Implementing Electronic Health Records Chapter 4 Implementing Electronic Health Records

Implementing Electronic Health Records Lesson 4.1 Implementing Electronic Health Records Explain the considerations that must be addressed in planning a successful transition from paper charts to electronic health record (EHR) systems. Develop a conversion plan for the EHR. Explain the requirements of the Centers for Medicare & Medicaid Services (CMS) meaningful use program for eligible professionals. Describe the information a practice should supply to each software vendor in its request for proposal document, and outline the information the practice should expect to receive from the vendors in return.

Implementing Electronic Health Records Lesson 4.1 Implementing Electronic Health Records Give examples of the workflow processes that must be redesigned when an EHR system is implemented. Outline the process of collecting and entering data from paper sources into the EHR. Discuss common problems that may be encountered when information is transferred from paper charts to EHR systems. Identify specific challenges that may arise in training to use a new EHR system.

Implementing Electronic Health Records Lesson 4.1 Implementing Electronic Health Records Indicate how patients can be introduced to the new EHR system. Specify the contingency plans that must be in place before an EHR is launched. Discuss the EHR implementation process. Explain how the success of an EHR can be measured after the transition period ends.

Planning a Successful Transition What is the practice’s motivation for making the change? What does it hope to achieve in making this change? Will the organizational culture support a technologic conversion, and can it endure the frustrations and sacrifices associated with it? Are patients likely to support a migration from paper to digital charting? A methodic approach seems to be the key to making a successful EHR transition. The first step in a well-planned transition is to assess the practice’s readiness for the change.

Planning a Successful Transition (Cont.) Does the practice have, or can it obtain at a reasonable cost, the necessary technological and operational resources to make the switch? Does the practice have enough capital in reserve to stay afloat during a period of reduced productivity? Does it have enough cash on hand to purchase hardware, software or a software license, and training and information technology (IT) support? The preimplementation process itself offers a chance for the practice to examine these questions in depth. Even if it has already decided to go digital, assessing readiness would produce a useful inventory of strengths and weaknesses.

Developing a Conversion Plan Create a team to help research, select vendors, train, implement, and evaluate the EHR system Maybe the entire staff or a select group Include providers, office managers, and support staff (medical assistants, receptionists, billers, medical records personnel, etc.) Various points of view can be invaluable in this process. It is important to be aware of possible pitfalls of EHR transitions in order to avoid them.

Pitfalls of EHR Transitions This table shows some common mistakes that medical offices make when making the EHR transition.

Pitfalls of EHR Transitions (Cont.) The table also offers tips for avoiding some of the mistakes.

Meaningful Use Certification The main goals of the MU program are: Improve quality, safety, and efficiency and reduce health disparities Engage patients and family Improve care coordination and population and public health Maintain privacy and security of patient health information EHR vendors are evaluated on a set of core and menu objective measures. The meaningful use (MU) incentive program is a payment incentive program made available for eligible professionals (EPs) or physicians who implement and use their EHR technology in a meaningful way. EHR usage must meet specific requirements. These are organized into three stages of core and menu objectives. Since the implementation of meaningful use incentive programs, have you noticed any changes in the way patients are seen in the medical office? (Answers will vary.)

Selecting a Type of Conversion Complete switch Incremental conversion Hybrid office Slow incremental conversion What is a hybrid office? (Existing patients’ charts are kept on paper and only new patients are entered into the electronic database.)

Selecting an EHR Vendor & Network Platform There are thousands of vendors; know what your practice wants Assessing practice needs Surveying available software applications You control the demos, not the vendor marketing team Selecting a network platform It’s important to base the decision on criteria specific to the practice.

Assessing Practice Needs Pick a company with long-term service, training, and software updates Is the system compatible with other systems? Is it CCHIT certified? Customizable? Templates? Cost? Many of the practice’s needs should have been identified during the initial readiness assessment/preimplementation discussions.

Surveying Available Applications Ask vendor to supply basic information for comparison of other vendors: References EHR features Proposed hardware and network architecture Customer service HIPAA and coding compliance features Interoperability functions Cost It’s good practice to submit a request for proposal (RFP) document after narrowing the list to a handful of vendors.

Selecting a Network Platform Client-server model: User purchases the software Installs it to practice hardware Application server provider (ASP): Subscription agreement Access software over a secure Internet connection EHR software can be licensed (purchased outright) or accessed by paying a monthly subscription fee to use it. Refer students to Table 4-2 (pp. 96-97) for a comparison of the two types of network platforms.

Redesigning Workflow With EHR implementation, workflow redesign is inevitable Ask vendor for redesign recommendations Start redesign process during preimplementation planning Refer to the policies and procedure manual to examine current routines EHR adoption is not just the launch of new technology, but a shift in the way the office conducts its business.

