empowered for implementation: slides
TRANSCRIPT
Empowered for Implementation
Clinical Involvement Driving Success
Speakers
Geralyn Saunders, RN, MSN Chief Nursing Information Officer
Eric Podradchik, MBA Director of EHR
Boston Medical Center
Boston Medical Center
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• 482-bed, Academic Medical Center - Affiliated with Boston University Medical School
• The largest safety net hospital in New England • Mission: to provide consistently accessible health services to all• Full spectrum of pediatric and adult care services, from primary
care and family medicine to advanced specialty care. • Largest and busiest provider of trauma and emergency services in
New England. In 2014 the Emergency Department had approximately 130K visits.
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Project Vision and Scope4
HIE* Logician
SCM
BHN Logician CHC*
OR MngrAnes Mngr
GE Pharm
SoftMed
CPN
Current State Future State
ED PulseCheck
* CHC integration into Epic in Planning Phase for Summer 15’ Implementation
** Revenue Cycle, Procedural systems (Endoscopy, Cardiology), Lab & Radiology not in scope
• Early Adopter of EHR including CPOE and eMAR
• Best of Breed– Highly Customized– Multiple Interfaces– System Maintenance– Struggled with Upgrades
• Lack of Clear Governance Structure– Optimization Management– Prioritization– Organizational Decision Making
• Lack of Clinical Involvement in EHR Initiatives
BMC’s History of Health IT Implementation
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• Fast Track Implementation– 17 months from contract signing (Dec 2012) to inpatient go-live
(May 2014)– Drivers: Meaningful Use, ICD-10, Local Competition
• Broad scope of implementation, particularly for inpatient go-live• Needed front-line clinicians to embrace change and challenge
the status-quo thinking – Needed to empower clinical leaders to steer this initiative to
success.• Quick decision making required with clear governance &
escalation pathways– Needed efficient mechanism to gather clinical input to:
▫ Narrow design options▫ Define pros and cons for options▫ Make clinician-driven decisions in the context of limited
time and resources
BMC’s Key Challenges
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• Aggressive analyst hiring and initial training in WI
• Established CNIO role
• Divided inpatient project into ‘workstreams’ to support concurrent design and build activities in different clinical areas
• Developed escalation paths for issue resolution
• Clinical practice issues: MD & RN leadership councils
• Project/Technical Issues: cascade of leadership forums from integrated project managers meeting to organizational steering committee
• Developed Clinical Lead Program to co-lead each workstream with IT Build team lead
• Secured funding
• Aggressive internal recruitment
Initial Plan of Attack
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• BMC has selected a first-class, integrated EHR that has been successfully implemented at many organizations similar to BMC. We will therefore stand on their shoulders and implement Epic’s “Model System” and avoid BMC-specific configuration or customization.
• BMC’s project timeline allows us to comply with rapidly changing regulatory requirements and local market forces.
• BMC has empowered clinical leaders to steer this initiative to success.
• BMC will use this implementation opportunity to embrace change and challenge status-quo thinking.
• Go Live is just the beginning. BMC will provide resources for ongoing improvement, optimization, and innovation after go-live.
Project Guiding Principles
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Implementation Timeline
Executive Education
Project Planning and Scope Decisions
Infrastructure & Interface Analysis
Project Team Staffed and scheduled for training
Delivery of System with Training Data (SWTD)
Site Visit (3/25-3/27)
Model System Variances Determined & Documented
Project Team attends training at Epic and completes Certification
Delivery of tailored version of Model System
Validation Sessions (workflows) with Stoplight Evaluations
(4/23-4/25)(5/14-5/16)
Final Validation sessions
Workflow User Labs
Specialty Validation
System Build completed
Application, Interface and Integrated Testing
Credential Training, Super-User Training, End-User Training
Go-live readiness assessments / Dress Rehearsal
Go-Live and cutover planning
Post Live Visits by Epic Team
Evaluation of Future Scope
Tracking of Key Performance Indicators
Resume Ambulatory Implementation
Prepare for Upgrades
Upgrade
• Prepare for Rollout
• Rollout
Education, Analysis & Design Adoption & TransformationImplementation
GO-LIVE
Project Definition & Direction Setting
Discovery & Project Scope
Validation
System Build & End-User Adoption
Testing, Training, & Go-Live
Post-Live Support & Optimization
Rollouts & Upgrades
Oct ’12-Feb ‘13 Feb ’13-Apr ‘13 Apr ’13-May ‘13 May ’13-Nov ‘13 Dec ’13-May ‘14 May ’14-Nov ‘14 Dec ’14-May ’15
• Rapid hiring process to kickoff project.
