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HIT Handbook

1. 34 Continuing to Update Improve and Add Functionality sssssissisossssnssssnccassevenevssssnnsssosvvsasseossnanes 34 Predictors Of SUCCESS 34 35 Examples and General 37 Appexdix A Vendor Evaluation 1 4 1 41 1 1 1 assa sesso tnos 38 Appexdix B Practice Assessment for EMR eene enne 46 Appexdix C Computer Knowledge Evaluation Form 54 INTRODUCTION The HIT Implementation Handbook is a resource guide for coaches facilitators and practice personnel charged with facilitating EHR implementation The Handbook outlines the essential steps necessary for successful EHR implementation Practice analysis and assessment Practice transformation Attention to organizational culture change processes and team formation HIT selection acquisition implementation achievement of meaningful use The Handbook provides a resource for facilitating the practitioner s exploration of the HIT implementation process by Outlining the entire HIT implementation process Identifying references a
2. Oe aE 6 Set up 1 s Mme SESSEL mee SESSEL e mee SESSEL EE 1 meme EE ESSE B LLL 5 s CT RN SESSEL Maintained by vendor 4 d Hours of live contact Why should we select your company Pe o Ye Ne u How you improve some of our office inefficiencies problems Did the vendor offer options and solutions to our problems Additional Comments APPENDIX Michigan Primar Care nsortium APPEXDIX Practice Assessment for EHR Acquisition Assessment Demographics and Implementation of Electronic Health Records Clinic Acumentra Health Consultant if appropriate Date of Completion Assessment Completed By Title Phone Clinic Medical Director Email Clinic Executive Director Email Clinic Office Manager Email Clinic Phone Number Clinic Fax Number Clinic UPIN Clinic Address Physical Champion who will Lead your EHR Effort Physician Participates Name UPIN
3. ECL 7 LLL EE s Evene ECL ECL s emend ECL ECL B xm C ECCE ECL Demo d Comments ee x hewmen EL PP OR Midas EL LLL B eere EL B Behpmiedage EL B menm EL a Peine EL Atowed aneumbynswer EL Cedere CP fi EL EE mme Meiner Ress Bom SESSEL LLL Mee 8 Flag active vs inactive 9 Example of aged insurance list 10 Generate collection letters EL E S CE DES wesmns aS ES ___ NEN PP B 3 Hmm EL LLL a EL s LLL t EL PPP ihre coreapbynentvyenome ff oi emend ____ ok emer CELL EL
4. 19 DIL E 20 Implementation Plan for Achieving the Future State Rp Ek Ee Len 20 Access Current Hit for Interoperability Interfacing 1 1 2 21 HIT EHR Structure and Planning ssccccccsscssssscscesccsscsssccscsscssssccssesssscsscsssescsscsesssssscssosossees 22 Continuous Improvement 22 CONTENTS A 1M Consortium La IS TS CI Po 23 IT Management Support for Infrastructure eee ente nen nennen nahen totns asas e eo tnnn 23 Key Implementation Processes 1 esee ee eene en nenne teen nannte sesso sees sa asse eo 24 HIPPA Specifications 26 Inter and Post Implementation ee eee ee eene eee enean tots assa 30 Meaningful Use M 3l Achieving Meaningful Use 3l Meaningful Use Criteria Regulations Published in NEJM July 13 2010 ees 32 Steady State and Ongoing 1 1
5. 146 666 673 Martin W 2007 Quality models selecting the best model to deliver results The Physician Executive May June 2007 24 31 Nelson E Splaine M et al 1998 Building measurement and data collection into medical practice Ann Int Med 128 460 466 Trisolini M Aggarwal J et al 2008 The Medicare physician group practice demonstration lessons learned on improving quality and efficiency in health care The Commonwealth Fund IMPLEMENTATION ichigan Primar Care Consortium IT MANAGEMENT SUPPORT FOR INFRASTRUCTURE Management support for infrastructure includes providing HIT training trouble shooting problems assuring adequate technical support and identifying clear roles for team members including the administrative champion physician champion and technical champion Identify a Project Manager The Project Manager will oversee and successfully deliver all components of the implementation The manager will need to accurately forecast and manage the budgeted funds set aside for the combination of projects and refine implementation and contingency plans Identify Key Team Members Identify individuals within the practice to contribute to the implementation process These individuals will ultimately take on the role of subject matter experts once the implementation project management team has completed its work This may or may not be the Office or Practice Manager Identify Contractual Re
6. CULTURE ALIGNMENT The culture of the organization can make or break HIT implementation Engage in ongoing assessment of the organization s alignment with HIT objectives and its openness to change As with any change process the involvement and support of senior leadership is imperative Senior leadership includes the board of directors executive directors and or chief executive officer Senior leaders provide the vision and priorities included in such a change VISION FOR CHANGE The vision serves as a roadmap to change and plots out the direction the organization needs to head in order to achieve the desired change Employees must share and support this vision and leadership should use the vision to guide the development of strategies to achieve quality objectives Staff should have realistic expectations regarding the introduction of HIT the purpose for implementing HIT how that will change the way staff functions how implementation of HIT will improve patient care etc KEY PLAYERS Gaining the support of key players and assisting each to carry out their important roles is crucial to success See Roles and Responsibilities for Information Systems Management and Support and OCHIN Implementation Expectations The Board and Leadership Need to Take an Active Role in the Process e Primary stakeholders buy in to the need for HIT e the buy in of clinical leadership such as the medical director and director of nursing Senior Leadership
7. Health care professionals can contact M CEITA for neutral unbiased information about HIT products and to receive subsidized consulting services to assist EHR implementation M CEITA services include System screening and selection support Group purchasing Project management Implementation preparation and oversight Practice and workflow redesign Meaningful use planning and support The agency for Health Research amp Quality AHRQ has devoted 260 million to projects that constitute a real world laboratory for examining HIT at work For more information check the webpage and HIT brochure at http healthit ahrq gov portal server pt community health it brochure 670 LA Consortium _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ 3 Tre rf 1 m RTT 6 Str ct re of the HandDoOK cu 6 Hit Implementation Flow Diagran ccsssssscscsssssscsscssssessssscesssssssscssssesssssssssssessesseeses 7 Engagement 8 Setting HIT EHR COBIGCEVES ________ _ _ _____ __ OM V 8 Assessing Readiness for the Hit Implementation Change 9 Practice Assessment 4 eee ee ee eee eee eee nonae e e senos aa aa sete tea tese eee sess sas 10 Pract
8. Name UPIN Name UPIN Name UPIN Answer all questions from the perspective of the entire patient population Estimated number of active patients 2 Average number of patient visits per day for entire clinic Medicare FFS Managed care Commercial 3 Average number of patient visits per day per provider 4 Estimated percentage of patients with chronic disease s 5 Are there any unique characteristics about the patients seen in your clinic Example large obstetrical patients x are ESL patients etc Number of exam rooms Number of exam rooms per provider Physicians FTEs Number Total number of mid level professionals by category Nurse practitioners Physician assistants Other e g nurse specialists pharmacists Medical records staff FTEs Number Who supports it In house staff External IT support 2 Number of treatment procedure rooms 2 Which specialists are represented and how many physicians in each Primary care internists Family physicians Other Mid level professionals NP PA FTEs Number Medical assistants FTEs Reception staff FTEs Number 10 In house IT staff if applicable Name Main job description Number of hours Other arrangement External IT support if applicable 12 Other staff positions please enter all that apply Do you use a company An individual Administration FTEs Number Company name Medical records
9. use of electronic medical records barriers and solutions Health Affairs 23 116 126 Shachak A Hadas Dayagi M et al 2008 Primary care physicians use of an electronic medical record system a cognitive task analysis Gen Int Med 24 341 348 Examples and General References and Resources Aarts J Koppel R 2009 Implementation of computerized physician order entry in seven countries Health Affairs 28 404 414 Adler Milstein Bates D Jha A 2009 US Regional health information organizations progress and challenges Health Affairs 28 483 492 CHCE 2006 It takes a region creating a framework to improve chronic disease care Chen C Garrido et al 2009 The Kaiser Permanente electronic health record transforming and streamlining modalities of care Health Affairs 28 323 333 Clancy C Anderson K White J 2009 Investing in health information infrastructure can it help achieve health reform Health Affairs 28 478 482 Dimitropoulos L Rizk S 2009 A state based approach to privacy and security for interoperable health information exchange Health Affairs 28 428 434 Friedman M Schueth S Bell D 2009 Interoperable electronic prescribing in the United States progress report Health Affairs 28 393 403 Grossman J Zayas Caban T Kemper N 2009 Information gap Can health insurer personal health records meet patients and physicians needs Health Affairs 28 377
10. FTEs Number Service arrangement hours or specific services Billing FTEs _____ Number Transcription FTEs _____ Number Insurance FTES Number Laboratory FTEs Number X ray FTEs Number Phyical therapy FTEs 2 Other FTEs Number Do you routinely have residents Do you conduct staff meeting meetings of doctors other clinical staff support staff administration Yes No Yes No If yes in average how many at a time If yes Weekly Bi monthly Monthlp How often Other please specify Other please specify If yes to 14 what are some of the discussion topics check all that apply Workflow Revised procedures Patient satisfaction Customer Service Interesting media cases Chronic disease Other 1 Patients seen without the medical chart How much time is spent daily on inefficient tasks estimate in minutes or percentage of time for each Number of patients category Percentage of patients By administration By clinical staff 3 Telephone calls to patients per day 4 Telephone calls to patients per day by MD NP PA Number of calls initiated per day Percentage that require chart pull Number of calls initiated by MD NP PA Percentage that require chart pull 5 Telephone calls to patients day by nursing staff 6 Workflow issues that cause the greatest problems in your office check all that apply Number of calls initiated by nurses Medi
