Performance Improvement within an EHR (El t i H lth R d)EHR (Electronic Health Record)

Launch

WCBF Lean Six Sigma Healthcare SummitMay 2011

Louis C. Rhodes

Purpose and Learning Objectives

Purpose: Introduce basic principles of an EHR

p g j

Purpose: Introduce basic principles of an EHR launch and how Lean-Six Sigma experts can contribute to its success

Learning objectives:• Describe HITECH Act and EHR related impactp• Identify key concepts associated with EHR

implementation• Describe points at which Lean-Six Sigma experts

can support EHR design and launch

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Key Questions/Issues

• The HITECH Act mandate that health care

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The HITECH Act mandate that health care entities must implement EHR's by 2015 or face monetary penalties in the form of reductions in Medicare reimbursements.

• What is “meaningful use of electronic health records”?

• The role of Lean Six Sigma in the EHR d l tdeployment process

• Crucial decisions that result in successful EHR adoption and a oidance of e pensi e EHRadoption and avoidance of expensive EHR mistakes

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Lou Rhodes, MBA, MBB

• Administrator, New York University (Department of Obstetrics and

, ,

Gynecology)• Graduate of United States Military Academy (BS Management –

Engineering) and Xavier University (MBA)• General Electric Certified Black Belt and Master Black Belt in Six

Sigma and Lean• Eleven years experience in Six Sigma Lean and ChangeEleven years experience in Six Sigma, Lean, and Change

Management roles:• Two years chemical industry (Millennium Chemicals)

Four years in healthcare equipment and service delivery (GE• Four years in healthcare equipment and service delivery (GE Healthcare)

• Five years academic healthcare (USF Health and NYU School of Medicine)Medicine)

• Expertise in curriculum development and skills transfer to clients4

Agenda, Ground Rules, and E t ti• Agenda:

Expectationsg

• HITECH Act provisions• EHR implementation considerations• EHR implementation at USF Health

• Ground rules:• Informal environment• Maintain speed• Limit cell phone use• Limit cell phone use• Anything else?

• As a group describe expectations for this sessionAs a group, describe expectations for this session.

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HITECH Act ProvisionsHITECH Act Provisions

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HITECH Act Provisions*

• Health Information Technology for Economic and

HITECH Act Provisions

Health Information Technology for Economic and Clinical Health Act

• Part of the American Recovery and yReinvestment Act of 2009

• $17B allocated for incentives for EHR implementation

• Major provisions:• Incentives and penalties• “Certified” EHR Systems• “Meaningful use” of EHR

7* - From HHS.gov

Incentives and Penalties*• Physician: Medicare (per Medicaid (per

Implementation in: eligible professional) eligible professional)

Incentives and Penalties

Implementation in: eligible professional) eligible professional)• ≤2012 $44K (5 year payout) $64K (6 year payout)• 2013 $39K (4 year payout) $64K (6 year payout)• 2014 $24K (3 year payout) $64K (6 year payout)• 2014 $24K (3 year payout) $64K (6 year payout)• 2015 - $64K (6 year payout)• 2016 Payment adjustment $64K (6 year payout)• ≥2017 Payment adjustment -

• Hospital: Medicare (base Medicaid (base Implementation in: incentive) incentive)

• ≤2013 $2M $2M• 2014 ≤$2M $2M• 2015 ≤$2M; Payment adj. $2M

8* - From HHS.gov

$ ; y j $• 2016 Payment adjustment $2M• ≥2017 Payment adjustment -

Certified EHR Systems*

• Assures purchasers and users that EHR system will meet

Certified EHR Systems

p yrequirements for:• Technological capability• Functionality• SecurityFor certification EHR s stem m st be tested and certified• For certification, EHR system must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB).

9* - From HHS.gov

Meaningful Use*

• EHR must be adopted, implemented, or upgraded.

Meaningful Use

• Show use of certified EHR technology that can be measured significantly in quality and in quantity:• Use of certified EHR in meaningful manner (i.e. - e-prescribing)Use of certified EHR in meaningful manner (i.e. e prescribing)• Electronic exchange of health information to improve quality of

health care • Submit clinical quality and other measures• Submit clinical quality and other measures

• Demonstrating “meaningful use”:• Professional:

• 3 core and 3 additional clinical quality measures• 15 core and 5 of 10 meaningful use objectives

• Hospital:Hospital:• 15 clinical quality measures• 14 core and 5 of 10 meaningful use objectives 10

* - From HHS.gov

Security Provisions*

• Strengthens civil and criminal enforcement of HIPAA:

Security Provisions

• Four categories of violations that reflect increasing levels of culpability;

• Four corresponding tiers of penalty amounts that significantlyFour corresponding tiers of penalty amounts that significantly increase the minimum penalty amount for each violation; and

• A maximum penalty amount of $1.5 million for all violations of an identical provisionidentical provision.

