IHS EHRIndian Health Service Electronic Health Record

Carolyn Johnson & Michele MillerCarolyn Johnson & Michele Miller

Warm Springs Health & Wellness Warm Springs Health & Wellness CenterCenter

Preparation & ImplementationPreparation & ImplementationToday’s PresentationToday’s Presentation

Medical RecordsMedical Records Medical ClinicMedical Clinic LabLab PHNPHN PCC & BillingPCC & Billing PHN/Community Health/ DiabetesPHN/Community Health/ Diabetes CAC/Computer SupportCAC/Computer Support

Medical Records ProcessMedical Records Process

When to stop pulling the chartWhen to stop pulling the chart Filing notes in chart during the transition?Filing notes in chart during the transition? Print And File Chart Copies? Batch Print?Print And File Chart Copies? Batch Print? Release Of Information?Release Of Information? Outside Consults? Scanning?Outside Consults? Scanning? TranscriptionTranscription

Medical Records Supervisory Medical Records Supervisory Process ChangesProcess Changes

Daily Report: Unsigned OrdersDaily Report: Unsigned Orders Daily Report: Unsigned NotesDaily Report: Unsigned Notes Retracting /Correcting Incorrect EntriesRetracting /Correcting Incorrect Entries Paper P&P changed to Electronic P&PPaper P&P changed to Electronic P&P Sensitive Pt TrackingSensitive Pt Tracking Medical Records Supervisor: Business Medical Records Supervisor: Business

rules/HIPAArules/HIPAA Who can view which parts of EHRWho can view which parts of EHR Works cooperatively with RPMS Site ManagerWorks cooperatively with RPMS Site Manager

Medical Records Staff Changes Medical Records Staff Changes at Warm Springsat Warm Springs

Staff shift from Medical Records to other Staff shift from Medical Records to other departments :departments : 2 Medical Records are in PCC part time2 Medical Records are in PCC part time 1 Med rec tech is a nurses aid1 Med rec tech is a nurses aid 1 Med rec tech is a Benefits Coordinator1 Med rec tech is a Benefits Coordinator More nurses aids after EHRMore nurses aids after EHR Staff will be utilized to scan documents once Staff will be utilized to scan documents once

VistA Imaging is implementedVistA Imaging is implemented

Medical Clinic PreparationsMedical Clinic Preparations

Formed TeamsFormed Teams Practiced EHR (on paper)Practiced EHR (on paper) Defined RolesDefined Roles Computers everywhereComputers everywhere

Medical Clinic ProcessMedical Clinic Process

Using templates/graphs instead of flow sheetsUsing templates/graphs instead of flow sheets Using the scheduling gui for visual routing of pt Using the scheduling gui for visual routing of pt

flowflow Selecting ICD/CPT codesSelecting ICD/CPT codes Using GUIs:Using GUIs:

Ward Order Lab EntryWard Order Lab Entry RCISRCIS Behavioral HealthBehavioral Health SchedulingScheduling

Lab PreparationsLab Preparations

All Labs need to be entered in RPMSAll Labs need to be entered in RPMS On-site LabsOn-site Labs Reference LabsReference Labs State LabsState Labs

Computer Access PointsComputer Access Points Changing from Esig to EHRChanging from Esig to EHR

IHS EHRIndian Health Service Electronic Health Record

PCC/CodingPCC/Coding

Krisanne BillyKrisanne Billy

Objectives for this SessionObjectives for this Session

Role ChangesRole Changes PCC Data Entry Coding ProcessPCC Data Entry Coding Process Error ReportError Report CommunicationCommunication New Coding QueueNew Coding Queue

Role ChangesRole Changes

Coding & Data Entry are a combined Coding & Data Entry are a combined position. position.

Instead of 2 data entry clerks, we have 70 Instead of 2 data entry clerks, we have 70 data entry providers who encode data.data entry providers who encode data.

AuditorAuditor EducatorEducator

PCC Coding ProcessPCC Coding Process

Coders are assigned days. Coders are assigned days. (ODD/EVEN)(ODD/EVEN)

Coding/Auditing from a coding queueCoding/Auditing from a coding queue We code from EHR/RPMS not the We code from EHR/RPMS not the

chartchart Corrections communicated to provider Corrections communicated to provider

via notification (demonstration)via notification (demonstration)

PCC Error ReportPCC Error Report

Daily Error Reports Daily Error Reports shouldshould be run be run Most Common Errors:Most Common Errors:

Missing POVMissing POV Missing E&M CodeMissing E&M Code .9999 - Uncoded diagnosis (Separate Report).9999 - Uncoded diagnosis (Separate Report) Duplicate VisitsDuplicate Visits

• 2 visits created on the same day – have to be 2 visits created on the same day – have to be mergedmerged

Coding QueueCoding Queue

Paperless list on RPMS that shows every visit Paperless list on RPMS that shows every visit for a specific date range, that have not been for a specific date range, that have not been audited by the coder.audited by the coder.