11. average time it takes to pull a chart 2 Who pulls the charts 3 What is the process for locating a lost or misplaced chart 4 Average number of calls from others e g other physicians pharmacists insurers per day requiring a chart pull None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 5 Do you employ contract for a transcription service Yes No If yes what is the average turn around time for a dictation to be translated If yes what are your monthly transcription costs Do you have problems or concerns around coding On average how many referrals are made to a speicalist eack week What types of manual referrals logs if any are maintained by the clinic Do you currently create reports or use a registry method to manage patients with similar conditions Yes No If yes what is the source of information If yes what do you do with the data 3 What reports would you like to see generated from an EHR 6 What are other reasons aside from above that cause a chart to be pulled 2 How does the referral process work in your clinic Do you generate key clinical reports to help providers manage their practice Yes No Describe the type of clinical reports What is the source of information Are there any plans for significant change with the clinic in 2 Is there any other information you feel the Acumentra the next few years e g growth
12. week for prescription issues None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 4 On average how many calls each week do you or your staff make to the lab about lab reports None 5 10 Less than 5 Greater than 10 6 Average number of radiology orders per day None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 8 Average number of new non refill prescriptions per day None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 10 Average number of REWRITTEN prescriptions per day e g for change of pharmacy or drug coverage None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 12 To what extent are any of the above order and or results automated through an interface 13 What is your biggest challenge with pharmacy services 14 Does your practice use an electric registration Laboratory services Radiology services scheduling and or billing system Pharmacy Electronic patient registration Yes No If yes which system Radiology Electronic scheduling Yes Laboratory If yes which system Electronic system Yes If yes which system Which systems interface with an EHR Registration Scheduling 15 If you do not have an electonic billing system what is your current method of billing Average claims turnaround time from submission to payment Average time from billing to payment 1 What is the
13. 2 Assigned Security Responsibility Required Implementation Specification Identify the security official who is responsible for development and implementation of the policies and procedures required by this subpart for the entity 3 Workforce Security Standard Implement policies and procedures to ensure that members of its workforce have appropriate access to EPHI and to prevent those workforce members who do not have access from obtaining access to EPHI Authorization and or Supervision Addressable lmplementation Specification Implement procedures for the authorization and or supervision of workforce members who work with EPHI or in locations where it might be accessed Workforce Clearance Procedures Addressable lmplementation Specification Implement procedures to determine that the access of a workforce member to EPHI is appropriate Termination Procedures Addressable lmplementation Specification Implement procedures for terminating access to EPHI when the employment of a workforce member ends 4 Information Access Management Standard Implement policies and procedures for authorizing access to EPHI that are consistent with the applicable requirements of this standard e Isolating Healthcare Clearinghouse Function Required Implementation Specification Implement policies and procedures that protect the EPHI of the clearinghouse from unauthorized access by the larger organization Access Authorization Addressable Implementati
14. 389 Hawn C 2009 Take two aspirin and tweet me in the morning how twitter facebook and other social media are reshaping health care Health Affairs 28 361 368 Kahn J Aulakh V Bosworth 2009 What it takes characteristics of the ideal personal health record Health Affairs 28 369 376 Koss S et al A Collaborative Partnership Resources to Help Consumers Patients and Families PCPCC Maro J Platt R et al 2009 Design of a national distributed health data network Ann Int Med 151 341 344 Mostashari Tripathi M Kendall 2009 A tale of two large community electronic health record extension projects Health Affairs 28 345 356 Examples and General References and Resources continued Paulus R Davis Steele 2008 Continuous innovation in health care implications of the Geisinger experience Health Affairs 27 1235 1245 Pawlson LG Barr M et al 2009 PCMH Vision to reality PCPCC Silvestre Sue V Allen J 2009 If you build it they will come Kaiser Permanente model of online health care Health Affairs 28 334 344 Tripathi M Delano D et al 2009 Engaging patients for health information exchange Health Affairs 28 435 443 Trisolini M Aggarwal J et al 2008 The Medicare physician group practice demonstration lessons learned on improving quality and efficiency in health care The Commonwealth Fund www commonwealthfund org Unive
15. Compliance Additional emphasis should be placed on the compliance activities of any and all third party business associates Please note that addressable implementation specifications are not to be interpreted as optional implementation standards The HIPAA Security Rule is designed to be flexible vendor neutral and scalable Administrative Safeguards Rule Security Management Process Standard Implement policies and procedures to prevent detect contain and correct security violations Risk Analysis Required Implementation Specification Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality integrity and availability of EPHI held by the CE Risk Management Required lmplementation Specification Implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level identifying selecting and implementing controls countermeasures reporting and verification to achieve an appropriate level of risk at an acceptable cost Sanction Policy Required lmplementation Specification Apply appropriate sanctions against workforce members who fail to comply with the security policies and procedures of the CE Information System Activity Review Required lmplementation Specification Implement procedures to regularly review records of information system activity such as audit logs access reports and security incident tracking reports
16. Health Michigan Primary Care nfo rm atio n Consortium Technology Implementation in Primary Care Practices Supporting Patient Centered Care MPCC Handbook 2011 HIT Implementation Workgroup Members Ernest Yoder MD Workgroup Chair Central Michigan University College of Medicine Joe Dylewski ATMP Consulting Group Dave Morin Cielo MedSolutions LLC Neal Colburn Michigan Primary Care Association Bruce Wiegand Michigan Primary Care Association Diane Nardon Oakland Physician Network Services Chris Geottes GlaxoSmithKline Pharmaceuticals Don Nease MD University of Michigan Health System Department of Family Medicine John Casey PRISM Susan Moran MDCH Medicaid Joe Fortuna MD PRISM Carol Callaghan MDCH Division of Chronic Disease and Injury Control Dana Watt Michigan Primary Care Consortium Editor John Cahill Dana Watt This handbook was designed by the Michigan Primary Care Consortium Health Information Technology Workgroup to guide organizations through the complex processes associated with successful implementation of health information technology HIT Interest in adopting electronic health record EHR technology has intensified for many primary care practices and hospitals as a result of Federal level initiatives through the U S Department of Health and Human Services Office of the National Coordinator for Health Information Technology ONC The American Recovery an
17. Should Secure the Support of Clinical Leadership Find champions for the project and allow them the autonomy to move the project forward e Identify a comprehensive transparent strategic planning process The Strategic planning team should be composed of members of the board and staff members e Medical director buy in will help secure the buy in from physicians because training models rely heavily on peer to peer models physicians are more apt to accept change from other physicians Create Improvement Teams at Every Level of the Organization from Top to Bottom Allows the change process to include the greatest number of people Infrastructure supports information flow decision making and problem resolution Develop Collaboration with External Organizations Develop a list of lessons learned from other organizations who have adopted an EHR e Schedule site visits with organizations that have adopted an EHR Utilize the Regional Extension Center as a reference Obtain Staff Input When Making Decisions inclusiveness Communication amongst all staff Provide regular status updates on project processes and progression Create a Plan to Address Naysayers Find champions within the organization and utilize them to enhance the change process TEAM FORMATION Developing strong teams and a culture that is supportive of HIT implementation is crucial for success Start with an assessment of team members current HIT skill knowledge Identify t
18. TER AND POST IMPLEMENTATION SUPPORT Even with the best of planning up front it is still necessary to continually update and improve the system and to add functionality Upgrade system to add functionalities Make workflow enhancements Change system configurations Address specific problems such as too many clicks to access a form pop up fatigue or slow response time A MEANINGFUL USE Michigan 3 Primary Care Consortium ACHIEVING MEANINGFUL USE Organizations wishing to take advantage of government incentive programs for EHR adoption need to be certain the products they acquire can meet meaningful use standards Consideration should be given to Product evaluation Evolving meaningful use definitions HIT optimization Public health reporting Meaningful use reporting CURRENT PROPOSED METRICS 2011 Stage Functions e Lab results delivery e E prescribing for physicians Claims and eligibility data Quality and immunization reporting CPOE for 10 of hospital orders Ability to generate patient list by condition and patient reminders and clinical summaries for each encounter Ability to generate problem lists Ability to perform medication reconciliation Ability to provide access to patient specific education Maintain allergy lists and perform drug interaction checks Provide patients with electronic access to their information e Conduct or review a security risk analysis in ac
19. ad and save a file Reload a page Reference Duvel C amp Pate S 2003 Computer knowledge Report from a Student Self Evaluation Journal of Industrial Technology 20 1 1 16 Michigan Primar Care Consortium
20. and Analysis Plan Use data throughout the implementation to determine if your project is achieving desired results or if adjustments are needed e Ifyou are lacking information that would be useful for your implementation project add measures that will provide the needed data SELECTION HARDWARE STRATEGIES AND NEEDS DETERMINATION Getting ready to select a product involves delving a little deeper into practice needs and the business case W Assess IT Governance Strategic alignment aligning IT operations with the enterprise Value delivery ensuring that IT delivers the promised benefits e Risk management ongoing assessment of potential IT risks e Resource management optimal investment use and allocation of IT resources such as people applications technology facilities data e Performance measurement tracking project delivery and monitoring IT service using measurable goals Asses Needs e Include clinical staff in this process e Conduct a detailed walk through of the practice Determine the goals of the project outline strategic goals Indentify current processes and workflow Determine gaps between future and present Define How Workflow Will be Impacted by Each Functionality or Tool If Define Where Workflow Could be Enhanced by HIT Consider the Downstream Effects All the Way to the Patient Determine if the EHR Wish list is Financially Feasible Asses HIT Infrastructure Needs Cur