• Also:• Strikes the previous bar on the imposition of penalties if the covered

entity did not know and with the exercise of reasonable diligenceentity did not know and with the exercise of reasonable diligence would not have known of the violation (such violations are now punishable under the lowest tier of penalties); and Pro ides a prohibition on the imposition of penalties for an iolation• Provides a prohibition on the imposition of penalties for any violation that is corrected within a 30-day time period, as long as the violation was not due to willful neglect. 11

* - From HHS.gov

Impact on EHR Implementation

• Restricts selection to approved vendors

Impact on EHR Implementation

Restricts selection to approved vendors• Offers incentives for early adopters (and

penalties for late adopters)p p )• Increases penalties associated with security

breaches and data management risksg• Requires investment in quality information

collection processes and security protocols

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EHR Implementation Considerations

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EHR Advantages andDi d tDisadvantages

Advantages DisadvantagesAdvantages• Reduction of errors

(information transfer,

Disadvantages• Initial investment (software,

hardware, internal staff, cross-checks)

• Data mining capacityD i i t f

consultants)• Ongoing support costs

(internal staff hardware• Decision support for streamlined workflows

• Immediate information

(internal staff, hardware, upgrades)

• Transition frictionImmediate information availability

• Single record (for hospital • Data entry time

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or practice)• Potential mobility (?)

EHR Promoters and InhibitorsEHR Promoters and Inhibitors

Promoters InhibitorsPromoters• Change readiness• Physician engagement

Inhibitors• Lack of incentives• Impact on productivity and y g g

• Regulatory requirements• Planning and preparation

p p yefficiency

• Lack of standardization

• Adequate support availability

• Cost of transition• Changes to workflow

Interactions and Trade-offs

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Transition Friction and InefficiencyTransition Friction and Inefficiency

1.Slow acceptance and efficiency improvement

2.Fast acceptance and efficiency improvement33• Physician engagement• Workflow development• Support mechanismsen

cy

20-30%22

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• Support mechanisms3.Efficiency improvement

and leverageEffi

cie

Implementation• Template set-up• Tablet use• Dictation software

Time

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• Further workflow improvements

IntegrationIntegration

• EHR enters as an technology initiative

• Leverage of the EHR th hPeople Process occurs through

improved processes• Adoption and

People Process

Adoption and utilization of the EHR occurs through people

Technologypeople

• All are needed for successful

EHR

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implementation and return on investment

Leveraging Patient DataLeveraging Patient Data

• Patient EHR:• Continuity and

availability of information

Patient Electronic

HealthHospital

WorkflowsData

• Hospital workflows:• Application of

clinical rule-sets

Health Record

Workflows

clinical rule sets • Triggers for orders

and actionsData Mining:

Data Mining (Education

• Data Mining:• Ease of case

review and comparison

and Research)

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comparison• Discrete data

availability

EHR Implementation at USF HealthEHR Implementation at USF Health

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USF Health Overview

• Mission: To improve life by improving health through

USF Health Overview

p y p g gpartnership, research, education and healthcare

• 3,500 team members of educators, staff, physicians, hresearchers

• Over 420 physicians, 135 allied health, and 70 nurse practitionerspractitioners

• 2 new out-patient buildings with imaging and an ambulatory surgery center

• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay

$350 illi t i• $350 million enterprise

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USF Health: EHR TimelineUSF Health: EHR Timeline

2006 2007 2008 20092006 2007 2008 2009

• Vendor l ti

• Initial go-live • Continued d t t

• Workflow i tselection

• Planning• Workflow

• Rolling department go-lives

department go-lives

• v11 upgrade

improvements• Tablet roll-out

development• IT platform

upgradespg

Initial investment

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Workflow Design: Deployment of N T h l F ilitNew Technology or FacilityCreate Future Identify Develop BuildCreate Future

StateIdentify

WorkflowDevelop

OrganizationBuild

Specifications

• Collect voice of c stomer

• Map current process

• Identify tasks and assign to

• Map layoutcustomer

• Describe future stateIdentify design

process• Build future

process maps• Identify gaps/

and assign to positions

• Create organizational

• Identify technology requirements

• Develop• Identify design principles

• Identify gaps/ constraints and needed actions

• Conduct walk-

organizational structure

• Build job descriptions

• Develop protocols/ policies

through

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Operational Mechanisms: Interdisciplinary Executive Team and Workflow Design Teams with change management skills

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Design Principles

• Fully e-enabled scheduling and check-in:

Design Principles

• Ability to schedule appointments, check-in, pay co-pay (or balances), and input health status information

• Check-in ticket print-out and streamlined on-site processCheck in ticket print out and streamlined on site process• All patient care occurs in exam rooms:

