1. IHS EHR Indian Health Service Electronic Health Record COMMUNITY HEALTH PROGRAMS Marge Koepping, RN, MN, FNP IHS Model Diabetes Education Program

2. Objectives  Process changes  Pros and Cons

3. Community Health Programs  Diabetes Program  Public Health Nursing  Nutrition Program/WIC  Community Health Representatives  Maternal Child Health  Community Wellness Team  Behavioral Health / Social Worker

4. EHR & Community Health  EHR oriented towards clinical encounters  Community Health visits may be different: Field Visits Field Visits Group Visits: clinic and community Group Visits: clinic and community Social Services Social Services Case management / coordination of care Case management / coordination of care

5. Process Changes:  All programs and providers need computer access.  Field visits may require portability.  Documenting group education/visits.  Drop in visits vs scheduled visits.  Entering newborns into RPMS.

6. Process Changes:  Case Management - Chart Reviews  Flow Sheets  Protocols, Guidelines, Standing Orders  Consult/Referral Process

7. Pros  Faster Entry of Case Management  Increased Visit Documentation  Increased Communication  Consults Between Departments  Chart Reviews enhanced

8. Cons  Group Visit Documentation  Case Management Communication  Increased Avenues of Referral  Increased visit documentation time  Drop in visit vs scheduled visit

9.  Questions?

10. IHS EHR Indian Health Service Electronic Health Record Lab Betty Hewson, MLT

11. Objectives for this Session  Finishing the Lab Order in RPMS  Lab Only Visits  Lab Process Changes  Pros and Cons

12. Finishing the lab order…..

13. Check for Past, Present and Future Orders in RPMS DATE to begin review: TODAY// (FEB 01, 2005) Test Urgency Status Accession Test Urgency Status Accession -Lab Order # 1662 Provider: RUDD,STEPHEN M -Lab Order # 1662 Provider: RUDD,STEPHEN M BLOOD BLOOD GLUCOSE ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 GLUCOSE ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 Sign or Symptom: : ~For Test: GLUCOSE : ~For Test: GLUCOSE : ~DM II : ~DM II ALT ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 ALT ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 Sign or Symptom: -Lab Order # 1662 Provider: RUDD,STEPHEN M -Lab Order # 1662 Provider: RUDD,STEPHEN M BLOOD BLOOD HB AIC ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 HB AIC ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:44 Sign or Symptom: -Lab Order # 1662 Provider: RUDD,STEPHEN M -Lab Order # 1662 Provider: RUDD,STEPHEN M URINE, CLEAN CATCH URINE, CLEAN CATCH URINALYSIS ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:4 URINALYSIS ROUTINE Requested (SEND PATIENT) for: 02/01/2005@14:4 T+30//March 1, 2005

14. Finishing the lab order in RPMS

16. Or …Look in EHR instead of RPMS

17. Lab Result in EHR

18. Lab Only Visits

19. Lab Process Changes  How does the lab know when the pt is there? Service copy can be printed in lab when the order is signed Service copy can be printed in lab when the order is signed Patients bring a “token” to the window Patients bring a “token” to the window Lab Schedule can be monitored by the receptionist Lab Schedule can be monitored by the receptionist

21. Lab Process Changes  How to handle add on labs  How to communicate the “Signs and Symptoms” (lab pov) to the lab

22. Pros & Cons  Training Issues: Signs and symptoms aren’t always communicated to the lab Signs and symptoms aren’t always communicated to the lab Ordering provider name =Clinician who signs Ordering provider name =Clinician who signs Training the patients Training the patients

23. Questions

24. IHS EHR Indian Health Service Electronic Health Record Radiology Bonnie Baxter, RTR

25. Objectives for this Session  Finishing the Radiology order in RPMS  Process Changes  Pros and Cons

26. Registering the Patient in the Radiology Package

28. Entering the Exam

29. Radiology Reports in EHR

30. Process Changes  Using RPMS Radiology Package  Providers order the exam electronically  Radiology orders print out automatically

31. Pros and Cons  LMP?  Modifiers?

32. Questions?

33. IHS EHR Indian Health Service Electronic Health Record Pharmacy LCDR Jim Gemelas, R.Ph. Chief Pharmacist

34. Objectives for this session  Demonstrate how to finish a prescription order in RPMS  Using EHR in the Pharmacy  Process Changes  Pros and Cons

35. Finishing the Pharmacy Order in RPMS

36. Order prints out in pharmacy and shows in RPMS

41. Stop-review provider note  Provider note- toggle feature RPMS/EHR  Review chart- IHS Pharmacy standards of practice Medication Profile Medication Profile Labs Labs

