The United Cerebral Palsy of Greater Birmingham (UCPGB) has recently moved to a new LINCPoint facility and identified the relocation as an opportune time to develop an electronic medical record keeping system. The UCPGB is a not-for-profit organization that provides various clinical health services to patients that have been diagnosed with Cerebral Palsy within the population of Birmingham, Alabama and reaches to the ten surrounding counties. The UCPGB is funded by a mixture of private and public funding, with most of its funding coming from the community through a parent organization, The United Way of Central Alabama.
It is committed to providing a wide variety of services on site that address the complete health needs of its patients. The new facility has been designed with consideration of the patients’ limited mobility, its square footage totals 42,000 with 8,000 set aside for service delivery. The move to this location has prioritized the need for an electronic medical record to maximize efficiency and improve health care delivery. UCPGB provides Family Medicine, Physical Medicine and Rehabilitation, Exercise and Physical Therapy, Speech Language Pathology, Occupational Therapy, Optometry, and Dental Medicine.
Due to the medical condition of these patients, most if not all patients utilize every service available and are followed by a multitude of providers. Each specialty is run in a different way; for example many of the therapy sessions are conducted in a group setting where one provider is working with multiple patients at one time and patients are often fast tracked to specialties. The center has many full time providers, nurses, therapist, dentists and auxiliary staff. It also has volunteer faculty for many of the specialties and allows residents to rotate for training purposes.
Due to the nature of addressing the needs of the complete patient, many departments have special processes and protocols which lead to a diverse medical record. The center suffered from huge inefficiencies with the paper system they had in place, ranging from inaccurate appointments to loss of patient information to constant repetition of tasks. However, the atmosphere in the center is of a pleasant informal nature and all the personnel are extremely devoted. They were aware of the inefficiencies but their devotion lessened their frustrations with the paper system.
The personnel were open to change and supported the implementation of the electronic record. This case shows the obstacles associated with implementation of an electronic medical record in a center that has multiple specialties and multiple providers that have been working on a complete manual paper system. The review paper will address the nature of the organization, its willingness to improve, its accuracy in assessments of its current state, identification of goals and its strategy to achieve the goals it set for itself with consideration of the obstacles it would face.
While UCPGB realizes that they must update their paper system to an electronic one, many barriers stand in their way. The first of their concerns is financial. As a non-profit organization, UCPGB has limited funds for an EMR. The organization directs 93% of their funds towards support and improvement of programs and services. Unfortunately, funds raised to build their new LINCPoint facility did not include an allocation for an EMR. Commercial EMR systems are expensive and vendors often set their prices based on the number of users.
This is problematic for UCPGB because they currently staff one full-time physician, 10 volunteer faculty and a large group of residents. UCPGB must also make sure that their EMR is reliable and fast. The system cannot afford any downtime during clinical hours and data cannot be lost due to software or hardware failure. The best way to avoid downtime is to back-up data on multiple disks within one or more servers. UCPGB should consider purchasing a server, or two, with a Redundant Array of Inexpensive Disks (RAID). This means that each piece of data is stored on the hard drive twice, or once on each disk.
If a single hard drive where to fail, the data would still be accessible on the second disk/drive. RAID is very inexpensive and is incredibly reliable. Another concern is protecting their server, and thereby the EMR, from damages from the elements. Having recently witnessed New Orleans’ experience with Hurricane Katrina, this is of concern to UCPGB. In order to protect their server from damage such as overheating, humidity, water, etc, UCPGB should consider co-locating their server. Co-location is a service that provides off-site server housing in environments designed to provide optimal functioning conditions.
Services include redundant power, internet connectivity, cooling, security, and protection against environmental factors such as flooding and fires. UCPGB also lacks the personnel resources and technical expertise needed to implement an EMR. In order to overcome this obstacle the organization has hired a consulting firm, Physician Innovations, LLC. Physician Innovations is a consulting firm that specializes in the installation and implementation of EMR systems. The consulting team uses eight key steps to design and implement an EMR.
These steps are as follows: 1. Understand the users’ needs and system requirements . Document and improve the current work process 3. Select and configure “best” products 4. Introduce and test prototypes 5. Customize the product to meet users’ needs 6. Populate the system and implement for use 7. Train users to maximize system functionality 8. Evaluate and plan for ongoing system maintenance This new technology push will create a need for IT personnel. Trained professionals will need to be on staff to handle VISTA software updates, prevent software and hardware downtime and provide training to providers. Such an EMR will decrease the need for medical records staff.
Resources from medical records can be transferred to a small IT department. In order to assure that UCPGB’s EMR is interoperable with other providers, they must first recognize the needs of the community and determine if there is even an interest for wide range usage. Once interest has been recognized, the hardware can be negotiated as a whole for the community and margining can be encouraged for detailed training and support. Such a community wide inter-related system would allow for easier referral services and ultimately improve patient care. Upon selecting an EMR system for UCPGB several factors were considered.
The priority criteria “adequate functionality to meet user needs at an affordable price” was met, among the other critical need for the new EMR system to be flexible enough- or customizable enough to incorporate a group of multi-specialists. Because UCPGB is a multi-specialist group consisting of doctors with various practice specialties, thus the EMR must be able to accommodate all of these sub-specialties. The VistA system which was chosen, tackled most, if not all of the major obstacles questioned. The first major concern was customization, which VistA addressed directly.
Medications, templates and diagnostic codes would all be unique to each clinic. Without these specialized templates, each doctor and clinician would have to type in individual orders, which would prove to be extremely time consuming. There were also several issues of concern which were unique to specialized clinics. Optometry and Dentistry have charts, orders and tests, which typically require EMR systems that are made for their respective specialties. For example, Optometry may require Optometrists to chart specific drawings of eye diseases, wave charts etc… While dentistry typically requires dental layout charts.
