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					Electronic Medical Records and
      Systems Integration
Today's Event Sponsored by:
Emdeon Practice Services helps practices meet the challenges of
  healthcare with innovative solutions, including electronic health
  records, encounter documentation, document and image
  management, and wireless and Internet connectivity.
For more information:
    Call: 877.WEBMD.01
    Visit: www.webmdps.com


Visit Emdeon's Virtual Trade Show exhibit at:
hdm.unisfair.com/prd.jsp?booth_id=13
                     Robecca Quammen
As President and CEO of The Quammen Group, Robecca is an
accomplished senior executive in healthcare information systems,
combining extensive healthcare administration, software vendor, and
consulting practice experience. She has over 25 years experience in
healthcare to include business development, sales, strategic and
tactical planning, operations and organizational development, product
development and delivery and emerging healthcare initiatives. With a
career history and reputation for superior quality business solutions
and customer service, Robecca has held senior management
positions for large healthcare delivery organizations, the nation’s
largest healthcare software vendor, and a large private healthcare
consultancy. Most recently she founded The Quammen Group as a
full-service healthcare consulting firm specializing in business planning
and development, strategic planning, large-scale software and
hardware implementation, software acquisition, outsourcing, and
organizational development.
        Do We Have an
Electronic Medical Record Yet?
                 Today’s Presentation

• Systems integration issues that arise when adopting an EMR
   – Hospitals dealing with integrating legacy systems with new
     systems, with departmental systems etc.
   – Stitching together EMR and Practice Management software
     at a clinic and then connecting them to the hospital data
   – Data Security challenges, single sign-on, etc.
   – The role of technology and standards in creating
     interoperability and data sharing across systems

• ESPECIALLY lessons learned on key hurdles and practical
  strategies that work...
                      Defining an EMR

• Automation of current paper chart
• Repository of financial and clinical data
   – Easily accessed, reviewed, updated
   – Concurrent and retrospective use
       • Clinicians
       • Physicians
       • Support personnel
• By-product of data gathered in HIS, CIS, and PM/EMR
  systems
  EMR Focus on All Care Providers
Attending Physician
Nursing
Consulting Physician(s)
Respiratory Care
Case Management
                                ELECTRONIC
Nutritional Services           PATIENT
Risk Management
                                DATA
IV Team
Patient Financial Services
Infection Control
Wound Management
Pastoral Care
Clinical Process Improvement
Cardiology
                                     BARRIERS:
PT/OT/Speech
                                     •   Access
Others                              •   Availability
                                     •   Acceptance
                                     •   Integration
                 Easier Said Than Done
• This frequently elusive metaphor for the traditional
  paper chart has been challenging to accomplish in
  every clinical setting, primarily due to
   – Cost and availability of solutions

   – Impact on the clinician workflow/practice

   – Implementation

   – Integration with Existing and Planned Solutions
                EMR - The Balancing Act


Heightened Demand for Solutions          Financial & Operational Results
 Multiple Unique User Demands             Competitive Market Pressures
   Clinical Reporting Demands            Capital & Operational Funding
    Impatience for Solutions                    Physician Affinity




                                Cost
                               Access
                              Security
                        Standards & Tools
                   Integration & Interoperability
         Why is Integration So Important?
EMR Adoption is a topic that transcends
                                the collection, storage, reporting,
                                    and transmittal of data.

EMR Adoption is a broad topic
                                   that   encompasses……




                   Business
                    Practice                     Systems
      People
         Inherent Challenges for EMR Adoption
People                                            Systems
                                                   Legacy Vs. New
 Big Picture
                                                   Availability
 Culture
                                                   Best of Breed
 Integration vs.
  Functionality                                    Vendor Strategies
 Individual Motivation   Business Practice        Integration
 Personnel Cost                                   Interoperability
                           Clear Vision and
 Fear of                   Priorities             Devices/Mobility
  Computerization          Strategic Plan         Portals/Single Sign-
                                                    on
                           Work Flows
       Compromise                                          Compromise
                           Process vs. Task
                            Orientation
                           Data Ownership
                           Access and Security
                           Patience and Time
                                  Compromise
        Where Does your EMR Journey Begin?
   Departmental Systems Impacting
Care Process (Emergency, Pharmacy)
 Departmental/Multi-Disciplinary Systems
      (Rehab, Respiratory, Surgery, etc.)
                      Specialty Documentation
         (Critical Care and Women/Children’s)
                  Advanced Clinical Documentation
                                  (workflow, rules)
      Physician Practice Management and EMR Systems