21. ating Teams and a Supportive Culture References and Resources Austin G Klasko S amp Leaver W 2009 November The Art of Health IT Transformation Modern Healthcare Bulletin of the National Center for Healthcare Leadership 5 16 Bodenheimer T Grumback 2007 Improving Primary Care Tools for Better Practice McGraw Hill Hunt J Siemienczuk J et al 2008 A randomized controlled trial of team based care impact of physician pharmacist collaboration on uncontrolled hypertension Gen Int Med 23 1966 1972 Kralweski J Kaissi A Dowd B 2008 Culture as a management tool for medical groups The Physician Executive Sept Oct 2008 12 18 Staren ED 2009 Optimizing staff motivation Physician Executive Journal July Aug 74 77 Waldman JD Smith Hood J 2003 Corporate culture the missing piece of the health care puzzle Hospital Topics 81 5 14 Winter 2003 COMMUNICATION PLAN No matter how great the vision is it cannot be successful unless everyone in the organization from the top to the bottom has a clear understanding of that vision The inability to keep the message clear and easy to follow will inhibit the organization s ability to move forward with the change process Staff Communication Participation Plan e Explain the business reasons for change using examples that relate to staff members work Explain costs and risks of not implementing HIT Define clear goals and object
22. cal records unavailable Percentage that requires pull chart Chart chasing Unable to stay on office schedule Phone fax processing Poor legibility of medical records Results tracking e g lab Patients unable to access provider Patient satisfaction Medication refills Patient wait Inefficient use of resources Timely referrals Other 7 What workflow and or staffing solutions have you implemented or considered check all that apply Hired a practice management consultant Outsourced billing Hired additional clinicians e g PA Changed workflow Reorganized supplies in exam room office Automated phone Implemented patient tracking system service Changed staffing to address phone triage Other 1 Average number of laboratory orders per day 2 Do you order laboratory tests using electronic laboratory system Yes If yes which system 3 Thinking about how your practice receives lab reports estimate the percentage received by each of the following methods Electronic Hard copies Other Do you have an electronic radiology system Yes No If yes which system Do you order prescriptions using an electronic pharmacy system Yes No If yes which system Average number of REFILLS per day for the entire clinic None 30 39 Less than 10 40 49 10 29 50 59 20 29 Greater than 59 Average number of follow up calls or faxes your clinic receives each
23. cons change process e Consider how all will be involved DEVELOP PROJECT CHARTER e Identify desired outcomes one three and five years in the future Create a vision statement Identify goals and objectives increase practice efficiency deliver high quality patient centered care increase revenue e Assign accountability e Improve clinical processes new patient preventive care chronic condition management lab review and follow up referrals and follow up e Improve business management processes Practice Assessment References and Resources California Community Clinics EHR Assessment and Readiness Starter Assessment DOQ IT University EHR Readiness Assessment Godfrey Nelson Batalden 2001 2005 Clinical Microsystems Assessing Diagnosing and Treating Your Outpatient Primary Care Practice Dartmouth Hitchcock Illinois Foundation for Primary Care Delivery 2007 Practice assessment using data to determine where to begin Illinois Medical Home Project 2008 On Site Medical Home Assessment Checklist Keroack M Youngberg B et al 2007 Organizational factors associated with high performance in quality and safety in academic medical centers Acad Med 82 1 178 1186 Kralweski J Kaissi A Dowd B 2008 Culture as a management tool for medical groups The Physician Executive Sept Oct 2008 12 18 Practice Change Planning References and Resources Berenson R Hammons T et al 2008 A house is not a hom
24. cordance with the requirements under 45 CFR 164 308 1 and implement security updates as necessary and correct identified security deficiencies as part of its risk management process 2013 Stage 2 Functions e Registry reporting public reporting Electronic ordering Home monitoring continuity of care summaries Populate personal health records 2015 Stage 3 Functions e Access comprehensive data e Experience of care reporting Medical device interoperability References and Resources CMS meaningful use overview Definition of Qualified EHR An electronic record of an individuals health related information that includes patient demographic and clinical health information history physical past health history etc and has the capacity to Provide clinical decision support Support provider order entry Capture and query information relevant to health care quality e Exchange electronic health information with and integrate such information from other sources ONC publishes a list of certified EHRs and EHR modules SUMMARY OVERVIEW OF MEANINGFUL USE OBJECTIVES This overview and the table below are reference tools indicating the key elements for achieving meaningful use of health information technology They do not provide sufficient information for providers to document and demonstrate meaningful use in order to obtain financial incentives from the Centers for Medicare and Medicaid Serv
25. ct plan identifies tasks and timelines to be completed during implementation It includes training and support for different types of users needs to accompany the technical tasks needed for implementation Necessary Roles During Implementation Determine if you have appropriate staff expertise or how you can access these resources dentify define critical roles such as physician leader project manager administrative leader technology leader trouble shooter techy on site e Consider how assuming the new roles will affect current roles IMPLEMENTATION CHECKLIST Develop target dates Identify gaps and prioritize for greatest benefit and logical sequence for implementation Create gap closure strategy and timeline Determine measures of progress Define the new workflow map workflow estimate times for new workflow f Identify new revised roles responsibilities Sf Develop training plan including practice before go live Visit a similar practice that has done what you want to do Plan roll out start simple add over time Assess cost effectiveness data entry queries reporting effect on workflow M Itemize costs license fee technical support training reports interfaces customization service fees upgrades annual maintenance customer support report submission transaction fees Plan for disaster recovery business continuity regular redundant remote back up of all practice data Identify an explicit plan
26. d Reinvestment Act of 2009 ARRA authorizes the Centers for Medicare amp Medicaid Services CMS to provide reimbursement incentives for eligible professionals and hospitals that become meaningful users of certified electronic health record EHR technology The Medicare EHR incentive program will provide up to 44 000 in incentive payments to eligible professionals EPs eligible hospitals and critical access hospitals that are meaningful users of certified EHR technology The Medicaid EHR incentive program will provide up to 63 370 in incentive payments to eligible professionals and hospitals for efforts to adopt implement or upgrade certified EHR technology or for achieving meaningful use during the first year of their participation in the program and for demonstrating meaningful use during each of five subsequent years The ONC funds state Health Information Exchange Programs and national Health Information Network activities to facilitate the exchange of health information between organizations using EHR systems that cannot communicate directly The ONC also funds the state regional health information technology extension centers that offer technical assistance guidance and information on best practices to support and accelerate providers efforts to become meaningful users of certified EHR technology M CEITA the Michigan Center for Effective Informantion Technology IT Adoption is Michigan s Health IT Regional Extension Center
27. d for recovery Determine the server hierarchy Determine the application hierarchy Identify the recovery strategy e System Testing o Develop test scripts verification and validation o Detail and module testing o Conference room pilot parallel installation User Training HITECH Updates HIPPA Compliance Additional emphasis should be placed on the HIPPA compliance activities of any and all third party business associates Business Associate Responsibility and Accountability e Execution of revised Business Associate Contracts BAC to include detailed use restrictions and allowances and HIPAA compliance audit and training entitlement Fines and Enforcement Definition e Covered entity did now know of vulnerability and would not have known through reasonable diligence 100 per violation maximum 25 000 per calendar year e Reasonable cause and not willful neglect 1 000 per violation maximum 100 000 per calendar year e Willful neglect with corrective action 10 000 per violation maximum 250 000 per calendar year e Willful neglect with no corrective action 50 000 per violation maximum 1 500 000 per calendar year Risk Analysis Implementation Specification This is an integral component of the meaningful use definition and should include a breach notification plan HIPPA SPECIFICATIONS The following detail provides guidance for the successful and complete implementation of HIPAA Security
28. dressable lmplementation Specification Implement security measures to ensure that electronically transmitted EPHI is not improperly modified without detection until disposed of Encryption Addressable lmplementation Specification Implement a mechanism to encrypt EPHI whenever deemed appropriate Organizational Requirements Standard Business Associate Contracts or Other Arrangements A covered entity is not in compliance with the standard if the CE knew of a pattern of an activity or practice of the BA that constituted a material breach or violation of the BA obligation under the contract or other arrangement BA Contracts o Implement administrative physical and technical safeguards that reasonably and appropriately protect the confidentiality integrity and availability of EHPI that it creates Ensure that any agent including a subcontractor to whom it provides such information agrees to implement reasonable and appropriate safeguards to protect it Report to the CE any security incident of which it becomes aware Authorize termination of the contract by the CE if the CE determines that the BA has violated material term of the contract Other Arrangements When the CE and its BA are both governmental entities the CE is in compliance if it enters into a memorandum of understanding with the BA other law contains requirements applicable to the BA References and Resources The HITECH Act The HITECH Survival Guide IN
