Shelley Corp

Case Study: Developing an Electronic Medical Record for an Integrated Physician Office Practice Shelley Corp Siena Heights University Dr. B. Schoenbart

Running Head: CASE STUDY EMR Case Study for Developing an EMR for the Beaches Clinic According to White and Wakefield (1998) the Beaches clinic is a prestigious, highly

specialized integrated physician practice located in beautiful Florida. The clinic encompasses180 physician practices offering over 32 specialty services and prides itself with its mission of providing holistic care by offering the highest quality patient care with access to research and education to its clinicians and patients. The clinic has grown over the last 12 years since its inception in 1986 from a newly opened practice to one that now serves over 33,000 patient registrations and provides more than 160,000 office visits annually. The clinic provides one stop shopping, a patient is provided a primary care physician upon admission into the practice but if at any time there is a need for a specialists input the patients care can be kept within the clinic with a quick referral to one of the many specialists. In addition, imaging, lab and diagnostic procedures are all available within the specialized clinic as well as an integrated partnership with the neighboring hospital PrimaCare. The clinic has had some operational issues related to the antiquated, labor intensive paper medical chart and has undertaken an ambitious project to make the move to an electronic medical record (EMR) in order to allow providers to track data over time, identify patients who are due for preventative visits and screenings, monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings and improve the overall quality of care provided in the practice ( HealthIT.gov, 2013) Although information stored in EMRs is not generally shareable outside of a practice, the steering committee that was charged with the planning and implementation of the EMR wanted to ensure that all of the patients information would be available to the clinicians from PrimaCare Hospital as well as from any one of the clinic practices so that any of the clinicians, administrative, business or

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technical staff that are providing care to the patient at any given point in time will have access to the EMR. According to the Project Management Institute (2013) a project is a temporary unique operation that is designed to accomplish a singular goal, such as the implementation of an EMR within a physician practice. So, a project team often includes people who dont usually work together along with set goals and strategies that must be expertly managed to deliver the on-time, on-budget results, learning and integration that organizations will need. Project management, then, is the application of the knowledge, skills and techniques to execute projects effectively and efficiently (PMI, 2013). According to Hayes (2004) more than 70 percent of healthcare IM/IT projects fail to achieve anticipated benefits. One of the primary causes of failed IM/IT projects stems from a silo IM/IT project management mentality, which occurs when projects are initiated, planned, and fully executed without effectively considering their impact on other, preexisting systems or other projects being planned and executed in a parallel approach. Glandon, Smaltz and Slovensky (2008) state that contemporary healthcare applications have significant interdependencies that, if not explicitly and deliberately are addressed, can have unintended consequences of IM/IT projects that were planned and executed in relative isolation. When we look at the planning and decision making process of the Beaches clinic IM/IT project it is important to look at the evidenced based process for project management. According to Glandon, Smaltz and slovensky (2008) project management entails five key processes. The Project initiation phase: this is where the Beaches steering committee were suppose to define and authorize the project. This part of the process was done somewhat effectively. Initially a group of administrators and clinicians were brought together due to a shared need and vision to provide a better way of record keeping within the clinic. The current practice was inefficient, expensive

Running Head: CASE STUDY EMR and all too often records were lost or not available when needed prompting patient visits to be cancelled or rescheduled. This first process should also include putting together a team of stakeholders that will ensure that the implementation of the project will not be negatively impacted due to literally thousands of cross-departmental interrelated workflows that must be considered when embarking on a new IM/IT project( Glandon, Smaltz and Slovensky, 2008). The steering committee included the CEO of the Beaches clinic, an associate administrator for

PrimaCare hospital, the president of the clinics medical staff, seven clinicians and the director of the clinics IT department. Here in lies one of the many problems that the steering committee committed. The team did not encompass all of the stakeholders that had a hand in the development of this new project. For instance an IT director from PrimaCare Hospital should have also been included initially on the team. In addition, a billing staff member IT person, a registration IT person as well as some of the ancillary staff that utilizes the records for their job duties. A person from the laboratory, diagnostic imaging, pathology etc should have all been included on the team so as to make sure that the EMR is suitable to being integrated and interfaced with all of the needed points of care such as admitting, radiology, lab etc. There could have been two teams the executive strategy and development team but then there should have been a working or user group team that were charged with working together and bringing their individual expertise to the table to effectively implement the project. The second key process is project planning which is where the objectives of the project are defined and the scope and plan of action to achieve the desired outcomes are defined by the project team ( Glandon, Smaltz and Slovensky, 2008). This was done extremely well by the Beaches project team. They clearly defined their goals and objectives of the project. They listed out what they wanted their EMR to provide them as well as how they wanted to see the program