Office Procedures Requiring Workflow Redesign Until the staff has some real-life experience using the software, it’s difficult to understand how to integrate it effectively into office processes. The keys to success are flexibility, communication about what’s working and what’s not, and a willingness to make continual readjustments on the fly.

Adjusting to Point-of-Care Documentation Documentation is done during or immediately after the patient encounter Adjustment for providers at first but: Increases the accuracy of patient visit documentation Will decrease the amount of “after hours” paperwork The most difficult new workflow for some clinicians to adapt to is point-of-care (POC) documentation.

Setting Up Billing Cycle Documentation The American Health Information Management Association (AHIMA) makes the following recommendations for practices that are going digital: Create a common list of diagnosis and procedure codes Take advantage of auditing features of documentation Pay attention to accuracy of code reporting Design the EHR to avoid shortcuts that could lead to fraudulent behavior When a practice converts to an EHR, it must identify potential glitches in claims processing and reimbursement or be prepared to sort out such problems once they’re discovered. The practice management capabilities of an EHR system are extremely useful in performing ongoing financial analysis and billing management functions.

Setting Up Billing Cycle Documentation (Cont.) Establish regular and random internal auditing to verify: Accurate data capture and documentation Procedures performed are medically necessary Progress notes are not cloned Electronic signatures are used appropriately Prescribing activities are well documented AHIMA has released a position statement on billing cycle documentation in the EHR, available online to AHIMA members.

Collecting and Entering Data Methods for data entry: Data input from compatible, interfaced systems Transcription using voice recognition technology or dictation Scanning of typed or handwritten documents Direct keying or rekeying (typing) Most of the data initially entered into the EHR come from the paper chart. However, to offer the best possible healthcare and to protect the practice legally, it’s important to gather patient data from all available sources. The need to key data from paper charts into the new EHR is one of the biggest deterrents to adopting an EHR system.

Under-documentation and Over-documentation Transfer of documentation from paper records to electronic has its risks: Requires judgment of clinician (provider) Under-documentation Over-documentation Prioritize information to transfer Example: Medication lists, allergies are given a high priority When too little information is entered, the skimpy EHR tends to generate drug interaction alerts and health promotion reminders more often. Excessive detail may indicate a higher level of care than was actually delivered, leaving the provider vulnerable to charges of fraud and abuse.

Structured and Unstructured Data Entry Controlled vocabulary Structured data entry Straightforward clinical findings Example: Strep negative, PERRLA Unstructured data entry Allows free documentation EHR templates Carry both structured and unstructured data entry abilities SimChart for the Medical Office (SCMO) offers a full range of experience using both structured and unstructured data entry options throughout the system.

Electronic Misfiling and Interfacing Information recorded in the wrong part of chart Establish guidelines for data during preimplementation phase Controlled vocabulary is able to communicate more easily with other systems Hospitals, labs, specialist offices What is the importance of software interface? (Using a controlled vocabulary, most EHR software systems can interface with at least some other systems, such as a hospital or laboratory system. When this interface is seamless, reports from one system automatically populate templates in another.)

Scheduling Training Staff to agree on customization options before the training begins Adhere to level of computer experience Train to level of access Provide training manuals for troubleshooting or refreshers at work stations The better the training before the transition is implemented, the less hand-holding everyone will need afterward. Costs will be lower and productivity will be higher.

Notifying Patients Introduce using three C’s: Connect Collaborate Close What different means may be used to notify patients of the change to EHR? (By connecting with the patient through interpersonal communication, by collaborating with patients to be sure they understand the new system, and by closing through showing patients that you are logging out to secure their information as well as thanking them for their support.)

Incorporating POC Documentation into the Patient Encounter: The Three C's Some patients will be delighted with the change, while others will be apprehensive. Modified from Doctor’s Office Quality Information Technology University, Centers for Medicare and Medicaid (Masspro), U.S. Department of Health and Human Services.

Incorporating POC Documentation into the Patient Encounter: The Three C's (Cont.) Medical assistants are among the first to make contact with the patient on each visit. They can begin the process of making the patient feel comfortable as the provider documents the visit. Modified from Doctor’s Office Quality Information Technology University, Centers for Medicare and Medicaid (Masspro), U.S. Department of Health and Human Services.

Making Contingency Plans Required by HIPAA Security Rule Backup plan Plan in event of an emergency Gradual rollout The rule requires that patients’ health information be protected from disasters of all sorts, including system crashes that may occur when a new system is launched.

Implementing the Transition Test phase Staff must be flexible IT support for troubleshooting Readiness to launch the implementation phase depends on the installation of technologic resources, the completion of staff training, the existence of funding to carry the practice through the transition period, and the availability of staff and clinicians. As the EHR is put into use, the plan for its implementation is tested. Its limitations quickly become apparent.

Measuring Results & Conducting Evaluations EHRs have been associated with improved safety and patient care, better financial performance, higher provider satisfaction, and more efficient communication Generate baseline data The attributes that can be measured with an EHR are nearly unlimited.

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