Background
• Awarded 3 year grant from the Robert Wood Johnson
Foundation entitled, Common Ground: Transforming Public
Health Information Systems
• Goal: Have public health electronically communicate with a
health information exchange (HIE), community health care
partners and consumers
• Project: Electronic Medical Record (EMR)/Practice
Management (PM) Evaluation Project
• Objectives: Develop requirements for evaluating and selecting
an EMR/PM system
• Develop efficient and effective best practice workflows for
clinic processes, case management and practice management
Overview of HIS Adoption Project &
EMR/Practice Management Project
• Why we did this?
–
EMR is a prerequisite to interface with a HIE
 Other Common Ground project is planning a regional HIE (SoPHIE =
Southern Piedmont Health Information Exchange)
 NC public health have a paper-based health record system
–
–
–
Develop efficient and effective best practice workflows for clinic
processes, case management and billing
New state-wide clinic management system, HIS, is not a
comprehensive EMR/practice management system
EMR requires significant business/service process changes from a
paper-based system
2
Overview of HIS Adoption Project &
EMR/Practice Management Project
• Project Objectives
–
–
Develop requirements for evaluating EMR/Practice Management
systems and electronic exchange of medical record data
Evaluate pilot version of HIS against the system and functional
requirements to make recommendations of future
enhancements and functionality to NC DPH

85 local health departments in NC have option to use HIS or other
solution – analysis benefits many health departments
• Two projects evolved:
–
–
HIS Adoption Project
EMR/Practice Management Evaluation Project
3
Overview of HIS Adoption Project
• Developed business process matrix, context diagrams, and
task flow diagrams from March -October 2008
–
–
Collaborative project with 35 subject matter experts (SMES) from
7 local health departments and NC Department of Public Health
Held over 18 collaborative workgroup meetings
• BPA & BPR of 15 business processes:
–
–
–
–
Child Health
Family Planning
Billing
Registration/Checkout
• Developed HIS IT recommendations
4
Overview of EMR/Practice Management
Evaluation Project
• Incorporated the HIS Adoption business process analysis
work into the EMR/Practice Management Evaluation
project
• Collaborated with 45 SME’s from 3 local health
departments:
–
–
–
Cabarrus Health Alliance
Iredell County Health Department
Mecklenburg County Health Department
5
Overview of EMR/Practice Management
Evaluation Project
• Analyzed other areas that would be affected by a new
EMR system from September 2008 – January 2009
–
–
–
–
–
Communicable Disease (CD)
Intensive Home Visiting (IHV)
Lab
Maternal Health
Maternal Care Coordination/Child Services Coordination
(MCC/CSC)
• Held over 30 workgroup meetings
• Redesigned 47 business processes
6
Example of BPA/BPR Work
• Family Planning BP #1 Handouts
–
–
–
Business Process Matrix
Context Diagram
Task Flow Diagrams


Redesign Task Flow Diagram
Redesign Task Flow Diagram with HIS Menu Paths
7
Business Process Matrix
Workgroup
29 Family Planning
BP#
Business Process Name
1 Client visit (new, annual,
problem -male or female)
Goal
* Provide appropriate family
planning services which meet
the client's needs
Objective
Business Rules
* Complete medical history
* HIPAA
* Medical exam
* Title X (Family Planning Federal Guidelines)
* Provide education
* NC Administrative rules
* Provide a method of birth control,
* Federal Poverty Guidelines
other reproductive information, and/or * Local Health Department policies and procedures
referral
* Title V (language assistance)
* NC Board of Nursing Rules
* NC Board of Pharmacy
* Title VI (Civil Rights Act)
Triggers
Task Sets
* Client registration complete 1. Greet client
2. Take vitals (height, weight, blood pressure), and calculate
BMI
3. Complete patient history form
4. Continue Interview
5. Complete consent forms
6. Complete required forms
7. Assess immunization status/provide immunizations if needed
9. Exam room setup/preparation