• Targeted Epic talent in leadership roles (i.e. Managers and Team Leads) to decrease consulting needs for guidance. Otherwise BMC experience was a requirement for these roles.
• Application staff hired from internal and external.• Limited Epic exposure• Targeted local talent with intent to certify
• Most consultants were brought on in “just in time” hiring to address needs throughout the project.
BMC eMERGE Application Team
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Applications
Inpatient
Orders Clin DocPharmacy
&Oncology
Departmental
OR & Anesthia
ED / HIM /BedTime
Ambulatory
Amb
Training
Training
BMC Application Team Structure
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• MD-RN dyad co-leading with ITS build team lead• Joint responsibility and accountability for scope, timeline and
quality of deliverables
• Clinical leads empowered to make build and design decisions under the project guiding principles
• Clinical leads brought their local workflow expertise and integrated them into the decision making process
• Escalated challenging clinical/workflow decisions to weekly clinical lead meetings
• Defined adoption, training, and communication strategy for each key module
Highlights of the Clinical Lead Role
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• Project Commitment • MD Leads: percentage of their time
• RN/Ancillary Leads: mixture of fulltime & part time
• Negotiation with primary department for part-time leads
• Workstreams• Weekly attendance – workgroups and subprojects
• Additional time with analysts and trainers
• Leadership meetings • Clinical Leads Weekly Huddles
• Leadership Councils (ad hoc)
• Communications • Demo/roadshow as needed
• Schedule ad hoc departmental work sessions
Time Commitment: Clinical Leads
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Clinical LeadershipCMIOCNIO
Inpatient Leads
MD (4)
RN (5)
RT (1)
Outpatient Leads
MD (2)
RN
ED Leads
MD (1)
RN (1)
OB Leads
MD (1)
RN (1)
Peri-Op Leads
Surgical MD (1)
Anesthesia MD (1)
RN (2)
Supplies Lead (1)
Heme-Onc Leads
MD (1)
RN (1)
RPh (1)
Pharmacy Leads
RPh (1)
RN (1)
BMC Clinical Leads Program
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Clinical Lead Role: Phase 0 (Project Planning)
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Clinical Leads Selected• Introduced to project leadership, analysts & Epic • Internal Candidates (majority)• Shifting of Current Responsibilities
Clinical Lead meetings started • Weekly MD/Practice Managers Lead Meeting• Weekly RN/Ancillary Lead Meetings • Combined Meetings Followed
Assignments to Workstreams and CCBO workgroups
Clinical Lead Role: Phase 1 (Discovering & Scoping)
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Site Visits • Participated as Session Leaders • Key to understanding current workflow
Education• Some attended Training @ Epic and obtained
certification • Most of the Epic specific training through BMC ITS &
Epic AM/AC
Foundation System reviewed • Started to review application on line • Kicked off meetings with analysts • Triage between clinicians & build team
Clinical Lead Role: Phase 2 (Validation)
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Validation Sessions • Assisted in planning
• Getting the right stakeholders: managers & staff• Identification of high risk workflows and possible
mitigation strategies • Facilitated Sessions
• Led consensus building
Governance Structures Kicked Off • Decisions processed through MD & RN clinical lead meetings
before being presented to leadership forums
Initial Governance & Project Structure
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Clinical Lead Role: Phase 3 (Build)
Re-engineering sessions• Identified Issues• Proposed workflow adjustments • Strategize with project leadership to address trouble spots • Drove decisions (and Hold to them!)