• Triage, assessment, treatment, and scheduling of appointments occur in the exam roomoccur in the exam room

• Phones and computers in each exam room• One-stop shopping:

• Referrals and procedures routinely go to USF Health• System and service level supports high availability of

appointments (immediate, space available, scheduled)

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pp ( , p , )• Additional services (x-ray, lab, ancillary) are completed at time of

appointment they were identified as a need23

Workflow Evaluation: Initial Id tifi tiProcesses: Processes (continued):

Identification

• Pre-Appointment• Arrival/Check-in• Paper Scanning

• No-Shows/Same Day Cancellations• Nurse/Tech Visit• Correspondence

Pro ider Actions• Provider Actions• Other Media Routing• Patient Visit

• Provider Actions

Standardization opportunities:• Positions and abbreviations• Protocol Driven Test

• CCS Post-Visit• Academic Secretary Post-Visit

• Positions and abbreviations• Greenie Construction• Exam Room Flags• Orders and Routing Options

• Point-of-Service Test• PSR Check-out• CCC check-out

g p• Provider/Designee Delivery• Test Classification• Internal Referral Appointment Needs

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• Messaging and Tasking• Results Verification

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Standardized Workflow: PatientVi it

CCS monitors IDX for

Visit

arrived Patients specific to supported Provider (CCC acts as back-up monitor)

CCS observes arrival CCS confirms Exam Room availability

Patient moves to Clinical Entry Point

CCS identifies appropriate Pager number of arrived Patient and trips Pager

CCS moves to appropriate Clinical Entry Point, greets Patient, and confirms identity

CCS collects Pager and drops into Pager Collection Point inside

CCS collects Greenie and escorts Patient to Exam CCS flags Exam Room

“CCS Intake”Collection Point inside Clinical Entry Point Room CCS Intake

CCS identifies brief Chief

25CCS starts AllScripts note

CCS identifies brief Chief Complaint/Reason for Visit and enters data into AllScripts

CCS takes Vitals and enters data into AllScripts

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Clinical Floor Design and FlowClinical Floor Design and Flow

87

6

53

4

Floor Guide greets Patient and fast pass checks in, or directs to kiosk or PSRPSR checks-in Patient, receives co-pay, and receives history and releasesPatient selects waiting areaMA accompanies Patient to exam room

3

4

5

6

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MA accompanies Patient to exam roomMA completes vitals and history; Physician provides care; MA schedules follow-on appointmentsMA escorts Patient to clinic exit and farewells

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8

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USF Health: EHR TimelineUSF Health: EHR Timeline

2006 2007 2008 20092006 2007 2008 2009

• Vendor l ti

• Initial go-live • Continued d t t

• Workflow i tselection

• Planning• Workflow

• Rolling department go-lives

department go-lives

• v11 upgrade

improvements• Tablet roll-out

development• IT platform

upgradesIT

Upgrade Train Design Supportpg

• Install computers/ printersCheck

• Provide basic training

• Identify specific needsSet up

• On-site support

• Transition to phone• Check

platforms• Set-up

templatesto phone support

27Implementation

Form: Past Medical HistoryForm: Past Medical History

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Change Aid: Provider Instruction T if ldTrifold

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After Action Review: Issue and A ti PlAction Plan

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Data Entry OptimizationData Entry Optimization

Other staff enters • Good use of staffdata into EHR

Physician types i t EHR

• Limited potential for transfer of workload

• ControlFamiliarity with processinto EHR

Physician uses dictation service

• Familiarity with process• Poor use of Physician time• Quick data entry• Dictation costdictation service

Physician enters data into discrete

Dictation cost• Requirement to check dictation

• Quick data entry• Supports ease of researchdata into discrete

fields in template

Physician utilizes

• Supports ease of research• Requires template set-up and some

standardization

• Quick data entryyvoice recognition

software

Quick data entry• Immediate check of dictation• Initial cost and training

Key Learning's: USF Health T iti t EHR• Purchasing:

Transition to EHR

• Select system based on reasonable expectation of need• Planning:

• Create roll-out plan for technology training and process actionsCreate roll out plan for technology, training, and process actions• Expect transition friction and temporarily reduce scheduled patient load

• Physicians:E l d ft• Engage early and often

• Consider a physician champion• Workflow:

• Plan on changes where technology, people, and process intersect• Consider standardization based on best practices before transition

• Communication:• Provide updates often through multiple channels

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The 4C’s of the EHR*

• Completion: All entries finished in total at

The 4C s of the EHR

Completion: All entries finished in total at time of service

• Communication: Ease of access to• Communication: Ease of access to information and appropriately routedC li M t ll l t• Compliance: Meets all regulatory requirements

• Quality: Information is of value

* - Dr. Lennox Hoyte, USF Health CMIO 33

Thank you for your time.

Questions?

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