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					EMR Implementation and Adoption:
    A View from Two Levels


 Manish Kohli, MD, MPH, MBA
            Medical Director
      Clinical Information Systems
      Overview of JHCP




http://www.hopkinsmedicine.org/jhcp/
                     Who Are We?
   Part of Johns Hopkins
    Health System
   Private, non-profit, primary
    care organization
   75/25 Fee-for-Service/
    Managed Care
   Network of 16 medical
    centers spanning 100 mile
    radius throughout Maryland
   129 clinicians
   500 support staff
                     What We Do
   Patient Care
     Provide primary and secondary care to over 150,000
      Maryland residents.
     Over 445,000 patient visits annually
   Teaching
       Provide practice experience for 50 medicine housestaff,
        16 pediatric housestaff and 80 ACIM medical student
        rotations
   Research
       Participate in research initiatives from Johns Hopkins
        Schools of Medicine, Nursing and Public Health
            Mission

TO BE THE MEDICAL HOME FOR
           OUR PATIENTS,
where everyone’s physical, emotional and
   social well being is valued and all are
 treated with kindness, competence and
                  respect.
                             Advanced Medical Home
     EBM and CDS tools to guide decision making at the
      point of care based on patient-specific factors
     Provide enhanced care for all patients with or
      without a chronic condition
     Integrated, coherent plan for ongoing medical care
      in partnership with patients and their families
     Enhanced and convenient access to care not only
      through face-to-face visits but also via telephone,
      email, and other modes of communication
http://www.acponline.org/hpp/adv_med.pdf
                                           Advanced Medical Home
         Identify and measure key quality indicators to
          demonstrate continuous improvement in health
          status indicators for individuals and populations
          treated
         Adopt and implement the use of HIT to promote
          quality of care, to establish a safe environment in
          which to receive care, to protect the security of
          health information, and to promote the provision of
          health information exchange
         Feedback and guidance on the overall
          performance of the practice and its physicians.
http://www.acponline.org/hpp/adv_med.pdf
    Advanced Medical Home
   Patient centered care
   Evolution of physician as a coach
   5 Rights
      Right Information

      Right Patient

      Right Provider

      Right Time

      Right Care
                “Modern Day”
             Primary Care Practice

 An   Individual PCP…
  Completes  20,000 forms per year
  Sees 24 patients a day

  Orders lab tests for 50% of patients

  Writes referrals for 10% of patients

  Has up to 8 interruptions during single patient visit
                                          “Modern Day”
                                          Medical Practice
    38% of physician time is spent writing chart notes
    Medical records are not found 30% of the time
    Once found, medical record volume is often
     unmanageable
    Organizing data improves efficiency
           Flow sheets results in a four-fold faster retrieval of
            clinical information


Zaroukian, M. Michigan State University
               Information Overload
   It is estimated that an
    individual physician
    must process 1
    million bits of
    information with each
    patient encounter…
     Causes of Medical Errors
 86%  system issues
 14% knowledge/ skill issues

 75.6 errors / 1000 primary care visits
   IOM: Statement on Health IT
“Information technology must play a central
role in the redesign of the health system if
substantial improvement in quality is to be
achieved over the coming decade”.

         “Crossing the Quality Chasm”
              Institute of Medicine, 2001
            Achieving the IOM Aims with
                    Technology
   Safe:          e-prescribing reduces errors in
                         drug prescribing and dosing
   Effective:     automated reminder systems
                         improve compliance with
    clinical                   guidelines and quality
   Patient centered:
                   enhanced information access and
                         communication
         Achieving the IOM Aims with
                 Technology
   Timely:      information available at the point
                 of care; no more “lost” charts or
                 misfiled results;
   Efficient:   reduction in redundant lab
                 tests and radiology
   Equitable:   internet-based communication can
                 enhance equity if technology
                 infrastructure is accessible to all
Drivers of Change and Business
            Strategy
   Enhance Safety
   Deliver Patient-centered Care
   Improve Quality and Outcomes
   Improve Practice Efficiencies
   Enhance Data Integration, Access and
    Security
   Contain Costs
   …to be the Medical Home
            Business Case for EMR Adoption:
                 Cost-Benefit Analysis
                                     Savings
    Eliminate chart pulls           100%
    Transcription savings           28%
    ADE prevention                  34%
    Use of formulary drugs          15%
    Appropriate lab testing         8.8%
    Appropriate radiology testing   14%
    Increased charge capture        +2%
    Decreased billing errors        78%
Veteran’s Affairs Medical Center
             First Step…


Electronic Prescriptions and Phone Notes
    Electronic Prescription Writing
   Pilot late-2003
   Initially Voluntary
                                  Praises
   Objections                          “A couple of clicks and I can
         Too much time, too             refill 10 rxs”
          many clicks                   “Drug interaction checking is
         Too slow                       nice”
                                        “I can give my patients/ ER
         Too many alerts
                                         a med list”
                                        “I have access to the med list
                                         when I am on call”
                                        “We can now read what the
                                         provider intended to
                                         prescribe”
       Electronic Prescription Writing
   Early-mid 2004 begin considering transition to full EMR
   Need to have allergies entered : October, 2004
   Portion of quality component tied to having allergy data in
    the EMR
   Measurement date: April, 2005
   Data in prescription writer will not need to be entered
    again
        Achieving Success:
Executive Mandate and Allergy Entry
                          100%