ProsPros• No more VGEN lists (only for research purposes)No more VGEN lists (only for research purposes)• Everything is there.Everything is there.• Flag errors & incomplete chart notes.Flag errors & incomplete chart notes.

PCC-Business Office PCC-Business Office CommunicationsCommunications

Bills are generated before PCC has Bills are generated before PCC has reviewed the visit. Communicate with reviewed the visit. Communicate with Business Office.Business Office.• What can they bill? What can they bill?

Questions?Questions?

Business Office ProcessBusiness Office Process

Services Pick List Development, Installation, Services Pick List Development, Installation, And TrainingAnd Training

No Hard Copy To Work WithNo Hard Copy To Work With No more missing E&M CodesNo more missing E&M Codes EHR Notes Are LegibleEHR Notes Are Legible Great Opportunity For Improved Provider Great Opportunity For Improved Provider

Documentation & Increase Billing/CollectionsDocumentation & Increase Billing/Collections

Preparation/ImplementationPreparation/ImplementationCACCAC

Elapsed time (in months)

Decisi

on to

imple

men

t EHR

Review

EHR W

ebsit

e

0

Comple

te E

HR Site

Sur

vey

Begin

EHR Site

Tra

cking

Rec

ord

Begin

hiri

ng pro

cess

for C

AC

Establi

sh E

HR Imple

men

tatio

n Tea

m

Attend L

esso

ns Lea

rned

cla

ss

RPMS c

urrent,

CACHE

Begin

phar

mac

y dru

g file

clea

nup

for P

harm

5/7* Beg

in pr

ocur

emen

t pro

cess

for h

ardw

are

Inst

all P

IMS

Optim

ize “P

oint-o

f-Ser

vice”

RPM

S Pac

kage

s

Optim

ize P

CC Erro

r Rep

orts

Inst

all/c

onfigure

Rad

iolo

gy 5.

0, L

ab 5

.2

Inst

all P

harm

acy

5/7

and E

HR GUI

Imple

men

t Pap

erle

ss R

efill

Attend C

AC trai

ning

On-site

Set

up with

Nat

’l EHR T

eam

EHR Super

Use

r tra

inin

g

EHR Go-L

ive

with N

at’l

EHR Tea

m

Full ro

llout

1 2 3 5 8 106 11 12 24

Please note that this is just a general timeline of how long it might take for your site to implement EHR. Every site will be different, and the amount of time it takes to implement EHR depends upon many factors, including size of the facility, services offered at the facility, current state of RPMS and packages installed and utilized.

EHR Planning & Implementation

* Most sites contract for external resources to complete pharmacy file preparation.

Imple

men

t Adv

erse

Rea

ction

Tra

cking

pac

kage

Step 1: Submit Site SurveyStep 1: Submit Site Survey

Step 1-Site Survey

Step 2: EHR Site TrackingStep 2: EHR Site Tracking

Implementation TeamImplementation Team

Administrator/Executive LeadershipAdministrator/Executive Leadership ClinicianClinician NurseNurse PharmacyPharmacy Medical RecordsMedical Records Billing/CodingBilling/Coding Information Technology staffInformation Technology staff Clinical Application CoordinatorClinical Application Coordinator

Implementation Team RolesImplementation Team Roles

Monitor and Execute Implementation PlanMonitor and Execute Implementation Plan Identify and define Policies and Procedures Identify and define Policies and Procedures Address staffing and scheduling during transitionAddress staffing and scheduling during transition Peer Training & MarketingPeer Training & Marketing Design and Approve EHR Menus, templates,etcDesign and Approve EHR Menus, templates,etc

Identify Clinical Applications Identify Clinical Applications Coordinator (CAC)Coordinator (CAC)

Works cooperatively with Site ManagerWorks cooperatively with Site Manager Coordinates ImplementationCoordinates Implementation EHR User SupportEHR User Support TrainingTraining Customize SoftwareCustomize Software WorkflowWorkflow Portland Area CAC: Bob Adams R.Ph.Portland Area CAC: Bob Adams R.Ph.

