1. EMR: IMPLEMENTATION LESSONS LEARNED THE HARD WAY Paul Kaye, MD Medical Director Hudson River Healthcare November 2005

2. Hudson River Healthcare 12 practice sites in 5 counties 42 primary medical care providers 130,000 visits/year Urban, migrant, homeless, public housing, and Ryan White funding JCAHO 1998, 2001, 2004 Diabetes, HIV, Prevention Pilot Collaboratives

3. EMR Project History 1999 Initial Contact with vendor and software developer 2000 Beta test site agreement Initial site:Adult Medicine at main site Server on site Integration with practice management system Desktop PC in all exam rooms and provider offices Computer readiness survey

4. EMR Project History Initial group: 6 providers Results: 2 proficient providers, 2 reluctant providers, 2 hapless souls 2001: Pediatrics-Peekskill Wireless laptops used Higher cost per PC but less needed;overall hardware cost the same

5. EMR Project History Results: 2 proficient providers, 2 reluctant providers, 2 hapless souls 2001: Pediatrics-Peekskill Wireless laptops used Higher cost per PC but less needed;overall hardware cost the same

6. EMR Project History Pediatrics implementation successful Less efficient because of previous use of checkoff sheets Time savings for physicals, school immunization sheets 2003 test: Tablet computer

7. EMR Project History 2002-3 3 sites added, wireless setup Server at main site Connectivity issues surfaced Rapid training and provider use Pre-entered problem lists, long term medications, immunizations Implementation schedule formalized

8. EMR Project History Additional sites added in 2003-5 New Start 2005 opened with EMR 3 sites wired and awaiting rollout Lingering Issues Interface with labs Interoperability with local countywide network Dual use of EMR and PECS

9. Choosing an EMR It’s the Support not the Product Contract Issues Clinical Expertise Compatibility Company

10. Choosing an EMR Check interfaces with existing software-ask to see working examples Buy it ready made-customizing is hard

11. EMR: Myths Less paperwork… yes but longer data entry time Easier Information Retrieval… but that means more information to retrieve and address Cost Savings-only in your dreams

12. IT Implementation Issues Network Structure Hardware Selection and Placement Network Reliability Internet Connectivity Redundancy Technical Support Software Support

13. Network Structure Client-Server Thin Client Citrex (multiple sites) Consider ASP Model

14. Hardware Selection Little hardware leadership from vendors They will support multiple platforms as a marketing issue Initially--providers chose devices “If they choose it they will use it" didn't succeed costly to support Now--IS selects hardware if it works, they will use it

15. Hardware Issues Tablet/Wireless/Wired/Thin Client Printer Location Nurses Station Placement within Exam Room Wall vs Countertop

16. More IT Issues Reliability EMR needs higher level of reliability and less down time than business functions Change of midnset for IT support staff as well as planning for redundancy Connectivity Need T1 level connection; DSL, cable inadequate

17. Training Issues Rate-limiting step Keep the user’s perspective Start with easier functions Solve problems, don’t automate them Workflow discussion should proceed training Develop a schedule and STICK TO IT

18. Training Issues Users missing basic computer skills Delete key, tab key, back key Typing skills holds back team training and whole implementation

19. Training Approach Work closely with vendor Support Staff Train first or concurrently 2-4 hours Clinicians 2 weeks training AM and PM sessions AM Classroom, PM Live 2 weeks followup support

20. Clinical Implementation Avoid Democracy-Embrace Dictatorship Set clear expectations 3 rd visit:Medications and problem lists 5 th visit: Full Medical History Preload some information Pediatric Immunizations

21. Clinical Implementation Issues Don’t automate a bad procedure Rethink information flow Rethink nursing and support staff roles Rethink how to capture information

22. Clinical Implementation Issues Letters Referrals Templates LabCorp interace Registry interface Reports mobile access Scanned document input Patient access Specialty services mental health nutrition dental

23. Clinical Implementation Issues Template Development Individual vs organizational Agreement on Standardized Use Process for Review Database Upkeep Pharmacies Specialists Access

24. Leadership Issues Senior Leadership Responsibility EHR key part of Strategic Plan Initial and Ongoing Funding Information Management Issues Redefine Medical Records role Security and Password Management HIPAA Compliance

25. Resource Issues Dedicated clinician time to develop functionality Anticipate decreased productivity during implementation-between 1 and 3 months Ongoing training costs-new providers, more detailed functions, new processes

26. Administrative Issues Exercise rigorous oversight of all consultants/vendors Identify responsible parties for issues and track to resolution Provide feedback on usage to staff and Board

27. Administrative Issues Leverage consultants for necessary expertise, including strategy development if needed Recruit/retain CIO type expertise Don’t underestimate workflow and organizational changes