Thomas G. Zimmerman, DO, FACOFP, CPHIMS
South Nassau Communities Hospital
Oceanside, NY
Hospital Demographics
 440-bed community hospital in suburb of NYC
 1023 Medical Staff
 850 Physicians (of which 75 are hospital-employed)
 3000 Employees
 720 RN’s
 Dually-Accredited Family Medicine Residency (18)
 Visiting Residents (OB, Surgery, Peds – total 18)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
2
Do your homework!!
 Thoroughly evaluate the project’s feasibility
 Preliminary architecture and design specifications
 “Informed consent” of all stakeholders
 Consider the financial impact of the project (as well as
work-hours involved)
 Complete EHR, or phased approach


Phase 1 – Orders and Results
Phase 2 – Clinical Documentation
© Thomas Zimmerman, DO, FACOFP, CPHIMS
3
Planning
 Clarify Project Objectives and Scope
 Proposed Timeline
 Cost and Quality objectives
 Scope of Project
 Deliverables
 Verify that all stakeholders agree to these guidelines to
avoid confusion, wasted effort or duplication, and/or
project failure.
© Thomas Zimmerman, DO, FACOFP, CPHIMS
4
Planning
 Identify a single leader of the project
 A large steering committee by itself does not allow for
personal responsibility and action.
 CMIO / CIO / VP EMR/HIM should take the lead in
monitoring progress and addressing obstacles
 Steering committee can serve as a resource to the project
leader to discuss issues and find solutions
© Thomas Zimmerman, DO, FACOFP, CPHIMS
5
Planning
 Full-Time Project Manager
 Day to day management, execution, and delivery of the
implementation
 Reports to Project Sponsor / Steering Committee
 Should have experience with IT implementations
© Thomas Zimmerman, DO, FACOFP, CPHIMS
6
Planning
 Interdisciplinary Implementation Teams
 Executive Sponsors
 Department or section leaders
 Experienced Subject Matter Experts (SME’s)

Physicians, IT tech’s, EMR consultants
 End-users with AND without IT experience
 Department of Medical Education

Residents, students (of all types)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
7
Planning
 Strong Administrative Sponsorship and
Involvement
 Ensures that each implementation team (not just the
Steering Committee) has the authority to make decisions
that will “stick”
 Expresses the strong commitment of the hospital for this
implementation (to the end-users)
 Ensures better communication and awareness
© Thomas Zimmerman, DO, FACOFP, CPHIMS
8
© Thomas Zimmerman, DO, FACOFP, CPHIMS
9
Planning
 Core Analyst Team

Hire flexible thinkers who have a sense of perspective and a sense of
humor – you will need both.
 Consultants – Caveat Emptor!!
Enlist their services judiciously, respect and acknowledge
their expertise, but make sure that hospital staff retain
ownership of the project
 Interfaces
 Lab / Rad / Dietary / Admitting


Make sure the time and costs for the
development/testing/verification for all of these are appropriately
accounted for in negotiations, contract, and scope
© Thomas Zimmerman, DO, FACOFP, CPHIMS
10
Identify Risks
 Technical – interface issues, equipment compatibility
issues, delays in upgrades
 End User Acceptance – resistance to change
(computerized physician order entry, medication
reconciliation, etc.)
 Recognize, monitor, and address these risks in a timely
manner, and ensure communication between
stakeholders (no surprises!)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
11
Question the Vendor
 Don’t accept “it’s hard coded” or “it’s working as
intended”
 Clinicians need to drive the train for patient safety
© Thomas Zimmerman, DO, FACOFP, CPHIMS
12
Staffing Concerns
 Clarify time commitments for staff members
involved with the implementation
 Identify times where their hours will need to be
back-filled with other staff to meet daily
operational needs
 If activities will occur after work hours, consider
what type of compensation will be provided
© Thomas Zimmerman, DO, FACOFP, CPHIMS
13
Review Policies
 Practice and policies will need to reflect the new world
order
 Don’t feel that you need to “own” the practice of the
entire hospital
 Users will ask you to “make the doctors and nurses
do…”. Avoid the temptation!
© Thomas Zimmerman, DO, FACOFP, CPHIMS
14
Remember…
 Everyone still needs to talk
 Avoid the “illusion of communication” that follows
implementation of an EMR
© Thomas Zimmerman, DO, FACOFP, CPHIMS
15
Scope
 Define the scope of the project, and really think it
through
 In-patient only?
 Out-patient areas?