Help Desk Requests

Warm Springs Computer/Cac Department

Implementation StrategyImplementation Strategy

Implementation-Who and WhenImplementation-Who and When Everyone at onceEveryone at once Lab ordering , then radiology ordering, Lab ordering , then radiology ordering,

then pharmacy ordering, then notesthen pharmacy ordering, then notes Bring up one team/dept at a timeBring up one team/dept at a time

Implementation-Implementation-Hardware/Infrastructure Hardware/Infrastructure

upgradeupgrade RPMS server RPMS server Backup/Training serverBackup/Training server Thin Clients, laptops, pcs?Thin Clients, laptops, pcs? Network Network Lab Interface UpgradeLab Interface Upgrade Workstation Access-EverywhereWorkstation Access-Everywhere Backup PowerBackup Power

Costs Associated with EHRCosts Associated with EHR

WorkstationsWorkstations Laptops, tablets, pc, thin clientsLaptops, tablets, pc, thin clients

Ergonomic SupportErgonomic Support Backup ServerBackup Server Backup GeneratorBackup Generator Clinical Applications Coordinator GS 12Clinical Applications Coordinator GS 12 Training costsTraining costs Software-$0.00Software-$0.00

EHR CostsEHR Costs Staff coverageStaff coverage TravelTravel Computers:Computers:

1 per room1 per room 1 per provider1 per provider Extras in ward areaExtras in ward area

Ballpark TimelineBallpark Timeline Scheduling Software (PIMS)Scheduling Software (PIMS)

Scheduling application-improvedScheduling application-improved Has a Windows based component Has a Windows based component Sensitive Patient Tracking featureSensitive Patient Tracking feature

Radiology 5.0-after PIMSRadiology 5.0-after PIMS Pharmacy 5/7-needs to be scheduled with ITSCPharmacy 5/7-needs to be scheduled with ITSC

Allow several months for file preparationsAllow several months for file preparations• Adverse drug reactions :1 month (4 staff)Adverse drug reactions :1 month (4 staff)• RPMS/Scriptpro Format :1-2 days (2 Staff)RPMS/Scriptpro Format :1-2 days (2 Staff)• Dosages in Pharmacy 7: 1 week (2 Staff) Dosages in Pharmacy 7: 1 week (2 Staff) • Quick orders : 2 weeks (2 Staff)Quick orders : 2 weeks (2 Staff)

Installation of EHR client – after PharmacyInstallation of EHR client – after Pharmacy EHR Set-up; Site visits - after PharmacyEHR Set-up; Site visits - after Pharmacy Go-live – 3-6 months after PharmacyGo-live – 3-6 months after Pharmacy

EHR SetupEHR Setup

Customize order menusCustomize order menus Lab, Pharmacy, RadiologyLab, Pharmacy, Radiology

Setup Referrals/ConsultsSetup Referrals/Consults Progress Note TemplatesProgress Note Templates

Design our ownDesign our own Share with other sitesShare with other sites

User SetupUser Setup ICD/ CPT Pick ListsICD/ CPT Pick Lists

EHR beforeEHR before ConfigurationConfiguration

EHR after ConfigurationEHR after Configuration

Preparation-Customizing Preparation-Customizing OrdersOrders

Preparation-Customizing Preparation-Customizing TemplatesTemplates

•Templates can be shared with other IHS and VHA facilities

•More Complete Documentation

Training/MarketingTraining/Marketing

EHR Demo Movie EHR Demo Movie VA Training ModulesVA Training Modules

PharmacyPharmacy CPRSCPRS

ITSC Web-Ex Demo for our clinicITSC Web-Ex Demo for our clinic Show and TellShow and Tell

NewslettersNewsletters Web UpdatesWeb Updates Meeting UpdatesMeeting Updates Email QuizzesEmail Quizzes

EHR TrainingsEHR Trainings

EHR CAC & Implementation Team trainingEHR CAC & Implementation Team training Must have 5/7 installedMust have 5/7 installed Must have RPMS packages OptimizedMust have RPMS packages Optimized

EHR Setup (on site)EHR Setup (on site) Super end user training (on site)Super end user training (on site) Go Live (on site assistance from OIT)Go Live (on site assistance from OIT) EHR for Techies, EHR for Inpatient, EHR for EHR for Techies, EHR for Inpatient, EHR for

HIM and Business OfficeHIM and Business Office http://http://www.ihs.gov/CIO/EHR/index.cfm?modulewww.ihs.gov/CIO/EHR/index.cfm?module==

rpms_ehr_trainingrpms_ehr_training

Going Live WeekGoing Live Week

How the Week First GoesHow the Week First Goes

0

20

40

60

80

100

120

Mon

Tue

sW

ed

Thu

rs FriM

on

Tue

sW

ed

Thu

rs

Friday

S tress Level

Growling at CAC’s

Crying, gnashing of teeth

Excited

TGIF

Cat in the microwave

Excited

Going LiveGoing Live

Intense CAC and IT SupportIntense CAC and IT Support Make Appropriate Scheduling AdjustmentsMake Appropriate Scheduling Adjustments Daily Debriefings….Daily Debriefings….

Procedural QuestionsProcedural Questions Technical IssuesTechnical Issues How did it work before EHR?How did it work before EHR? More Training-Email trainingMore Training-Email training

Next StepsNext Steps

RemindersReminders VistA ImagingVistA Imaging Voice RecognitionVoice Recognition Electronic Dental RecordElectronic Dental Record

Questions?Questions?