46. Document Patient Ed- Wellness Tab

47. Using EHR in the Pharmacy Pharmacy Only Visits  Refill template  Anticoagulation template  Outside Rx template  Tobacco Cessation template

52. Paperless Refills

58. Pharmacist will use refill template

64. Pharmacy Process Changes  Pharmacists Finish all new prescriptions Finish all new prescriptions All refills with a note Include screen captures All refills with a note Include screen captures  Pharmacy Technicians No more data entry No more data entry Assemble and batch all prescriptions (ScriptPro) Assemble and batch all prescriptions (ScriptPro) Customer Service- phone calls, initial patient contact Customer Service- phone calls, initial patient contact  Outside Prescription Orders  Printing pharmacy service copies for orders  Printing controlled substances  How to incorporate pharmacy patient signature log  Pharmacy Requirement for Completed/Signed Notes  Pain contract

65. Where are the charts? “I don’t look back darling, it only distracts from the now!” …Edna Mode

66. Pharmacy Pros and Cons  Dislikes- lots of preparation and teamwork! (this was a good process for the clinic! Tidal wave to smooth sailing) (this was a good process for the clinic! Tidal wave to smooth sailing) Providers finishing notes Providers finishing notes Dual system of charts and EHR Dual system of charts and EHR Chronic Medication List in EHR Chronic Medication List in EHR  Likes No charts No charts Better documentation and clinical practice Better documentation and clinical practice  Refill and New prescriptions aren’t always grouped

67. IHS EHR Indian Health Service Electronic Health Record PCC/Coding Krisanne Billy

68. Objectives for this Session  PCC Coding Process  PCC Error Report  Pros and Cons

69. PCC Coding Process  Coding and Data entry is combined position at our facility  Coders are assigned to provider teams  Coding/Auditing from daily reports (VGEN and Audit Report)  We code from EHR/RPMS not the chart  Corrections communicated to provider via notification (demonstration)

70. Demonstration

71. PCC Error Report  Instead of 2 data entry clerks, we have 70 data entry providers who encode data  Daily Error Reports should be run  Most Common Errors: Missing POV Missing POV Missing E&M Code Missing E&M Code.9999 - Uncoded diagnosis.9999 - Uncoded diagnosis Duplicate Visits Duplicate Visits 2 visits created on the same day – have to be merged2 visits created on the same day – have to be merged Dental makes 2 visits that need to be mergedDental makes 2 visits that need to be merged Patch comingPatch coming

72. PCC-Business Office Communications  Bills are generated before PCC has reviewed the visit

73. Pros & Cons  Enjoy Paperless  We don’t have to bring the chart to the provider to fix, we can communicate  Incorrect Patient Selected-easier to fix  Providers cant correct a code after the claim has been approved

74. Questions?

75. IHS EHR Indian Health Service Electronic Health Record Carolyn Johnson & Michele Miller Warm Springs Health & Wellness Center

76. Objectives  Preparation & Implementation  Cost Estimates

77. New Terminology POE – Provider Order Entry POE – Provider Order Entry CAC – Clinical Application Coordinator CAC – Clinical Application Coordinator GUI – Graphical User Interface GUI – Graphical User Interface OE/RR – Order Entry/Results Reporting OE/RR – Order Entry/Results Reporting CPRS – Computerized Patient Record System CPRS – Computerized Patient Record System VueCentric Framework VueCentric Framework Server side applications – roll and scroll; back end applications Server side applications – roll and scroll; back end applications PIMS – Patient Information Management System PIMS – Patient Information Management System TIU – Text Integration Utilities TIU – Text Integration Utilities Vista – Veterans Health Information System & Technology Architecture Vista – Veterans Health Information System & Technology Architecture

78. Preparation/Implementation

79. Implementation-Commitment  Confirmed Leadership support  Tribal Endorsement  Area Office Support  Patient Awareness  Clinician driven

80. Software

81. Ballpark Timeline  PIMS install  Radiology 5.0 install – after PIMS  EHR-Pharmacy 5/7 - needs to be scheduled Requires several months of preparation Requires several months of preparation Pharmacy needs to be used 3-6 months before implementing medication order entry. Pharmacy needs to be used 3-6 months before implementing medication order entry.  Installation of GUI client – after Pharmacy  EHR Set-up; Site visits - after Pharmacy  Go-live – 3-6 months after Pharmacy

