HCA620 Hospital Systems
Electronic Medical Record (EMR) Implementation Plan
Grand Canyon University
February 10, 2022
HCA 620 Business/Project Plan Evaluations and Development
Professor M. Jordan
Executive Summary
“Time is of the essence.” Centers for Medicare and Medicaid Services (CMS) mandated Electronic Medical Record (EMR) Incentive Program enforcement began last year, 2015. This means for eligible health care providers that failed to comply with CMS’s reimbursement penalty is in effect. HCA620 hospital systems understand the timing and criticality of the EMR implementation from both patient care and regulatory perspectives. This project team, composed of Noelle Powell and Jean Hung, prepared an EMR implementation plan for the leadership team to effectively complete EMR deployment in the following 8-12 months of 2016. Detailed timeline and project milestone is presented in section 8 of the implementation plan.
Beyond governmental mandate, EMR implementation proved to offer solid economic benefits. Based on information obtained from American Heart Association (AHA), the average EMR deployment cost in 2014 for a 200 bed healthcare system, was between $2.9 million to $4.1 million (AHA, 2015). The average Return on Investment (ROI) based on 5 year study is approximately 25.8% (see Implementation/Operational plan for costing information). Preliminary
Our research of EMR deployment indicated the use of turn-key solution to be advantageous particularly for smaller hospital system, in where the in-house IT resources may be limited. The turn-key solution offers experience and know-how to this complex undertaking. Most turn-key services provide software and hardware selection and costing, deployment personnel, data reconciliation and integration, system turn-up and testing, user training and on-going application maintenance and support. Preceding the Request for Proposal (RFP) process, management buy-in will be secured for the turn-key solution.
Finally, our research indicated that the community served, e.g., inner-city demography, has limited access and requirement to Patient Health Record (PHR). Therefore, the planned EMR deployment will follow a phased approach. Hospital deployment will be introduced first, followed by network of clinics and offering of PHR for public access will be the final phase.
Goals/Objectives
The objective of this document is to present the overall EMR implementation strategy for HCA620 hospital systems. The planning and recommendation set forth in this documentation are critical and timely to successful transition of EMR for the hospital systems.
Management Team
The HCA620 Hospital Corporation is located in Any-City, USA. The hospital system was started by thirty Primary Care Physicians (PCPs). HCA620 Hospital Corporation is a privately owned and operated, not-for-profit hospital system. The hospital systems includes a 200-bed hospital and 4 clinics operating the same community. It includes one hospital and four clinics dispersed throughout the service area. This document represents the EMR implementation plan for the hospital system. It addressed eight areas of the implementations which include:
- Current Environment Assessment: cultural, literacy and language concerns
- Selection of the vendor for the EMR software
- Hardware and Real Estate-Related Cost Estimates
- Integration with any current electronic data sources (imaging, laboratory, dictation, billing, quality software systems)
- Staffing for design, implementation, training, future support
- Staff training
- Physician training
- Timelines for design, implementation, testing, training
Implementation/Operational Plan
Current Environment Assessment: Cultural, and Language Concerns
According to the Office of the National Coordinator (ONC), for Health Information Technology, the “assessment phase is foundational to all other EHR implementation steps, and involves determining if the practice is ready to make the change from paper records to electronic health records (EHRs), or to upgrade their current system to a new certified version”. HCA620 is a smaller hospital system operating in the inner city. The demographics of patient base is a mixed racial and ethnic population. Approximately 60% of the residents are minorities and live below the poverty line. A major portion of the residents are foreign born and whose language preference is other than English. Majority of the residents live in apartments and are in close proximity. Most of the patients of HCA620 hospital’s system have either private or state funded insurances.
HCA620 hospital was at one time a city-owned hospital due to lack of funding was slated for closure. A group of thirty dedicated medical doctors who have practices in the area came together and purchased the failing hospital from the city. 15 years ago, HCA620 hospital was reborn. In keeping the goal of the founding doctors, the hospital was there to serve the community however, funding from billing and documentation from insurance and governmental sources continued to be a problem. Although most of the patient’s records, were “computerized”, the records are remain separated by health provider’s locations and by practice. In effect, the same patient record can appear in several different databases, e.g., one record in the MD’s office and another one in the hospital’s radiology department. The only way to transfer the patient information is either by fax or physical transport. The problem is exacerbated by the language confusion. Often there are multiple identifiers for the same patient due to misspelling of name and date of birth. All these resulting in delay in diagnosis and missed revenue.
