Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

When my father was in his early 60’s, he began to experience a mysterious, debilitating pain.   He initially thought it might be arthritis, but it kept getting worse.   It reached an extreme where my father could no longer move without discomfort.    Our family was devastated when we received the diagnosis.  He had a treatable cancer, that had moved past the point of treatment… it was in his bones.

We sought out specialists in our area and my father began treatment with a top of the line cancer center.   Like me, my father was a bit of a geek.  I can remember him becoming completely enthralled with the Electronic Health Record utilized by his team.   The oncologist, the urologist and pain clinic managed all of my father’s information from one organized and easy to use electronic document.   During the early stages of his illness, the computer in the room was something my father considered a “neat feature” of his care.  I would call to see how he was doing and he would talk about his latest visit and tell me about how the It wasn’t until later that we all realized how valuable that “neat feature” truly was.

Time progressed, as well as my father’s illness, but his incredible treatment never wavered.  There was a point where my father was taking more than 10 medications daily, in addition to the infusions and injections administered at the cancer center.  Even with a complex schedule of medications to follow and numerous underlying medical conditions to monitor, his quality of life vastly improved through the blending of the specialists’ knowledge and the EHR’s accessibility.  Once again, my father was able to enjoy life’s simple pleasures, like a walk through the woods or a trip to the market, without pain.  Life however, was not without its ups and downs.

It was a complex medical situation and we needed to be prepared for the possibility of emergency intervention.    I made an “Emergency Fact Sheet” that listed all of his Active problems, medications, allergies, phone numbers for all of his providers and immediate family members.    We taped it to the inside of the front door so that it could be easily found for a trip to the ER or if the paramedics needed to be called.

The day arrived when the paramedics had to come to the house and rush my father off to the local community hospital.  The experience of the local hospital was a stark contrast to the care of the cancer center.   The paper process for providing care was so unbelievably cumbersome, that the simplest of tasks took days, even with the detailed background information we given the hospital.   The time delay between visits from the appropriate physicians, ordering the correct medications, requisitioning the orders from the hospital pharmacy, and getting the medication to my father, caused a major disruption in his daily pain management schedule.  This delay ultimately resulted in the recurrence of that intense bone pain while waiting for the medication schedule to be re-established.

The next hospitalization we had his medication list and were ready to advocate for him as soon as we stepped in the door.   Advocacy was unnecessary as he had been admitted to the inpatient unit of the cancer center.   The EHR contained not only all the information from my homemade “Emergency Fact Sheet”, but it contained the actual orders for the medication that could easily be transmitted to the in-house pharmacy.   Dad didn’t miss a dose of his pain medication on that trip.    I saw beauty in the simple efficiencies that resulted in excellent patient care and comfort.

Everyday there are news stories on the politics and profitability of electronic health records, but it is less often you hear this story being told.   My loved one received better care, and because of that, suffered one less day of pain.   Somewhere, someone’s father is receiving better care, because an EHR generated a reminder to perform a prostate screening blood test, which resulted in the early detection and treatment of his Prostate Cancer.  Sometimes the Return on Investment is not about finances, sometimes it is about life.

Tags: Allscripts Consultants, EHR Implementation

When: July 28 – 29th, 2009
Where: Orlando, Florida during the ACE pre-conference sessions
Price: $1500

Expert training on the AE EHR database is key to understanding this complex data
model.

The Allscripts Database Architecture and Reporting Workshop will provide you with the
fundamentals necessary to build reports out of the Allscripts Enterprise EHR Database.
Throughout the two day event we plan to review the key tables within the Allscripts databases,
strategies for reporting repositories, deployment methods, and we will walk through reporting
examples provided by the different attendees.