82. Pharmacy Preparation  Adverse drug reactions :1 month  RPMS/Scriptpro Format :1-2 days  Dosages in Pharmacy 7: 1 week  Quick orders : 1 week

83. Implementation- Hardware/Infrastructure upgrade  RPMS server  Training server  Network  Lab Interface Upgrade  Workstation Access-Everywhere  Backup Power

84. Implementation Team Members  Clinical Champions from each discipline (lab,rn, rph,md,etc)  Administration/Executive Leadership  Information Technology  Include Area IRM representation  Clinical Application Coordinator

85. Implementation Team Roles Identify and define Policies and Procedures Identify and define Policies and Procedures Address staffing and scheduling during transition Address staffing and scheduling during transition Peer Training & Marketing Peer Training & Marketing Monitor and Execute Implementation Plan Monitor and Execute Implementation Plan Design and Approve templates, menus, and ordering lists for E.H.R. Design and Approve templates, menus, and ordering lists for E.H.R.

86. Project Plan

88. Implementation Strategy Implementation-Who and When  Everyone at once  Lab ordering, then radiology ordering, then pharmacy ordering, then notes  Bring up one team/dept at a time

89. Implementation Sample Schedule

90. Medical Clinic Preparations  Formed Teams  Practiced EHR (on paper)  Defined Roles

91. Lab Preparations All Labs need to be entered in RPMS On-site Labs On-site Labs Reference Labs Reference Labs State Labs State Labs  Computer Access Points  Changing from Esig to EHR

92. DM Program Preparations  Have Good Templates for Diabetes Care Prompts for DM standards of care, DM audit, GPRA Prompts for DM standards of care, DM audit, GPRA Templates for DM ed assessment, Community BP/BS screening Templates for DM ed assessment, Community BP/BS screening  Diabetes Program Referrals  Review forms,flowsheets DM Curriculum flowsheet DM Curriculum flowsheet Case management review form Case management review form Education assessment form Education assessment form

93. Preparation-EHR Configuration  Design templates  Design Menus and Quick Orders Meds, Labs, Rad, Nursing Meds, Labs, Rad, Nursing  Define consults  Pick lists and Superbills  Note Titles  User Setup (keys)  Parameters  Printing Chart Copy and Orders  Print Formats

94. EHR beforeConfiguration EHR before Configuration

95. EHR after Configuration

96. Preparation-Setting up Orders

97. Lab Quick Orders

98. Preparation-Setting up templates

99. Training/Marketing  Staff Training: EHR Demo Movie EHR Demo Movie Pharmacy Training Module: Pharmacy Training Module: CPRS Training Module: CPRS Training Module: National Programs Web-Ex Demo for our clinic National Programs Web-Ex Demo for our clinic

100. Pre-Implementation Training  View Patient data in EHR  Everyone got to Play  Show and Tell Newsletters Newsletters Web Updates Web Updates Meeting Updates Meeting Updates

101. Training – Go Live Week  4-6 hours training outside of clinic  Departmental Trainings  Use Knowledgeable Trainers (IHS/VA)  One-On-One Training Also  Competency Checklists

102. Going Live Week I can’t take it anymore!!

103. How the Week First Goes Growling at CAC’s Crying, gnashing of teeth Excited TGIF Cat in the microwave Excited

104. Going Live  Intense CAC and IT Support  Make Appropriate Scheduling Adjustments  Daily Debriefings…. Procedural Questions Procedural Questions Technical Issues Technical Issues How did it work before EHR? How did it work before EHR? More Training More Training

105. Daily Debriefings MONDAY and TUESDAY of Go-Live Week Tom

107. Miscellaneous Policies/Procedures  Use of personal templates  Template approval process  Use of chat and broadcast

108. Things to Think About  Referral / Consults  Patient Registration: Centralized / Decentralized  People who aren’t using E.H.R. yet- how are they handled?  Handle the missing PCC elements? SHX, colonscopy, refusal,mammogram (offsite)

109. Medical Records Process  When to stop pulling the chart  Filing notes in chart?  Print And File Chart Copies? Batch Print?  Release Of Information?  Outside Consults? Scanning?  Incorrect Entries?