                          90%

                          80%

                          70%
 % Pts. w/ Allergy Data




                          60%                                                 % of distinct Patients with Allergy data

                          50%

                          40%

                          30%

                          20%

                          10%

                           0%
                                         4          4         4          05           5          5          5          5            5
                                       -0        -0         -0                      -0         -0         -0         -0           -0
                                     ct        ov         ec        n-           eb         ar          pr         ay         n
                                 O           N          D         Ja           F           M          A           M        Ju
                                                                                   Month
            Achieving Success:
       Annual electronic prescriptions
Thousands


     600                                  616




     500                         511



     400                409




     300



     200

               154

     100



       0
            2003     2004     2005     2006
          Next Step…


EMR Selection and Implementation
         EMR Selection Strategy
   RFP                             Technology Assessment
   Structured                       and Integration
    Presentations/ Site Visits      Project Management
   Administrative/Financial         Team and Strategy
    & Clinical Scenarios            References
   Vendor Assessment               Total Cost of Ownership
   Clinical Functionality          Comparative SWOT
    Analysis                         Analysis
          EMR Selection Strategy
   Group Choice
       Multidisciplinary selection team
       Involve providers, Practice Admins., Support staff
        in selection process
       Buy in from the JH Health System
EMR Selection
             Success with e-Rx:
           the “New” Challenge
   Paper AND electronic database
   No precedence
   Over 1.3 million data elements
     663,000 Problems
     513,000 Medications

     152,000 Allergies

   20,000-25,000 hours of effort for manual data
    entry
    EMR Implementation: Phase 1

   End User Expectations
     System performance
     Cannot go back to paper prescriptions
     Do not want to do data preload
     “G.Y.M” syndrome
    EMR Implementation: Phase 1
   Tasks
     Data   conversion
        Prescriptions   and problem lists
     Allergies
     Phone  notes
     Messaging (“flags”)
     JHML lab interface
     Letters and handouts
EMR Implementation: Phase 1
   Strategies
     Provide  functionality available with electronic
      prescription writer
     Sequential site roll-out
        March-   Aug., 2006, 1 site/week
     Data conversion prior to each site go-live
     On going learning and refinement

     Phase 1 competency assessment
     EMR Implementation: Phase 1
   Critical success Factors
     Executive  mandate
     Familiarity w/ e-Rx
     Delivering on promise of data conversion
     User involvement in selection
     RVU protection
     Clinical/ IS leadership
EMR Implementation: Phase 1
   Challenges
     Data  conversion
     Staff turnover
     Training
     Dual environments- paper and electronic
     Technical issues
        Network /Citrix
        Database
        Third party application
Preload @JHCP
             Project Update
         Electronic Prescriptions at JHCP

60,000
50,000
                                    Touchworks
40,000
                                    (2005)
30,000
20,000                              Centricity (2006)
10,000
     0
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                    Quick Wins:
                  Medication Recalls

   Vioxx recall
       recalled Thursday, September 30, 2004
       By Oct. 2nd, we had contacted 1,533 patients using Televox
   Zelnorm recall
       Recalled Friday, March 30, 2007
       By April 3rd contacted 302 patients using Televox
   Grifulvin V Oral suspension
       Wednesday, April 11, 2007
       Contacted 110 patients using Televox
Make it fun…
EMR Implementation: Phase 2
    EMR Implementation: Phase 2
   Tasks
     Documentation

     Orders

     Immunizations

     Scanning(pilot sites)
     New “paperless” site
    EMR Implementation: Phase 2
   Initial end users’ concerns
       Autonomy, style, individuality and need to reduce
        variability
          “I have to change”
          “I do it this way”

       Effectively engaging with patients
            “I don’t want to look stupid in front of my patients”
     Productivity
     Enhancements
      EMR Implementation: Phase 2
   Initial end users’ concerns
     Training   and support
        Need   to be able to get help quickly
     High   availability very important
        Network/ connectivity
        Home access

     Downtime      plans
        Planned
        Unplanned
    EMR Implementation: Phase 2
   Anticipated Challenges
     Change-  top to bottom
     Fear, anxiety, lack of knowledge, perception

     Managing user expectations

     Balancing site and user autonomy w/ need for
      conformity
     Training
    EMR Implementation: Phase 2
   Anticipated Challenges
     Making  “high touch” happen
     Limited support resources

     Hardware upgrade and deployment

     Relocation of some old practices
EMR Implementation: Phase 2
   Strategies
     High network availability
     Centralized training
     “High touch” go-live support
     Go- live approach
        Alpha teams- March, 2007
        Beta sites- April, 2007
        Waves 1,2,3
     On going learning and refinement
     Phase 2 competency assessment
    EMR Implementation: Phase 2
   Critical success Factors
     End user familiarity with EMR
     Clear mandate- “vanilla”
         Limited custom content
         CCC forms
     Superusers
     IS Staff stability
     Network stability
     “High touch” support
     RVU protection
     Leadership
         Infrastructure Upgrades
   Network analysis resulted in upgrade for 2 sites
   Server capacity analysis resulted in addition of 8
    servers to citrix farm
   Ongoing review of workstation configurations,
    upgrading PCs, monitors, thin client
                                                                                  Johns Hopkins Community Physicians