• Course Highlights
  • Enterprise EHR Database Architecture Review (key tables)
  • Develop Reports Based on Attendee Submissions
  • Review Reporting Methodologies
  • Review Report Deployment Methods
• Recommended Audience
  • Reporting Analysts and Architects: Your decision support or reporting group is
    likely flooded with requests for reports from Allscripts. We recommend using a
    data warehouse of some sort for reporting (direct copy of production, or one
    populated by an ETL process). The reporting analysts and architect(s) within
    your organization will need to understand the Allscripts EHR data model in order
    to service these report requests. They will obtain a thorough review of the key
    tables in the Allscripts database, how they link together (foreign keys are
    frequently not available), and the challenges found in retrieving data from the
    EHR database. Data warehouse options and design considerations will be
    reviewed.
  • Database Administrators: The DBA will obtain a thorough review of the key
    tables in the Allscripts database, how they link together (FKs are frequently not
    available), and the challenges found in reporting from the EHR database – both
    in the data structure for reporting and performance impact of the queries and
    how the transactional data model affects the ability to write efficient reporting
    queries. Data warehouse options and design considerations will be reviewed.
  • Physician IT leaders – we have trained a handful of physician-cum-IT directors who have had great success in understanding the data model, and being able to use both ad-hoc queries to make quick analyses of situations, and help their team write meaningful reports.
  • IT leaders – often times the managers and directors of IT groups are not hands-on writing reports. There are times, however, that leaders within the IT organization need to understand the EHR data model at a detailed level. The course is a perfect match for this situation.
• Prerequisites
  • Prior knowledge of T-SQL is essential. Querying including multiple joins, CASE statements, temporary tables and GROUPing should be an area of comfort for the attendees.
  • An understanding of the Allscripts Enterprise EHR with regards to management/admin and end-user use is required.
  • A basic understanding of the Allscripts Enterprise EHR databases is preferred, but not necessary
  • Prior use of Crystal Reports and SQL Server Reporting Services will also be helpful.

Allscripts Analytics and ETL– this course is well-suited for groups who already have Analytics or the Allscripts ETL, as well as those who don’t. We will cover a variety of data not available in
Analytics/ETL, as well as allowing your DBA group to query the data real-time, such as needed during performance or error troubleshooting.

Attending this Course

Contact Mike Dow for more information and to sign up. Space is limited and seats will be filled
on a first-come, first-served basis.
Mike.Dow@GalenHealthcare.com
617-379-0840

Tags: Allscripts Enterprise EHR, Custom Reports, EHR Implementation

Downtime. The often daunting word has many different meanings and severity levels for every individual. Within health care organizations, almost every application and form of communication is electronic, save for the chart. Thanks in large part to the new Administration, that gap will be closing quickly. As we move towards a paperless environment of complete technological dependency, new challenges emerge that may threaten the accessibility of patients’ health records. While the merits of moving to an electronic atmosphere are recognized industry-wide, the assumption that the availability of health records are 100% guaranteed is an unrealistic and potentially dangerous notion. What guarantee do physicians, nurses and clinical staff have that promises constant, uninterrupted access to clinical information? What access will they have should the system become unavailable?

Imagine in the middle of the night, an air-conditioning unit blows a circuit and consequently causes a dramatic rise in the core temperature of the server room. At over 100 degrees, the servers that haven’t already shut themselves down automatically are shut down manually, rendering all systems temporarily inaccessible. We have undoubtedly all experienced, at one time or another, email failure and while frustrating, the unwelcome disruption by no means prevents us from doing our job. Now couple this email outage with a clinical system that is down for an extended period of time. Finally, imagine the organization is an oncology group with patients scheduled for infusion, follow-up appointments, labs pending review, etc. In this case and most clinical care scenarios, it would be next to impossible to make a safe and well-informed clinical judgment. Luckily, in the true-life scenario painted above, the implementation was mid-stream so paper charts were still available. Despite their good fortune, this eye-opening incident caused the organization to scrutinize what downtime procedures they have in place if the EHR application goes down again.

It seems almost unfathomable that this issue has not been seriously addressed in any extensive manner. Some EHR vendors have tried to address the issue but most have not. With that said, this isn’t necessarily a bad thing; most would probably agree that they would rather have their vendor focused primarily on EHR functionality, expanded features, interoperability and other client needs. Some vendors have gone so far as to try and create a complete “working” application at the local site. Why create complexity in a scenario where access, particularly quick and painless access, is the only key requirement for clinicians?

We decided it was time to address this critical problem by creating a downtime solution, VitalCenter, which allows access to clinical data in any circumstance. In developing this solution we sought to account for all scenarios—server failure, LAN/WAN outage, application slowdown—not just extreme situations as in the previous example as well as a tool to assist with planned downtime, like upgrades. Every user will have a different threshold for what he or she considers ”unavailable.” Some will struggle through periods of intermittent slowness, while others will simply revert back to paper. Notably, VitalCenter can support a specific user in any unique situation.

At a high level, VitalCenter delivers patient charts, known as VitalCharts, to physician locations based on provider schedules. The access and delivery of this information is completely configurable by organization as well as per provider. For example, some providers may only require the previous Progress Note, while a specialist may require the most recent Note within the same specialty as well as the most recent Note. VitalCenter has the ability to incorporate such features. The application will extract patient data for a specified period of time going forward and in the past, again configurable to the individual needs of each physician.

