Part I- Organization Planning & Internal Governance

Developing a project charter is the first step. The project charter has several components that include the project description and business objectives and success criteria. This is an important part of the charter, if you do not know what you are hoping to accomplish or know what success of the project means to the organization the chances of reaching success will be difficult at best.  Other components of a project charter include listing the stakeholders, vision, project scope (another important piece, as scope creep will happen without it), assumptions and dependencies, constraints, milestones, business risks, resources and finally an approval section where the executive team’s signatures will be placed to demonstrate their approval and acceptance of the project charter.

The development of a formal project plan with identified milestones will assist not only the project manager but the executive steering committee to determine the health of the project. The creation of a great project plan includes receiving input from the project team.  This allows each member to buy into the journey that are about to embark upon.

The next component of planning for your organization’s EHR project is developing a communication strategy.  A well thought-out strategy that includes formal communication channels is crucial.  Once the project picks up speed the lack of communication can cause unnecessary hurdles.

Some additional components of organization planning and internal governance are determining a decision matrix that outlines how specific types of decisions will be made and ultimately approved.  Forming your committees that include providers, executives, and clinic leadership will facilitate the support required for your EHR project to be a success.  Having a commitment from the members of these committees is crucial as you may need their backing upon occasions throughout the project.

The final component is establishing a solid infrastructure and reliable network.  Addressing any infrastructure concerns before you begin your project is essential because once you pick up speed on the project, this area risks being left unattended which can cause hardship on reaching your goal of achieving SUCCESS!

Watch for Part II – Exceptional Project Management and Control

Several sources researched had varying numbers for the cost per provider. The cost for implementation, range from $25,000 to $60,000 with a mean of $42,500. Maintenance costs range from $5,000 to $18,000 per provider per year. The details from several sources are listed below: 

Harvard – “Based on the informatics literature, the initial implementation cost of an EHR for private practices averages between $40,000-$60,000 per provider and the cost of maintenance averages $5,000-10,000 per provider per year.” http://mycourses.med.harvard.edu/ec_res/nt/191A1C43-AEF8-4244-8215-F39C690A4E6B/EHRseries.pdf

 Ahrq.gov – “The research indicates that the average purchase and implementation cost of an EHR was $32,606 per FTE physician. Maintenance costs were an additional $1,500 per physician per month. Not surprising was the finding that smaller practices had the highest per-physician implementation cost at $37,204. The study also found that the average cost for EHR implementation was about 25 percent more than initial vendor estimates.” http://www.ahrq.gov/news/press/pr2005/lowehrpr.htm

Perot Systems – “For physician groups, the CBO reported that total implementation costs for office-based EHRs ranged from $25,000 to $45,000 per physician, with annual operating, licensing, and maintenance costs ranging between $3,000 and $9,000 per physician” http://www.perotsystems.com/MediaRoom/Library/ServiceOverviews/ServiceOverview_CostsAndBenefits.pdf

EMR and HIPAA – “It is estimated that the cost of purchasing an EHR system is $33,000 for each physician, with an additional cost of $1,500 per doctor per month for maintenance. This expense has cost challenges for many providers, especially those in small practices. Some estimate that the long-term cost-savings produced by a national health information network could reach $77.8 billion a year from a reduction in medical errors, diagnostic test duplication, and administrative expenses.” http://www.emrandhipaa.com/emr-and-hipaa/2009/06/01/scholarly-study-on-cost-of-ehr/

Since the federal incentive payments are being offered, the next question is whether or not those funds will cover the cost of implementing an EHR will be covered. 

Avalere Health - “These new incentives are intended to motivate doctors to adopt EHRs, yet for many physicians, the level of the incentive may not reflect current financial realities,” said Jon Glaudemans, a senior vice president at Avalere Health.  “Given this gap, EHR adoption will still require a significant investment by small physician practices.  In today’s economic climate, many physicians will struggle with this calculus.” http://www.avalerehealth.net/wm/show.php?c=1&id=808

MGMA - “…physician-owned practices with paper medical records generally spend $20,000 per full-time equivalent (FTE) physician on IT (chiefly for hte billing system) and have less profit (medican total medical revenue after operating cost per FTE physician) compared with groups with EHRs that spend more than $20,000 per FTE physician on IT have a substantially greater profit than those that spend $20,000 or less on IT.”   Gans, MSH, FACMPE, D. N. (2010, July). Investing in Technology: How Information technology expenditures affect the bottom line. MGMA Connexion,  19-20.

Jerri Cowper

I’ve created a few examples that I’ve added to our Wiki page.