The management team at HCA620 understands the need for EMR implementation for the hospital and its 4 satellite clinics. Through the management savvy of the board members, the hospital system was granted collateralized loan by the Inner City governance board to proceed with the hospital-wide EMR deployment.
Selection of the vendor for the EMR software
Based on our research of industry statistics, for a smaller hospital system like HCA620, economy of scale favors a “turn-key” EMR implementation solution (AHS, 2016). Using the RFP process approved by CMS, the project team will present to hospital’s Board of Directors, EMR vendor implementation proposal and cost estimates (see project schedule and milestone for details) based on turn-key solution. This solution is adopted to reduce EMR turn-up time and personnel resources. The project team recommended outsourcing of Information Technology (IT) portion of software and hardware support which includes initial software and hardware sourcing, testing and turn-up through on-going system hosting and maintenance. Staff training and network and on-site application support will remain with HCA620 in-house staff.
The proposed RFP procedures are compliant to current CMS guidelines (EHR program-2016). EMR proposal solicitation is opened to CMS approved turn-key solutions vendors for a period of 30 days. As stated, project team’s recommendation is for outsourcing of IT implementation only. Training and ongoing level one network and user support functions will remain the functions of HCA620 hospital systems staffs. The following is a listing of RFP specifications for EMR implementation services (please refer to Appendix A for RFP templates used):
- EMR Implementation: vendor assessment and recommendation of best practice study, product quality review and comparison for EMR software selection. Data security study and HIPPA compliance review. Medical records conversion, application testing and turn up. Cutover and go-live on site support. Provide post conversion support and post conversion review and recommendation.
- IT Hardware: vendor assessment and recommendation for purchasing new hardware or replacing existing user hardware such as a laptops, desktops, printers, scanners, cameras, and other peripherals, and network IT equipment such as servers, switches and other necessary network hardware. Configuring, installation and setup of IT hardware to ensure network security and EMR availability and reliability.
- Find & Lease Space: whether your practice is finding office space for the first time or needs to relocate, ACES Medical will help you find a suitable location close to your patients, with easily accessible parking, with a layout that facilitates the workflow needs of a medical practice.
- Hosted Solution: review and recommendation of IT help desk, application support, system hosting and maintenance support services. Provide on-going maintenance services: databases maintenance, disaster recovery and off-site backup solutions to ensure 24/7 patient data is secure and available.
Hardware and Real Estate- Related Cost Estimates
HCA620 hospital system is currently at 1.8 healthcare personnel to patient ratio. There are 255 healthcare service providers and 310 ancillary personnel in the hospital and 105 medical personnel in the 4 clinics. Review of health system’s hospital and clinic facility indicated no additional need to acquire real estate for the EMR deployment. Newly acquired EMR hardware will be co-located with existing network and servers. Based on marketing data, EMR application and data repository will likely be hosted centrally. In the event that the EMR data is housed locally, additional one time installation cost of $100,000 may apply.
The hardware estimates are based on $1,000 per desktop or laptop unit which does not include EMR software cost and related test and turn up. Real estate/facility, cost facility, preparation cost and includes 2 high capacity server per site- 4 server sites at hospital and one server site per each clinic. Tabulated hardware requirements and associated cost estimates as followed:
| Medical Clinicians (MD, PA, RN, Therapists, etc.) | Administrative Personnel (Management, Billing, Legal etc.) | Ancillary Personnel (Facility Maint., Food Prep) | Real estate/Facility Cost (EMR remote and local hosting solution) | |
| Head Count | 255 | 105 | 310 | 8 network server locations |
| Hardware Requirement/Cost PP | $1500 (desktop +laptop) | $1000(desktop only) | $500 (½ desktop pp) | $5, 000 (primary + back-up+ facility cost) |
| Sub Total | 382,500 | 105,000 | 155,000 | 40,000 |
| Grand Total (Hardware + Facility Prep. Cost) | $682,500 (Remote Hosting) $782,5000 (Local Hosting |
Data Integration of current electronic data sources (imaging, laboratory, dictation, billing, quality software systems)
HCA620 Hospital Systems, similar to most hospital systems, manages multiple sources of patient information. In the case of a cardiac patient: vital signs, cardiograms, EKGs, blood results, are necessary components of the patient’s diagnostic evaluation. There are numerous vehicles to achieve information aggregation and integration. One of the methods is the use of middleware which is an HL7 unified workflow platform. It is a common language interface that accepts, modifies and stores different format structures. EMR Hub by Life Point Informatics is one of such device. It requires “only a single interface to LIS, RIS or CIS format. This reduces implementation time, effort and cost and enables diagnostic testing facilities to connect with every EMR in their provider community”. The middleware interfacing software is compatible with any EMR or EHR and seamlessly processes clinical messages between existing systems and referring physicians’ EMRs.