29. e keeping patients at the center of practice redesign Health Affairs 27 1219 1230 Blue Ribbon Panel 2007 Redesigning the practice model for general internal medicine A proposal for coordinated care Gen Int Med 22 400 409 Rimmerman C Heidenreich D Appel D 2009 The role of a clinical operations analyst in implementing a successful electronic medical record Physician Executive Journal Nov Dec 34 39 Improving Care Delivery PCMH References and Resources Bodenheimer T Laing B 2007 The teamlet model of primary care Ann Fam Med 5 457 461 Illinois Foundation for Primary Care Delivery 2007 Practice improvement easy ways to enhance care delivery PCPCC 2008 Overview physician practice connections patient centered medical home PCPCC 2009 Meaningful Connections resource guide for using health IT to support the patient centered medical home Dylewski J 2009 Electronic Medical Records Now or Later Leu M Cheung M et al 2007 Centers speak up the clinical context for health information technology in the ambulatory care setting Gen Int Med 23 372 378 Moore LG Wasson JH 2007 Maximizing efficiency quality and the doctor patient relationship Fam Pract Manage Sept 2007 20 24 Sinsky CA 2006 Improving office practice working smarter not harder Family Practice Management 13 28 36 DOQIT Strategic vision for an EHR generic sample
30. eam functions and member roles Training will be essential throughout implementation Early training sessions should provide an overview of the HIT implementation process and provide an introductory exposure to the continuous improvement methods that will be used 4 Identify an implementation team that will perform essential functions such as continuous quality improvement workflow optimization etc Describe the current roles responsibilities of team members Consider Is this group already functioning as a team If not How should this team function and What team member roles are needed Assign roles responsibilities so team can accomplish essential tasks o Conduct a baseline skill assessment Plan for staffing needs for implementation Identify a project manager Establish a method for communicating progress Analyze products and options Contract with vendors etc 0000 0 INVOLVE PATIENTS INTHE PLANNING PROCESS HIT implementation will affect patients during and after implementation so include them on the implementation team and identify other means for getting input For example focus group of patients could provide assistance with planning the implementation of a patient portal that allows patients Register online Access lab and test results Access their personal health record e Input update their health data Learn about a referral process Access appropriate educational materials Cre
31. edicare Quality Improvement Organization under contract with the Centers for Medicare amp Medicaid Services CMS an agency of the U S Department of Health and Human Services The contents presented do not necessarily reflect CMS policy 8SOW OR DOQIT 05 02 9 2 05 APPENDIX APPENDIX C Computer Knowledge Evaluation Form Computer Knowledge Evaluation Tool for Physician Staff eme cenam ____________ _________ PTT EL CS Fee Wee teen TELLS nny eren mena __ Deme iam T T ELS EL eco E EL dT Pme E Set up a page in portrait or landscape form and use the header and footer function ELE EL ELE Set an address book and send email more than one address simultaneously Word Processing Functions can am able to P Create and save a new document Save a document to a different drive Save a document as a different file type Check spelling and grammar in a document Internet Use can am able to Use and change search engines and search using keywords Print the screen Save an image to file downlo
32. ementation Unexpected or unbudgeted hardware and or infrastructure purchases unanticipated needs costs Unexpected or unbudgeted software and or software purchases unanticipated costs of customer software and application to application interfaces e HIPAA or meaningful use non compliance realize solution fails to meet criteria and standards after implementation e Information technology skill deficit reliance on vendor to lead or assist with HIT implementation e Staff acceptance this is change and if preparation is inadequate acceptance can be a problem resistance to change recidivism to old ways expectation that software is THE SOLUTION Stability of vendor CCHIT Certification many vendors issues of meeting standards for which certification may be voluntary e Poor vendor support level of vendor commitment follow through is inadequate after implementation Barriers to EMR Use Miller and Sim e High initial cost and uncertain financial benefits e High initial physician time costs e Technology challenges Difficult complementary changes and inadequate support e Inadequate electronic data exchange e Lack of incentives e Physician attitudes References and Resources Baron 2007 Quality improvement with an electronic health record achievable but not automatic Ann Int Med 147 549 552 HEMA 2006 Overcoming barriers to electronic health record adoption www hfma org EHR Miller R Sim 2004 Physicians
33. ent risk management capitation contracting participation in studies Create a business plan and budget Identify funding revenue sources for capital outlay operations Cost Benefit Analysis What value will be obtained by implementing the following potential improvements Improvment in communication Remote access to records Increased revenue Improved quality and safety error reduction Enhanced legibility and accuracy Decrease medical record retrieval time Assist HIPAA privacy compliance New data analysis and reporting capabilities Increased efficiency of office services procedures BUDGET DEVELOPMENT FOR HIT Consider what can you afford to do What do you think you want to do View HIT aquisition as 5 10 year investment Estimate the total costs hardware software installation training maintenance and support services such as Internet Identify the funding financing method Identify opportunities to gain additional revenue Remember innovation is generally an incremental process but a change in technology can be revolutionary Cost Categories Hardware infrastructure cabling switches servers workstations etc Software licenses Installation Training Maintenance and support fees staff vs contracting Services software hardware Internet interfaces Business Case Development Links AHRQ Technology Cost and Benefits Database AHRQ business case bibliography HIMSS HIT and Return on Inv
34. eporting Meaningful use reporting Current proposed metrics Planning Implementation plan timeline Workflow for new HIT Access current HIT HIT structure amp planning Templates amp forms Chart conversion Workflow Interface support HIE integration Continuous improvement skill development Steady State Ongoing Improvements Update improve add fuctionality to HIT Increase valve derived from HIT Create user groups Share proven practices Continuously improve practices processes ENGAGEMENT Consortium The initial phase of HIT Implementation is engagement This involves Setting premliminary objectives for implementing health information technology Assessing the practices hospitals readiness to take on a HIT implementation project Engaging key players Laying the groundwork for changing culture Beginning workflow design SETTING HIT EHR OBJECTIVES Well defined HIT objectives assist in determining the scope of the HIT project and serve as the basis for choosing EHR functions down the road Objectives emerge from a careful consideration of the goals needs and wants of the practice If one objective is to qualify for Medicare or Medicaid incentives then the eligible professional or hospital should demonstrate they have implemented electronic technology and are using it to meet meaningful use criteria This goes beyond the simple transference of medical records to an electronic format to using t
35. erly population J Gen Int Med 23 399 404 Zhou Y Garrido T et al 2007 Patient access to an electronic health record with secure messaging impact on primary care utilization Am Manage Care 13 418 424 HIT ACQUISITION Acquisition involves decision making about which vendor to use contracting for specific products installing or accessing products and achieving meaningful use The United States Department of Health and Human Services publishes a Certified HIT Product List of Complete EHRs and EHR Modules that have been tested and certified under the Temporary Certification Program maintained by the Office of the National Coordinator for Health IT ONC Vendor Vetting Evaluation Criteria standards successes failures See APPENDIX A comprehensive vendor evaluation e Evaluate contracts Service level agreements e Execute strategy Monitor progress measurement HIT Acqusition References and Resources AAFP Adler K How to select and electronic health record system 2007 EHR Selection Toolkit for Community Health Centers Sage 2009 Evaluating electronic health records HRSA 2009 Electronic Health Records Selection guidelines for health centers Steckler D Epstein F Riner R 2009 Getting ready for EHR RHIOs and next generation co management agreements Physician Executive Journal Nov Dec 48 52 PLANNING E e Consortium The master proje
36. estment Cost Benefit References and Resources Aita S 2008 Implementing an EHR with ROI in mind The Journal of Med Practice Management 23 244 246 CBO 2008 Evidence on the costs and benefits of health information technology Congressional Budget Office Crosson Obman Strickland P et al 2007 Electronic medical records and diabetes quality of care results from a sample of family medicine practices Ann Fam Med 5 209 215 Goldzweig C Towfigh A et al 2009 Costs and benefits of health information technology new trends from the literature Health Affairs Web Exclusive 28 w282 w293 Parente S McCullough J 2009 Health information technology and patient safety evidence from data Health Affairs 28 357 360 Foundation 2009 Enhancing patient care with practice systems results are mixed Solberg L Asche S et al 2008 Practice systems are associated with high quality care for diabetes Am Manage Care 14 85 92 Wang 5 Middleton et al 2003 A cost benefit analysis of electronic medical records in primary Am Med 14 397 403 Weber V Bloom et al 2007 Employing the electronic health record to improve diabetes care a multifaceted intervention in an integrated delivery system J Gen Int Med 23 379 382 Weber V White A Mcllvried R 2007 An electronic medical record EMR based intervention to reduce polypharmacy and falls in an ambulatory rural eld
37. for recovery in case of technology failure amp Include provisions for security measures such as data encryption Plan for migration of current patient data Implementation Plan References and Resources Frisse M 2009 Health information technology one step at a time Health Affairs Web Exclusive 28 w379 w384 Frankel R Altschuler A et al 2005 Effects of exam room computing on clinician patient communication Gen Int Med 20 677 682 ASSESS CURRENT FOR INTEROPERABILITY INTERFACING Consider how your current HIT components such as your practice management system interfaces with lab x ray e prescribe registry system and others Assess what is currently in use and determine whether you want to continue with the same product or upgrade it Asses Existing information systems functionality and use Existing interfaces functional versus piecemeal Existing reporting tools functionality capabilities UDS meaningful use state reports patient specific Forms and documents manual or electronic Determine the Potential for Interfacing with External Systems External technology you wish to connect with data warehouse External data sources you wish to connect with State HIE Michigan Care Improvement Registry hospitals specialists etc Consider the Office Network and External System Factors e Payers incentive programs Patients patient mix desire for electronic interac
