Testing, Testing and More Testing

An electronic health record is a very complicated beast.  Not only complicated in it’s own right, but doubly complicated due to interfaces with many other products.  Installation of new software involves multiple rounds of testing to make sure the software will function as desired. In the early phases, the testing is only as robust as the technicians and analysts doing the testing.  With experience, repetitive testing can follow a standard script. 

Once the software is installed, testing must occur every time there is a change in software settings or an upgrade to the software program. Though vendors perform a series of tests prior to a release, there is never software without bugs.  The vendor can not test how you have deployed their product. Your testing needs to find where the product is no longer functioning as it did previously.  You have a certain element of control over the timing of testing when vendors send you new releases to install on your servers. You have no control over timing if your software is hosted by the vendor and updated on their schedule not yours. 

Today’s electronic health record is typically a summation of data gathered through multiple interfaces to products provided by a multitude of vendors.  Whenever any of the associated programs is updated, additional testing is necessary to ensure the integrity of the entire system.

Testing requirements quickly mount since the complexity of the system increase by the square of the number of elements involved. For example, if the number of connections doubles, the complexity of the system increases by a factor of four. Complexity increases the chance a small change in how a program operates, will have significant downstream effects.

As your  EHR  becomes more complex, you reach a point where automated testing scripts makes sense.

Medication Reconciliation

The implementation of our electronic health record is Ministry Health Care’s largest and most important patient safety and quality of care initiative.  Perhaps the largest improvement in patient safety will occur with improvements to our medication list allowing easier and more complete medication reconciliation.

Over the years, I have become convinced a patient’s outpatient current medication list just cannot be accurate without a total commitment to electronic prescribing.  Without an accurate medication list, medication reconciliation at every clinical encounter becomes very difficult to achieve. 

Medication reconciliation has become the standard within the hospital setting but is just now gaining momentum in the outpatient world.  Though most clinicians are reluctant to admit it, most of the time we are not 100% sure what medications the patient is taking. Patients often take medications differently than prescribed or are taking medications prescribed by other clinicians.  Pharmacies convert prescriptions from trade name to generic medications further adding to the confusion.  I have frequently found patients taking both the generic and trade name version of the same drug thinking they were actually taking different medications, not a double dose of the same medication. You will not reliably know what medications a patient is taking without a specific process of medication reconciliation that includes a monitoring for accuracy.

The electronic health record will allow us to have a single enterprise wide medication list that will be used for medication reconciliation at every outpatient clinical encounter and admission/discharge from our hospitals.

Outside Innovation

Ministry Health Care is a large organization spread over northern and central Wisconsin.  Communication is always a challenge and collaboration on projects is problematic.  When a project is centered around a campus, our usual mode is to host large gatherings soliciting input and feedback. 

Our electronic health record is a huge project involving multiple medical campuses.  I was contemplating how one obtains a collaborative atmosphere when a project spans a large geographically area when I happened to read a book by Patty Seybold titled Outside Innovation. 

Patty Seybold offers the following description of Outside Innovation:

“It’s when customers lead the design of your business processes, products, services, and business models. It’s when customers roll up their sleeves to co-design their products and your business. It’s when customers attract other customers to build a vital customer-centric ecosystem around your products and services. The good news is that customer-led innovation is one of the most predictably successful innovation processes. The bad news is that many managers and executives don’t yet believe in it. Today, that’s their loss. Ultimately, it may be their downfall.”

Outside Innovation provides multiple examples of how companies have used their customers to produce truly customer focused products. I was particularly intrigued reading how software had been successfully developed in a collaborative atmosphere.  Viewing our clinicians and staff as one of the customers of our EHR, I began to see how we had another avenue to build a collaborative atmosphere for our project.

We used Quickbase, a web based system wide resource available to us through Intuit, to construct a wiki variant.  A wiki is a type of website allowing visitors to add, remove, and sometimes edit the available content (you may be familiar with Wikipedia).  We place proposed EHR content and policies on the website and then invited our clinicians and staff to review and comment.  Though the proposed content cannot be edited, an adjacent comment section is in a forum format allowing each author to be identified.  We have found comments from one author invites others to post their own thoughts.  The comments are then incorporated into updated content.

Communication and collaboration within an organization must be in many forms.  The concepts outlined in Outside Innovation is another tool we can use to improve our effectiveness.

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Document Before Doing

We implement electronic health records in an effort to improve care. If we simply turn on a computer  instead of using a paper record, why would we expect care processes to improve? To achieve improvement, we have to redesign our care processes to take advantage of the EHR.