We’re all in this together, and VitalCenter will provide a critical, albeit small, component to delivering patient care. VitalCenter allows everyone to focus on their job – clinicians continue to care for patients, administration ensures the organization is running smoothly and IT continues to work with its vendors to provide valuable and more reliable solutions to the organization.
VitalCenter removes the distraction that unmitigated downtime creates, and allows your organization to focus on what’s important – providing patient care.

For more information, please visit: http://vitalcenter.galenhealthcare.com

Tags: Allscripts Enterprise EHR, EHR Implementation, VitalCenter

EHR utilization

Talking about EHRs and their respective utilization is much like making a blanket statement about cars or computers.  It just can’t be done at that level.  There are many organizations that would consider themselves live on an “EHR.”  Truthfully most are somewhat using some EHR functionality.  As humans we only use a small portion of the capability of the human brain and we live normal lives without using the rest.  Most EHRs are used to some similar level but we have a capability to tap into more of that functionality that we have invested in.

Much of this functionality requires that front end effort be made to make the back end benefits evident.  The effort is often not made based on lack of understanding or education of the necessary effort.  Unfortunately, the sales pitch that sold the back end benefit did not explain the detail.  This is not to place blame on the sales person, but to illustrate the necessity to read the manual.

Reluctance to change is amazing.  It is beyond my understanding why as educated adults we think that results with EHR will happen so instantaneously without necessary effort.  Nobody expects it to all change tomorrow, but give it some time it is truly a transformation.  With EHR you can see some results and benefits very fast but making it all takes some time.

EHR projects require such an involvement from both the clinical and the IT side in a world where most things used to be handled on one side of the fence or the other.  Now we are truly working on the fence.  Unfortunately we tend to staff these projects by giving 20-30% of 20 individuals time to the project.  I am not sure how the mathematical equation works but the manpower of those part time individuals, not dedicated to the project often ends up less than the 4 it should be.  Personally I would take 3 teachable full-timers over 20 part-timers almost all of the time.

The way that we implement or utilize an EHR greatly determines its success.  It is a large project deserving of an amount of forethought and effort correlated to the magnitude of the desired success of the project.

Tags: EHR, EHR Implementation, Successful EHR Implementation

Interoperability of EHRs with all of the peripheral devices that make an EHR a one-stop shop that the clinicians cannot live without seems to still be a challenge.  Despite “standards” such as HL7 which define how the systems communicate there still is significant challenge in getting through the projects.  It is by no means “plug and play” and the difficulty is in getting the parties to even have their own version of the standard specification.  The flexibilities of the standards leave some room for interpretation and this is where difficulty sometimes arises.

The desire to freely communicate is not there yet.  When folks start to understand that the end game is quality healthcare and if a system is easy to integrate with the customers will be more happy and everyone wins.  Unfortunately now, it seems that everyone sees integration as a constant revenue generator.  The costs associated are not bogus but without proactive thought to how to make a system be repetitively interoperable there is a significant waste of resources crafting the same wheels over and over.   I have been involved with projects where copious amounts of hours are spent discussing the most basic details of an HL7 interface because the parties involved don’t know anything about the fields or the data.  I have also been involved in the antipodean scenario where both parties show their standard specifications, discuss the minor differences and they agree upon who is going to accommodate the differences and moments later they can send test transactions.

The tendency for integration points to become projects by themselves inherently lengthens the process.  With the lack of knowledge often exhibited on such projects they tend to collect teams of individuals who collectively should have the knowledge to make the integration work, but the points of ignorance of those individuals in other areas exponentially increase the topics of discussion that are in play to educate everyone involved.   This becomes very annoying to the individual that has their stuff together on the the other end of the integration.

The challenge to healthcare organizations is that the complexity of the EHR is not only a complex IT project but one that also demands a clinical understanding to help with all of the integration.  Clinical organizations are required to have resources that are more technical and the technical resources have to have clinical knowledge about what they are doing.  It is extremely difficult to complete a lab interface if you don’t have the knowledge of how to flip the flags and when to flip the flags.

The resources involved in integration need to step up and take the time to learn what they are doing rather than spending one hour a week trying to make something work.   Know your part and then some and don’t waste others time.  If you know what you are talking about and what you want the efficiency of the process is greatly increased.

I argue that a clinical organization that takes the time to acquire or train an individual that knows their business on integration will recover his/her salary multiple times in EHR efficiency, buy-in and ability.  I have seen organizations where they pay both vendors $30,000 to complete 20 integration points, why not pay one individual $60,000 for 10 years or $100,000 for 6 years.  I have seen this work.   Once you have the individual on staff the integrations become easier and easier and even a small interface that only aids a few clinicians is now justifiable.

