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Roadmap to Success in a Rural Local Health Department Deb McCullough DNP, RN, FNP Gordon Mattimoe RN, MSN, FNP 6/5/2013.

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Presentation on theme: "Roadmap to Success in a Rural Local Health Department Deb McCullough DNP, RN, FNP Gordon Mattimoe RN, MSN, FNP 6/5/2013."— Presentation transcript:

1 Roadmap to Success in a Rural Local Health Department Deb McCullough DNP, RN, FNP Gordon Mattimoe RN, MSN, FNP 6/5/2013

2 AdvantagesDisadvantages Improved patient safety and efficiency (immediate access to up-to-date patient information in the office or remote access). 1 Require back-up systems to prevent data loss, user computer skills, can delete information inadvertently if record is not locked, requires extensive training. 2 Improved office efficiency (multiple staff can access the record simultaneously, no lost time searching for or retrieving records, only staff with access rights can view the record, legible record, and promotes a more consistent and thorough approach to documentation). 1 EHRs are not standardized, more difficult to use than paper records, implementation decreases productivity and disrupts workflow (in the beginning). 2 Potential financial benefits (clear, timely, legible documentation). 2 Cost. EHR benefits society and payers not providers, physician resistance. 2,3 Cultural resistance and inertia; vendor product immaturity, legal and regulatory benefits; and required infrastructure and lack of standards. 3

3 Steps to Select EHR conducted a needs assessment ◦ Staff  FTEs: 2 FNPs, 3 RNs, and 5 clerical  Contract: MD, 2 NPs ◦ Health services  Public health  Primary health care  Family planning  Immunizations  STD/HIV/TB

4 Steps to Select EHR ◦ Funding sources  County  DSHS grants  Medicaid/CHIP/WHP/Medicare ◦ Billing  Electronic immunization, family planning, Medicare ◦ Special needs  communicate with DSHS when possible  immunization inventory, billing, and upload to ImmTrac

5 Who is an Eligible Professional under the Medicare EHR Incentive Program? Eligible professionals under the Medicare EHR Incentive Program include: ◦ Doctor of medicine or osteopathy ◦ Doctor of dental surgery or dental medicine ◦ Doctor of podiatry ◦ Doctor of optometry ◦ Chiropractor

6 Who is an Eligible Professional under the Medicaid EHR Incentive Program? Eligible professionals under the Medicaid EHR Incentive Program include: ◦ Physicians (primarily doctors of medicine and doctors of osteopathy) ◦ Nurse practitioner ◦ Certified nurse-midwife ◦ Dentist ◦ Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant. To qualify for an incentive payment under the Medicaid EHR Incentive Program, an eligible professional must meet one of the following criteria: ◦ Have a minimum 30% Medicaid patient volume* ◦ Have a minimum 20% Medicaid patient volume, and is a pediatrician* ◦ Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals * Children's Health Insurance Program (CHIP) patients do not count toward the Medicaid patient volume criteria.

7 Steps to Select EHR Workflow analysis ◦ Organizations’ current structure  Paper appointment, medical record, and billing ◦ Workflow progression ◦ Patient flow  Documented patient and staff activities from check- in to check-out Changed clinic set-up and processes

8 ACHD Workflow Analysis

9 Workflow Analysis with EHR

10 Steps to Select EHR Hosted (Cloud computing) vs onsite system ◦ ease of use; ◦ immediate availability of software updates; reduced start-up expenses; ◦ vendor provided system redundancy, back-up, privacy and security; 7 and the LHDs limited IT support and expertise. The limitations of a hosted EHR system ◦ Internet connectivity and potential downtime

11 Steps to Select EHR Evaluated multiple vendors for meeting meaningful use and national certification regulatory requirements

12 Staff Expectations Decrease medication errors Provide a better mechanism for updating the medication list Eliminate physician’s handwriting issues Reminders to patients per patient preference for preventive/ follow up care Improve preventive care services provided and compliance with clinical guidelines Meet national EHR goals Meet meaningful use and clinical decision support (CDS) criteria Reduce administrative and reporting burden Retrieve files and sort medical records Gather and help analyze data Improve prescription process, patient safety, and workflow management Conduct clinical quality improvement (QI) research Provide clinical decision support (CDS) Enhance practice management (integrate scheduling, billing, and coding)

13 Steps to Select EHR Involved staff in EHR selection and implementation EHR demonstrations ◦ 3 online ( WTHIT REC) ◦ I onsite demonstration (LHD with eCW)

14 Successful EHR Implementation People skills (leadership, communication, and training) Articulate vision Actively involve staff and MD in pre- implementation planning phase Example of non-participation in EHR selection

15 Organizing Framework Step 1: learn basics of EHR Step 2: conduct workflow analysis, compare paper and EHR processes, identify EHR champions Step 3: determine appropriate EHR based on budget and work flow needs, purchase EHR. Step 4: implementation phase – changing from paper to electronic

16 Implementation Steps Formed a team to complete the 15-week pre-implementation tasks Recruited based on job descriptions and potential contribution to the team Met weekly answering these questions ◦ What did we accomplish? ◦ What are the next steps? ◦ List things to do? ◦ What went well? ◦ What didn’t work? Team determined criteria for successful EHR implementation

17 ACHD Criteria for Successful Implementation Live with an EHR by October 1, Eliminates paper charting and generates minimal paper forms to add to the EHR. Uses the EHR to its best capacity as determined by reassessing and streamlining workflow processes. Meets the Stage 1 meaningful use criteria by November, ◦ January 22, 2013.

18 Meaningful Use Certificate

19 Implementation Steps Reviewed equipment and technical requirements Workflow needs and space requirements ◦ Computer on wheels in each clinic room, staff can face patient, or use computer where needed in the clinic

20 Implementation Steps Reviewed processes, conducted workflow analyses, and established redesign strategies. For example, to avoid transitioning ACHD’s dysfunctional Medicaid Texas Health Steps (THS) paper process to an electronic format, the staff redesigned and streamlined the documentation.