38. he EHR system to achieve health and efficiency goals HITECH s incentives and assistance programs seek to improve the health of Americans and the performance of their health care system through meaningful use of EHRs to achieve five health care goals Improve the quality safety and efficiency of care while reducing disparities Engage patients and families in their care Promote public and population health Improve care coordination and Promote the privacy and security of EHRs HIT Functions EHR and other electronic systems are designed to organize and store patient records They are designed to assist with some or all of the following functions See section 19 for more details on meaningful use criteria and timelines Care management decision support clinical guidelines care plans list problems medications allergies patients and conditions by provider e Patient self management Enhanced patient access to clinicians e Prescribing and medication management Communication e Test and referral tracking o Flow sheets with lab results and findings o Alerts and recall reminders for results and needed care Communication o Enhanced patient access to clinicians o Contact patients for notification of test results education etc Recall reminders alerts prevention results etc A patient portal can be used for patient contact notification of test results education etc Patient transition management Q
39. ice Change Planning References EDEN V YORK MP OX PODES RENDUM A POR 10 Improving Care Delivery PCMH References eee e eee eee ee eee nennen nnns teen asas esso iem m Ar amr 9 9 Team GV ROUX POLVO EUR RR CUBA HA EIL UM RR 12 Involve Patients in the Planning 1 1 enn nnn nnne nnne nee 12 Creating Teams and a Supportive Culture 12 Communication PIar say 13 SNA E E EET ATE E AT E 13 Work Flow Analysis and Optimization ssseeeeesssseeoeeeeessoooeeeesssooeesesssoooceesessooeocesssosoeeseesseoeee 15 HIT EHR Impact Planning ccsscccssscsccsscssssccecesccsscsscccescsscssscceesescoscsecsesescsscsssesesecssososeess 16 eiiis 9 C C M 17 Hardware Strategies and Needs Determination ssccccssssssssscsccssssssssscescssccsssccsecssoscssese 17 Business Planning for Hit ACqUiSition cccsccccsccscssscsssccccssccsscccesescessscsesescssccesssssecssoscssees 18 Budget Development for eee eee eee eene enne enne seen nasa se asas esee etes uuu 18 HIT Aquistion
40. ices The regulations and filing requirements that must be fulfilled to qualify for the Health IT financial incentive program are detailed at http www cms gov EHRIncentivePrograms Core Set These objectives are to be achieved by all eligible professionals hospitals and critical access hospitals in order to qualify for incentive payments Additional Choices In addition to the Core Set eligible professionals hospitals and critical access hospitals may select any five choices from the menu set not included Core Meaningful Use Criteria Regulations published in NEJM July 13 2010 David Blumenthal and Marilyn Tavenner used with permission OBJECTIVE Core Set MEASURE Core Set Record patient demographics sex race ethnicity More than 50 of patients demographic data date of birth preferred language and in the case recorded as structured data of hospitals date and preliminary cause of death in the event of mortality Record vital signs and chart changes height More than 50 of patients 2 years of age or older weight blood pressure body mass index growth have height weight and blood pressure recorded charts for children as structured data Maintain up to date problem list of current and More than 80 of patients have at least one entry active diagnoses recorded as structured data Maintain active medication list More than 80 of patients have at least one entry recorded as structured data Maintain active medicat
41. ion allergy list More than 80 of patients have at least one entry recorded as structured data Record smoking status for patients 13 years of age More than 50 of patients 13 years of age or or older older have smoking status recorded as structured data OBJECTIVE Core Set MEASURE Core Set For individual professionals provide patients Clinical summaries provided to patients for more with clinical summaries for each office visit for than 50 of all office visits within 3 business days hospitals provide an electronic copy of hospital more than 50 of all patients who are discharged discharge instructions on request from the inpatient department or emergency department of an eligible hospital or critical access hospital and who request an electronic copy of their discharge instructions are provided with it On request provide patients with an electronic More than 50 of requesting patients receive copy of their health information including electronic copy within 3 business days diagnostic test results problem list medication lists medication allergies and for hospitals discharge summary and procedures Generate and transmit permissible prescriptions More than 40 are transmitted electronically electronically does not apply to hospitals using certified EHR technology Computer provider order entry CPOE for More than 30 of patients with at least one medication orders medication in their medication list have at least one medica
42. ion that can access EPHI Workstation Security Standard Implement physical safeguards for all workstations that access EPHI to restrict access to authorized users targets configuration of equipment Device and Media Controls Standard Implement policies and procedures that govern the receipt and removal of hardware and electronic media that contain EPHI into and out of a facility and the movement of these items within a facility e Disposal Required Implementation Specification Implement policies and procedures to address the final disposition of EPHI and or the hardware or electronic media on which it is stored Media Re use Required Implementation Specification Implement procedures for the removal of EPHI from electronic media before the media are made available for re use Accountability Addressable Implementation Specification Maintain a record of the movements of hardware and electronic media and any person responsible therefore Data Backup and Storage Addressable Implementation Specification CE must create a retrievable exact copy of EPHI when needed before movement of equipment Technical Safeguards Rule Access Control Standard Implement technical policies and procedures for electronic information systems that maintain EPHI to allow access only to those persons or software programs that have been granted access rights requires some form of authentication Unique User Identification Required Implementati
43. iques to evaluate the case for the acquisition See references for excellent practice assessment tools The assessment should include all practice personnel Are you ready Are they ready Follow these steps Assess Organizational culture Does the organization have the ability to support HIT adoption and associated changes 15 the project supported driven by leadership Are there role models who walk the talk 15 there open communication Is there a plan for change management Management and leadership Is there a readiness to improve health information management To allocate sufficient human financial and other resources to the project To plan for future HIT requirements Operations Is there ability and willingness to measure infrastructure facilitate HIT adoption To redesign workflow processes Provide staff training Involve patients e Technical skills What is the current practice personnel technical involvement computer skills and expertise Existing HIT use IT support structure Ability to support needs of future IT adoption e Care management What is the practice approach to care management and supporting care process What are current IT functions supporting measurement of guideline apperance and patient outcomes What is the current program for continuous quality improvement Capture and Prioritize e Identify strengths weaknesses problems threats opportunities e Delineate the need for HIT e List pros
44. ities Electronic technology can be used to facilitate office functions for individual care management and increasingly to manage the care for specific populations of patients Identify which functions are most important for your setting and then be certain the products under consideration can do them well Functionality is what the product gives you how it supports practice growth evolution and your unique needs Hidden functionality includes the way data is mapped and coded items are configured and reports are requested and or built Common HIT functions include e Practice management billing coding Electronic scheduling patient intake demand management planned visits scheduled check ups immunizations screenings etc same day scheduling e E mail and messaging Patient portal patient access patient education communication self management support e E prescribing prescribing and refills Registry including population management reporting assessment embedded clinical guidelines care plans etc Analytics practice performance efficiency cost of operations etc e EHR patient examination and charting Clinical decision support reminders alerts prompts see description below Computerized provider order entry ordering reporting of results Conversion of existing active patient chart e Regional health information exchange e Referral management CPOE ordering reporting of resul
45. ivacy of individually identifiable health information the HIPAA Security Rule which sets national standards for the security of electronic protected health information and the confidentiality provisions of the Patient Safety Rule which protects identifiable information being used to analyze patient safety events and improve patient safety The following components are needed e Data center computer room Review building security e g accessibility multiple security access tests badges codes and locks environmental conditions climate control fire suppression redundant power redundant Internet connections e Back up system o Develop backup strategy Full Backup includes system state OS all files and folders Incremental backs up information that has changed since the last backup Differential backs up data that has changed since the last full back up Back up retention policy Offsite vault storage o Successful backup plan Develop routines to verify back up success Monitor logs for any errors o Successful recovery plan Develop restore procedures Develop strategy for testing restorability and accuracy Test quarterly basis and document results Disaster recovery contingency planning o Develop management and administartive teams to handle recovery Create contact lists and disaster declaration and activation policy o Develop network application and server recovery plan Estimate hours neede