There are other staffing changes that seem and are significantly different, but when you compare them to what you might spend paying to have the work done elsewhere, they make sense.

Tags: EHR, EHR Implementation, Interoperability

I have worked on many projects with the objective of implementing an EHR.  It seems that somewhere along the way, the goal sometimes gets lost.  Yes, from an IT project perspective, sometimes the goal is to get the EHR live, however healthcare organizations should not have EHR projects with the goal of “getting an Electronic Health Record live.”

They have to go back to the reasons why the project started.  What were all of those questions or requirements that were in the RFP or search process, that get out of focus?  There are now government organizations and others with initiatives to help encourage EHR adoption which can be interpreted hundreds of ways.  It sounds dreadfully obvious, EHRs exist to improve healthcare in many ways and those are the reasons for the projects, not the implementation milestones.

As part of an organization with a large focus of helping healthcare organizations embrace technology to improve patient care, I often find myself reminding myself and others why we are doing what we are doing.   Admittedly it is easy to get caught up in the race to the finish line.   If the light at the end of the tunnel doesn’t remain the target it becomes easy to make poor decisions along the implementation path that drastically affect utilization.

Cost reduction, efficiency gain are often a large part of the focus, but properly implemented EHRs can enable more thorough, compliant and consistent care.  The accessibility of the information available in a properly implemented EHR  to individuals within the healthcare organization can be phenomenal.  Once organizations realize the magnitude of the data available, the old reporting mechanisms and their data become minuscule compared to the power of the discrete data in an EHR.

Problem list population can be overwhelming, but on the back side, order entry can be achieved much easier if driven by the problem lists, notes can have problems automatically cited,  health maintenance can be driven by these problems etc.

I could go on with a many more examples and don’t contend that an EHR implementation can take place without the IT folks, but want to do everything to make it clear that we are implementing EHRs for healthcare and the technology is just what gets us there.

Tags: EHR Implementation, Successful EHR Implementation

We recently did a presentation at the Allscripts conference titled “Your EHR is Live.  What’s next?”  To me it seems like a fairly simple concept, but I am amazed at the applicability to most groups using an EHR.

The simple concept is around optimization.  The initial push of the implementation is to meet all of the vendor milestones and accomplish all of the things that were decided way back when.  This often seems to leave some low-hanging fruit.  There are varying reasons these exist.

Often, the reason is what we know now, doesn’t quite line up with what we thought we knew or understood then.  It may have been a lack of understanding or possibly that some additional people weren’t in the decision process.

Another reason is the learning curve is limited by the “go-live” timeframe.  Some of the users aren’t as quick as others and they learned what was required but nothing beyond.  The EHR might be just one of the changes the users are currently absorbing.

The number of reasons could go on and on.  The reasons aren’t as important if you are already using a system.  If you aren’t you might want to ask others what they might have done differently.  The next step is what’s important.

I was introduced to the term “process re-engineering” some time ago and have been continually process re-engineering my life since that time.  When going through the implementation process to bring up an EHR, we often duplicate bad processes in the EHR because we don’t see the opportunity to improve other than the technology.  When I say we don’t see the opportunity, it could mean a couple of things.  One might be that the build team asked “How do you do it now?” and never examined if that was the best process.  The other side is that those answering the question don’t understand the technology available to know how to improve the process.

I recently came across a group where everyone is “e-prescribing.”  Interestingly there are several flavors of how “everyone” is accomplishing this.  There are some who are writing everything on paper as they always have done but now also entering the information into the computer.  There are some who are writing all of the prescriptions in the computer and printing them all out.  Both of these have missed some of the efficiencies of e-prescribing.  Among the efficiencies, are the medication list and allergy/DUR reconciliation that these two examples are gaining.  However, they are missing out on the delivery efficiencies available, as well as not using paper and incurring those costs.

I would suggest that groups schedule periodic process improvement evaluations that look at utilization, efficiencies and priorities from a technical and clinical perspective.  The main focus should be to get the most out of the systems in the most efficient manner.  Here is a list of some of the questions that should be asked?

How are you using the EHR?
What are your challenges with the EHR?
What are possible solutions to the challenges?
What would make the EHR most valuable to you?
Has the EHR made you more efficient?

Work with those that are having challenges, often the learning curve is what is holding them back.  They want things that are already there, they just need education on how to use the features.

Additionally study some individuals to see how they are accomplishing what they are doing in the system.  Use this to compare it to “best-practice” not as a tool to reprimand but as a way to show them the easier way.

Tags: EHR, EHR Implementation, Successful EHR Implementation