21 Staff Training Attended Crossroads Conference 2011 ◦ Meaningful use, patient safety, ◦, e-Prescribing, medication reconciliation, and CPOE 4 day vendor training ◦ Demonstrations and hands-on practice time for front office, RN, provider, and billing staff. End of day meeting to address clinic policy questions and identify how-to questions eCW assigned ACHD a strategic account manager and access to online chat for how- to-questions

22 Lessons Learned Encourage and promote continual improvement and workflow redesign

23 PDSA Cycle Carry out the plan Summarize what was learned Change or test Determine what changes are to be made ActPlan DoStudy

24 Clinical Decision Support (CDS) Systems provide tools to deliver intelligently filtered, appropriately timed, and actionable information to patients or clinicians.

25 Promote Continual Improvement Immunizations ◦ Didn’t understand how all the components (EHR, billing, inventory) worked together.

26 Inventory and Billing

27 Billing


29 Order Sets

30 CDS/Alerts

31 Documentation in EHR

32 Work Flow

33 Workflow Interface with ImmTrac EHR interface with the statewide immunization registry (ImmTrac) is not automatic. For more information: trac/attestation.shtm ACHD is waiting on eCW to set-up the interface.

34 Reminder/Recall Schedule appointments for the next vaccine ◦ Phone call reminders from the system Enroll immunization only patients in the patient portal – sends an and provides access to immunization record Form letters for appointment missed For vaccine recall – easy to pull patients who received the vaccine

35 Lessons Learned - EHR facilitated and improved the immunization program’s administrative and clinical processes. - Workflow analysis with all staff increased understanding of the system and individual role within the program. - Adding the vaccine history to the EHR versus scanning records improved provider assessment of vaccine needs at all clinic visits. - Adding CDS influenza and tetanus alerts decreased adult vaccine missed opportunities.

36 Lessons Learned - Adding order sets decreased immunization documentation time. - Scheduling patients for follow-up vaccine visits aided in reminder and recall (phone calls prior to appointment and letters sent to no-shows). - Adding the vaccine record to the patient portal increased patient access to records.

37 Diabetes Goal: To meet the diabetes standards of care.

38 Diabetes Minimum Practice Recommendations Complete H&PInitial visit and at clinician’s discretion Diabetes EducationInitial visit and at clinician’s discretion Medical Nutrition Therapy Initial visit and at clinician’s discretion Exercise CounselingInitial visit and at clinician’s discretion

39 Diabetes Minimum Practice Recommendations Psychosocial CounselingInitial visit and at clinician’s discretion Lifestyle/Behavior Changes Counseling Initial visit and at clinician’s discretion Smoking Cessation /Alcohol reduction Weight/Height/BMIEvery visit BPEvery visit Foot Inspection Visual inspection for skin and mail lesions, calluses, infection Every visit

40 Diabetes Minimum Practice Recommendations Oral/Dental InspectionEvery visit Growth and Development (Children) Every visit Aspirin/Antiplatelet Prophylaxis Every visit A1c2Every 3-6 months Kidney evaluationType 2: initial visit and annually Dilated funduscopic eye exam Type 2: initial visit and annually

41 Diabetes Minimum Practice Recommendations Oral/Dental ExamAnnually or as needed Foot exam Complete foot exam and neurologic assessment Annually or as needed Lipid ProfileAnnually if at goal otherwise every 3 – 6 months Immunizations Influenza Td Vaccine Pneumococcal Vaccine Childhood Immunizations According to CDC

42 Order Set - Meds

43 Order Set

44 CDS/Alerts

45 CDS/Alerts

46 Flow Sheet

47 Lessons Learned Determine scanning policy Scan enough of the chart to avoid pulling paper charts Adopt standardized nomenclature to access and retrieve the scanned data quickly Pre-EHR plan laborious and time consuming. Final policy ◦ HX, medication list, immunization record, past year of progress notes, and lab/x-ray reports

48 Lessons Learned Decrease patient load post-implementation. Some processes should model existing paper practices ◦ 1 per hour, took 2 hours for HX ◦ Cumbersome EHR process ◦ Paper HX provided structure ◦ Resolved issue by arranging EHR format to replicate paper HX form

49 Lessons Learned Repetitively encouraged staff to report EHR problems or write on a flip chart 6 months after implementation nurses identify EHR issues quickly and strive to redesign to improve efficiency ◦ Eg, lab billing for in-house and referral lab

50 Lessons Learned New users embrace the EHR more rapidly if it is easy to use and meets their needs System flexibility is important Created templates for Texas Health Step visits, family planning physical exam, STD visits, health risk assessment and preventive health education Blood sugar and waist circumference added to the vital sign section

51 Lessons Learned Select a flexible electronic system, and ◦ Ability to add component eg well child history, exam ◦ Building DX codes ◦ Treatment (ease of attaching the diagnostic code to lab or imaging, referrals) ◦ Medication reconciliation (easy to list all the meds under correct diagnosis)

52 Lessons Learned Pre-implementation policies not transferred to post implementation state Staff adhered to how-to as learned in the vendor training, focused on technology and not their clinical expertise and knowledge Observe staff using EHR and identify barriers, challenges, and mechanisms for improvement to avoid staff frustration, work-around and necessity to unlearn behaviors

53 Lessons Learned Interfaces require IT

54 Summary Successful EHR implementation and use involves: ◦ gaining leadership, stakeholder, and end-user buy-in; ◦ using a step-by-step process; and ◦ matching the selected EHR’s capacity to the staffs’ perceived benefits.

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