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run. They wanted to allow for data integration between all of the entities that were affiliated with the clinic, the hospital, the newly established HMO as well as any of the new clinics that were being networked into the clinics practice. They wanted all of the clinicians to have access to the information from wherever they may be within the system, they wanted real time lab and test results to be available for decision making and treatment planning, as well as the ability for diagnostic and procedural billing to be electronically transmitted to the business office. They wanted the system to offer ease of use as well as the ability to access data for research purposes. The only aspect of this process that they could have improved upon was to rank order what aspects of the EMR were most important to them to better help them look for a vendor and decide on what were truly the must haves and what they were willing to wait on or maybe incorporate down the line instead of having everything at once, which often times is truly not feasible. The next process is project execution; this is where actions to complete the work that was defined in the project planning phase are done. This was an area where the project team failed. Firstly, they did understand that they did not have the expertise in house to build such a program which was honorable. However, they only sent out a request for proposals to three vendors. This phase is similar to doing a literature search for a paper that we write for our leadership graduate program. You cannot only look at three vendors or research papers to fully understand what knowledge or information is available. This part of the process may take months to adequately look at all options and evaluate which vendors would best suit your goals and objectives. The steering committee did not follow the goals and objectives that were clearly outlined in the planning phase and hence decided to veer off course due to the fact that this vendor was the closest to what they wanted, albeit completely not able to meet their stated goals and objectives.

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As a growth opportunity the steering committee could have taken more time to find a vendor that clearly met their needs and was able to provide them with the EMR and database they required based on their stated requirements. In addition the implementation phase of the project is included in the execution phase. The steering committee that now included the vendor project manager decided that they would implement the EMR with a pilot program on a busy internal medicine clinic. According to Techtarget.com (2013) a pilot program, also called a feasibility study is a small-scale, short-term experiment that helps an organization learn how a large-scale project might work in practice. A good pilot program provides a platform for the organization to test logistics, prove value and reveal deficiencies before spending a significant amount of time, energy or money on a large-scale project. An effective practice for pilot programs is to begin with a proposal that lists the objectives of the pilot program and documents how the program will be carried out. The documentation should also provide a time-line for the pilot and metrics for how successes will be determined (Rouse, 2013). This is a very important part of the project. The initial error the steering committee made was to not fully inform the other 3 physicians on the sixth floor of the goals and objectives of implementing the EMR. There should have been an educational overview and discussion regarding the pilot program, the goals and objectives of the project as well as ample opportunity for questions, concerns and issues related to the implementation of the EMR by all of the associates that would be included in the Pilot program. Communication is pivotal during any new project or roll out of a new system. According to Robinson, Segal and Segal (2013) effective communication helps us better understand a person or situation and enable us to resolve differences, build trust and respect, and create environments where creative ideas, problem solving, affection, and caring can flourish. This is the environment in which a pilot program should be rolled out if it is to be successful. The project team did

Running Head: CASE STUDY EMR provide assistance and adequate support to the pilot program in the way of a designated individual trainer available at all times by pager, scheduled training sessions, resource material available as manuals and quick reference guides to be carried in physician pockets, as well as establishing a help line for immediate access to questions or concerns. The next phase is the project monitoring and controlling phase which is where measurements are designed to assess how well a project is being executed to budget and deliverables as well as to alert project managers to potential corrective actions that might be necessary from time to time ( Glandon, Smaltz and Slovensky, 2008). Although the steering committee did address problems or issues as they came up during the pilot phase they really didnt follow the guidelines for a pilot project or project management. They initially established a pilot program for the EMR however did not list out the metrics they would use to determine whether it would be considered a success or not, instead of holding a formal evaluation of the

system the steering committee took the information that the five doctors seemed to like it so they utilized it as a vehicle to implement the plan to move from the paper medical record to the EMR rather than as a testing and evaluation mechanism of an EMR idea (White and Wakefield, 1998). As the rollout and implementation progressed there were numerous issues and concerns that were being brought to light from Physicians regarding time requirements, training, unfamiliarity and productivity. These are issues that if the pilot program had been properly done would have been foreseeable and the administration could have proactively addressed it prior to commencing with the implementation. If administration had told the physicians up front to expect some time delays and a decrease in their productivity they would not have become concerned about it as it happened because they would have understood this was part of the learning curve and the administration was supportive of it keeping in mind the end outcome. In addition, they did not