EBMC               Charles County           Greater Dundalk            Hager Park                   Laurel             Montgomery Grove               Riverside                 White Marsh




       Annapolis                    Frederick         Green Spring Station        Howard County                 Odenton                 Westminster               Wyman Park                  Tindeco




                                                                                    Johns Hopkins and Verizon
                                                                                       Network Connections




                                                                                             CITRIX FARM
                                                                                  Production/Development/Test servers
                                                                             MT. Washington Data Center & 1830 Data Center




                                                Replicated                                                                                                          Oracle
                            EMR                                 Biscom Fax          Data Transfer     Development             Test            Training
                                                  EMR                                                                                                              Enterprise
                         Production                                Server              Station        Environment         Environment       Environment
                                                Database                                                                                                           Manager




                                                                                                                                              EMR Infrastructure Overview
                                                                                                                                                                       July, 2007
        EMR Implementation: Phase 2
   Managing End user expectations and issues
     Too much to learn in a short time
        4 hr. training!
        Expect familiarity not proficiency
        3 “Golden” Rules
        On going learning
     More work
        Leverage support staff for data entry
        Work effort less for subsequent visits
        Learning to do focused data entry
        Getting comfortable with skipping
    EMR Implementation: Phase 2
   Managing End user expectations/issues
     Reducing  Data entry time and effort
        Getting used to templates

        Navigating the EMR

        “correct” template or “typing”

        Quick text and macros

     Knowledge vs. workflow

     Help desk and Go-live Support
    EMR Implementation: Phase 2
   “Discovered” Challenges
     Workflow   re-engineering
     Data Transparency

     Communication

     Quality of documentation

     Quantity and usefulness of documentation

     Balancing the early, mid and late-adopters

     Need for new/revised policies and procedures
         Achieving Success
 100%     JHCP Live by July, 2007!
    5   months ahead of schedule
 Providers   and Staff
   Thiscan be fun!
   How did we manage without it
   We NEED the system to be available
    24/7 and from where ever we are
                       Project Update
           Go-live
                       Dec-06   Jan-07   Feb-07 Apr-07    Jul-07
           Date
Of f ice
           11/17/2006 1,051     4,152    11,144 46,578
Visits                                                    114,789
Lab
           11/1/2006   36,554   67,022   86,091 137,681
reports                                                   379,287
Lab
           11/1/2006   9,735    19,210   25,818 46,802
letters                                                   79,832
Clinical
           3/17-
list                   201,444 236,904 259,512 303,457
           8/17/06
update                                                    339,786
Rx         3/17-
                       155,525 186,134 203,086 245,402
Ref ill    8/17/06                                        295,152
Phone      3/17-
                       105,616 127,576 139,438 173,005
note       8/17/06                                        219,889
Total                  509,925 640,998 725,089 952,925    1,428,735
            Project Update
                                       % change from
                 Documents Change      previous month
December, 2006      509,925
January, 2007       640,998 131,073       25.70%
February, 2007      725,089   84,091      13.12%
April, 2007         952,925 227,836       31.42%
July, 2007        1,428,735 475,810       49.93%
           EMR Implementation:
             Beyond Phase 2
   Phase 3
     Quest and Labcorp interfaces
     Patient portal

     Provider portal

   And beyond…
     Device interfaces
     QS-EMR interface

     Secure messaging
Secrets of Success…
             Secrets of Success
   Executive mandate
   Phased rollout
   Alpha and Beta teams
   Super users locally
   Training and Go-live support
   Schedule and RVU protection
   Communication
   Leadership
                            Challenges
   Network and infrastructure
   Geographic distances
   Scheduling challenges
   Patient care needs
   People factors
       Skills
            Physician and Staff computer literacy
            Typing proficiency
       Fear of change
   Staff turnover
               Take Home Messages
   This is a workflow re-engineering and process
    improvement project, not just an EMR implementation
       Assess workflow impact
       Do not automate broken processes
   Have a positive attitude
       Balance optimism with practicality
   Be flexible and adaptable
       Be willing to think “outside the box”
       Manage expectations
               Take Home Messages

   Innovate
   Leverage change agents
   Be tolerant of risk
   Get ready for culture change
   Remind everyone:
       “When you are a patient, how would you like the health care
        providers and the system to care for you?”
   Remember that CHANGE is hard
       Plan to Have fun!
         A Clinical Innovation:
           The Stethoscope
“ That it will ever come into general use,
  notwithstanding its value, is extremely doubtful
  because its beneficial application requires much time
  and gives a good bit of trouble, both to the patient
  and to the practitioner because its hue and character
  are foreign and opposed to all our habits and
  associations.”

                   The London Times (circa. 1834)
   Questions?

Manish Kohli, MD
   mkohli2@jhmi.edu

				
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