1. Performance Improvement, Risk Management and EHR Colleen A. Hayes, MHS, RN CAPT, USPHS Cherokee Indian Hospital Colleen A. Hayes, MHS, RN CAPT, USPHS Cherokee Indian Hospital

2. EHR Can Become an AWESOME CHANGE ! Where the most trivial of things can become deadly projectiles

3. Decreasing the emotional impact of change Communication with providers and patients about any impending change will decrease the number of issues demanding attention during the change. Without communication about every important aspect of the change, expect to hear more from everyone who is affected by the change.

4. EHR and the Hospital Strategic Plan EHR implementation concurrent with a number of efforts being undertaken for performance improvement (continuity model, changes in staffing, etc.) Change to EHR occurs within an entire system – impacts both clinical and financial indicators EHR implementation concurrent with a number of efforts being undertaken for performance improvement (continuity model, changes in staffing, etc.) Change to EHR occurs within an entire system – impacts both clinical and financial indicators

5. Mission Statement: To Continually Improve the Health Status of the Eastern Band of Cherokee Nation Through a Comprehensive Health Care System Sensitive to the Culture and Values of the Community Governing Board: Mission, Vision, Values Employee Performance Standards Monthly and Quarterly Reporting Executive Team: Strategic Goals and Objectives Department Goals, Objectives, Measurements

6. Implementation Work Plan and Communication Timeline - IT, training, clinical readiness Tasks and assignments Staff training: identification of needs and levels of training Process changes Timeline - IT, training, clinical readiness Tasks and assignments Staff training: identification of needs and levels of training Process changes

7. Consult all departments who will use EHR then: Create a list of meaningful measurements for each discipline Chose metrics based on everyday QI rules: high risk, high volume, problem prone Don’t reinvent the wheel,consult others that have gone before you Make staff part of this process Create a list of meaningful measurements for each discipline Chose metrics based on everyday QI rules: high risk, high volume, problem prone Don’t reinvent the wheel,consult others that have gone before you Make staff part of this process

8. EHR and Clinical Indicators GPRA indicators – review quarterly Monitoring by team and providers Plan to continue to monitor change Specific department targets – use of templates in EHR based on some specific clinical targets [tobacco screening and CAGE assessment to nurse triage tab] GPRA indicators – review quarterly Monitoring by team and providers Plan to continue to monitor change Specific department targets – use of templates in EHR based on some specific clinical targets [tobacco screening and CAGE assessment to nurse triage tab]

9. Strategic GoalCategorySpecific Dept Objective Goal FromTOJanFebMar Customer Satisfaction Goal#2/Obj ective#1 Customer satisfaction - survey 30 pts/mo : increase satisfaction score by 10%4.124.53 Outcome Indicators Goal#2/Obj ective#2GPRA Indicators(active clinical population) Health factor/Tobacco increase tobacco screening to 60% of target population48%60% Health factor/Tobacco increase tobacco counseling to 30%/active tobacco users21%30% Health factor/ETOH screen Increase the % of pts screened for alcohol use Prevention/IMMincrease pneumovax rates to 75%68%75% Health factor/Obesityincrease BMI to 70%60.40%70% Goal#1/Obj ective#5Process Efficiency Increase number of patients empaneled by ?% (or #)31925000 Increase number of nurse visits per month by ? % current # # increa sed 20% Increase the number of times an empanelled pt sees their primary care provider

10. Provider Scorecards Specific feedback to providers and teams re: progress toward goals set by the OPD team Accountability/input toward process improvements Specific feedback to providers and teams re: progress toward goals set by the OPD team Accountability/input toward process improvements

11. OPD Provider/Team Report GPRA IndicatorsProvider Rate Green Team All OPD Providers 2004 baselineTarget High Provider Tobacco Screening/age 5 and older42.60%41.60%39.50%48.00%60.00%60.8 Tobacco Counseling/current users11.10%8.30%9.20%21.00%30.00%26.5 Pneumovax/age 65 and older58.30%70.00%72%68.00%75.00%80.7 Alcohol Screening/female/ages 15-440.00%2.30%3.70%4.50%20.00%15. BMI Calculated/ages 2-7455.80%60.10%61.20%60.40%70.00%75.8 BP Control/ages 20 and older/33.70%29.90%29.80%28.60%24.00%22.7 IPV/DV Screen/age 13 and older0.00%1.10%0.70%1.10%20.00%8.1 Lipids <13053.60%52%52.70%49.00%55.00%61.6 asthma staged asthma controller

12. Visit DataProvider OPD Av/MoBlue Av/Mo Green Av/Mo Provider Range High Provider Total number of visits126 Number of FP-15 visits123 Number of Same Day-New- 153 Number of Prenatal New - 300 No Show Rate/FP-1511%23.428.519.210%-30%10% No Show Rate/Same Day New-15 22.321.822.812%-50%12% No Show Rate/Prenatal New - 30na17.620.814.37%-33%7% Number of general clinic days8.5 Number of prenatal clinic days0 Av number of general pts/clinic day14.811.210.312.18.5-15.115.1 Av number of prenatal pts/clinic dayna6.3 3.0-8.68.6

