Performance Improvement within an EHR (Electronic Health Record)

Launch

WCBF Lean Six Sigma Healthcare SummitMay 2011

Louis C. Rhodes

Purpose: Introduce basic principles of an EHR launch and how Lean-Six Sigma experts can contribute to its success

Learning objectives:• Describe HITECH Act and EHR related impact• Identify key concepts associated with EHR

implementation• Describe points at which Lean-Six Sigma experts

can support EHR design and launch

Purpose and Learning Objectives

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• The HITECH Act mandate that health care entities must implement EHR's by 2015 or face monetary penalties in the form of reductions in Medicare reimbursements.

• What is “meaningful use of electronic health records”?

• The role of Lean Six Sigma in the EHR deployment process

• Crucial decisions that result in successful EHR adoption and avoidance of expensive EHR mistakes

Key Questions/Issues

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• Administrator, New York University (Department of Obstetrics and Gynecology)

• Graduate of United States Military Academy (BS Management – Engineering) and Xavier University (MBA)

• General Electric Certified Black Belt and Master Black Belt in Six Sigma and Lean

• Eleven years experience in Six Sigma, Lean, and Change Management roles:

• Two years chemical industry (Millennium Chemicals)

• Four years in healthcare equipment and service delivery (GE Healthcare)

• Five years academic healthcare (USF Health and NYU School of Medicine)

• Expertise in curriculum development and skills transfer to clients

Lou Rhodes, MBA, MBB

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• Agenda:• HITECH Act provisions• EHR implementation considerations• EHR implementation at USF Health

• Ground rules:• Informal environment• Maintain speed• Limit cell phone use• Anything else?

• As a group, describe expectations for this session.

Agenda, Ground Rules, and Expectations

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HITECH Act Provisions

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• Health Information Technology for Economic and Clinical Health Act

• Part of the American Recovery and Reinvestment Act of 2009

• $17B allocated for incentives for EHR implementation

• Major provisions:• Incentives and penalties• “Certified” EHR Systems• “Meaningful use” of EHR

HITECH Act Provisions*

7* - From HHS.gov

• Physician: Medicare (per Medicaid (per

Implementation in: eligible professional) eligible professional)

• ≤2012 $44K (5 year payout) $64K (6 year payout)

• 2013 $39K (4 year payout) $64K (6 year payout)

• 2014 $24K (3 year payout) $64K (6 year payout)

• 2015 - $64K (6 year payout)

• 2016 Payment adjustment $64K (6 year payout)

• ≥2017 Payment adjustment -

Incentives and Penalties*

8* - From HHS.gov

• Hospital: Medicare (base Medicaid (base

Implementation in: incentive) incentive)

• ≤2013 $2M $2M

• 2014 ≤$2M $2M

• 2015 ≤$2M; Payment adj. $2M

• 2016 Payment adjustment $2M

• ≥2017 Payment adjustment -

• Assures purchasers and users that EHR system will meet requirements for:• Technological capability• Functionality• Security

• For certification, EHR system must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB).

Certified EHR Systems*

9* - From HHS.gov

• EHR must be adopted, implemented, or upgraded.

• Show use of certified EHR technology that can be measured significantly in quality and in quantity:

• Use of certified EHR in meaningful manner (i.e. - e-prescribing)

• Electronic exchange of health information to improve quality of health care

• Submit clinical quality and other measures

• Demonstrating “meaningful use”:

• Professional:

• 3 core and 3 additional clinical quality measures

• 15 core and 5 of 10 meaningful use objectives

• Hospital:

• 15 clinical quality measures

• 14 core and 5 of 10 meaningful use objectives

Meaningful Use*

10* - From HHS.gov

• Strengthens civil and criminal enforcement of HIPAA:

• Four categories of violations that reflect increasing levels of culpability;

• Four corresponding tiers of penalty amounts that significantly increase the minimum penalty amount for each violation; and

• A maximum penalty amount of $1.5 million for all violations of an identical provision.