EHR systems required an average of 52.5 hours of training at a cost of $4,277. The system’s physician end-users received an average of 23.9 hours of training at a cost of $2,538 per physician. (Downing Peck, 2013.)
Staffing for design, implementation, training, future support
The approach for each go-live section involves: deployment, cutover support, end user support, issue documentation and resolution, and validation to achieve the total quality improvement and outcomes. “It is a short time frame once the go-live comes into play after all the work of the EMR building, conversion design, data transformation and interfaces come together.” (Maher & Bloemer, 2010, p. 3.)
The first phase of the process is “assessing if your practice readiness”. (“HealthIT,” 2013, Section 1) HCA620 Hospital Systems has determined that through inconsistencies with documentation between department and interpretation of names and dates between users creating a disconnection and congruency of patient records, reimbursements and improvements in patient outcomes.
Planning our approach for HCA620 Hospital System by delineating the right tasks with prioritization and clear communication of the tasks. (“HealthIT,” 2013, Section 2.) The tasks delineated for our EMR process include: EMR implementation assessment and best practices and software selection; IT Hardware with vendor assessment and recommendation of needed equipment; design and allocating for the proper office and equipment space, and Host solution for IT application, support, maintenance and data security.
Selection of EMR system is the critical and significant planning task which HCA620 Hospital System chose the turn-key solution due to turn around time and personnel resources while meeting the CMS standards and criteria for “Meaningful Use” to acquire proper reimbursement for properly aligned documentation, coding and quality outcomes.
“Meeting the CMS EMR Incentive program provide financial incentive achieving Meaningful Use through the utilization of a EMR,” (“HealthIT,” 2013, Section 5) which then needs to set baselines for electronic data capture and information sharing between the hospital and physician practices. Initial baseline is established through quarterly data submissions. The data submissions will address quality, safety, efficiency, engagement of patients and families, improved coordination of care and population health and ensure safety and security of personal health information (PHI). (“HealthIT,” 2013, Section 5.)
The final phase of implementation is ever evolving reassessment of training and use of the new EMR and practice goals and needs to improve workflows achieve individual physician practices needs and outcomes. These goals will change with the development of the Affordable Care Act (ACA) and CMS standards and Meaningful Use standard criteria which is evolving annually. “Achievement of Meaningful Use is the backbone of a practice’s ability to gain recognition.” (“HealthIT,” 2013, Section 6.)
Professional fee for outsourced HR is $150 per man hour. Assuming there are 500,000 (average # for 200 bed hospital) patient record for conversion, an average of 52.5 hours of training at a cost of $2,777. The system’s physician end-users received an average of 23.9 hours of training cost of $1,538 per physician.
Staff training
Proper training of physicians, nurses and other staff members can overcome the resistance that is common when transitioning from paper-based documentation to the electronic version. Training is essential in the implementation to avoid frustrations, errors, time efficiency, and increase staff confidence while progressing into a smooth transition. There are five effective training elements that need to be followed to create a smooth movement and evolution into the new EMR include: 1) identifying employee computer skill levels; 2) designated Super Users; 3) train employees only in the areas that they will be using; 4) conduct post evaluations sessions; and 5) utilize on-line resources provided by vendor. (Guerrero, 2013)
Every staff member have different comfort levels with computers depending on their job role and generation which needs to be assessed to ensure that all staff members have a comfortable shift from paper-based to computer based EMR. Once the proper skill levels have been assessed, those staff members who need to get up to speed can attend classes through free on-line resources from organizations such as Google, Go Army, or Goodwill. Additional training for specific measures on “Meaningful Use” can be done by hospital educators. This process is best to start at least 12 to 18 months prior to go-live to ensure comprehension, comfort and ease of transition.
Designated “Super Users” are highly computer literate, adventitious to learning new concepts quickly and easily, well respected and will assist the other team members to navigate through the new EMR. Super Users will “serve as the ambassadors to facilitate buy-in and user acceptance, assist with EMR optimization and provide feedback on EMR user proficiencies.” (Byers, 2012, p. 1.) Super Users receive additional training in the EMR to facilitate their comprehension and utilization of the EMR to aid in their role as ambassadors and lead the way into the computer-based technology arena. It is often best to offer the Super Users some form of incentive whether it be a small bonus, additional time off, or compensation days for their additional time to train and teach others. It is best if Super Users are given exposure and training to the new EMR 12 months before go-live to ensure comprehension of the new EMR.