Ambulatory areas vs. Procedural areas?
 Consider areas that serve a combination of in-patients
and out-patients
© Thomas Zimmerman, DO, FACOFP, CPHIMS
16
Scope (cont)
 Will you use niche products in areas such as:
 Cath Lab
 Labor & Delivery Suite
 OR
 General EMRs are “a mile wide, and an inch deep”
while niche products are “an inch wide and a mile
deep”
© Thomas Zimmerman, DO, FACOFP, CPHIMS
17
Create a detailed project plan
 Gantt Chart or Excel spreadsheet
 Document all major outcomes/deliverables
 Target dates
 Responsible Sponsor / Resources
 Approximate work effort
 Update these tasks as they are completed or
delayed/modified
© Thomas Zimmerman, DO, FACOFP, CPHIMS
18
Scope Creep
 The expansion of the project to include
additional products/functionalities not
originally accounted for in the project plan
and/or contract
 Extra Time / work effort
 Extra Costs
 Increased complexity, confusion
© Thomas Zimmerman, DO, FACOFP, CPHIMS
19
Change Control
 Changes to the original software are inevitable; the
product must be tailored to suit the individual needs
of your organization
 Be prudent in making modifications to the core
software
 Document all changes in detail:
 Date of change
 Reason modification was needed
 Exact description of the change (in case it needs to be
restored after an upgrade)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
20
Current State & Future State Design
 All stakeholders involved – better design, more user




acceptance/skills
Identify every workflow in every department of the
hospital: clinical, administrative, financial.
Critically evaluate current policies and procedures,
and watch for opportunities for improvement that the
EMR may provide
Identify key issues / problems created by the EMR
Document the future state of operations clearly
© Thomas Zimmerman, DO, FACOFP, CPHIMS
21
Sample Workflow Diagram
Provider
Inpatient Documentation of Home Meds List
Provider sees
patient
before RN
assessment
Continue with
Admission
Reconciliation
process
MD option
Either Clinician
Have home meds
been documented
in Rx Writer?
Yes
Validate list
with patient
Perform “Copy
from Rx Writer”
function
Add last dose date
& time info for
home meds
No
Nurse
Add home
meds to
patient profile
in Rx Writer
Nurse interviews
patient before
provider
assessment
End
© Thomas Zimmerman, DO, FACOFP, CPHIMS
22
Future State Design Guiding Principles
Key Theme
Description
Clinical Excellence –
Quality and Outcomes
Focus
What will the approach be for identifying outcomes as part of the
EMR implementation? Which outcomes are of the highest priority?
Care Standardization
Determines the extent to which care and clinical applications will be
standardized.
CPOE Strategy
This defines the degree to which CPOE will be rolled out as standard
practice or policy. Medical executive committee establishes
expectations regarding compliance and consequences for physician
non-compliance.
Describes the approach to clinical documentation: what types data
Clinical Documentation will be entered, who will enter it, and how.
Clinical Decision
Support
Describes the approach to the tools that guide real-time clinical
decision-making.
© Thomas Zimmerman, DO, FACOFP, CPHIMS
23
Future State Design Guiding Principles
Key Theme
Description
Training
Identifies the approach and level of investment for how the hospital
addresses staff training for clinical quality improvements to include
use of advanced clinical systems.
Access Strategy –
Remote and Internal
This defines the strategy for the placement of devices to enhance
adoption and also determines the extent the physician portal and
remote access will be utilized.
Content Strategy
This will define the content strategy (order sets, clinical
documentation, and clinical decision support) to ensure system
utilization and improve quality and efficiency.
Redesigning current workflows with EHR as an enabler will allow
Workflow Optimization hospital to maximize the integration of system utilization and clinical
workflows.
Communication
Strategy
An institutional communication strategy that outlines the audience,
methods, tools and frequency of communication must be developed
to improve institutional ownership.
© Thomas Zimmerman, DO, FACOFP, CPHIMS
24
Timeline
 Nov. 2009 – Presentations by 2 Vendors
 Jan-March. 2010 – Site visits to nearby Hospital
using each system
 July 2010 – Contract signed with Vendor
 January – May 2011 – Current / Future State Design
Sessions
 August 2011 – Present – Physicians Advisory Group
Meetings
 June 2012: Go-Live!
© Thomas Zimmerman, DO, FACOFP, CPHIMS
25
Site Visits
 Two hospitals with similar demographics
 Community hospital with residency programs
 Bed size, service lines, patient population
 Evaluation Team
 HIM (VP HIM, EMR Manager, Coding Director)
 IT (CIO, Network specialist)
 Financial (VP Finance and staff )
 Medical Staff (President of Med. Staff, Physician
champion)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
26
Site Visit Itinerary
 Presentation by Hospital’s CMIO
 Divide and Conquer:
 Medical Team: Floors, ICU, ED, Ambulatory Clinic
 IT Team: IT dept., floors
 Finance: Administration, Billing/Coding
 Coding: HIM department, Billing/coding
© Thomas Zimmerman, DO, FACOFP, CPHIMS
27
Core Build
 Extensive work effort to establish the pharmacy formulary
 Order sets – Diagnosis Based
 Core measures (VTE assessment, time to treatment, etc.)
 Meaningful use measures
 Convenience
 Congruent to Paper forms (for downtime episodes)
 Communication / Workflows for ancillary processes
 Respiratory therapy, Floor-obtained samples, Codes
 Discharge Process
© Thomas Zimmerman, DO, FACOFP, CPHIMS
28
Pharmacy Build
 Have a pharmacy build that reflects:
 Front-end needs, i.e.