1. http://wiki.galenhealthcare.com/Patient_Portal_Integration

With this case study Galen had a client who has implemented a patient portal application whereby patients are able to send messages to their doctors regarding tests, results and general questions. The client was looking for a way to have the provider be able to integrate this application directly into the EHR. With RelayHealth’s help we have succesfully built a prototype whereby a provider can seamlessly communicate with a patient in the most efficient manner possible!

2. http://wiki.galenhealthcare.com/images/5/57/Add_new_Web_framework_documents_to_the_EHR.pdf

In this example a client was looking for a new link on their vertical toolbar which would allow them to display any website in their current workspace (the main viewing pane of the EHR). This one example integrates the website directly into the EHR window without having to navigate through a new tab or window, showing a FRAX calculator. The other tab actually has the ability to take in patient context (height, weight, blood pressure, etc.) and pass it into a form automatically populating fields to save physicians valuable time. This article goes through the steps involved in setting up new vertical toolbars, horizontal toolbars, and workspaces to set up these outside websites in the EHR. The actual code to populate patient context is fairly complex but definitely something Galen would love to help out with!

Keynote Address: The State and National Vision for Health IT and HIE

Dr. David Blumenthal, National Coordinator for Health Information Technology – U.S. Dept. of HHS,  presented his own anecdotal experiences with the EHR, namely a story of how he was going to prescribe a patient a drug containing sulfa, yet the clinical decision support software in the EHR flagged him for a drug-to-drug interaction. If CDS tools within the EHR not available, would the pharmacist have caught this? Could the patient potentially been adversely affected?

Dr. Blumenthal then elaborated on two key components to which he felt would impact behavior via policy: writing regulations and spending money.

Regulations

• There have been 2000 comments received on the Interim Final Rule, with the publication of the final regulation anticipated by the end of the spring
• No comments questioned the conceptual framework nor the direction of Meaningful Use.
• The framework of Meaningful Use consists of 5 domains – quality, efficiency, patients & family, coordination of care, protection and security
• In speaking of the Interim Final Rule, Dr. Blumenthal utilized the analogy of an escalator – allow providers ease of introduction and steps for clear path of usage while lowering barriers to entry.
• Information Exchange – infrastructure is poorly developed for information to follow the patient and thus policy needed to address this. Certification will be the key to interoperability and with tighter standards, HIX should be more interoperable.
• CLIA (Clinical Laboratory Improvement Amendments): Currently, legacy regulations are being addressed such that the barriers to LDX (Laboratory Data Exchange) can be removed.
• Privacy & security: Providing authorities with the means of penalizing individuals and organizations for violations to ensure controls, access, protection

Spending money

• Regional Extension Centers (RECs) are currently modeled after US agriculture, which was intended to disperse new info to the family farm. The goal is to ensure that HIT is reaching the family physician and providing advice in terms of selection and implementation.
• Focused on <10 provider practices such that the full benefits of HIT can be reaped by the practice. Facilitation of re-design of work flows and mobilization of information for quality and efficiency improvements
• 50 states have been funded to promote RECs.
• Different localities will have different solutions for health information exchange (HIX)
• 70 community colleges were funded for workforce training and it is anticipated this will facilitate staffing of RECs

Next Year: Direction

• Implementation
• Finalize requirements for Meaningful Use
• Beacon Community Program – Fund 15 communities around the country directly through a grant program with the intent to offer a source of lessons and inspiration. There have been over 130 applicants to the program thus far.

F/U Questions/Concerns

• Physicians are worried that HIT happens to them, not with them and that users not intimately involved with the design

Panel – Consumer-Centric: The Role of the Patient in Health IT and HIE

• John Moore from Chilmark Research introduced term the term “citizen” as the term patient can often be paternal. He mentioned a John Halamka quote – “automating bad processes will not lead to improvement”.
• David Szabo, a partner, Edward Angell Palmer & Dodge brought up the point of how do we go about engaging citizens and brought up some serious concerns over privacy, especially in regards to patient portals. The topic of behavioral advertising in PHRs was brought up and it was mentioned that  FTC may provide governance to this regard.
• A question was posed about those surveyed and focused on in regards to Healthcare IT in that they are predominately affluent and white. John Moore responded with mobile health technologies being the enabler to reach all demographics and minorities.
• A comment was made concerning the power of secondary data to pre-populate EMRs. Barbra Rabson, Executive Director, Mass Health Quality Partners, provided a response and brought up a cautionary tale in the highly publicized case of e-patient Dave as published in the Boston Globe.
• To touch on concerns about patient security and privacy in regards to the Personal Healthcare Record (PHR), John Moore also brought up a really cool Massachusetts company called “Patients Like Me”  and highlighted the fact that through this vehicle,  “citizens” currently share their healthcare stories and experiences.