46. ives e Repeat the message until everyone understands the vision e consistent to lend credibility to the process senior leadership must lead by example by working in the new vision e Communicate how staff will be involved o Leave out the technical jargon the vision is not how the system will work but how it will change the organization o Communication must be free flowing and come from many different avenues including meetings memos electronic mail and information communication amongst staff e Clarify pro and cons e Clearly delineate benefits of HIT implementation for THIS practice e Cleary allocate project planning duties e Assure staff participation throughout STAFF TRAINING Staff training is needed during all phases of implentation During the engagement phase staff needs some understanding of HIT functions and how HIT implementation will change the way they do their jobs See AHRO Training Resources Steps for setting up training programs include Identify how training for general skills as well as HIT functionality is normally done e Review what training methods are used proposed e Review potential resources time methods including vendor program classes online meetings etc and complete basic skills training prior to start see Appendix C Computer Knowledge Evaluation Form e Consider workflow and process change training Functional Requirements Information technology products differ in their capabil
47. licies and procedures to limit physical access to its electronic information systems and the facility or facilities in which they are housed while ensuring that properly authorized access is allowed e Contingency Operations Addressable Implementation Specification Establish and implement as needed procedures that allow facility access in support of restoration of lost data under the DR plan and emergency mode operations plan in the event of an emergency Facility Security Plan Addressable Implementation Specification Implement policies and procedures to safeguard the facility and the equipment therein from unauthorized physical access tampering and theft Access Control and Validation Procedures Addressable Implementation Specification Implement procedures to control and validate a person s access to facilities based on their role of function including visitor control and control of access to software programs for testing and revision Maintenance Records Addressable Implementation Specification Implement policies and procedures to document repairs and modifications to the physical components of a facility which are related to security hardware walls doors locks 2 Workstation Use Standard Implement policies and procedures that specify the proper functions to be performed the manner in which those functions are to be performed and the physical attributes of the surroundings of a specific workstation or class of workstat
48. mponents entity s assessment of the sensitivity vulnerabilities and security of its programs and information it receives manipulates stores and or transmits application and data inventory 8 Evaluation Standard Perform a periodic technical and non technical evaluation based initially upon the standard implements under this rule and subsequently in response to environmental or operational changes affecting the security of EPHI that establishes the extent to which an entity s security policies meet the requirements of this subpart Business Associate Contract or Other Arrangements Standard Covered entity must obtain satisfactory assurances from the business associate that it will appropriately safeguard the information in accordance with the requirements of the Security Rule Covered entities that electronically exchange information must enter into a contract or other arrangement with persons or entities that meet the definition of BA Does not apply to Transmission by a CE of EPHI to a health care provider concerning the treatment of an individual Transmission by a CE of EPHI to a health plan or HMO or health insurance issuer on behalf of a group health plan to a plan sponsor Transmission by a CE of EPHI to or from other agencies providing the services when the covered entity is a health plan that is a government program providing public efforts Physical Safeguards Rule Facility Access Controls Standard Implement po
49. n resources and provide those to the specific education resources patient as appropriate Perform medication reconciliation between care Medication reconciliation is performed for more settings than 5076 of transitions of care Provide summary of care record for patients Summary of care record is provided for more referred or transitioned to another provider or than 5076 of patient transitions or referrals setting OBJECTIVE Core Set Submit electronic immunization data to immunization registries or immunization information systems Submit electronic syndromic surveillance data to public health agencies MEASURE Core Set Perform at least one test of data submission and follow up submission where registries can accept electronic submissions Perform at least one test of data submission and follow up submission where public health agencies can accept electronic data Additional choices for hospitals and critical access hospitals Record advance directives for patients 65 years of More than 50 of patients 65 years of age or age or older Submit of electronic data on reportable laboratory results to public health agencies older have an indication of an advance directive status recorded Perform at least one test of data submission and follow up submission where public health agencies can accept electronic data Additional choices for eligible professionals Send reminders to patients per patient preference for preventi
50. nd resources to facilitate practice transformation and HIT implementation Providing tools or links to tools that facilitate the HIT implementation process Providing online access to resources for coaches facilitators and practice personnel STRUCTURE OFTHE HANDBOOK The Handbook has a section for each phase of HIT implementation Each section contains An outline of the key steps to be taken for successful implementation of that segment Embedded references and web addresses for online resources that provide additional details for each step HIT Implementation Flow Diagram The HIT Implementation Flow Diagram provides the big picture of aspects to be considered for achieving a successful implementation though integration of practice transformation and HIT acquisition Engagement T Implementation Setting HIT objectives T management support Project Scoping Key implementation Readiness assessment processes Culture Alignment Team development Communication plan Functional requirements Installation Security Data management System testing Workflow analysis User training HIT impact planning Inter post implementation support Selection Hardware and strategies Business planning Budget development Setting HIT objectives HIT decision making Vendor evaluation Contract evaluation Service level agreements Meaningful Use Evaluation Evolving definitions HIT optimization Public health r
51. new providers or specialty Health team should know about your clinic operation to anyone retiring soon new affiliations moves help inform EHR planning implementation and optimization Yes No If yes what are they Have you explored any EHR systems 2 Do you want assistance in selecting an EHR Yes No Yes No If yes how have you gone about it Check all that apply Pu What is your greatest need Read an article in peer reviewed journal Read an article in a trade or medical magazine Attended vendor demonstration s Completed an online vendor return on investment Talked to a colleague who uses an EHR Visited colleagues practice to see EHR they use Other Do you want assistance in implementing an EHR Do you want assistance in optimizing the EHR once it is in place Yes No Yes No What is your greatest need What is your greatest need 5 What are the reasons you have not implemented an EHR Please prioritize in order using for the most important and 10 for the least important Financial constraints Unable to gain partner commitment Vendor support was inadequate Initial data entry is too labor intensive Could not find a viable stable vendor Could not find software that worked for practice Could not see spending additional Found it difficult to select an EHR system hours at the office each day Do not know where to begin Other This material was prepared by Acumentra Health Oregon s M
52. ole 2006 PICK THE RIGHT TEAM FOR AN EMR HOME RUN Avoid costly errors by choosing the right players for your software implementation team Behavioral Healthcare ThePractical Resource for the Field s Leaders Kaur Satinder 2010 Project Management Why is it so important KEY IMPLEMENTATION PROCESSES Procurement Execute contracts with vendors such as EMR software practice patient management software HIE server and desktop hardware Managed hosting Document imaging ancillary peripherals and record retention and storage network Interface development Define service level agreements the degree to which value added services are delivered from each key partner for example in this component the response time on EMR software programming bug fixes the response time on resolving network outages and the warranties and service contracts for computer servers and hardware may be defined Infrastructure Hardware and Application Installation The first step in creating the EMR environment is to install infrastructure components which include but are not limited to Internet connections Internet service provider e Telecommunications connections e Wide area networks Local area networks internal cabling network hubs switches routers wireless components e HIPAA compliant data center components redundant power redundant cooling physical security addressing facility access controls workstation use worksta
53. omparison of electronic physician prompts versus waitroom case finding on clinical trial enrollment 23 447 450 Sage 2009 Evaluating electronic health records Wess M Schauer D et al 2007 Application of a decision support tool for anticoagulation in patients with non valvular atrial fibrillation 23 41 1 417 Crosson J Isaacson et al 2007 Variation in electronic prescribing implementation among twelve ambulatory practices Gen Int Med 23 364 371 Miller R Sim 1 2004 Physicians use of electronic medical records barriers and solutions Health Affairs 23 1 16 126 Spiegel 2009 Five ways a visual communications approach can help medical practices get more from their EMR systems Teams and Roles Varpio L Schryer C et al 2006 Working off the record physicians and nurses transformations of electronic patient record based patient information Academic Medicine 81 Supplement S35 S39 HIT EHR STRUCTURE AND PLANNING The plan should describe logistics for how decisions and work will be accomplished Selecting and creating templates and forms see AHRO sample pediatric templates Chart conversion from paper to electronic EHR What records will be included Will information be scanned or keyed in Interface support for connecting with practice management systems laboratories pharmacies and home or office based medical devices etc HIE integration Will
54. on Specification Assign a unique name and or number for identifying and tracking user identity digital signatures soft tokens biometrics as well as other mechanisms may be used Emergency Access Procedure Required Implementation Specification Establish and implement as needed procedures for obtaining necessary EPHI during an emergency Automatic Logoff Addressable Implementation Specification Implement electronic procedures that terminate an electronic session after a predefined time of inactivity Encryption and Decryption Addressable Implementation Specification Implement a mechanism to encrypt and decrypt EPHI Audit Controls Standard Implement hardware software and or procedural mechanisms that record and examine activity in information systems that contain or use EPHI Integrity Standard Implement policies and procedures to protect EPHI from improper alteration or destruction e Mechanism to Authenticate Addressable Implementation Specification Implement electronic mechanisms to corroborate that EPHI has not been altered or destroyed in an unauthorized manner Person or Entity Authentication Standard Implement procedures to verify that a person or entity seeking access to EPHI is the one claimed 5 Transmission Security Standard Implement technical security measures to guard against unauthorized access to EPHI that is being transmitted of an electronic communications network Integrity Controls Ad