Physician needs for ease of item selection and understanding
of order guidance. Will you build brand name synonyms?
Nursing needs for clarity on the orders tab and eMAR
 Back-end needs
 Pharmacy needs consistency of build and a full view of the
medications ordered and access to the patients’ clinical
picture
 TEST each item from order entry, to dispensing and
delivering, to display on the orders tab and eMAR, to
medication administration
© Thomas Zimmerman, DO, FACOFP, CPHIMS
29
Downtime Plans
 Have firm downtime plans and tools well before Go-
Live
 Devise a method of running reports in the background
that can be printed on demand in advance for a planned
downtime, and just in time for an unplanned downtime



Patient list by location
Orders report with all active, on hold, suspended orders
MAR with a list of all medications administered within the
prior 48 hours, with a list of all tasks for the next 24 hours
© Thomas Zimmerman, DO, FACOFP, CPHIMS
30
Downtime Plans
 Create a “Meaningful Use Checklist”
 Ensure all MU measures during downtime are correctly
entered during recovery period (backfill)
 Strongly consider building a redundant database on a
local server to be viewable during downtimes/no
internet access
© Thomas Zimmerman, DO, FACOFP, CPHIMS
31
Training
 No amount of training is too much!!
 Combination of delivery methods to account for
differences in end-user preferences and
schedules




Live, classroom-based sessions (at hospital or office)
Web-Based Training Modules (auto-tutorial)
Remote webinar sessions
One-on-one
© Thomas Zimmerman, DO, FACOFP, CPHIMS
32
Superusers
 Essential to have key team members receive extra
training and practice with the system
 Creates a cadre of first-line support at the unit
level during Go-Live and thereafter
 Improves end-user acceptance, they serve as
ambassadors of the EMR team
 Helps identify issues in the system earlier in the
process (these people know what works and
what won’t work!)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
33
Preparing for Go-Live
 Big-Bang vs. Phased Approach
 Entire House or Unit by Unit
 Central Command Center
 Embed IT and EMR support personnel throughout the
building
 Superusers, hospital IT/EMR staff, vendor support
 Deploy more staff in busier or more critical units
 Two weeks minimum, 24/7
© Thomas Zimmerman, DO, FACOFP, CPHIMS
34
Activation
 Telephone Support Center
 Have the Informatics team (Level 2 Help Desk) and the
IT team (Level 1 Help Desk) share a Telephone Support
Center where they handle calls from the users during
Go-Live. It will pay off later with increased knowledge
and compassion on both sides later
 Keep detailed logs of all issues (as well as their
solutions)
© Thomas Zimmerman, DO, FACOFP, CPHIMS
35
Allow for Decreased Productivity
 Overstaff units (especially ED, ICU, OR, other critical
areas of the hospital
 Consider Go-Live on a weekend, to avoid elective
surgeries and imaging procedures (although ED may
be busier)
 If a weekday, reschedule as many elective procedures as
possible
© Thomas Zimmerman, DO, FACOFP, CPHIMS
36
© Thomas Zimmerman, DO, FACOFP, CPHIMS
37