation Identify times where their hours will need to be back-filled with other staff to meet daily operational needs If activities will occur after work hours, consider what type of compensation will be provided © Thomas Zimmerman, DO, FACOFP, CPHIMS 13
Review Policies Practice and policies will need to reflect the new world order Don’t feel that you need to “own” the practice of the entire hospital Users will ask you to “make the doctors and nurses do…”. Avoid the temptation! © Thomas Zimmerman, DO, FACOFP, CPHIMS 14
Remember… Everyone still needs to talk Avoid the “illusion of communication” that follows implementation of an EMR © Thomas Zimmerman, DO, FACOFP, CPHIMS 15
Scope Define the scope of the project, and really think it through In-patient only? Out-patient areas? Ambulatory areas vs. Procedural areas? Consider areas that serve a combination of in-patients and out-patients © Thomas Zimmerman, DO, FACOFP, CPHIMS 16
Scope (cont) Will you use niche products in areas such as: Cath Lab Labor & Delivery Suite OR General EMRs are “a mile wide, and an inch deep” while niche products are “an inch wide and a mile deep” © Thomas Zimmerman, DO, FACOFP, CPHIMS 17
Create a detailed project plan Gantt Chart or Excel spreadsheet Document all major outcomes/deliverables Target dates Responsible Sponsor / Resources Approximate work effort Update these tasks as they are completed or delayed/modified © Thomas Zimmerman, DO, FACOFP, CPHIMS 18
Scope Creep The expansion of the project to include additional products/functionalities not originally accounted for in the project plan and/or contract Extra Time / work effort Extra Costs Increased complexity, confusion © Thomas Zimmerman, DO, FACOFP, CPHIMS 19
Change Control Changes to the original software are inevitable; the product must be tailored to suit the individual needs of your organization Be prudent in making modifications to the core software Document all changes in detail: Date of change Reason modification was needed Exact description of the change (in case it needs to be restored after an upgrade) © Thomas Zimmerman, DO, FACOFP, CPHIMS 20
Current State & Future State Design All stakeholders involved – better design, more user acceptance/skills Identify every workflow in every department of the hospital: clinical, administrative, financial. Critically evaluate current policies and procedures, and watch for opportunities for improvement that the EMR may provide Identify key issues / problems created by the EMR Document the future state of operations clearly © Thomas Zimmerman, DO, FACOFP, CPHIMS 21
Sample Workflow Diagram © Thomas Zimmerman, DO, FACOFP, CPHIMS 22
Key ThemeDescription Clinical Excellence – Quality and Outcomes Focus What will the approach be for identifying outcomes as part of the EMR implementation? Which outcomes are of the highest priority? Care Standardization Determines the extent to which care and clinical applications will be standardized. CPOE Strategy This defines the degree to which CPOE will be rolled out as standard practice or policy. Medical executive committee establishes expectations regarding compliance and consequences for physician non-compliance. Clinical Documentation Describes the approach to clinical documentation: what types data will be entered, who will enter it, and how. Clinical Decision Support Describes the approach to the tools that guide real-time clinical decision-making. Future State Design Guiding Principles © Thomas Zimmerman, DO, FACOFP, CPHIMS 23
24 Key ThemeDescription Training Identifies the approach and level of investment for how the hospital addresses staff training for clinical quality improvements to include use of advanced clinical systems. Access Strategy – Remote and Internal This defines the strategy for the placement of devices to enhance adoption and also determines the extent the physician portal and remote access will be utilized. Content Strategy This will define the content strategy (order sets, clinical documentation, and clinical decision support) to ensure system utilization and improve quality and efficiency. Workflow Optimization Redesigning current workflows with EHR as an enabler will allow hospital to maximize the integration of system utilization and clinical workflows. Communication Strategy An institutional communication strategy that outlines the audience, methods, tools and frequency of communication must be developed to improve institutional ownership. Future State Design Guiding Principles © Thomas Zimmerman, DO, FACOFP, CPHIMS