110. Impact on Staffing  Provider support during implementation  Staff shift from Medical Records to other departments : 2 Medical Records are in PCC part time 2 Medical Records are in PCC part time 1 Med rec tech is a nurses aid 1 Med rec tech is a nurses aid 1 Med rec tech is a Benefits Coordinator 1 Med rec tech is a Benefits Coordinator More nurses aids after EHR More nurses aids after EHR

111. Staffing-Clinical Applications Coordinator Duties  Works cooperatively with Site Manager  Coordinates Implementation  EHR User Support  Training  Customize Software  Workflow

114. What does EHR cost?

115. Cost Estimates-WSP

117. Questions?

118. Quality Improvement, Risk Management and Lessons Learned from EHR Michele Gemelas, R.Ph. QI/RM/GPRA Coordinator Warm Springs Health and Wellness Center

119. If there’s one thing we can say about EHR, it’s that it is an enormous, cataclysmic, earth shattering, life altering....

120. AWESOME CHANGE !!! Where the most trivial of things can become deadly projectiles

121. Decreasing the emotional impact of change Communication with providers and patients about any impending change will decrease the number of issues demanding attention during the change. Without communication about every important aspect of the change, expect to hear more from everyone who is affected by the change.

122. Pre-EHR –Communication  Newspaper articles, radio interviews  Flyers to hand out during implementation  Facilitators and greeters  Bulletin Boards For patients For patients For employees For employees

123. Why measure? Michele’s Top 4  #4: If you don’t know where you’re coming from, how will you know if you’ve gone anywhere?  #3: To gain support for the change from those doing the changing (provide reinforcement)  #2: So that you can say the change was bad and we need to re-design, or to rejoice because the change was good.  And…the #1 reason to measure……….

124. You need to monitor and maintain patient safety during implementation!!!!!

125. We can’t measure everything, so how do we select?

126. Consult all departments who will use EHR then:  Create a list of meaningful measurements for each discipline  Chose metrics based on everyday QI rules: high risk, high volume, problem prone  Don’t reinvent the wheel,consult others that have gone before you  Make staff part of this process!!!

127. Remember……. Sometimes, no change in pre- and post-EHR results equals success! Depends on where you started.

128. Subjective Measures/Metrics  Staff satisfaction at various intervals after implementation  Patient satisfaction based on survey  Patient complaints/concerns

129. Objective Metrics  Provider productivity – expect a dip, and plan for this in your staffing  Medication errors – don’t expect improvement until all “old” errors have had time to surface.  Compliance with health maintenance reminders (smoking, various cancer screens, etc.)

130. Provider Productivity

131. Productivity Comparison

132. Pharmacy Medication Errors

133. Objective Metrics  Error reports in PCC-expect an increase Coding – takes time to build the tools and convince providers to use them. Coding – takes time to build the tools and convince providers to use them. Missing E&M codes Missing E&M codes Missing POVs, Providers, Multiple providers Missing POVs, Providers, Multiple providers Data Entry backlog-expect it to increase Data Entry backlog-expect it to increase  Billing backlog-due to data entry backlog Changes in revenue – patience…… Changes in revenue – patience……

134. Pages in the Error Report * Before 26-Apr-04

135. Things We Have Done  Coding tools in EHR Links to coding sites, reference guides, E&M Coder Links to coding sites, reference guides, E&M Coder

136. Things We Have Done (cont.)  Pick Lists ICD-9 ICD-9 Superbills Superbills

137. Things We Have Done (cont.)  Coding training for users (MD,RN,etc)  Provider gets an automatic notification for the missing purpose of visit or E&M Code  Quality Improvement Uncoded Diagnosis Uncoded Diagnosis Provider Audits Provider Audits  Errors are communicated to provider via notifications

138. Objective Metrics  Time Study (before and after)  Discipline specific peer review – use basic criteria to assure that patient care remains appropriate and that all correct data is gathered.  GPRA performance – keep an eye on it, but expect results in 6 months to a year.

139. GPRA Indicators - Flu Vax

140. GPRA Indicators – Pneumovax over 65 y/o

141. GPRA Indicators – Tobacco Use Assessment

142. GPRA Indicators – DV/IPV

143. GPRA Indicator – BMI 2-74 y/o

144. GPRA Indicators – Med Ed

145. Other Improvments – Non-GPRA

146. DM audit impacts:  PROVIDER ENTRY vs. CLERK DATA ENTRY affects the capture of some audit data: DM and Nutrition educationDM and Nutrition education ImmunizationsImmunizations Eye ExamsEye Exams Dental ExamsDental Exams Foot ExamsFoot Exams  HISTORICAL & REFUSED EXAMS and IMMUNIZATIONS train providers/nurses to entertrain providers/nurses to enter review DMS taxonomy to ensure it recognizes both.review DMS taxonomy to ensure it recognizes both.