This problem was solved by incorporating a scanner into the EMR system. The clinicians will physically draw any needed information on a paper chart, which in turn will be scanned into VistA EMR. Group Therapy was another area of UCPGB which was a difficulty to overcome. Speech therapists see anywhere between three and eight patients at a time, and entering manual notes has been a challenge, taking up a tremendous amount of time in the past. VistA solved this problem by employing a notes section. Progress notes are automatically copied to all of the patients seen in a given session; changes are then able to be made, if warranted.
One of the last problems with the new EMR system was the actual implementation of the system. Previously, UCPGB was 100% paper. A method of transitioning patient charts into the new system had to be devised. One approach would have been to use paper along with the EMR system for several patient visits, integrating patient information into the EMR with each visit, and then eliminating the paper chart. The alternate choice, which was chosen was to manually enter patient data into VisaA in the prior weeks of implementation, it took three people, who were trained clinicians (i. . doctors or nurses) two weeks to do this. In order to make VistA a success in the long term, ongoing support and account modifications of user satisfaction was needed. Continuous modifications were implemented, user input was taken into account and adjustments were made as needed. This was a necessity to make the EMR a success. Training people on the new system was the last piece of the puzzle. An initial group demonstration of the software was given to everyone, followed by a one-on-one training session for each clinician.
This one-on-one proved to be a pivotal role in providing training success. Since there were so many distinct clinical roles, individual training to specially target each user was a key to success. One last aspect of training involved personal computers. Wireless computers had the advantage of bringing the EMR directly to the point of care. All of these recommendations and evaluations made implementation of VistA a success. The new EMR system was able to handle UCPGB’s multi-disciplinary practice and implement a successful system to match their needs at an affordable price.
In implementing a new system, especially a site wide system, it is important to understand not only the goals of the project, but also the needs of the users involved. An effective EMR can only be created through strong communication, observation and acceptance. UCPGB acknowledged its lack of personnel resources and technical expertise, bringing in a consultant team to take control. The System Selection and Implementation Process created by the team showed a strong sequence of steps to help engage the entire center in the process.
Understanding user needs and requirements, documenting and improving current processes, selecting and configuring products, introducing and testing prototypes, customizing products to meet needs, implementing systems for use, training and evaluating plans for maintenance all are crucial steps in creating an acceptable pilot. Observation and customization must begin early on, focusing on communication and negotiating. Interaction between all staffing assists in coordinating ideal programs to enhance patient care and generate better processes. UCPGB’s consultant team was aware that different departments and doctors call for various needs.
Creating these options for data entry and scheduling are required in a site wide implementation. UCPGB also focused on why this new implementation would be an important resource. The informal atmosphere and drawn out processes lent itself to too many opportunities for mistakes to be made and information to be lost. With the movement of patients from doctor to doctor, this exchange of information is a crucial part of their care. As addressed, everyday changes such as change in medication could have a negative impact if not properly monitored.
It is through this interactive EMR system that not only will all areas be able to communicate with one another and processes be made simple, but patient care can be improved even with the growth of the patient population. UCPGB’s is an organization ready to take on the real time challenges, faced with implementing this new system infrastructure, and address the needs of an expanding client base. UCPGB choose to make an IT investment based on the realized value of an EMR, rather than on “anecdote, inference, and opinion”, which ultimately lead to more improved and sustainable data management.
Using keys concepts of “sensemaking” and “baking in knowledge”, one of UCPGB’s core rationales for implementing an EMR was to increase efficiencies. However, specifically UCPGB transitioned for EMR for the following reasons: ?Eliminate labor-intensive steps by storing patient records on a shared system ?Increase information-sharing relationship with other organizations ?EMR centered on work flow allows for better communications ?Provide real time patient information to providers for increased efficiency The criteria used for selection was simple: adequate functionality to meet user needs at an affordable price.
As money was a major barrier, coupled with being a non-profit organization whose funds were primarily directed towards building the new facility LINCPoint and not allocation for a new EMR, UCPGB was looking for an economical solution with long term payoff. In addition to limited financial resources, UCPGB also had limited personnel resources to plan the system conversion. Nevertheless, both obstacles were overcome when UCPGB employed Physician Innovations, LLC to train staff, who also had the insight to recommend VistA.
An EMR developed by Veteran’s Health Administration, VisitA is a free and open source software (FOSS) system which allows for application customization. UCPGB ultimately chose VisitA Office, which can be integrated successfully with Microsoft Windows for client component and low cost/high performance Linux for server component. To be further cost effective, rapid prototyping was then executed to gain feedback and develop modification for a more stable system. It should be noted however that VistA did not indicate whether an “Alert” or “Reminders” application was put into practice.
Such applications are highly favorable in reducing medical error, while increasing time management of valuable resources. Successful implementation of this new EMR system will bring many new benefits and increased satisfaction to both managerial processes and patient care. Reduction of loss of patient information and medical error, improved patient flow and billing processes and increase communication between departments and physicians are direct benefits that will be seen site wide.
These benefits will lead to increased client satisfaction, provider satisfaction, increased revenue and cost efficiency. This will make EMR a strong return on investments. In addition as more clinicians are added to the system, the hardware can be assessed accordingly and updated as well. Upgrades must also be initiated as the current EMR system reaches maximum capacity. Furthermore, UCPGB is also anticipating an influx of patients due to the graduation of special education students.
Thus the system would need to increase it’s user terminals, electronic storage capacity, and IT support staff. While implementing a new EMR system can be a tremendous endeavor, the importance of providing state of the art care is the mission of the organization. As the EMR becomes a necessary component of everyday workings at UCPGB, the benefits of this project will help to ensure long term future success.