Timeline Nov – Presentations by 2 Vendors Jan-March – Site visits to nearby Hospital using each system July 2010 – Contract signed with Vendor January – May 2011 – Current / Future State Design Sessions August 2011 – Present – Physicians Advisory Group Meetings June 2012: Go-Live! © Thomas Zimmerman, DO, FACOFP, CPHIMS 25
Site Visits Two hospitals with similar demographics Community hospital with residency programs Bed size, service lines, patient population Evaluation Team HIM (VP HIM, EMR Manager, Coding Director) IT (CIO, Network specialist) Financial (VP Finance and staff) Medical Staff (President of Med. Staff, Physician champion) © Thomas Zimmerman, DO, FACOFP, CPHIMS 26
Site Visit Itinerary Presentation by Hospital’s CMIO Divide and Conquer: Medical Team: Floors, ICU, ED, Ambulatory Clinic IT Team: IT dept., floors Finance: Administration, Billing/Coding Coding: HIM department, Billing/coding © Thomas Zimmerman, DO, FACOFP, CPHIMS 27
Core Build Extensive work effort to establish the pharmacy formulary Order sets – Diagnosis Based Core measures (VTE assessment, time to treatment, etc.) Meaningful use measures Convenience Congruent to Paper forms (for downtime episodes) Communication / Workflows for ancillary processes Respiratory therapy, Floor-obtained samples, Codes Discharge Process © Thomas Zimmerman, DO, FACOFP, CPHIMS 28
Pharmacy Build Have a pharmacy build that reflects: Front-end needs, i.e. Physician needs for ease of item selection and understanding of order guidance. Will you build brand name synonyms? Nursing needs for clarity on the orders tab and eMAR Back-end needs Pharmacy needs consistency of build and a full view of the medications ordered and access to the patients’ clinical picture TEST each item from order entry, to dispensing and delivering, to display on the orders tab and eMAR, to medication administration © Thomas Zimmerman, DO, FACOFP, CPHIMS 29
Downtime Plans Have firm downtime plans and tools well before Go- Live Devise a method of running reports in the background that can be printed on demand in advance for a planned downtime, and just in time for an unplanned downtime Patient list by location Orders report with all active, on hold, suspended orders MAR with a list of all medications administered within the prior 48 hours, with a list of all tasks for the next 24 hours © Thomas Zimmerman, DO, FACOFP, CPHIMS 30
Downtime Plans Create a “Meaningful Use Checklist” Ensure all MU measures during downtime are correctly entered during recovery period (backfill) Strongly consider building a redundant database on a local server to be viewable during downtimes/no internet access © Thomas Zimmerman, DO, FACOFP, CPHIMS 31
Training No amount of training is too much!! Combination of delivery methods to account for differences in end-user preferences and schedules Live, classroom-based sessions (at hospital or office) Web-Based Training Modules (auto-tutorial) Remote webinar sessions One-on-one © Thomas Zimmerman, DO, FACOFP, CPHIMS 32
Superusers Essential to have key team members receive extra training and practice with the system Creates a cadre of first-line support at the unit level during Go-Live and thereafter Improves end-user acceptance, they serve as ambassadors of the EMR team Helps identify issues in the system earlier in the process (these people know what works and what won’t work!) © Thomas Zimmerman, DO, FACOFP, CPHIMS 33
Preparing for Go-Live Big-Bang vs. Phased Approach Entire House or Unit by Unit Central Command Center Embed IT and EMR support personnel throughout the building Superusers, hospital IT/EMR staff, vendor support Deploy more staff in busier or more critical units Two weeks minimum, 24/7 © Thomas Zimmerman, DO, FACOFP, CPHIMS 34
Activation Telephone Support Center Have the Informatics team (Level 2 Help Desk) and the IT team (Level 1 Help Desk) share a Telephone Support Center where they handle calls from the users during Go-Live. It will pay off later with increased knowledge and compassion on both sides later Keep detailed logs of all issues (as well as their solutions) © Thomas Zimmerman, DO, FACOFP, CPHIMS 35
Allow for Decreased Productivity Overstaff units (especially ED, ICU, OR, other critical areas of the hospital Consider Go-Live on a weekend, to avoid elective surgeries and imaging procedures (although ED may be busier) If a weekday, reschedule as many elective procedures as possible © Thomas Zimmerman, DO, FACOFP, CPHIMS 36
© Thomas Zimmerman, DO, FACOFP, CPHIMS 37
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