1. Successful Implementation of Centricity EMR in an Academic Family Medicine Department Don Clothier Frank Lawler, M.D. Jim Cacy, Ph.D.

2. Presentation objectives: l On completion of this lecture-discussion the participants should be able to: List factors related to choosing an EMR Discuss key factors in successful Centricity EMR implementation List strengths and weaknesses of Centricity EMR software Discuss general principles of EMR implementation in a residency program

3. Why an EMR? l Longstanding interest Lawler F, Cacy JR, Viviani N, Hamm RM, Cobb SW. Implementation and Withdrawal of a Computerized Medical Information System. Journal of Family Practice 1996;42:233-236.

4. Why an EMR? l AAFP/RRC recommendations l Enhance resident recruitment in a competitive environment l Enhance patient care l Enhance patient safety

5. EMR Readiness l Culture l Individuals l Financial l Technical

6. EMR Selection Considerations l Initial Purchase/Lease Cost Hardware cost Software licenses Ongoing cost

7. EMR Selection Considerations Software capabilities Prescriptions Lab interface Network function Dictation Size of practice Hardware requirements Rating schemes CCHIT AAFP

8. EMR Selection Procedures Contact the vendors Take a test drive What’s included/What’s optional Compute total cost w/various options Do not believe anything a salesperson says without independent verification Avoid Versions 1.0 (or 1.x)

9. Which EMR for OUDFPM? l Previous failed implementation Lawler F, Cacy JR, Viviani N, Hamm RM, Cobb SW. Implementation and Withdrawal of a Computerized Medical Information System. Journal of Family Practice 1996;42:233-236. l Enterprise decision by university physicians administration l Lack of political power l Under-represented on ?key committees l CCHIT? l AAFP/FPM etc. reviews/surveys

10. OU DFPM l Describe program l Personnel 13 MD faculty, 5 Ph.D. 8 PA Faculty 36 residents One sports medicine fellow One emergency medicine fellow l 54,000 outpatient visits annually l Active inpatient and OB services

11. Structure of implementation l OUHSC environment 400 physicians Specialty oriented Academic Medical Center l Choice of EMR l Previous implementation of Centricity and expertise in rural site and urban sister program l Jumped the Implementation Queue

12. Process of implementation l Key factors Timeline Preloading problem, medication, and allergy lists Extensive training of clerical, nursing, and clinicians Workflow diagrams Phased implementation Started w/Faculty Only clinics 6-7 different clinics, new one brought on-line q 2 wks

13. Key factors l Patience l Commitment We will do this We will do it to the best of our ability l Positive attitude l Leadership enthusiasm progress promise/potential benefits by example l Give no viable alternatives (a la Hernando Cortez) “Burn the ships”

14. Key factors Flexibility Teamwork and Communication “Firepersons” in each clinic during implementation Frequent (weekly) staff meetings to discuss issues Frequent (weekly) physician/PA meeting Both weekly meetings unstructured, rambling Solicit buy-in Discuss key, critical issues “Weekly Reader” Independence Project manager issues

15. Key factors Costs Hardware/software computers user fees Lab interface hospital interface Decreased patient flow for several weeks ?Improved “level of service” billing Net for FY was ~2% in patient numbers and clinical revenue over prior year

16. Key factors Resident supervision issues Identification of attending physician Completion of charts and sign-off of labs/test Residents facile w/ computers Residents love EMR access from hospital, L&D, and home Needed NPI to allow labs to flow to resident desktop Changed workflow for referral authorization/oversight

17. Key factors Computer Lo-jack Missing computer found Document scanning Our process set model for whole campus Access from home/hospital for clinicians Uses VPN Enables clinicians to get home/work from home

18. Key factors l Expected/projected psychological phases of EMR implementation (with apologies to Kubler-Ross)* Excitement/Anticipation “the Wall” (at 3-6 months) “the Plateau” (at 6-12 months) Acceptance (one year) Full Competence (two years) *Your mileage may vary

19. Implementation Dos l Create a healthy department/environment Get everybody involved Easier said than done Allot sufficient time for training l Decrease patient numbers for 2-3 wks during implementation l Create a strong implementation team l Anticipate complaints and deal with them calmly and objectively

20. Implementation Dos l Mark McCormack Hire people smarter than you are Leave them alone l Accept input from everyone A key scanning innovation came from an unexpected (but not unlikely) source l Solicit consensus when possible l Turn the screws when necessary Outstanding charts (paper and EMR)

21. Implementation Don’ts l Don’t assume you know how an employee should adapt the EHR to their job l Don’t skimp on training l Don’t go-live on a Monday or during flu season l Don’t turn on an EMR function without extensive testing and piloting l Don’t expect everyone to use the EMR in the same way.