147. Diabetes QI : Aspirin Therapy EHR Implementation Begins

148. More QI: Diabetes Education Documentation by Provider EHR Implementation Begins

149. Diabetes QI: Annual Eye Exams EHR Implementation Begins

150. Risk Management

151. Every time a person is asked to change their role or a make a change in a process, there are inherent risks. We must quickly identify and eliminate these risks in order to protect patients. Here are examples of the good, the bad and the ugly from EHR.

152. The Good

153. Good Stuff: EHR helps to manage risk by:  Virtually eliminating legibility problems and transcription errors  Increasing the likelihood that information will get into the Medical Record, i.e. significant medical advice (JCAHO and AAAHC standards).

154. Good, continued  Allowing up to the minute information to be accessed from any computer in the clinic, and some computers outside the clinic by private network as well.  Using templates to help decrease opportunity for omissions/errors  And much, much more!

155. Example: Solution to RM Issue Using EHR Template  Erythropoietin (formulary change to darbo)  Complex protocol difficult to follow. Things needing to be addressed include: Adequacy of iron stores important to address.Adequacy of iron stores important to address. Safety issue of overshooting hematocrit targets, screening for symptoms of adverse events required.Safety issue of overshooting hematocrit targets, screening for symptoms of adverse events required. High cost if patient ends up on large doses or Medicare doesn’t cover because patient over targetHigh cost if patient ends up on large doses or Medicare doesn’t cover because patient over target

156. Solution Using EHR Template created to help decrease risk:  used as decision-making tool  charting template that ensures both quality of care and comprehensive documentation for meeting billing requirements.

158. Bad  Dragging labs and vitals into the note and forgetting to address a wildly abnormal value  Documenting your treatment in the note and prescribing something totally different w/o an addendum

159. Ugly  Using EHR to document a QI finding  Using EHR to indicate that you’ve asked a provider to do something a hundred thousand times  Using EHR to identify which GPRA indicator we failed to address  Using EHR to tell IT folks that there is a problem and, by golly they need to come fix it

160. RM issues During EHR Implementation  Be aware that weirdness can happen in the beginning until you figure it out. Monitor ALL your processes and pay attention to ALL end users. This is how you discover problems and fix them!

161. Lessons Learned  EHR implementation does NOT necessarily decrease overall waiting time—we’ll see in February!  People document the darndest things in charts. EHR makes these things more apparent because you can more easily see everything at the click of the mouse.  Every provider has a vastly different slope on their learning curve

162. Lessons Learned - continued  Everyone wants to start the visit! This generates errors.  Doctors, Nurses and Pharmacists are NOT coders  We will always need Data Entry folks, but their roles are changing (more coding and sleuthing)  Having a “table of contents” for notes makes reviewing records more efficient

163. Lessons Learned, Cont’  Case Management and Chart Reviews Templates can be built with objects that pull in the needed data. Also the ability to document patient reminder letters at the same time they are created. Templates can be built with objects that pull in the needed data. Also the ability to document patient reminder letters at the same time they are created. Per Dr. Howard Hays: “Integrated Case Management is in the conceptual development phase at the present time. We hope to have it available for general use in about a year. It will be available either in the traditional RPMS format or as a component of the EHR.” (December, 2004) Per Dr. Howard Hays: “Integrated Case Management is in the conceptual development phase at the present time. We hope to have it available for general use in about a year. It will be available either in the traditional RPMS format or as a component of the EHR.” (December, 2004)

164. Lessons Learned, continued  Flow Sheets –why is a flow sheet needed and is it still an issue with EHR? Ex: erythropoietin- same information entered on a flow sheet is available to view in EHR. Ex: erythropoietin- same information entered on a flow sheet is available to view in EHR. Notes with continuous addendums can sometimes take the place of a flow sheet. Notes with continuous addendums can sometimes take the place of a flow sheet. Use note titles to be able to retrieve related visits- may eliminate the need for a flow sheet. Use note titles to be able to retrieve related visits- may eliminate the need for a flow sheet.  Protocols, Practice Guidelines, Standing Orders – can be addressed by using templates that contain decision trees as with darbopoeitin (Aranesp).

165. Take home message  EHR is no different than the paper record. It is the legal document that will go to court when things go wrong. It is important to monitor regularly what is going in the record. Charting mantras that have not changed: If it wasn’t documented, it wasn’t done If it wasn’t documented, it wasn’t done Just the (pertinent) facts, Jack Just the (pertinent) facts, Jack

166. Quality Improvement, Risk Management and Lessons Learned from EHR Michele Gemelas, R.Ph. QI/RM/GPRA Coordinator Warm Springs Health and Wellness Center