       E-signature for Physician Signature of Medical Records

     Results Repository Made Available to Remote and Mobile User

    Orders/Results Upgrade/Replacement in preparation for CPOE or to
       Create Integration with Planned Clinical Documentation Projects
                                 Legacy Laboratory and Radiology Systems
                                                    (upgrade or replace?)
    Where Is your EMR Journey Taking You?
• Paperless or Partial Paperless System
• Population of a Data Warehouse for Clinical Reporting
• Comprehensive Clinical Decision Support (Rules,
  Workflow)
• Integration of Solutions for Continuum of Care
• Complete Remote Access for Physicians and Clinicians
• Complete or Partial Nurse Documentation
• Integration of IT with BioMed
• Multidisciplinary Charting
• Clinically Driven Revenue Cycle
        Common Hurdles Along the Journey
• COST - EMR Systems are Expensive to Implement and Support
• LEGACY SYSTEMS – Integrate, Displace, Replace
• INTEGRATION - Best of Breed/Disparate/Closed Systems
• DATA SHARING & Interoperability – Information Available As Needed
• STANDARDIZATION - Adoption of Nomenclature/Data Dictionary
• ACCESS – Device Strategy, Mobility, Remote
• SECURITY – Network, Application, Single Sign-On
• DATA INTEGRITY – Who Owns It?
• WORKFLOW – Enhance It, Don’t Break It!
• TRAINING – Of Just About Everyone – What Works?
So, How Are We Doing?

 Efforts have been arduous, lengthy,
          and expensive, but

 effective EMR Adoption is within
          reach when completed as
          a series of initiatives.
                 Real World Experiences #1
• Goal: Provide an Online Medication Administration Record (MAR)
    – 1800+ bed integrated delivery system with multiple campuses and
      outreach clinics
    – Orders/results/repository in place with clinical documentation system
      implementation underway
    – MAR integration between HIS (third party) and RX (in-house
      developed)
        •   Vendor usage of record format that did not 100% comply with HL7
            standards, resulting in a significant amount of custom code in the interface
        •   Complex nature of medications compounded the issue
        •   Change management becomes critical to insure systems are in sync

• Outcome: Through integration, this organization was able to accomplish its
  goal. Change management continues to be critical to the success of this
  initiative.
                           Real World Experiences #1

                           CLINICAL DOCUMENTATION PROJECT




                                       FUNCTIONS


                                       Documentation
                                       •Assessments                   Electronic
                            Pharmacy                     Alerts and                  Care
  Orders         Results               •I & O                          Medical
                             (MAR)     •Progress Notes
                                                         Reminders                 Protocols
                                                                       Record
                                       •Vital Signs




                                        PRODUCTS




 Brand X         Brand X     Brand X      Brand X         Brand X      Brand X     Brand X




KEY:   Proposed Phase I
       Proposed Phase II
                                                                  Existing Products #1
                                                                    Registration/ADT/Results/
                                                                       Orders/Order Status                                              Repository
  FINANCE                                                              Update/Master Files

                                      MRI                                                                   CIS
RECEIVABLES                                                           ADT/Orders/Order Status
                                                                     Update/Charges/Master Files
 RADIOLOGY                                                                                                                                       Pharmacy
RESPIRATORY
                                             Orders/OSU Results
                                             Registration/ADT/




                                                                                                                       Registration/ADT/
                                                                                                                          Orders/OSU
                       OSU/Charges/Results
                        Registration/ADT/
                         Add-on Orders/




                                                                                                                                                   Lab
                                                                                                   Add-on Orders/OSU/Results



Reporting
                                                                                                                                                  Dietary
                                                                                                      Registration/ADT/Orders/OSU
      Clin. Dec.                                                      INTEGRATION
       Support                                                           ENGINE

                                                                                                                                               Other Systems

 LEDGEND
                   Scheduling
                                                                                                                  Registration/ADT
                                                      Registration/ADT/
 Bi-directional                                                                                                                                Drug Dispenser
                                                       Orders/Results
   data flow
                     PACS                                                                                                            Charges


                                             Registration/ADT/Lab Orders/                             Registration/ADT/Lab Results
Unidirectional                                     Radiology Results
                   Ambulatory                                                                                                                    ER System
  data flow
                                                                                                                         Transcribed Results
  Impact of Integration on the MAR


before




after
                    Real World Experiences #2
• Goal: To Provide Cardiology Functionality to a New Specialty Facility
     –   Primary organization has implemented a third party clinical orders/results/documentation
         system
     –   Specialty (cardiology) organization selected a different third party vendor for their
         Cardiology Information System
          •   Lack of outbound charting records from specialty system effectively isolating data
              to that system
          •   Necessitated printing of record to transfer with patient
          •   Investigating CCOW single sign on utilizing industry available products