Regional Collaboration Meetings (CT, ME, MA, NH, RI, VT)

Later in the afternoon a breakout session allowed public officials to meet with neighboring states to discuss current plans, areas of concern, regional interoperability and opportunities for collaboration.

• NESCO (New England States Consortium Systems Organization) represents a business model built around collaboration and their Deputy Director, Nancy Peterson, acted as the facilitator.
• The idea of health delivery system reform was immediately brought up in that the system incentivizes and currently pays for sickness instead of for health via preventative and behavioral care.
• The model of the state of ME was addressed. Currently they have an operational provider-only HIE available to facilitate treatment improvement and representative of six of the largest healthcare systems in the state. The HIE, established in 2004 and live as of the summer of 2009, covers 50% of the hospitals 46% of ambulatory care.
• Some of the questions and comments posed by the audience included the following
  • How do we bridge between standards?
  • The business case needs to be established as this will drive investment. We need to clarify a vision and clearly express the financial incentive model.
  • Challenges with the business case in that savings on one side put costs on another.
  • We need to attack some of the low-hanging fruit first by implementing a common consent framework.
  • Ownership of the data: Who owns the data? The patient?
  • HIEs need to be consumer-driven.
  • Are we focusing too much on the standards with meaningful use, whereas we should be focused on the transport and the “network”?
  • Where are the interconnections in healthcare delivery that have the highest yields in terms of clinical data?
  • We face the underlying competing entities in clinical standards versus claims standards. Integration of the two needs to be addressed.
  • We are up against perverse incentives as there are many other resistive forces towards HIE, namely disincentives, in the health system.

These will be structured in a similar format to university courses – the initial three classes will be at 100, 300 and 500 levels.  The list of the webcasts and their times may be found below.

100 Series – Configuration and Deployment of Imagelink: Overview of Imagelink configuration within the AE-EHR and implementation of corresponding result interface dependencies.

• Wednesday, May 19th, 2010 at 2:00pm EST

300 Series – Advanced Troubleshooting: Error analysis and resolution as well as custom techniques for error remediation

• Wednesday, June 23rd, 2010 at 2:00pm EST

500 Series – Advanced Design: Interface filtering techniques and interface-driven tasking

• Wednesday, July 21st, 2010 at 2:00pm EST

To attend, please contact Justin Campbell, justin.campbell@galenhealthcare.com.You must be an existing Allscripts Enterprise EHR client to attend.

We also offer training courses and reporting services for the Allscripts Enterprise EHR database, ETL database, Analytics and the ConnectR  database.  Please contact sales@galenhealthcare.com for more information regarding these courses and our reporting services.

Many important questions are sparked by the users during these meetings as Joe reviews the differences in their workflow today and what their workflow will look like with the EHR. These are questions that are typically answered during the meeting and often times reassure any anxieties the group may be experiencing prior to their go live. A thorough review and understanding of the clinical workflows will give users an appreciation for the need to adjust their workflow to the EHR and provide more efficient use of the EHR from day one

Other items to note in regards to lingering questions surrounding Meaningful Use and ARRA as a whole:

• Dr. John Halamka also addressed the public comments on the Interim final rule on his blog post.
• Many questions persist surrounding interoperability standards, and as John over at EMR and EHR addressed on his blog post, the Healthcare Information Technology Standards Panel (HITSP) was recently extended to be operational until April 30th only. How will this impact communication of meaningful use from organization to the government?
• We recently updated our meaningful use matrix to include which functionality supporting MU measures are delivered in the Allscripts Enterprise EHR (AE-EHR). John at EMR and HIPAA is also collecting a number of the various matrixes that people have put together around the EMR meaningful use criteria

If your organization is looking for assistance in exhibiting meaningful use, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical and professional service offerings.

As with any data conversion, one must be cautious in terms of negative implications. For instance, administrative data has its limitations, and an example or where the process can go wrong is the highly-publicized case of e-Patient Dave.  Ultimately, problem conversions can be useful, but the data needs to be reviewed, and almost treated as suspect.  The value in the conversion is saving the entry of the problems that are accurate – say 80-90%.  Any that are incorrect, will be reviewed with the patient and can easily be marked EIE.