Provide method education
10. Review history, ask/answer questions
11. Conduct exam
12. *Perform lab tests (*order of lab test task set varies)
13. *Exit Interview (*order of exit interview task set varies)
13A. Share exam results
13B. Provide education
13C. Dispense medication
13D. Make necessary referrals
14. Complete encounter form
Inputs
* Registration information
* Exam supplies
* Interpreter
* Previous medical information
Outputs
* Referrals
* Follow-up appointment
recommendation
* Encounter form
Outcomes
* Complete medical history
* Medical exam
* Provide education
* Provide a method of birth control
and other reproductive information
8
Context Diagram
9
Task Flow Diagram
10
Task Flow Diagram
11
Overview of EMR/Practice Management
Evaluation Project
• Requirements definition phase - January - June 2009
–
–
–
–
Produced functional and technical requirements
Held 32 collaborative workgroup meetings with 45 SME’s
680 requirements defined
Over 4000 data fields determined
12
Overview of EMR/Practice Management
Evaluation Project
• Software evaluation phase – July - September 2009
–
–
Developed 6 sales demo use cases
Developed evaluation tools for SME’s to score each vendor
solution



–
Evaluated 3 vendor solutions



–
Each health department scored independently
Scoring included determining weighted averages for each
workgroup area prior to the evaluation process beginning
Each vendor also completed the evaluation to allow us to compare
our evaluation results with their responses
Netsmart Technologies Insight (Public Health focus)
Cerner PowerWorks (Provider/Hospital focus)
HIS (State’s clinical system)
Customer site visits
13
Overview of EMR/Practice Management
Evaluation Project
• Recommendation – December 2009
–
–
Team recommended an EMR/Practice Management – Netsmart
Technologies - Insight
CHA Board approved EMR/Practice Management selection on
Tuesday, 12/8/09
• Share work with other health departments in NC and
nationally
– Web site – www.cabarrushealth.org/commonground
– Projects described in chapter 25 of the, Managing the Public
Health Enterprise. “Business Process Improvement: Working
Smarter Not Harder”
• Total # of Hours for Entire Project - 8557.5 hours (36% of
hours was project manager)
14
EMR/PM Evaluation Project Timeline
March 2008
November 2008
Objective
Business Rules
Triggers
* Complete
and accurate
registration
records for
all clients
* Complete and
accurate client
registration
record
(demographic
info, payor info,
income info,
appointment
history) to
maximize
reimbursements
and collections
* HIPAA regulations
* NC Administrative Rules
* Federal Poverty Guidelines
* Local Health Department
policies and procedures
* Title X (Family Planning Federal
Guidelines)
* Title IXX (Medicaid) - Proclaims
that at the states discretion, it can
finance the healthcare for
individuals who were at or close
to the public assistance level
* Title VI (Civil Rights Act, provide
language assistance and
translated materials)
* Title V (language assistance)
* NC Identity Theft Protection Act
* Client calls for an
appointment
* Appointment
* Client walk-in
* Physician referral
Business Process Analysis
Business Process Redesign
•Redesigned 46 Business Processes
January 2009
Requirements Definition
•Defined 680 Requirements
•Determined over 4000 Data Fields
July 2009
Evaluate Vendors
Site Visits
September 2009
Gap Analysis of
Meaningful Use Criteria
Health Outcomes
Policy Priority
Care Goals
Objectives
Eligible Providers
[EP]
Improve quality, • Provide access to
safety, efficiency, comprehensive patient
and reduce health health data for patient’s
disparities
health care team
Selected and Acquired a
PM/EMR System - Insight
Measures
Requirements Defined
Data Fields Defined
Hospitals
Inpatient = [IP]
Outpatient = [OP]
2011 - Objectives & Measures - Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions
1
• Use evidence-based order
sets and CPOE
• Apply clinical decision
2
support at the point of care
December 2009
Goal
3
• Generate lists of patients
w ho need care and use
them
to reach out to patients (e.g.,
reminders, care instructions,
etc.)