Running Head: CASE STUDY EMR fulfill their goal of getting rid of the paper chart and move into sole use of the EMR due to regulatory compliance and protected health information issues. In essence they set out to make

the process easier but instead ended up making more work for themselves as they now needed to ensure that the information was contained both in the paper record and the EMR. Additional costs were incurred in buying new equipment such as point of service scanners to be placed on each floor as well as in the HIS department to better capture still prominent loose papers, in addition to hiring 30 new temporary staff to perform quality control process as well as 10 other staff to manage and maintain the filing of the loose reports. The steering committee should have had this all spelled out in their initial planning stage, instead they recognized late into the implementation that they would be required to maintain the dual record system for at least two years, costing the clinic a considerable amount of time and money-the exact opposite of what they envisioned at the initiation phase. In addition, they soon found out that the two year plan ended up crossing over into actually four years. It wasnt until the end of the project that the steering committee put together user groups to present their issues about the system to the EMR steering committee as well as send out a formal survey to physician users to solicit their input. The planning and implementation phases of this project were ill defined and ended up costing the clinic much more than what they initially thought it would provide in benefit. According to Garrett (2013) projects fail for all sorts of reasons from low budgets to tight schedules however there are many reasons that continue to show up as the leading reasons IT projects fail. Some of those reasons are why this EMR implementation could be viewed as a failed project implementation. All too often projects that fail have ill defined scopes-this is not necessarily true of the EMR implementation at Beaches clinic. Scope is simply the project managers term for the sum of the work to be done on a project; it details what is required of the project, what is not

Running Head: CASE STUDY EMR required, and what the end product needs to look like. This EMR project did have a scope but somewhere in the planning stage the scope of the project wasnt referred to and the end product did not provide the Beaches clinic with what they originally wanted. In addition Garrett (2013) suggests that a lack of planning is a major cause for unsuccessful projects. If a project is to succeed it must be planned thoroughly. Garret advises to ensure that the plan is written with as much detail as possible, such as writing out a project charter, mission, a scope statement and a

communications plan, and above all else stick to it, revisit it frequently, ask if we are we working toward our goal, Will we be able to achieve our goals and mission with these strategies and tactics? If the Beaches clinic steering committee had followed these two rules they most likely would have had a successful project outcome. The Beaches project has not reached the project closing phase at the time of the paper submission; this is when actions are formally taken to terminate all activities associated with the project either by delivering a finished product or by ceasing effort on a canceled project. The project planned to continue over the next two years when the steering committee feels that the EMR will be fully implemented and the realization costs will be seen. Although they eventually will be able to implement an EMR it will be essential that the data integrity be ensured across and integrated system. According to the American Health Information Management Association (2012) the overarching goal of EMRs is to allow authorized users to quickly and accurately exchange health information to enhance patient safety and improve efficiency. Any inaccurate or missing health information may adversely affect the quality of an individuals healthcare outcomes. Briefly explain how the EMR provides each of these ascribed benefits:

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1. Immediate physician access to patient information from within either the hospital or clinic EMRs provide access quickly and easily to test results. Clinicians are able to pull up results and review with patients right in exam rooms. In addition multiple care providers can simultaneously review a patients medical record instead of having to wait for the paper chart to make its way over to the provider that needs it. 2. Improvement in creation of a timely and complete medical record, benefitting patient care. Clinicians can verify past tests, diagnoses, surgeries etc in order to provide a comprehensive diagnosis and treatment plan to the patient. They are able to get up to the minute information on a patients test results and recommendations from other specialists. It enables them to work more efficiently in determining further action needed for the patient. 3. Elimination of lost information in the record. Due to the fact that information is put in at the time of service there is little to no potential for lost documents. The fact that the information is put into the record at the point of service allows for a more comprehensive and detailed account of the patients history, this in turn gives the clinician the data they need to determine the best course of action for the patient. 4. Improvement in turnaround time for scheduling patient appointments and followup visit. EMRs allow for quick access to reference information needed to schedule appointments. It also allows for easily updating the record with changes in address or insurance carriers. In addition,

