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

2. Preparation & Implementation Today’s Presentation  Medical Records  Medical Clinic  Lab  PHN  PCC & Billing  PHN/Community Health/ Diabetes  CAC/Computer Support

3. Medical Records Process  When to stop pulling the chart  Filing notes in chart during the transition?  Print And File Chart Copies? Batch Print?  Release Of Information?  Outside Consults? Scanning?  Transcription

4. Medical Records Supervisory Process Changes  Daily Report: Unsigned Orders  Daily Report: Unsigned Notes  Retracting /Correcting Incorrect Entries  Paper P&P changed to Electronic P&P  Sensitive Pt Tracking  Medical Records Supervisor: Business rules/HIPAA Who can view which parts of EHR Who can view which parts of EHR Works cooperatively with RPMS Site Manager Works cooperatively with RPMS Site Manager

5. Medical Records Staff Changes at Warm Springs  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 Staff will be utilized to scan documents once VistA Imaging is implemented Staff will be utilized to scan documents once VistA Imaging is implemented

6. Medical Clinic Preparations  Formed Teams  Practiced EHR (on paper)  Defined Roles  Computers everywhere

7. Medical Clinic Process  Using templates/graphs instead of flow sheets  Using the scheduling gui for visual routing of pt flow  Selecting ICD/CPT codes  Using GUIs: Ward Order Lab Entry Ward Order Lab Entry RCIS RCIS Behavioral Health Behavioral Health Scheduling Scheduling

8. 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

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

10. Objectives for this Session  Role Changes  PCC Data Entry Coding Process  Error Report  Communication  New Coding Queue

11. Role Changes  Coding & Data Entry are a combined position.  Instead of 2 data entry clerks, we have 70 data entry providers who encode data.  Auditor  Educator

12. PCC Coding Process  Coders are assigned days. (ODD/EVEN)  Coding/Auditing from a coding queue  We code from EHR/RPMS not the chart  Corrections communicated to provider via notification (demonstration)

13. PCC Error Report  Daily Error Reports should be run  Most Common Errors: Missing POV Missing POV Missing E&M Code Missing E&M Code.9999 - Uncoded diagnosis (Separate Report).9999 - Uncoded diagnosis (Separate Report) 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

14. Coding Queue Coding Queue  Paperless list on RPMS that shows every visit for a specific date range, that have not been audited by the coder.  Pros No more VGEN lists (only for research purposes)No more VGEN lists (only for research purposes) Everything is there.Everything is there. Flag errors & incomplete chart notes.Flag errors & incomplete chart notes.

15. PCC-Business Office Communications  Bills are generated before PCC has reviewed the visit. Communicate with Business Office. What can they bill? What can they bill?

16. Questions?

17. Business Office Process  Services Pick List Development, Installation, And Training  No Hard Copy To Work With  No more missing E&M Codes  EHR Notes Are Legible  Great Opportunity For Improved Provider Documentation & Increase Billing/Collections

18. Preparation/Implementation CAC

20. Elapsed time (in months) Decision to implement EHRReview EHR Website 0 Complete EHR Site Survey Begin EHR Site Tracking Record Begin hiring process for CAC Establish EHR Implementation Team Attend Lessons Learned classRPMS current, CACHE Begin pharmacy drug file cleanup for Pharm 5/7 * Begin procurement process for hardware Install PIMS Optimize “Point-of-Service” RPMS Packages Optimize PCC Error Reports Install/configure Radiology 5.0, Lab 5.2 Install Pharmacy 5/7 and EHR GUI Implement Paperless Refill Attend CAC training On-site Setup with Nat’l EHR Team EHR Super User training EHR Go-Live with Nat’l EHR Team Full rollout 123581061112 24 Please note that this is just a general timeline of how long it might take for your site to implement EHR. Every site will be different, and the amount of time it takes to implement EHR depends upon many factors, including size of the facility, services offered at the facility, current state of RPMS and packages installed and utilized. EHR Planning & Implementation * Most sites contract for external resources to complete pharmacy file preparation. Implement Adverse Reaction Tracking package