4
• Report to patient registries
for quality improvement,
5
public reporting, etc.
• Use CPOE for all orders 2
• 10% of all orders (any type)
• % of orders (for medications, lab • Lab - #1-#8
directly entered by authorizing
tests, procedures, radiology, and • Maternal Health - #21
provider (e.g., MD, DO, RN, PA, NP) referrals) entered directly by
• Global - Education - #1-#8
through CPOE2
physicians through CPOE
• Global - Immunizations - #2, #20
• Global - Medication - #29-#34
• Global - Referral - #1-#6
• Implement drug-drug, drug-allergy, • Implement drug-drug, drug-allergy,
• Global - Medications - #15-#19, #21-#23
drug-formulary checks
drug-formulary checks
• Maintain an up-to-date problem list • Maintain an up-to-date problem list • % patients at high-risk for cardiac
of current and active diagnoses
of current and active diagnoses
events on aspirin prophylaxis [EP]
based on ICD-9 or SNOMED
based on ICD-9 or SNOMED
• % eligible surgical patients w ho
receive VTE prophylaxis [IP]
• Lab - #1-#7, #12-#13, #15-#16
• Global - Education - #1-#10
• Global - Immunizations - #1-#4
• Global - Medication - #28-#53
• Global - Plan of Care - #1-#7
• Global - Referral - #1-#34
• Generate and transmit permissible
prescriptions electronically (eRx)
• Global - Medications - #28-#53
• Maintain active medication list
• Global - Medications - #20, #24-#26, #28, #29-#34
• Maintain active medication list
• % of all medications, entered into • Global - Medications - #1-#14
EHR as generic, w hen generic
options exist in the relevant drug
class [EP, IP]
• Global - Progress Notes - #1-#5
• Global - Medications - #1-#11
• Use of high-risk medications (Re:
Beers criteria) in the elderly
6
7
• Maintain active medication allergy • Maintain active medication allergy
list
list
• Record demographics:
• Record demographics:
• Stratify reports by gender,
◦ preferred language
◦ preferred language
insurance type, primary language,
◦ insurance type
◦ insurance type
race ethnicity [EP, IP]
◦ gender
◦ gender
◦ race3
◦ race3
◦ ethnicity
◦ ethnicity
• Global - Allergies - #1-#8
• Global - Allergies - #1-#4
• Registration/Checkout - #18, #20
• Registration/Checkout - #30-#34, #134, #137-#138, #141
• CSC - #30, #33-#35, #43
• IHV - #49-#51, #78
• MCC - #30, #33-#35, #43
Task Sets
Inputs
1. Collect/enter basic
* Appointment
demographic information * Medical record
2. Verify & update payor
and income information
and Medicaid eligibility
3. Complete consent forms
(i.e. eligibility, HIPAA,
financial policies, terms and
conditions)
4. Schedule appointment if
needed
5. Reinstate bad debt that
was written off if applicable
6. Provide self-history form
to client
7. Collect payments
8. Give patient receipts
Outputs
Outcomes
* Client
* Registration
checked in for record is
clinic
completed
appointment
* Appointment
* Payment
receipt (copayments and
flat fees)
Gap Analysis of Meaningful Use Criteria
Health Outcomes
Policy Priority
Improve quality,
safety, efficiency,
and reduce health
disparities
Care Goals
Objectives
Eligible Providers
[EP]
• Provide access to
comprehensive patient
health data for patient’s
health care team
Measures
Requirements Defined
Data Fields Defined
Hospitals
Inpatient = [IP]
Outpatient = [OP]
2011 - Objectives & Measures - Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions
1
• Use CPOE for all orders 2
• 10% of all orders (any type)
directly entered by authorizing
provider (e.g., MD, DO, RN, PA, NP)
through CPOE2
• Implement drug-drug, drug-allergy,
drug-formulary checks
• Maintain an up-to-date problem list
of current and active diagnoses
based on ICD-9 or SNOMED
• Implement drug-drug, drug-allergy,
drug-formulary checks
• Maintain an up-to-date problem list • % patients at high-risk for cardiac
of current and active diagnoses
events on aspirin prophylaxis [EP]
based on ICD-9 or SNOMED
• % eligible surgical patients w ho
receive VTE prophylaxis [IP]
• Use evidence-based order
sets and CPOE
• Apply clinical decision
2
support at the point of care
3
• Generate lists of patients
w ho need care and use
them
to reach out to patients (e.g.,
reminders, care instructions,
etc.)