13. Clinical Outcomes Comparison of EHR using clinic to a Non-EHR using clinic

14. Plan for continued monitoring: Sometimes, no change in pre- and post-EHR results equals success! Depends on where you started. Note any differences between “EHR” and “non-EHR” (PCC+) providers Take what is working from both systems – both have strengths and weaknesses

15. Subjective Measures/Metrics Staff satisfaction at various intervals after implementation Patient satisfaction based on survey Patient complaints/concerns Staff satisfaction at various intervals after implementation Patient satisfaction based on survey Patient complaints/concerns

16. Objective Metrics Provider productivity – expect a dip, and plan for this in your staffing - changes to provide schedules Medication errors – don’t expect improvement until all “old” errors have had time to surface. Compliance with health maintenance reminders (smoking, various cancer screens, etc.) – smoking and CAGE screen moved to nurse triage tab Provider productivity – expect a dip, and plan for this in your staffing - changes to provide schedules Medication errors – don’t expect improvement until all “old” errors have had time to surface. Compliance with health maintenance reminders (smoking, various cancer screens, etc.) – smoking and CAGE screen moved to nurse triage tab

17. Productivity Scheduling Changes One patient per hour – gradually increase number of pts per hour Scheduling Changes One patient per hour – gradually increase number of pts per hour

19. Medication Processes Medication Ordering difficulties/risks Med errors Process Changes Problems with patients with “long med lists” – difficulty in PCC+ transition to EHR Medication Ordering difficulties/risks Med errors Process Changes Problems with patients with “long med lists” – difficulty in PCC+ transition to EHR

20. Objective Metrics Error reports in PCC-expect an increase –Coding – takes time to build the tools and convince providers to use them. –Missing E&M codes –Missing POVs, Providers, Multiple providers –Data Entry backlog-expect it to increase Billing backlog-due to data entry backlog –Changes in revenue – patience…… Error reports in PCC-expect an increase –Coding – takes time to build the tools and convince providers to use them. –Missing E&M codes –Missing POVs, Providers, Multiple providers –Data Entry backlog-expect it to increase Billing backlog-due to data entry backlog –Changes in revenue – patience……

21. Risk Management

22. RM issues During EHR Implementation Be aware that weirdness can happen in the beginning until you figure it out. Monitor ALL your processes and pay attention to ALL end users. This is how you discover problems and fix them Weekly EHR meetings greatly facilitated identification of ongoing issues/risks/problem areas – attendance by all parties (clinical, med records, PI/RM, IT, etc.) Be aware that weirdness can happen in the beginning until you figure it out. Monitor ALL your processes and pay attention to ALL end users. This is how you discover problems and fix them Weekly EHR meetings greatly facilitated identification of ongoing issues/risks/problem areas – attendance by all parties (clinical, med records, PI/RM, IT, etc.)

23. Every time a person is asked to change their role or a make a change in a process, there are inherent risks. We must quickly identify and eliminate these risks in order to protect patients. Here are examples of the good, the bad and the ugly from EHR. Here are examples of “the good, the bad and the ugly” from EHR

24. The Good

25. Good Stuff: EHR helps to manage risk by: Virtually eliminating legibility problems and transcription errors Increasing the likelihood that information will get into the Medical Record, i.e. significant medical advice (JCAHO and GPRA targets). Virtually eliminating legibility problems and transcription errors Increasing the likelihood that information will get into the Medical Record, i.e. significant medical advice (JCAHO and GPRA targets).

26. Good, continued Allowing up to the minute information to be accessed from any computer in the clinic, and some computers outside the clinic by private network as well. Using templates to help decrease opportunity for omissions/errors Allowing up to the minute information to be accessed from any computer in the clinic, and some computers outside the clinic by private network as well. Using templates to help decrease opportunity for omissions/errors

27. Bad Dragging labs and vitals into the note and forgetting to address a wildly abnormal value Documenting your treatment in the note and prescribing something totally different w/o an addendum

28. Ugly Using EHR to document a QI finding Using EHR to indicate that you’ve asked a provider to do something a hundred thousand times Using EHR to document a QI finding Using EHR to indicate that you’ve asked a provider to do something a hundred thousand times Using EHR to identify which GPRA indicator we failed to address Using EHR to tell IT folks that there is a problem and, by golly they need to come fix it

29. Compliance and EHR Plan to have a comprehensive review of provider documentation, coding and billing compliance audit in May05 Will compare prior audit (September 04) of provider documentation Current problem with bills being generated prior to coding review Plan to have a comprehensive review of provider documentation, coding and billing compliance audit in May05 Will compare prior audit (September 04) of provider documentation Current problem with bills being generated prior to coding review

30. Take home message EHR is no different than the paper record. It is the legal document that will go to court when things go wrong. EHR documentation also affects the data in your system related to GPRA and IHPES indicators. It is important to monitor and communicate changes to your clinical and administrative processes in the change to EHR. The rest of your world doesn’t stop changing just because EHR is being implemented – just one part of multiple efforts being undertaken at the same time in your system. EHR is no different than the paper record. It is the legal document that will go to court when things go wrong. EHR documentation also affects the data in your system related to GPRA and IHPES indicators. It is important to monitor and communicate changes to your clinical and administrative processes in the change to EHR. The rest of your world doesn’t stop changing just because EHR is being implemented – just one part of multiple efforts being undertaken at the same time in your system.

31. Evaluations Log in to SurveyMonkey