• Also:

• Strikes the previous bar on the imposition of penalties if the covered entity did not know and with the exercise of reasonable diligence would not have known of the violation (such violations are now punishable under the lowest tier of penalties); and

• Provides a prohibition on the imposition of penalties for any violation that is corrected within a 30-day time period, as long as the violation was not due to willful neglect.

Security Provisions*

11* - From HHS.gov

• Restricts selection to approved vendors• Offers incentives for early adopters (and

penalties for late adopters)• Increases penalties associated with security

breaches and data management risks• Requires investment in quality information

collection processes and security protocols

Impact on EHR Implementation

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EHR Implementation Considerations

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EHR Advantages andDisadvantages

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Advantages• Reduction of errors

(information transfer, cross-checks)

• Data mining capacity

• Decision support for streamlined workflows

• Immediate information availability

• Single record (for hospital or practice)

• Potential mobility (?)

Disadvantages• Initial investment (software,

hardware, internal staff, consultants)

• Ongoing support costs (internal staff, hardware, upgrades)

• Transition friction

• Data entry time

EHR Promoters and Inhibitors

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Promoters• Change readiness

• Physician engagement

• Regulatory requirements

• Planning and preparation

• Adequate support availability

Inhibitors• Lack of incentives

• Impact on productivity and efficiency

• Lack of standardization

• Cost of transition

• Changes to workflow

Interactions and Trade-offs

Transition Friction and Inefficiency

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1.Slow acceptance and efficiency improvement

2.Fast acceptance and efficiency improvement

• Physician engagement

• Workflow development

• Support mechanisms

3.Efficiency improvement and leverage

• Template set-up

• Tablet use

• Dictation software

• Further workflow improvements

Eff

icie

ncy

Time

Implementation

20-30%22

11

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Integration

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• EHR enters as an technology initiative

• Leverage of the EHR occurs through improved processes

• Adoption and utilization of the EHR occurs through people

• All are needed for successful implementation and return on investment

People Process

Technology

EHR

Leveraging Patient Data

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• Patient EHR:

• Continuity and availability of information

• Hospital workflows:

• Application of clinical rule-sets

• Triggers for orders and actions

• Data Mining:

• Ease of case review and comparison

• Discrete data availability

Patient Electronic

Health Record

Hospital Workflows

Data Mining (Education

and Research)

Data

Data

EHR Implementation at USF Health

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• Mission: To improve life by improving health through partnership, research, education and healthcare

• 3,500 team members of educators, staff, physicians, researchers

• Over 420 physicians, 135 allied health, and 70 nurse practitioners

• 2 new out-patient buildings with imaging and an ambulatory surgery center

• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay• $350 million enterprise

USF Health Overview

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USF Health: EHR Timeline

2006 2007 2008 2009

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• Vendor selection

• Planning

• Workflow development

• IT platform upgrades

• Initial go-live• Rolling

department go-lives

• Continued department go-lives

• v11 upgrade

• Workflow improvements

• Tablet roll-out

Initial investment

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Workflow Design: Deployment of New Technology or Facility

Create Future State

Identify Workflow

Develop Organization

Build Specifications

• Collect voice of customer

• Describe future state

• Identify design principles

Operational Mechanisms: Interdisciplinary Executive Team and Workflow Design Teams with change management skills

• Map current process

• Build future process maps

• Identify gaps/ constraints and needed actions

• Conduct walk-through

• Identify tasks and assign to positions

• Create organizational structure

• Build job descriptions

• Map layout

• Identify technology requirements

• Develop protocols/ policies

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• Fully e-enabled scheduling and check-in:

• Ability to schedule appointments, check-in, pay co-pay (or balances), and input health status information

• Check-in ticket print-out and streamlined on-site process

• All patient care occurs in exam rooms:

• Triage, assessment, treatment, and scheduling of appointments occur in the exam room

• Phones and computers in each exam room

• One-stop shopping:

• Referrals and procedures routinely go to USF Health

• System and service level supports high availability of appointments (immediate, space available, scheduled)

• Additional services (x-ray, lab, ancillary) are completed at time of appointment they were identified as a need

Design Principles

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Processes:• Pre-Appointment

• Arrival/Check-in

• Paper Scanning

• Provider Actions

• Other Media Routing

• Patient Visit

• Protocol Driven Test

• CCS Post-Visit

• Academic Secretary Post-Visit

• Point-of-Service Test

• PSR Check-out

• CCC check-out

• Messaging and Tasking

• Results Verification

Processes (continued):• No-Shows/Same Day Cancellations• Nurse/Tech Visit• Correspondence• Provider Actions

Standardization opportunities:• Positions and abbreviations• Greenie Construction• Exam Room Flags• Orders and Routing Options• Provider/Designee Delivery• Test Classification• Internal Referral Appointment Needs

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Workflow Evaluation: Initial Identification

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CCS monitors IDX for arrived Patients specific to supported Provider (CCC acts as back-up monitor)

CCS observes arrivalCCS confirms Exam Room availability

Patient moves to Clinical Entry Point

CCS collects Pager and drops into Pager Collection Point inside Clinical Entry Point

CCS collects Greenie and escorts Patient to Exam Room

CCS flags Exam Room “CCS Intake”

CCS identifies appropriate Pager number of arrived Patient and trips Pager

CCS starts AllScripts note

CCS identifies brief Chief Complaint/Reason for Visit and enters data into AllScripts

CCS takes Vitals and enters data into AllScripts

CCS moves to appropriate Clinical Entry Point, greets Patient, and confirms identity

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Standardized Workflow: PatientVisit

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Clinical Floor Design and Flow

Floor Guide greets Patient and fast pass checks in, or directs to kiosk or PSRPSR checks-in Patient, receives co-pay, and receives history and releasesPatient selects waiting areaMA accompanies Patient to exam roomMA completes vitals and history; Physician provides care; MA schedules follow-on appointmentsMA escorts Patient to clinic exit and farewells

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USF Health: EHR Timeline

2006 2007 2008 2009

• Vendor selection

• Planning

• Workflow development

• IT platform upgrades

• Initial go-live• Rolling

department go-lives

• Continued department go-lives

• v11 upgrade

• Workflow improvements

• Tablet roll-out

IT Upgrade

Train Design Support

• Install computers/ printers

• Check platforms

• Provide basic training

• Identify specific needs

• Set-up templates

• On-site support

• Transition to phone support

27Implementati

on

Form: Past Medical History

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Change Aid: Provider Instruction Trifold

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After Action Review: Issue and Action Plan

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Data Entry Optimization

Other staff enters data into EHR

Physician types into EHR

Physician uses dictation service

Physician enters data into discrete fields in template

Physician utilizes voice recognition

software

• Good use of staff• Limited potential for transfer of

workload

• Control• Familiarity with process• Poor use of Physician time

• Quick data entry• Dictation cost• Requirement to check dictation

• Quick data entry• Supports ease of research• Requires template set-up and some

standardization

• Quick data entry• Immediate check of dictation• Initial cost and training

• Purchasing:• Select system based on reasonable expectation of need

• Planning:• Create roll-out plan for technology, training, and process actions

• Expect transition friction and temporarily reduce scheduled patient load

• Physicians:• Engage early and often

• Consider a physician champion

• Workflow:• Plan on changes where technology, people, and process intersect

• Consider standardization based on best practices before transition

• Communication:• Provide updates often through multiple channels

Key Learning's: USF Health Transition to EHR

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• Completion: All entries finished in total at time of service

• Communication: Ease of access to information and appropriately routed

• Compliance: Meets all regulatory requirements

• Quality: Information is of value

The 4C’s of the EHR*

* - Dr. Lennox Hoyte, USF Health CMIO 33

Thank you for your time.

Questions?

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