4
• Report to patient registries
for quality improvement,
5
public reporting, etc.
• % of orders (for medications, lab
tests, procedures, radiology, and
referrals) entered directly by
physicians through CPOE
• Generate and transmit permissible
prescriptions electronically (eRx)
• Maintain active medication list
• Lab - #1-#8
• Maternal Health - #21
• Global - Education - #1-#8
• Global - Immunizations - #2, #20
• Global - Medication - #29-#34
• Global - Referral - #1-#6
• Global - Medications - #15-#19, #21-#23
• Global - Progress Notes - #1-#5
• Global - Medications - #20, #24-#26, #28, #29-#34
• Maintain active medication list
• Lab - #1-#7, #12-#13, #15-#16
• Global - Education - #1-#10
• Global - Immunizations - #1-#4
• Global - Medication - #28-#53
• Global - Plan of Care - #1-#7
• Global - Referral - #1-#34
• % of all medications, entered into • Global - Medications - #1-#14
EHR as generic, w hen generic
options exist in the relevant drug
class [EP, IP]
• Global - Medications - #28-#53
• Global - Medications - #1-#11
• Use of high-risk medications (Re:
Beers criteria) in the elderly
6
7
• Maintain active medication allergy • Maintain active medication allergy
list
list
• Record demographics:
• Record demographics:
• Stratify reports by gender,
◦ preferred language
◦ preferred language
insurance type, primary language,
◦ insurance type
◦ insurance type
race ethnicity [EP, IP]
◦ gender
◦ gender
◦ race3
◦ race3
◦ ethnicity
◦ ethnicity
• Global - Allergies - #1-#8
• Global - Allergies - #1-#4
• Registration/Checkout - #18, #20
• Registration/Checkout - #30-#34, #134, #137-#138, #141
• CSC - #30, #33-#35, #43
• IHV - #49-#51, #78
• MCC - #30, #33-#35, #43
Insight Solutions – Phase 1 Implementation
Practice Management Modules Licensed
Appointment Scheduling
ARX CoSign (Digital Signature)
Encounter Processing
Event Management
HIS State Reporting (with Title X Extract)
HIS Remittance Posting (NC)
Patient Accounts
Patient Registration
Patient Tracking
* Indicates being implemented in practice management implementation phase
Insight Solutions – Phase 2 Implementation
EMR Modules Licensed
Electronic Medical Records
Family Planning
Immunization Tracking & Inventory
Infoscriber
Laboratory Tracking
Maternal and Prenatal Health
Order Entry
Pharmacy
STD/HIV
Supplies Inventory
Tuberculosis
Insight Solutions – Phase 2 Implementation
Insight Development Services
Interfaces
Child Health Module
Dentrix Dental Interface
Lab modifications
Sunquest Interface
Maternal Health Modifications
State’s StarLIMS Interface
Medical History Modifications
Lab Instrument Interfaces (3 total)
Medications and Allergies Modifications
Insight Solutions - Later
Later Implementation Insight Modules
Case Management
Consumer Connect for Insight
Provider Charting
Reference Materials
• Taking Care of Business: A Collaboration to Define
Local Health Department Business Process - Public
Health Informatics Institute’s
http://phii.org/resources/doc/Taking_Care_of_Busin
ess.pdf
• Project Web site –
www.cabarrushealth.org/commonground
• Project described in chapter 25 of the, Managing
the Public Health Enterprise. “Business Process
Improvement: Working Smarter Not Harder”