Build: Continue to partner with analyst team • Co-Led workflow & design decisions with IT analysts
• Defined the problem(s) to solve• Defined reasonable options within Epic application• Articulated Pros/Cons and Recommendation
• Led clinical content build
Testing Involvement: script development
Training Involvement: lesson plan development
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Clinical Lead Role: Phase 4 (Testing & Training) (1)
Completion of the “build” • Participated in “build nights”
• All hands on deck – “certified leads assumed some build responsibility
• Drove tracking of clinical content (in Red Status)• Order sets • Oncology protocols• Care plans
• Engaged colleagues as needed
Workflow updates• Implementation required some changes • Migration work with departmental owners • Epic would not replace all legacy EHR functionality • Drove decision making and designing new workflows
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Clinical Lead Role: Phase 4 (Testing & Training) (2)
Training Kick Off • Identified super users • Signed off on lesson plans & training materials • Attended pilot training • Proctor end user training • Monitored staff engagement
Clinical Readiness • Assisted with planning (ensured the right leaders were
invited)• Active participation in kick off and ongoing operational
readiness meetings • Creation of presentations & checklists for significantly
changing and high risk workflows
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Clinical Lead Role: Phase 4 (Testing & Training) (3)
Testing, testing & more testing• Running through the scripts (RN leads > MD leads)• ‘Clinical’ voice in the testing room
Clinical Readiness Program• Facilitated kickoff and biweekly sessions starting 3 months pre-go-
live• Discussed ‘future state’ workflows, anticipated problems and
identified remediation strategies
Technical Dress Rehearsal • Technical RN lead • Led collaboration with departmental nursing leadership
Key Performance Indicators • Evaluation of metrics • Identification of pre & post go-live measures
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Clinical Lead Role: Phase 4 (Go-live)
Cutover Planning• Participated in multiple dry runs• Identified scope and clinical staff for manual transcription• Support during cutover
Clinical Dress Rehearsals • Key planning & communication role • Identification of scripts to execute • Led the actual event in clinical area
Communications• Departmental and leadership forums
Go-Live!• At The Elbow – the master super users • Explained clinical rationale behind design decision• Participated in daily clinician huddles • Resolution of key issues – drove rapid cycle solution development with
front line clinicians and within command center
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Clinical Lead Role: Phase 5 (Post Go-live)
Post Go Live • Continued: Master super users • Issue vs. Request management
Optimization Governance• Led User groups • Developed and prioritized optimization lists “Top
Ten” for each key clinical area
Training • Identified Ongoing needs • Thrive Training for clinicians • Nursing Competency Day
Evolutionary Lineage
Current Scope of Activities• Solicits feedback and suggestions for system change/improvements from end-
users• Vets system design decisions for approved initiatives• Communication channel to end-users• Prepares preliminary prioritization for review and approval by Governance
Membership • Clinical leads, readiness owners & super users• Clinical/Departmental leaders/Directors• ITS application leads
eMERGE User Groups
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Pre Go-live:
Work stream Meetings + Clinical &
Operational Readiness
Groups
Go-live: Leadership
Go-live Huddles
Post Go-live: Workstream Meetings + User groups
• Leadership’s sanity• Delegation • Divide and Conquer
• On-time and On-budget inpatient go-live May 2014• Efficient clinician-driven design process• Rapid cycle decision making• Anticipation of workflow issues and proactive remediation
• Fostered broad organizational clinician engagement
• Calm go-live
• Post go-live Epic score card – 4.75/5.0
Outcomes
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• Recognize each clinical lead’s authority within clinical department
– Have clinical leads perform regular check-ins with their department leadership
• Challenging role for clinicians new to organization– Lack of workflow knowledge – Time to make connections
• Guidance as needed for change management
• Required management of conflict between build lead and clinical lead…… when is something approved/done??
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Lessons Learned
• Project management support needed
• Managing/limiting downtime
• Manage conflicting responsibilities: ITS & departmental
• Turnover – some redundancy helps
• By Go Live, Clinical Leads often seen as part of IT instead of Clinicians
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Lessons Learned
• Project has been a large success!• Governance
• Workstreams & User Groups• Optimization Prioritization
• Key Optimization Efforts:• Epic 2014 Upgrade• Nursing: Acuity, IV Concentration Naming• Physician: iPASS Handoff, Care Teams, Results Tree Redesign• ED: Blood Transfusion, Order Panels, Interactive Map, Lynx• Hem/Onc: Survivorship Program
• Nursing Competency Day• Achieved Stage 6 of the HIMSS Analytics EMR Adoption Model• 2 months until Ambulatory!
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Inpatient Post Live 10 months
Post Go-Live Governance
• 3 Pronged Leadership Approach• Operations• Finance• IT
• Department Representation Required from Operations• Medical Director• AD/PM• Clinical SME
• Impact to Revenue Cycle is Significant
• Addressing legacy compliance issues
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Ambulatory Implementation