To keep things simple, realistic and decrease frustration to the staff members by only teaching those areas of the new EMR that they will be using on a day-to-day basis. Only the Super Users need to learn the entire EMR program to assist with navigation through the system. When training staff only on those areas that they will be using assists with decrease learning time and training, creates comfort and decreases stress and facilitates efficiency to utilization of the EMR.
To assist with identifying issues with workflows and functionality after implementation of the new EMR a post-implementation evaluation is should be conducted. This feedback assists with identifying these issues that will assist with quick resolution through this assessment. This feedback should occur weekly with an interdisciplinary team approach to ensure all members are represented. The team members’ feedback can address areas of improvement in workflows or training. Identification of problems need to be prioritized of urgency, patient care issues are first and productivity not as urgent. The changes to address the identified issues need to be taken in one step at a time to ensure ease of transition while promoting patient safety. Eventually the meetings can be tailored down to monthly, quarterly to an entire team member survey.
After implementation and utilization of Super Users to facilitate answers to the new EMR and free training from vendors of the initial implementation has become extinct, utilization of on-line resources provided by vendors through training videos, step by step instructions, workflow processes, and on-line tutorials can be accessed through the vendor’s website with appropriate user name and password to team members. This can also be facilitated with training staff members especially physicians to study at their own time and speed.
Physician training
The physician training will follow the same protocols as staff training with the addition of an extreme challenge. Physicians’ time is limited due to daily patient care, procedures and lack of utilization of computer-based documentation. The key piece of guidance in training physicians is “keep it brief”. (Cryts, 2016, p. 1.) Be concise, clear and brief when addressing training and answering questions. Utilize an internal physician Super User coach to which promotes comfort in addressing a colleague vs. an IT professional. The physician Super User should be present in all interdisciplinary meetings pertaining to the new EMR, utilizing their advice on training physicians. Training needs to pare down due to time constraints yet be creative in the format and setting. An example would be to have a training video looping in their office as information can be absorbed through routine office duties.
Empower the physicians to use the new EMR by presenting how the new EMR will impact their daily operations and routines which will drive the physician to adaption of the EMR. Design and elbow-to-elbow dedicated support team to be present on patient care units and/or attend physicians’ meetings to provided one on one support when needed. Dedicated physician phone line to assist with quick alleviation of the problem. Community forums can be used to provide an outlet for physicians to ask questions. Time is of the essence to train and acquire support of the new EMR otherwise we risk losing them altogether. (Cryts, 2016, para. 9.)
Conclusion
HCA620 Hospital business plan reveals the inconsistency of their current paper-based medical record between the hospital, departments and physician practices. The selection of the turn-key option with the new EMR will facilitate a faster transition into the new computer-based system. Proper stages suggested by the HealtIT.gov, proper multi-disciplinary team members, effective communication and training will elicit proper alignment of records between areas; resulting in proper reimbursement, patient safety and establish quality outcomes to meet the “Meaningful Use” criteria.
References
Ace Health Solution Corp. (AHS), 2016. Retrieved from http://www.acehealthsolutions.com/services/emr-consulting-2/
CMS (Centers for Medicare and Medicaid Services), 2016. EHR Certification Program-2016. Retrieved from: https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/certification.html
Cryts, A. (2016). Four tips for training physicians on your EHR. Retrieved from http://www.physicianspractice.com/ehr/four-tips-training-physicians-your-her
Downing Peck, A. (2013). EHR implementation: training pays dividends. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/accelerating-roi-your-ehr-purchase/ehr-implementation-training-pays-d
How to implement EHRs. (2013). Retrieved from https://www.healthit.gov/providers-professionals/ehr-implementation-steps
Guerrero, A. (2013). Five best practices for training staff on using a new EMR. Retrieved from http://profitable-practice.softwareadvice.com/five-best-practices-for-training-staff-on-ehr-0513/
Maher, T., & Bloemer, L. (2010). Hayes white paper data conversion best practices. Retrieved from http://www.entretechforum.org/Sept2014Mtg/Hayes-White-Paper_-Data-Conversion-Best-Practices.pdf
NYS Office of Mental Health (OMH), 2015, New York State Electronic Medical Record System (EMR) Request for Proposal (RFP). Retrieved from https://www.omh.ny.gov/omhweb/rfp/2011/emr/
ONC (Office of the National Coordinator for Health Information Technology), 2015. How to Implement EHRs. Retrieved from:
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