55. on Specification Implement policies and procedures for granting access to EPHI for example through access to a workstation transaction program process or other mechanism Information use policies that establish the rules for granting access Access Establishment and Modification Addressable Implementation Specification Implement policies and procedures that based upon the entity s access authorization policies establish document review and modify a user s right of access to a workstation transaction program or process 5 Security Awareness and Training Standard Implement a security awareness and training program for all members of its workforce Security Reminders Addressable Implementation Specification Periodic security updates to members of its workforce Protection from Malicious Software Addressable Implementation Specification Procedure whereby approved anti virus software must be installed and kept current with frequent updates not only on company equipment but on portable or home equipment used to connect with the organization s network Login Monitoring Addressable lmplementation Specification Procedures for monitoring log in attempts and reporting discrepancies Password Management Addressable lmplementation Specification Procedures for creating changing and safeguarding passwords 6 Security Incident Procedures Standard Implement policies and procedures to address security incidents Response and Re
56. ons such as diabetes and asthma e Registry reports performance feedback reports physician or practice level reports on specific measures for a target group of patients References and Resources HIT Adoption Toolkit Arora V 2009 Tackling care transitions mom and apple pie vs the devil in the details JGIM 24 985 987 Baker L 2005 Benefits of interoperability a closer look at the estimates Health Affairs Web Exclusive W5 22 w5 25 CCHIT An introduction to health IT certification http www cchit org about CHCF 2008 Tools for clinics Four health centers use chronic disease management systems Diamond C Mostashari Shirky C 2009 Collecting and sharing data for population health a new paradigm Health Affairs 28 454 466 Doctors office quality information technology functional requirements Prepared for CMS by Stratis Health Margret A Consulting LLC 10 02 05 HHS 2009 Health Information Technology Standards and Certification Privacy and Security and Health http healthit hhs gov portal server pt HIMSS Tools for EHR Professionals HIMSS Project Management HIMSS Standards and the electronic health record McGraw Dempsey et al 2009 Privacy as an enabler not an impediment building trust into health information exchange Health Affairs 28 4 6 427 Mehta Partin M 2007 Electronic health records a primer f
57. or practicing physicians Cleveland Clinic Journal 74 826 830 Neupert P Mundle C 2009 Personal health management systems applying the full power of software to improve the quality and efficiency of care Health Affairs 28 390 392 Sequist T von Glahn T et al 2009 Statewide evaluation of measuring physician delivery of self management support in chronic disease care 24 939 945 Snow V Beck D et al 2009 Transitions of care consensus policy statement American College of Physicians Society of General Internal Medicine Society of Hospital Medicine Geriatrics Society American College of Emergency Physicians Society of Academic Emergency Medicine JGIM 24 97 976 Steckler D Epstein Riner R 2009 Getting ready for EHR RHIOs and next generation co management agreements Physician Executive Journal Nov Dec 48 52 Walker J Pan E et al 2005 The value of health care information exchange and interoperability Health Affairs Web Exclusive W5 10 W5 25 WORK FLOW ANALYSIS AND OPTIMIZATION The processes needed to implement new electronic technology should not just be added on to the way things are currently done If an EHR is to improve the efficiency of care new and appropriate processes need to be developed New processes will need to be identified to enable optimal information storage access disease prevention management reminders and alerts clinical decision support scheduling communica
58. pare to use HIT to optimize the workflow and practice processes References and Resources Nace D et al 2007 Meaningful connections resource guide for using health IT to support th patient centered medical home Keshavjee Bosomworth J et al 2006 Best practices in EMR implementation systematic review Proceedings of the Ith International Symposium on Health Information Management Research HIT EHR IMPACT PLANNING Information Management Plan how the office will handle information received from disparate sources to improve access quality relevance and sharing of data information e Define document how the practice presently manages disparate information e Identify and review present management and use of data from the practice management system Identify report requirements for population management health and quality improvement e Develop document vision of how HIT will improve these processes Identify What Your Organization 15 Using to Measure Progress and Achievement e Goal achievement timelines action checklists e Practice and provider performance reports Patient experience reports Reporting of standard measures to external organizations Others Select or Develop Useful Measures and Instruments to Use During and After HIT Implementation Measures that need to be selected or developed e Instruments that need to be selected or developed Formulate a Basic Data Collection
59. porting Required Implementation Specification Identify and respond to suspected or known security incidents mitigate to the extent practicable harmful effects of security incidents that are known to the CE and document security incidents and their outcomes 7 Contingency Plan Standard Establish and implement as needed policies and procedures for responding to an emergency or other occurrence fire vandalism system failure and natural disaster that damages systems that contain EPHI Data Backup Plan Required Implementation Specification Establish and implement procedures to create and maintain retrievable exact copies of EPHI Disaster Recovery Plan Required Implementation Specification Establish and implement as needed procedures to restore any loss of data in the event of fire vandalism natural disaster or system failure Emergency Mode Operation Plan Required Implementation Specification Establish and implement as needed procedures to enable continuation of critical business and clinical processes for protection of the security of EPHI while operating in emergency mode Testing and Revision Procedures Addressable Implementation Specification Implement procedures for periodic testing and revision of contingency plans Applications and Data Criticality Analysis Addressable Implementation Specification Assess the relative criticality of specific applications and data in support of other contingency plan co
60. rent hardware infrastructure work stations printers scanners fax machine network infrastructure cabling wireless routers switches and Internet service provider e Usage hardware application software IT systems internal IT training and support staff computer competencies Technology knowledge assessment e Current IT integration with an EHR clinical and business application avoid piecemeal configurations ign Hardware Assessment wit ecification of Current stems Align Hardware h Specifi fC EHR Sy Consider minimum versus optimal hardware needs Needs Assessment References and Resources PITO IT needs assessment tool HIMSS Tools and Topics Chavannes Lew D Conducting an IT Governance Assessment 13 Jun 2006 BUSINESS PLANNING FOR HIT ACQUISITION Development of the business plan includes a review of the practice HIT needs assessment Appendix B Compare the costs of desired products with potential HITECH incentive payments that can be received for meeting meaningful use criteria Finance and Budget Document the anticipated cost of the HIT project software hardware implementation training network costs List the anticipated benefits quality patient experience time efficiency risk reduction business continuity Determine the funding method capital operational lease purchase loan Explore possible revenue opportunities services to patient subsets disease managem
61. rsity of Illinois 2007 A medical home primer for community pediatricians and family physicians http internet dscc uic edu forms medicalhome MedHomeMonograph pdf Walker J Carayon P 2009 From tasks to processes the case for changing health information technology to improve health care Health Affairs 28 467 477 APPENDIX A APPEXDIX A Vendor Evaluation Comprehension Vendor Demo Evaluation pes i PPP B P E Seachem PP PP PP 1 EE BWem PP fawn PP ___ r teokseensa PP 3 ESL EL PP PP E EL PP eoe pes Ne EL Set new insurance company Ju d cureview pewter PP compere 8 Recent H amp P d c summary x rays 9 General search for information 22020 Mee E order labs and x rays a EL EL f Normal letter request 222210501 EL Meiste
62. sources that will Contribute to Implementation These are individuals from outside the practice that contribute to the implementation They are typically utilized for one off tasks The transfer of knowledge from a contracted subject matter expert to an in house subject matter expert should be included in the plan and should take place as early in the implementation process as possible Protracted use of contracted resources to provide high value long term application support will prove to be costly Identify Key External Vendors During the selection you will identify several key partners who may ultimately contribute to the final product e software vendor e Practice patient management software vendor HIE vendor Hardware vendor Managed hosting center vendor e Document imaging vendor Ancillary peripheral vendors e Record retention and storage vendor e Network vendor Interface development vendor Plan and Arrange for Services Contact key partners in the solution process and begin scheduling the following installations e Network infrastructure Hardware and server infrastructure Local or remote hosted Hardware co location versus application hosting o Storage infrastructure EMR and PM application Document imaging solution Ancillary peripheral hardware Interface development resources Project Management References and Resources AHRO Toolkit Project Management and Oversight Passage Nic
63. the EHR be connected to health information exchange that will allow transfer of information between the practice specialists hospitals etc CONTINUOUS IMPROVEMENT DEVELOPMENT Continuous skill improvement and knowledge development among practice personnel will be necessary Determine a model of improvement Lean etc contract for training create plan schedule and implement training References and Resources Toolkit Evaluating Optimizing and Sustaining Endsley 5 Magill M Godfrey M 2006 Creating a lean practice Family Pract Manage 13 34 38 Feifer C Ornstein S et al 2001 System supports for chronic illness care and their relationship to clinical outcomes Top Health Info Manage 22 65 72 Fergusson K 2007 A roadmap for quality improvement in physician offices The Physician Executive Sept Oct 2007 38 41 Holmboe E et al 2005 Primary care physicians office based practice and the meaning of quality improvement Am J Med 118 917 922 Illinois Foundation for Primary Care Delivery 2007 Establishing a medical home through continuous quality improvement Illinois Foundation for Primary Care Delivery 2007 Getting started quality improvement strategies for your practice lowa Healthcare Collaborative 2009 Lean in Health Care Lynn J Baily MA et al 2007 The ethics of using quality improvement methods in health care Ann Int Med