21. Step 1: Submit Site Survey

22. Step 1-Site Survey

23. Step 2: EHR Site Tracking

24. Implementation Team Administrator/Executive Leadership Administrator/Executive Leadership Clinician Clinician Nurse Nurse Pharmacy Pharmacy Medical Records Medical Records Billing/Coding Billing/Coding Information Technology staff Information Technology staff Clinical Application Coordinator Clinical Application Coordinator

25. Implementation Team Roles  Monitor and Execute Implementation Plan  Identify and define Policies and Procedures  Address staffing and scheduling during transition  Peer Training & Marketing  Design and Approve EHR Menus, templates,etc

26. Identify Clinical Applications Coordinator (CAC)  Works cooperatively with Site Manager  Coordinates Implementation  EHR User Support  Training  Customize Software  Workflow  Portland Area CAC: Bob Adams R.Ph.

27. Help Desk Requests Warm Springs Computer/Cac Department

28. 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

29. Implementation- Hardware/Infrastructure upgrade  RPMS server  Backup/Training server  Thin Clients, laptops, pcs?  Network  Lab Interface Upgrade  Workstation Access-Everywhere  Backup Power

30. Costs Associated with EHR  Workstations Laptops, tablets, pc, thin clients Laptops, tablets, pc, thin clients  Ergonomic Support  Backup Server  Backup Generator  Clinical Applications Coordinator GS 12  Training costs  Software-$0.00

31. EHR Costs  Staff coverage  Travel  Computers: 1 per room 1 per room 1 per provider 1 per provider Extras in ward area Extras in ward area

32. Ballpark Timeline  Scheduling Software (PIMS) Scheduling application-improved Scheduling application-improved Has a Windows based component Has a Windows based component Sensitive Patient Tracking feature Sensitive Patient Tracking feature  Radiology 5.0-after PIMS  Pharmacy 5/7-needs to be scheduled with ITSC Allow several months for file preparations Allow several months for file preparations Adverse drug reactions :1 month (4 staff)Adverse drug reactions :1 month (4 staff) RPMS/Scriptpro Format :1-2 days (2 Staff)RPMS/Scriptpro Format :1-2 days (2 Staff) Dosages in Pharmacy 7: 1 week (2 Staff)Dosages in Pharmacy 7: 1 week (2 Staff) Quick orders : 2 weeks (2 Staff)Quick orders : 2 weeks (2 Staff)  Installation of EHR client – after Pharmacy  EHR Set-up; Site visits - after Pharmacy  Go-live – 3-6 months after Pharmacy

33. EHR Setup  Customize order menus Lab, Pharmacy, Radiology Lab, Pharmacy, Radiology  Setup Referrals/Consults  Progress Note Templates Design our own Design our own Share with other sites Share with other sites  User Setup  ICD/ CPT Pick Lists

34. EHR beforeConfiguration EHR before Configuration

35. EHR after Configuration

36. Preparation-Customizing Orders

37. Preparation-Customizing Templates Templates can be shared with other IHS and VHA facilities More Complete Documentation

38. Training/Marketing  EHR Demo Movie  VA Training Modules Pharmacy Pharmacy CPRS CPRS  ITSC Web-Ex Demo for our clinic  Show and Tell Newsletters Newsletters Web Updates Web Updates Meeting Updates Meeting Updates Email Quizzes Email Quizzes

39. EHR Trainings  EHR CAC & Implementation Team training Must have 5/7 installed Must have 5/7 installed Must have RPMS packages Optimized Must have RPMS packages Optimized  EHR Setup (on site)  Super end user training (on site)  Go Live (on site assistance from OIT)  EHR for Techies, EHR for Inpatient, EHR for HIM and Business Office  http://www.ihs.gov/CIO/EHR/index.cfm?module= rpms_ehr_training http://www.ihs.gov/CIO/EHR/index.cfm?module= rpms_ehr_training http://www.ihs.gov/CIO/EHR/index.cfm?module= rpms_ehr_training

40. Going Live Week

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

42. 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-Email training More Training-Email training

44. Next Steps  Reminders  VistA Imaging  Voice Recognition  Electronic Dental Record

45. Questions?