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Chapter 19

Implementing and Upgrading an Information System Solution

Reasons for Net New Implementation or Upgraded Healthcare System

American Reinvestment & Recovery Act (ARRA) and Meaningful Use

Health Insurance Portability and Accountability Act (HIPAA) Mandatory Transition to International Classification of Diseases–10th revision (ICD-10) Codes

HIPAA mandatory migration to 5010 standards

Best practices and evidence-based content

Clinical Decision Support (CDS) System

Patient safety

Improved quality of patient care

Vendor-Certified versus Home-grown Healthcare Systems

Advantages of certified systems

Disadvantages of certified systems

Advantages of home-grown systems

Disadvantages of home-grown systems

EACH (Electronic Health Records [EHR] Alternative Certification for Hospitals) Program

Advantages of Vendor Certified Systems:

Certification by CCHIT (Certification Commission for Healthcare Information Technology) validates that the commercial system has the ability to allow users to meet Meaningful Use.

Each vendor usually has customer-managed organizations to exchange ideas and use of the vendor’s products; e.g., INSIGHT for McKesson products.

Vendors have resources to quickly incorporated the ever-changing and increased government-issued mandates.

Disadvantages of Vendor-Certified Systems:

Usually more expensive

Vendors slow to incorporate changes that are not mandated by a certification organization like CMS, JCAHO, etc.

Interoperability problems - Difficult to interface products from different vendors

Advantages of Home-grown Systems:

More robust and customizable to meet unique needs

Do not have to wait for vendor to make desired changes or new features, or correct bugs.

Disadvantages of Home-Grown Systems:

Specialized staff to build and maintain system

More difficult to interface with commercial applications

Decision Points: Net New Implementation versus an Upgrade

Sufficient resources

Staff

Financial

Physical or environmental restraints

Risk factors and strategies to minimize them

Upcoming visit from The Joint Commission (TJC)

Possibility of a union strike

New construction

Loss of key members of a project

Decision Points: Net New Implementation versus an Upgrade (Cont.)

Scope creep

Best of breed versus fully integrated system

Advantages and disadvantages of each

Opportunities for improvement

CDSS

Evidenced-based medicine (EBM)

Alerts

Implementation Success Factors

Determine how success will be measured before the project starts and what metrics will be used.

Establish a baseline measurement of the above metrics.

Examples of metrics:

Nonformulary medication orders

Amount of time between order entry and the first dose of medication

Amount of time between order entry and completion of “stat” orders

See Table 17-2.

Implementation Success Factors (Cont.)

Receive support from top management and clinical leaders.

Receive input from representatives from every discipline.

Map all current preproject workflows and work-arounds and future workflows and processes.

Start a detailed go-live plan, with every task assigned to a specific individual or department.

Implementation Success Factors (Cont.)

TEST–TEST–TEST

TRAIN–TRAIN–TRAIN

System design

Minimal clicks and scrolling

Minimal interruptions

Alert fatigue

Location of common toolbars and shortcut buttons in the same location across the screens, if possible

Success Factors for a Successful Go-Live Plan

Providing a detailed go-live plan with tasks assigned to specific names

Publicizing go-live dates

Avoiding go-live dates on Mondays, Fridays, and weekends or near major holidays

Planning elbow-to-elbow support for users during the first week

Providing roaming superusers

Success Factors for a Successful Go-Live Plan (Cont.)

Planning for clinical coverage of clinicians who are providing support during the go-live

Scheduling regular rounds of senior leadership and clinical leaders to all departments

Acknowledging every user’s suggestions, comments, and complaints

Informing visitors about go-live via posters in the cafeteria, lobby, elevators, and newsletters

Command Center Readiness

Staff: Well-skilled personnel for each application

Shifts: Usually 10- to 12-hour shifts

Scheduled status meetings:

Review all issues, especially highly critical issues.

Schedule two or three status meetings everyday for the first 2 or 3 days; then decrease as needed.

Well-publicized hot line number: Bank of telephones for call-ins to roll over to the next available telephone

Command Center Readiness (Cont.)

Mechanism to report go-live issues

Call-ins to the hot line

Reports from roaming superusers

System to catalog and assign critical issues

Preprinted issue-reporting templates and forms

Establishment of levels of criticality

Direct communication with vendor support

Command Center Readiness (Cont.)

Physical environment:

Sufficient number of personal computers with all applications loaded for troubleshooting

Sufficient number of printers

Sufficient number of telephones with outside lines to communicate with vendor

Poster-sized sticky pads

White board with markers

Paper, pens, pencils, and staplers

Celebrate Go-Live

Balloons and banners in lobby and cafeteria announcing go-live

Treats or food for staff across all shifts

Shared successful metrics with regular announcements regarding:

Computerized physician (provider) order entry (CPOE) application

Reduction in call backs

Reduction in nonformulary medications

Increased compliance with core measures

Post Go-Live: User Input

Mechanisms for user feedback, questions, comments, and suggestions

Call ins

Suggestion boxes in public places such as in the cafeteria and the main lobby

Specially marked notebooks in the nurses’ lounges and the physicians’ lounges that are picked up and reviewed on a regular schedule

Frequently asked questions (FAQ) document to share with the staff

Post Go-Live: Maintenance

Change Control Committee

Increase the frequency of scheduled meetings immediately after go-live to evaluate quickly all requested changes.

Patches

Upgrades

Change requests (bugs) identified and submitted to vendor

Post Go-Live: Maintenance (Cont.)

EHR education:

New staff and role changes of current staff

New functionalities or features with upgrades or patches

Refresher courses

Interfaces with new add-on ancillary systems such as a cardiology application

New interfaces with ancillary systems such as laboratory and radiation that change vendors

Post Go-Live: Maintenance (Cont.)

Order item master maintenance: Inactivating select orders, building new orders, and creating aliases

Introduction and refinement of EHR features that were not implemented with the initial go-live

Continual refinement of documentation screens, reports, workflows, security, and EHR-related policies

Meaningful Use–Stage 2

Meaningful Use–Stage 2: January 1, 2014

Thresholds of Meaningful Use–Stage 1 criteria are increased.

Expansion of Meaningful Use–Stage 1 criteria: Eligible professionals (EPs) must use CPOE for 60% of ALL orders, not just for medication orders.

10% of the summary of care records must be electronically transmitted to healthcare providers outside of the network and those that have a different EHR system.

Meaningful Use–Stage 2 (Cont.)

New criteria requiring patient engagement for EPs:

10% of patients must view, download, or share their medical records.

50% of patients must have access to visit summaries within 24 hours.

50% of patients must be able to receive electronic versions of their health information on request.

10% of patients must be able to receive health education materials.

10% of patients seen within the past 24 months must receive electronic reminders of upcoming appointments and preventive care.

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