Running Head: CASE STUDY EMR there is no need to have to hunt down the chart and locate it prior to setting up an appointment, all of the needed information is available at your fingertips. 5. Improvement in timeliness and access to billing information With the addition of EMRs comes the ability of coding systems that are able to facilitate the selection of correct billing codes for patient encounters. It allows for improved accuracy of billing codes etc. 6. Improvement in capability for abstracting research data

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Researchers can utilize the EMR to look and analyze large amounts of patient data speeding the application of new research findings to improve patient care. According to the Mayo Clinic (2013) the EMR allows researchers to efficiently search patient medical information by medical condition, data of treatment, physician name and test category. Researchers can more quickly focus their attention on medical information that supports their research efforts; develop databases to study patient outcomes, and cross-check complex medical information. 7. Improvement in access to quality management data. EMR vendors have developed reminder systems that can identify patients who are due for preventative care interventions, alert systems that detect contraindications among prescribed medications as well as decision support tools that can assist in providing a diagnosis or the right antibiotic that is best suited for the particular infection etc. It will allow for the ability to look at large populations of patients and ensure treatment for them is based on evidence based protocols and pathways. Leading to further cost savings as pay-for-performance becomes the norm and

Running Head: CASE STUDY EMR keeping chronic patients out of the hospital will be rewarded by higher reimbursement rates by insurance carriers.

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8. Elimination of faxing, copying, and mailing of patient information between hospital and clinic. It will not eliminate the use of paper but will significantly impact the amount of paper that is used. Fax and mailers can be done electronically via the EMR to other Physician offices, to insurance companies etc. And if there is a patient portal test results and patient questions, concerns can be done electronically as well. 9. Reduction of clerical personnel involved in record movement and record retrieval. With the implementation of an EMR there will be a decreased need for personnel to house charts and to maintain them since it will all be online maintenance. This will provide a cost savings to the clinic. 10. Additional cost reductions projected as system performance improves. As IT systems and EMRs improve their platforms and interoperability there will be an opportunity for providers to improve communications, increase patient engagement and compliance and boost patient customer satisfaction ( Zahalsky, 2013) as well as improving patient outcomes. In addition there will be the ability to explore new practice innovations such as e-consults and other tele-medicine options which will further offer cost reductions and increase the ability for all patients to have access to quality, affordable care.

Running Head: CASE STUDY EMR References American Health Information Management Asscociation. (2012). Ensuring Data Integrity in Health information exchange. In American Health Information Management Association. Retrieved October 28, 2013, from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049675.pdf Benefits of the EMR at Mayo. (2013). In The Mayo Clinic. Retrieved October 28, 2013, from http://www.mayoclinic.org/emr/benefits.html Robinson, L. Segal, J. Segal, R (2013) Effective communication: Improving communication skills in business and relationships.(2013). In HelpGuide.org, http://www.helpguide.org/mental/effective_communication_skills.htm Garrett, D. (2013). 10 Reasons why projects fail (And how to avoid them). In CertifcationMag.com, from http://www.certmag.com/read.php?in=1394 Glandon, G. L., Smaltz, D. H., & Slovensky, D. J. (2011). Information Systems for Healthcare Management (7th Ed.). Chicago, IL: Health Administration Press

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Hayes, F. (2004). "Chaos is Back". Computerworld, 38(70).

HealthIT.gov. (2013). Benefit of EHR's. In HealthIT.gov. Retrieved October 28, 2013, from http://www.healthit.gov/providers-professionals/electronic-medical-records-emr Rouse, M. (2013). What is a pilot program. In SearchCIO.TechTarget.com. from http://searchcio.techtarget.com/definition/pilot-program-pilot-study

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What is a project? (2013). In Project Management Institute. Retrieved October 28, 2013, from http://www.pmi.org/ White, A. W., & Wakefield, G. R. (n.d.). Developing an Electronic Medical Record (pp. 316325). Zahalsky, H. (n.d.). Integration, Analytics -Key to next generation EMR's. In Health Management Technology. Retrieved October 28, 2013, from http://www.healthmgttech.com/articles/201301/integration-analytics-key-to-nextgeneration-emrs.php