22. Implementation Don’ts l Don’t create a lot of custom clinical content Use standard forms and encounter types. Beg, borrow, steal (but you get what you pay for) Sister programs A good lab-letter form from one Fairly useless clinical content that required considerable political capital (from another) Listserv http://www.centricityusers.com/Mail%20List Users group http://www.centricityusers.com/Forum

23. Implementation Don’ts l Don’t cater to special groups/situations We’re all in this together We don’t have time, skill, expertise, or money for special projects or forms, etc. l Don’t scrimp on hardware; you need the best you can afford Physician laptops Wireless network

24. Things we did right l Set expectations l Insist on training l Preload problems, meds, allergies into EMR l Bring clerks up first l Pull charts for first 3 visits on EMR

25. Things we could have done better l Lab interface slow to develop l ?Aids to physician/PA documentation

26. Rank Aspects of Software l Ease of use user interface frustrating, not intuitive (0-1/4 stars) Comprehensive menus (3/4 stars) Incomplete diagnosis pick lists (3/4 stars) Phone messages (4/4 stars) Prescriptions (4/4 stars) Flag system (4/4 stars) Locked-in syndrome (frozen computers, 0/4 stars) Now rare

27. Current status l Ongoing issues Rank hardware Pen tablets (don’t use pen function or tablet mode due to formatting problems) Very reliable and durable Some buttons too easy to push (e.g., wireless) 4.5/5 stars Wireless capability Surprisingly robust 5/5 stars Network reliability Very robust Unscheduled down time about 25 minutes over a period of ten months (until a fateful Monday when it was down all day). Have a disaster plan ready; use it

28. Current Headaches l Time in documentation by physicians/PAs Exploring options Dictation CCC-VRI (computer) Transcribed and entered into EMR Scribe? l Other

29. Pending tasks l Facilitate documentation by clinicians Dictation Macros/Quick text l Scanning of patient-completed Scantron(c) type forms Over 50 available types w/cheap customized forms available Huge upside potential

30. Pending tasks l Implement reminder/preventive services system OSIIS interface PSRS l Two-way physician-patient communication Kryptiq patient portal E-mail Patient completion of forms on-line

31. Pending projects Patient portal Orders modules Referrals Done and works fairly well Lab X-ray E-prescribing

32. Applications of EMR l Identify QI issues/problems Diabetic patients not on ACE inhibitors Aspirin use for CAD patients List of patients on Avandia l Large demand for QI projects Integrate w/PQRI

33. Ratings Benefits and Hassles of EMR (four point scale) l UserBenefitHassle l Clerical Staff l Billing Staff l Nursing Staff l Physicians/PAs l QI Personnel none l IT Personnel

34. Bottom line l Lots of work and money l Current benefits Problem, med, and allergy lists improved handling of phone messages legibility and ease of prescription initiation and refills document management l Future benefits Improved interface Ease of data queries and analysis

35. Recommendations l Start with a healthy department l Have low expectations l Expect 2 year time frame l Be flexible l Be positive l Hire crackerjack IT personnel/dept. l Don’t skimp on hardware l Preload Problems, Meds, Allergies

36. Bibliography l Lawler F, Cacy JR, Viviani N, Hamm RM, Cobb SW. Implementation and Withdrawal of a Computerized Medical Information System. Journal of Family Practice 1996;42:233- 236. l Cacy JR, Lawler F, Viviani N, Wells D. The sixth level of electronic health records: a look beyond the screen. MD Computing 1997; 14:46-49. l http://www.aafp.org/fpm/20080200/25user.html Edsall RE, Adler KG. User Satisfaction with EHRs: Report of a Survey of 422 Family Physicians. Fam Pract Mgmt February 2008; 25-32. http://www.aafp.org/fpm/20080200/25user.html l McCormack MH. What They Don't Teach You at Harvard Business School. Bantam, 1985. l Dunn CL, Nelson R. The EMR, Part 3 of 5: Communicating Change to Ensure Successful Implementation. Primary Care Quarterly, 1Q, 2008:47-48. l Dunn CL, Nelson R. The EMR, Part 4 of 5: What Steps to Take Once the System Is Implemented. Primary Care Quarterly, 2Q, 2008:11-15.

37. Bibliography Lowes R. Keys to a successful EHR rollout. Medical Economics July 4, 2008, pp 46-56. l http://www.centricityforspecialty.com/cddemos/demogens.h tml http://www.centricityforspecialty.com/cddemos/demogens.h tml l Block BM. How we improved our practice and our bottom line with a new EMR system. Fam Pract Management July/August 2008:25-30. l Sterling, Ronald. Keys to EMR Success: Selecting and Implementing an Electronic Medical Record. Paperback, 253 pages ISBN: 0-9814738-1-4 $129.00 $9.95 S&H