EMR:IMPLEMENTATION LESSONS LEARNED THE HARD WAY

Paul Kaye, MDMedical Director

Hudson River HealthcareNovember 2005

Hudson River Healthcare 12 practice sites in 5 counties 42 primary medical care providers 130,000 visits/year Urban, migrant, homeless, public

housing, and Ryan White funding JCAHO 1998, 2001, 2004 Diabetes, HIV, Prevention Pilot

Collaboratives

EMR Project History 1999 Initial Contact with vendor and

software developer 2000 Beta test site agreement Initial site:Adult Medicine at main site

Server on site Integration with practice management system Desktop PC in all exam rooms and provider

offices Computer readiness survey

EMR Project History Initial group: 6 providers Results: 2 proficient providers, 2

reluctant providers, 2 hapless souls 2001: Pediatrics-Peekskill

Wireless laptops used Higher cost per PC but less

needed;overall hardware cost the same

EMR Project History Results: 2 proficient providers, 2

reluctant providers, 2 hapless souls

2001: Pediatrics-Peekskill Wireless laptops used Higher cost per PC but less

needed;overall hardware cost the same

EMR Project History Pediatrics implementation

successful Less efficient because of previous

use of checkoff sheets Time savings for physicals, school

immunization sheets 2003 test: Tablet computer

EMR Project History 2002-3 3 sites added, wireless setup Server at main site Connectivity issues surfaced Rapid training and provider use Pre-entered problem lists, long term

medications, immunizations Implementation schedule formalized

EMR Project History Additional sites added in 2003-5 New Start 2005 opened with EMR 3 sites wired and awaiting rollout Lingering Issues

Interface with labs Interoperability with local countywide

network Dual use of EMR and PECS

Choosing an EMRIt’s the Support not the Product

Contract IssuesClinical ExpertiseCompatibilityCompany

Choosing an EMR

Check interfaces with existing software-ask to see working examples

Buy it ready made-customizing is hard

EMR: Myths

Less paperwork… yes but longer data entry time

Easier Information Retrieval… but that means more information to retrieve and address

Cost Savings-only in your dreams

IT Implementation Issues Network Structure Hardware Selection and Placement Network Reliability Internet Connectivity Redundancy Technical Support Software Support

Network Structure Client-Server Thin Client Citrex (multiple sites) Consider ASP Model

Hardware Selection

Little hardware leadership from vendors They will support multiple platforms as a

marketing issue Initially--providers chose devices

“If they choose it they will use it" didn't succeed costly to support

Now--IS selects hardware if it works, they will use it

Hardware Issues Tablet/Wireless/Wired/Thin Client Printer Location Nurses Station Placement within Exam Room

Wall vs Countertop

More IT Issues

Reliability EMR needs higher level of reliability

and less down time than business functions

Change of midnset for IT support staff as well as planning for redundancy

Connectivity Need T1 level connection; DSL, cable

inadequate

Training Issues

Rate-limiting step Keep the user’s

perspective Start with easier

functions

Solve problems, don’t automate them

Workflow discussion should proceed training

Develop a schedule and STICK TO IT

Training Issues

Users missing basic computer skills Delete key, tab key, back key

Typing skills

holds back team training and whole implementation

Training Approach

Work closely with vendor Support Staff

Train first or concurrently 2-4 hours

Clinicians 2 weeks training

AM and PM sessions AM Classroom, PM Live

2 weeks followup support

Clinical Implementation Avoid Democracy-Embrace

Dictatorship Set clear expectations

3rd visit:Medications and problem lists 5th visit: Full Medical History

Preload some information Pediatric Immunizations

Clinical Implementation Issues

Don’t automate a bad procedureRethink information flowRethink nursing and support

staff rolesRethink how to capture

information

Clinical Implementation Issues

Letters Referrals Templates LabCorp interace Registry interface Reports mobile access

Scanned document input

Patient access Specialty services

mental health nutrition dental

Clinical Implementation Issues

Template DevelopmentIndividual vs organizationalAgreement on Standardized UseProcess for Review

Database UpkeepPharmaciesSpecialistsAccess

Leadership Issues Senior Leadership Responsibility EHR key part of Strategic Plan Initial and Ongoing Funding Information Management Issues

Redefine Medical Records role Security and Password Management HIPAA Compliance

Resource Issues

Dedicated clinician time to develop functionality

Anticipate decreased productivity during implementation-between 1 and 3 months

Ongoing training costs-new providers, more detailed functions, new processes

Administrative Issues

Exercise rigorous oversight of all consultants/vendors

Identify responsible parties for issues and track to resolution

Provide feedback on usage to staff and Board

Administrative Issues

Leverage consultants for necessary expertise, including strategy development if needed

Recruit/retain CIO type expertiseDon’t underestimate workflow and

organizational changes