•   Outcome: This organization accomplished the goals of the specialty area but did not
    provide a solution that meets the organizational requirements for having access to
    clinical data by anyone who needs it. They will be faced with manual solutions such
    as chart printing until they determine a method to populate a central EMR with
    integrated or scanned data from the specialty system. Additionally they are facing a
    common user issue in the need to allow single sign-on to multiple systems and are
    attempting to solve that problem with technology.
                   Real World Experiences #3
• Goal: To Provide Specific Departmental Functionality to the
  Respiratory Department with Emphasis on Charging and Work
  Scheduling
     – Third party clinical orders/results/documentation

     – Purchased and implemented specialty niche respiratory system
          •   Lack of outbound charting records from specialty niche respiratory
              system, effectively isolating data
          •   Necessitated printing of record to transfer with patient
          •   Interdisciplinary care charting was not accomplished
•   Outcome: By permitting a departmental solution to be purchased and implemented
    to solve the specific problems of the respiratory department, this organization has
    lost significant opportunity to meet regulatory guidelines for interdisciplinary
    charting and to insure that all care givers have access to the complete patient
    experience as they are performing their specific functions.
                     Real World Experiences #4
•   Goal: To Provide a Comprehensive EMR Solution in a Small Community-
    Based Facility in Which Funding was Challenging
     – Purchased a single source solution for all departmental and nursing functions
       and a third party specialty ER system
     – Chose to implement the comprehensive solution in three distinct phases over
       several years
          • Phase 1 included the population of a repository for local and remote access by
            physicians and care givers
          • Phase 2 introduced Medical Records, Pharmacy and Radiology functionality with
            a sub-phase to introduce an ER system
          • Phase 3 will introduce clinical documentation
•   Outcome: This organization knew its limitations with funding and staff to
    support multiple systems from multiple vendors and chose to purchase and
    implement a single source solution for departmental, advanced clinical and
    electronic medical record functions. They faced competitive pressures in their
    community to retain ER physicians and consequently purchased a niche ER
    system to meet their requirements. They chose to implement in relatively small
    increments to provide functionality and benefit to end users at various milestones.
                Real World Experiences #4
Current State (2004)                 Legacy HIS/CIS
                                       Rad/Orders/Rx
                              ADT
                                     PA/Payroll/HR/ADT
      Medical Records
          Coding
                                           ERP
                                          MM/GL




        Drug Dispensing



                                     Integration Engine

              OR Scheduling




                                                          LAB
                               EKG
                                             TV
                             Real World Experiences #4
              Phase 1          Legacy HIS/CIS
                                                                   Transcription            Transcription
                                 Rad/Orders/Rx     ADT
  MR Coding           ADT
                               PA/Payroll/HR/ADT



                                     ERP
                                    MM/GL

                                                          ADT
                                                         Results            Integration Engine
                                                   (text/discrete)
Drug Dispensing




                                                                                           ADT
                                 Integration
                                    Engine
      OR Scheduling


                                                                                   Clinical Data
                                                                                   Repository


                                                    LAB
                       EKG
                                       TV
                          Example Second Phase #4
Phase 2                   Legacy HIS/CIS                                                                                                   Transcription
                            Rad/Orders/Rx
                          PA/Payroll/HR/ADT
                                ERP                                                                                                         Results (Rad)

                               MM/GL




                                             Orders - Results
                                                Charges         Results (RT/ECG)                  Open Engine
                                                                Orders (w/statuses)           Clinical Data Repository
                                ADT




                                                                                                      (Text/discrete)




                                                                                                                                             Clinical Data


                                                                                                                                                             Statuses
                                                                                                ADT


                                                                                                                        Results




                                                                                                                                                              Order
                                                                                                                                  Orders



                                                                                                                                                 (text)
  EKG
          Results (ECG)   Integration Engine
                                        Orders - Results




                                                                                                 ED System
                                ADT


                                           Charges




                                  LAB
                                                                                      Medical Devices                                           Physician Billing
    Sample Information Flow Diagram #4

                     Cardiology               Registration



                                                               Laboratory
       Radiology




Respiratory
 Therapy                                                          Medical Records
                                  Clinical Data
                                  Repository