Statistics:

• 1,007,238 problems were loaded to the EHR for 205,831 patients via the interface engine, taking about 11 hours to process totally.
• PM Extract file statistics:
  • Total matchups of ICD9s to patients: 5,405,874
  • Total Unique ICD9s: 8346
  • ICD9s that only match up with 1 patient:1295
  • ICD9s that match up with 100 or more patients: 2027

Approach and Components:

• Master approved “ICD9” list provided by client
• Extract of ICD9 data from PM system provided by PM vendor
• Automated macro that attempts to match ICD9 to Medcin. Potential matches include the following:
  • 1 to 1
  • One to many (20 or less)
  • One to many (20 plus)
  • One to none
  • Each of the different flavors of matches were marked with an annotation (highlighted via an asterisk) to identify to clinicians the logic that was used in importing the problems:

• Once the translation was finalized, it was loaded into the interface engine and mapping logic loaded problems into the patient chart in the EHR via the API (existing stored procedure).

Known Issues Mitigated:

• Due to incorrect logic, some ICD9s were linked to patient profiles improperly. To mitigate this, a script was run to mark these problems as “entered in error”
• Problems were loaded to the “Past Medical History” section of the patient chart with a status of active. However, given this status, it didn’t facilitate providers to easily change the problem to be an active problem linked to a note.

Lessons Learned:

• Execute a proof-of-concept and as with any technical project, get clinician feedback. The client had a pilot group of 5 clinicians to vet out issues and bless the data before the live conversion was run.
• Do NOT use spreadsheets to track the cross-walk between administrative ICD9 diagnoses and clinical Medcin problems. Rather utilize a staging DB to serve as a single repository in developing ICD9 to Medcin translations. Also, the data from flat-file export from PM can be loaded into a staging environment via SSIS such that it can be analyzed and summarized while facilitating persistence.
• Make sure to tie the problem conversion load to a specific provider, that way if side effects or issues are identified after the fact, there is a clear way to identify which problems were loaded in the conversion via the provider they are tied to. The interface log should also have a record of this, but most organizations set the retention time to 90 days.
• Workflow validation – ensure that the workflow to move problems from PMH to Active will not be a barrier to use.

If your organization is looking for assistance in data conversion, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical service offerings.

Some of our clients have recently expressed the desire for a limited, read-only view in to the AE-EHR to extend access to audit entities. For instance, the requirements of one organization included a limited patient-access read-only environment to be in compliance with FDA Research Part 11 restrictions for clinical trials. Another organization needed it for insurance audit purposes. And still again, others desired to provide an extended environment to allow hospitalists, ED physicians, and critical care physicians access to selective patient charts.

Approach

One of the more popular approaches has been to segment out a separate read-only organization in the Allscripts Enterprise Electronic Health Record (AE-EHR). The AE-EHR handles organizations quite nicely and facilitates an approach of segmenting out entities – the following Galen Wiki article covers a scripted means of deploying a new organization in v10 AE-EHR.

Once the organization has been created, patients can then be “bulk-loaded” to the organization via SQL scripts. New AE-EHR users can then be created and associated to this organization. Finally, to setup the read-only portion, security gates can be implemented.

Extendability

An additional requirement of one of our clients included an approach that offered the capability to dynamically add/remove patients to the “Audit” organization real-time. We facilitated this via creation of a file-based interface from ConnectR to the AE-EHR. The interface accepted its input from a well defined flat-file (comma-delimited, including MRN, Action – Add or Remove, and OrganizationID) and utilized that data to add/remove patients to the org via a custom stored procedures – the de facto application programming interface (API) to the AE-EHR clinical database.

And still further, another client requested that the audit/read-only entities (users of the system) be granted the ability to create tasks . For example, the client desired a specific, high priority task, identifiable as originating from the audit/read-only entity – in this case hospitalists which could be assigned to the patient’s PCP. In this case, the clients’ hospitalists could communicate high priority continuity of care tasks, which require prompt reaction, to the PCP at discharge. However, the PCPs should not be able to task back to the hospitalists, and this can be achieved by setting the EnableOrgFilterFlag preference in the AE-EHR.

If your organization needs assistance in setting up a audit environment to provide limited, read-only access to the AE-EHR, please contact sales@galenhealthcare.com and visit our website for more information regarding our technical and professional service offerings.

There are different options available to increase accessibility. Permanent workstations in each exam room provide the providers with the ability to access the EHR directly from the exam room and complete any tasks needed for the current visit: order medications, diagnostic tests, submit charges, input visit data. Tablet PCs give the provider the flexibility of moving around the clinic and working in different areas. They are able to access the EHR while in the exam room, in their office, or standing at the nursing station.

I have seen the use of both the Permanent workstations and Tablet PCs in different sized organizations. They are both viable options that depend on the needs and infrastructure of the organization.