1. IHS EHR Indian Health Service Electronic Health Record Carolyn Johnson Warm Springs Health & Wellness Center

2. Facility Planning  Confirmed Leadership support  Tribal Endorsement  Area Office Support  Patient Awareness  Clinician driven

3. E.H.R. Team Members  Clinical Champions from each discipline (lab,rn, rph,md,,etc)  Administration/Executive Leadership  Health Information Services  Information Technology  Include Area IRM representation  Clinical Application Coordinator

4. EHR Team Roles Identify and define Policies and Procedures Identify and define Policies and Procedures Address staffing and scheduling during transition Address staffing and scheduling during transition Peer Training & Marketing Peer Training & Marketing Monitor and Execute Implementation Plan Monitor and Execute Implementation Plan Design and Approve templates, menus, and ordering lists for E.H.R. Design and Approve templates, menus, and ordering lists for E.H.R.

5. Hire a Clinical Applications Coordinator  Works cooperatively with Site Manager  Coordinates Implementation  EHR User Support  Training  Customize Software  Workflow

6. Portland and Indianapolis VA 1 CAC for each 250 users Portland and Indianapolis VA 1 CAC for each 250 users The CAC is a new, specialized position separate from Network Specialist, CIO, User Support The CAC is a new, specialized position separate from Network Specialist, CIO, User Support Sample Positions descriptions on EHR Website Sample Positions descriptions on EHR Website

7. Clinical Applications Coordinator  Clinical Background  RPMS experience  Project Management /Leadership Skills  Facility Working Process Knowledge  Computer Skills

8. Super-Users and AD-Pacs  Clinical Super Users (rn, rph, lab,dm,md) Training Training Peer Support Peer Support Templates optional Templates optional  Pharmacy Ad-Pacs Quick Orders Quick Orders ART setup ART setup Training on medication orders Training on medication orders Pharmacy 7 duties Pharmacy 7 duties

9. Cherokee Implementation

10. Implementation Timetable- Wind River

11. Infrastructure upgrade  RPMS server  Training server  Network  Wireless network  Lab Interface Upgrade  Workstation Access  Backup Power

12. Software  Package upgrades to RPMS Radiology Radiology Text Integration Utility Text Integration Utility Adverse Reaction Tracking Adverse Reaction Tracking Pharmacy 7 Pharmacy 7 Scheduling (PIMS) Scheduling (PIMS) Pharmacy Inpt Suite Pharmacy Inpt Suite Behavioral Health Behavioral Health Cache Cache Numerous RPMS patches Numerous RPMS patches

13. Major Software Updates  Pharmacy Upgrade to version 7 (March 7) Required several days to prepare drug files Required several days to prepare drug files Utilized Portland VHA pharmacist to assist Utilized Portland VHA pharmacist to assist Worked overtime and weekends to get ready Worked overtime and weekends to get ready Major process changes for pharmacists Major process changes for pharmacists  Implemented the Pharmacy Allergy and Adverse Reaction Tracking System: All of the allergies that have been entered into PCC had to be manually entered into the new tracking system and verified by a pharmacistAll of the allergies that have been entered into PCC had to be manually entered into the new tracking system and verified by a pharmacist

14. Major Software Updates  Implement the new scheduling package (PIMS) This software was substantially different than the old version of scheduling and required facility wide training This software was substantially different than the old version of scheduling and required facility wide training Checking in pt using the scheduling package Checking in pt using the scheduling package

15. E.H.R. Configuration  Design templates  Design Menus and Quick Orders Meds, Labs, Rad, Nursing Meds, Labs, Rad, Nursing  Define consults  Pick lists and Superbills  Note Titles  User Setup (keys)  Parameters  Printing Chart Copy and Orders  Print Formats

18. Setting up Orders

19. Setting up templates

20. Staff Orientation  Staff Training: CPRS Training Module Presented at Staff Meetings CPRS Training Module Presented at Staff Meetings Pharmacy Training Module: Pharmacy Training Module: Available on Warm Springs Web SiteAvailable on Warm Springs Web Site Mandatory for all pharmacy staffMandatory for all pharmacy staff CPRS Training Module: CPRS Training Module: Interactive training posted on Warm Springs Web SiteInteractive training posted on Warm Springs Web Site Mandatory for providersMandatory for providers Mary Hager Demo Mary Hager Demo Portland VHA visit and hands on training Portland VHA visit and hands on training

21. Pre-Implementation Training  2 hour training for everyone on VIEWING patient data in E.H.R.  Site Manager Training at VA, Camp CPRS, EHealth University EHR Test System Loaded On All User’s Computers  Newsletters, Web Updates, Meeting Updates

22. Training – Go Live Week  4-6 hours training outside of clinic  Departmental Trainings  Use Knowledgeable Trainers  One-On-One Training Also  Competancy Checklists

23. Going Live  Intense CAC and IT Support  Make Appropriate Scheduling Adjustments  Daily Debriefings…. Procedural Questions Procedural Questions Technical Issues Technical Issues Training Training

25. Questions?

26. Medical Records Process  When to stop pulling the chart  Filing notes AND orders in chart?  Print And File Chart Copies? Batch Print?  Release Of Information?  Outside Consults? Scanning?  Incorrect Entries?

27. PCC Coding Process  Coding done from daily lists of visits  No hard copy to code from  Daily Error Reports  No POV, E&M Code, Activity Time  ICD Coding By Providers  Duplicate Visit Creation

28. Business Office Process  Services Pick List Development, Installation, And Training  Missing E&M Codes  No Hard Copy To Work With  EHR Notes Are Legible  Great Opportunity For Improved Provider Documentation & Increase Billing/Collections

29. Pharmacy  Outside Prescription Orders  Printing pharmacy service copies for orders  Refill and New prescriptions aren’t always grouped  Printing controlled substances  How to incorporate pharmacy patient signature log  Pharmacy Requirement for Completed/Signed Notes

30. Completing Notes Encounters documented by staff members in the electronic health record are expected be completed and signed electronically at least 95% of the time at the end of the encounter with the patient. In the other 5 % of cases, these notes will be completed and signed at a maximum of 24 hrs after the encounter. Additional documentation related to that visit (i.e., lab results or delayed documentation of referral information) will be added to the note as an addendum when this additional information is available.

31. Miscellaneous Issues  Relax Provider schedules during first 2 weeks of implementation  Productivity issues while learning.  How to handle Flowsheets in E.H.R  How to get reference lab results in E.H.R.  Standardization of Note titles  Specialty Clinic Providers

32. Miscellaneous Policies/Procedures  People who aren’t using E.H.R. yet- how are they handled?  Use of personal templates  Template approval process  Note content - immunizations  Use of chat and broadcast  Handle the missing PCC elements? SHX, colonscopy, refusal,mammogram (offsite)  Checking in a pt  How to communicate the “Signs and Symptoms” (lab pov) to the lab

33. Template Approval Process Template approval process Required Form Elements : Plan that notes be able to stand on their own if printed. This is intended that pertinent information related to the visit be a part of the form. Name Date of Visit Clinic Encounter History Personal History/GPRA ExamDiagnosis/POVPlanEducationRefusalsSignature Needs: Patient education templates for adults, GPRA, DM standards “###” symbols used around information needed to be entered by data entry Procedures for new forms : Deploy new forms in “Test” folder on the Live EHR : EHR Team will give e-concurrence of the form prior to deployment