64. tion needs e Government Medicare Medicaid PORI meaningful use other standards and criteria Suppliers lab vendors outsourcing hospital systems etc e Part of system network PHO IPA reporting group programs e Current system HIT characteristics functionality e mpact on practice decision making Assess Current HIT For Interoperability Interfacing References and Resources Health IT Bibliography Standards and Interoperability 2009 Making a connection Clinics collaborate on EHR deployment 2007 EHR Selection Toolkit for Community Health Centers Fugh Berman A 2008 Prescription tracking and public health Gen Int Med 23 1277 1280 Hicks L Sequist T et al 2007 Impact of computerized decision suupport on blood pressure management and control a randomized controlled trial 23 429 441 HRSA 2009 Electronic Health Records Selection guidelines for health centers Kern L Barron Y et al 2007 Electronic result viewing and quality of care in small group practices Gen Int Med 23 405 410 Lapane K Waring M et al 2008 A mixed method study of the merits of e prescribing drug alerts in primary care Gen Int Med 23 442 446 Leveille S Huang et al 2007 Screening for chronic conditions using a patient internet portal recruitment for internet based primary care intervention 23 472 475 Rollman B Fischer G et al 2007 C
65. tion prescription medication management consultation request follow up prevention of missed charges streamlined diagnostic test review analysis and reporting Use the PITO Needs Assessment Tool to assist with workflow evaluation and optimization Assess Current Processes and Begin to Identify Future States e Record the process flow for all activities how does the entire patient visit currently work scheduling patient arrival greeting verify information update information prescription ordering refills telephone messaging diagnostic test ordering and results patient examination charting chart conversions in process coding and billing Superimpose the workflow the office floor plan map flows of people equipment information patients etc Measure workflow times Identify the forms and documents currently in use Define all assignments and roles Fix optimize all flows implement new processes and tools such as planned care appointments new roles for non physician clinicians such as RNs NPs PAs huddles standard operating procedures notes orders prescription management annual comprehensive care and rapid access visits e Cllarify define all roles responsibilities e Identify the external factors payers patient population government suppliers your health system PO PHO IPA Address only what YOU can control not the remainder Analyze current HIT policies and procedures e Plan pre
66. tion ordered through CPOE Implement drug drug and drug allergy interaction Functionality is enabled for these checks for the checks entire reporting period Implement capability to electronically exchange Perform at least one test of EHR s capacity to key clinical information among providers and electronically exchange information patient authorized entities Implement one clinical decision support rule and One clinical decision support rule implemented ability to track compliance with the rule Implement systems to protect privacy and security Conduct or review a security risk analysis of patient data in the EHR implement security updates as necessary and correct identified security deficiencies OBJECTIVE Menu Set MEASURE Menu Set Implement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period Incorporate clinical laboratory test results into More than 4076 of clinical laboratory test results EHRs as structured data whose results are in positive negative or numerical format are incorporated into EHRs as structured data Generate lists of patients by specific conditions Generate at least one listing of patients with a to use for quality improvement reduction of specific condition disparities research or outreach Use EHR technology to identify patient specific More than 1076 of patients are provided patient educatio
67. tion security and device and media controls fire suppression protection contingency plan Application mail database and domain servers e Workstation hardware desktop computers thin client tablet PC printers scanners and ancillary and peripheral devices Application installation database and application server instance EMR and PM application workstation instance EMR and PM Interface Development Identify interface requirements analysis and review Arrange for configuration and code development in house programmers or vendor selection for development and discovery of data elements e Apply quality assurance processes verify the interoperability of the two systems test interface communication send test data batch analyze and fix issues send final test batch and run reports against data to validate accuracy move to pilot environment Software and Process Integration iterative process if necessary e Review and analyze intergration requirements Apply quality assurance processes verification and validation Move to the pilot environment Desired State Software Configuration e Configuration the EMR and practice management software based on practice requirements and process rationalization Apply quality assurance processes verification validation Move to pilot environment Security HIPAA Measure Implementation The Office for Civil Rights enforces the HIPAA Privacy Rule which protects the pr
68. ts e Existing active patient chart conversions e RIE RHIO Functionality This includes information storage access disease prevention management reminders and alerts clinical decision support scheduling communication prescribing medication management consultation request follow up prevention of missed charges streamlined diagnostic test review analysis and reporting Plan for information management handling of office information received from disparate sources to improve access quality relevance and sharing of data information e Define document how practice presently manages disparate information e Identify and review present data management use of the practice management system Identify report requirements for population management health and quality improvement e Develop document vision of how HIT will improve these processes Clinical Decision Support System CDSS These IT tools use evidence based guidelines and patient data to generate case population specific aids e Point of care reminders alerts highlighting indicates when preventive services such as immunizations and Mammograms lab tests or follow up visits are due and and prompts when education counseling is indicated for lifestyle changes such as for smoking cessation Interactive forms initial encounter content disease severity assessment screening tools such as depression and mental status Order sets condition based care protocols for conditi
69. uality improvement vision o Population management o Health care improvement registry o Quality reporting Some functions such as a patient portal and patient registries may be built into a EHR system or may be separate modules Wants and Needs Complete the Practice EMR Assessment Appendix B Then determine how HIT can assist your practice to improve care lower operating costs increase efficiency increase revenue and make the best use of clinician time What could your practice do better amp What new things do you need want to do How can you improve patient access Do you want real time access to patient information How can you have offsite access to patient information Can you improve accuracy and compliance by using electronic entry of orders Resources for Getting Started AHRO IT Adoption Toolkit Toolkit Getting Started AHRO Tools and Resources AHRO Knowledge Resource Library click on needs assessment under organizational strategy HIMSS Tools and Topics EHR Louisiana Health Care Quality Forum Electronic Health Record Resource Toolkit Vol The Adoption Process Assessing HIT Needs References and Resources The resource library has an extensive section on assessing HIT needs ASSESSING READINESS FOR THE HIT IMPLEMENTATION CHANGE Once the initial objectives are set the assessment involves looking at the organization and then using simple techn
70. ve and follow up care Provide patients with timely electronic access to their health information including laboratory results problem list medication lists medication allergies More than 20 or patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders More than 10 of patients are provided electronic access to information within 4 days of its being updated in the EHR References and Resources HIMSS Definition of meaningful use of certified EHR for hospitals HIMSS Definition of meaningful users of certified EHR technology CMS Final Rule and Supporting Materials Battani J 2010 Meaningful Use for Health Plans Five Things to Consider CSC May 2010 Zywiak W Metzger J Mann M 2010 Meaningful Use for Eligible Professionals The Top Ten Challenges April 2020 Porter Research 2010 The Road Traveled Providers Perceptions of ARRA Legislation from Inception to Meaningful Use Monegain B 2010 CMS ONC Deliver Meaningful Use Package Nace D Marchibroda J et al 2010 Meaningful Connections A Resource Guide for Using Health IT to Support the Patient Centered Medical Home STEADY STATE AND ONGOING IMPROVEMENT a Se Consortium CONTINUING TO UPDATE IMPROVE AND ADD FUNCTIONALITY Determine the increased value derived from the added HIT functions Improve and update HIT products Create user groups Share pro
71. ven practices with peers Continuously improve the HIT processes PREDICTORS OF SUCCESS References and Resources 2009 Safety net providers bring patients on line Lessons from early adopters HFMA 2006 Overcoming barriers to electronic health record adoption Healthcare Financial Management Association HIMSS Case studies and success stories HIMSS EHR Implementation Success Factors for Practices with between Six and 10 Physicians Senior leadership is involved in setting objectives and providing oversight An enthusiastic physician champion is the executive leader Project leaders acquire a solid knowledge base and pursue opportunities to learn about what worked and what didn t in other practices Goals for the implementation are clear feasible and based on the practice needs Workflow is redesigned to streamline processes Each staff member is assigned a role in the implementation and receives training before during and after the implementation Strategies to facilitate and sustain culture change are build into the implementation plan CAUSES OF FAILURE Definition of Failure Protracted implementation Exceeding budget Software abandonment Causes of Failure Misalignment of vision lack of early vision statement including goals lack of shared vision among practice members Insufficient business requirements failure to spend requisite time evaluating needs or purchase software and force impl

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