                                                             Home
          Hospital                                            or
                                                             Office
                        Real World Experiences #5
•   Goal: To Provide a Comprehensive EMR Solution in a Community-Based
    Facility in Which Funding was Challenging and Many Initiatives Were Already
    Defined and Underway
     – Faced many projects to upgrade or replace existing functionality before moving forward with
       advanced clinical functionality
     – Identified sum total of initiatives required to achieve the desired electronic medical record
          • Established strategy to guide all purchasing decisions and align organization around key
            vendors and solutions
          • Formulated 5 year budget projections to educate the organization on priorities based on
            funding availability
          • Gained consensus from organization regarding pending and future EMR initiatives
•   Outcome: This organization now has a roadmap to guide their information technology
    activities according to their operational strategic plan for the next 5 years. Annual
    review and validation of the plan is scheduled. This organization fully understands the
    implications of their short and long term activities as they relate to deployment of an
    EMR. Further they understand that the EMR deployment is a series of projects.
Strategies for Success: Establish Goals & Objectives
 • Establish Health System Objective
    – Completely paperless
    – Hybrid medical record (part electronic/part paper)
 • Establish relationships with all ancillary departments and
   vendors
 • Future purchases: disparate systems versus integration
        • Decisions driven from critical data to be available in the
          EMR based on feedback from advisory groups
 • Development and adherence to Information Systems Strategic
   Plan
 Strategies for Success: Understand Current State
• Development of Current State Model
   – Inventory of all departmental systems
   – Inventory all existing interfaces
   – Understand the mix of integrated and disparate systems
   – Understand the integration limitations with various systems
• Evaluate Clinical Workflow
   – Understand impact of decisions on current and proposed clinical
     workflow
       •   Patient Movement
       •   Interdisciplinary
       •   Nursing
       •   Physician
        Strategies for Success: Acquiring Systems
• Maintain Focus on Strategic Direction
    – Unrelenting focus on goals
    – Executive leadership
         • Be realistic
         • Be objective
         • Be concrete (how & when questions)
    – Clinician and physician involvement
• Seek Outside Advice and Counsel (these decisions are expensive and
  have huge organizational impact)
    –   Experiences from staff who have worked in other environments
    –   Vendor References
    –   Internet
    –   Consultants
    Strategies for Success: Disparate Systems
• Disparate Systems
  – Potentially more robust functionality
  – HL7 Compliance for Interfacing to EMR
  – Cost of Ownership
     • Additional Interfaces to support
     • Additional application support fees
     • Additional Upgrades
Strategies for Success: Integration & Interoperability
 • Integrated Systems vs. Interoperability
    – Departmental/user specific functionality
    – Support and maintenance (impact on technical
      architecture)
    – Data availability/sharing
    – Clinical workflow
    – Short and long term use of data
       • Discreet data vs. textual
Strategies for Success: Establish Rational Expectations
  • Establish EMR Timelines
     – Map out timelines for each project
     – Overall timeline is driven by labor and financial resources
     – Start with basics to ensure initial success
          • ADTs
          • Laboratory results (discrete and text)
          • Radiology results (text)
          • Cardiology results (text)
          • Respiratory results (discrete)
          • Documentation (H&Ps, Op Rpts, Discharge Summaries, Consults, etc.)
             Strategies for Success Summary
• Choose an EMR product strategy that offers the greatest potential for
  success in your particular circumstances
    – Choose as many modules as possible that are integrated into a suite of products
    – Carefully choose products that have a strong history of integration with other
      products
    – Use disparate system integration as sparingly as possible to accomplish your
      EMR goals
    – Leverage a variety of technologies to create visual, functional, and database
      integration
• Gradually phase in the EMR to lessen the impact
    – Understand that the EMR is a series of projects and initiatives
    – Take best advantage of available technologies
    – Group products/modules in a way that allows users to recognize incremental
      victories and obtain functionality in shorter time frames
    In Closing, The Successful EMR Adoption
encompasses much more than the relationship
  between the physical parts of the system.

                               Health
                               Outcomes
                               Cost

Successful adoption is measured by the user and
validated in the meaningful application of data in
the care delivery process.
Robecca Quammen
President/CEO

The Quammen Group
1400 S. Orlando Avenue, Suite 204
Winter Park, FL 32789
407-758-3390 (cell)
407-539-2040 (fax)

E-mail: becky@quammengroup.com
Today's Event Sponsored by:
Emdeon Practice Services helps practices meet the challenges of
  healthcare with innovative solutions, including electronic health
  records, encounter documentation, document and image
  management, and wireless and Internet connectivity.
For more information:
    Call: 877.WEBMD.01
    Visit: www.webmdps.com


Visit Emdeon's Virtual Trade Show exhibit at:
hdm.unisfair.com/prd.jsp?booth_id=13

				
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Description: Presentations Showing Change Management Timeline document sample