A common practice within medicine’s paper based world is to never document a procedure or administration of a medication prior to actually doing it.  EHRs give us an opportunity to utilize decision support to prevent errors, but they only work if a certain amount of document takes place prior to administration to a patient.

A workflow of vaccine administration typically has documentation following administration.  In a paper based world, this work flow may make sense since documentation does not in itself prevent administration errors.  In a smart EHR or vaccine registry, vaccine lot numbers are entered into a database as they are placed into inventory.  Lot numbers identify the specific type of immunization. If the lot number is documented prior to administration, decision support can provide alerts that the wrong immunization is being given, the immunization is being given too early or the immunization has already been provided.  Without recording the lot numbers first,  these errors are not prevented.

Changing of long established workflows is a difficult but necessary function if one is to achieve improvements in quality and patient safety.

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Pre-loading Data into the EHR

Our EHR Project is now officially underway with the Kickoff off at our Pilot. There are so many tasks needed to allow the Pilot to be successful but one in particular  will be preloading important data. Many organizations have choosen not to preload data, the philosophy seems to be that care teams learn how to use the EHR through the process of entering baseline data.  We believe the EHR should be of value to our care teams from the very first day. Entering data should be a by-product of patient care, not preparation for patient care.  

We have initiated a large project aimed at identifying what data from our paper chart, lab systems and hospital information systems should be loaded into CattailsMD before the EHR is used for patient care.  We are building interfaces that once established, will load current labs, reports, dictations, x-ray reports and links to x-ray images into CattailsMD. There are historical results that will be necessary to track essential preventive and disease management services. We  will identify and load these items into CattailsMD before Go-Live.

In addition, we will identify types of historical paper documents we will routinely scan and load into CattailsMD.  Care providers will also be able to identify those special documents unique to a patient that should be scanned and loaded.

Part of the pre-Go-Live process at each site will be to preload the current medication and allergy lists.  The more accurate the paper lists, the more accurate the initial EHR list will be.

From the very first use of CattailsMD, our clinicians will have access to all the documents and data loaded since the interfaces went live plus all the data we have preloaded.   Our efforts will be rewarded when our clinicians open a patient’s record for the first time and have a WOW moment because they see the value of EHR with their own eyes.

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CattailsMD EHR – A Private RHIO (1.021)

Our decision to use Marshfield Clinic’s CattailsMD was featured in a story on AMNews (July 21, 2008), the newspaper of the American Medical Association.

http://www.ama-assn.org/amednews/2008/07/21/bisb0721.htm

 

CattailsMD was attractive to us for a number of reasons including the development of what the newspaper is calling a private RHIO. There is also a State of Wisconsin effort to develop a data exchange linking information from multiple health care providers. Our use of CattailsMD will make it easy for us to participate.  Patients are best served when health information is avialable to their health care providers.

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EHR Journey 1.2

Once embarked on an EHR journey, Ministry needed to develop supporting corporate infrastructure, tasks such as finding a Chief Information Officer (CIO) and Chief Medical Information Officer (CMIO). While those efforts were underway, we pulled together a team of clinicians and staff who were using or had used an electronic medical record in the past. This team gathered virtually on a regular basis to develop a joint vision of what practicing clinicians need in an EHR.

I have found clinicians who have used EMRs in the past possess unique insights as to how an EMR can be used to improve provision of care. Clinicians who have not used an EMR, tend to develop workflows duplicating their paper flows rather than finding new processes to leverage the technology.

We gathered over the noon hour once a week via a telephone conference. We generally talked about a topic and flushed out our functional specification.  Offline, we developed representative screen shots depicting the functionality we desired. Screen shots and functional requirements were shared using PowerPoint Presentations sent via our internal e-mail server. Today we would collaborate using WebEx as the communication tool.

 

By the time Ministry had hired a CIO and CMIO, the clinicians had formed a very clear vision of our functional specifications.

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Types of EHRs (1.02)

In a previous post, I stated there are there three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database

A data exchange provides a mechanism where information from disparate data systems is collected and then presented for viewing.  The data, while useful as a reference source, is of limited value because of a restricted ability to package the information in meaningful ways or be used as a driver of decision support. Patients are often not uniquely identified in the database resulting in duplicate records.  Some entities maintaining data exchanges do not adhere to the same patient confidentiality standards as the organizations that contribute the data. These exchanges are expensive and ongoing funding to support continued use has been problematic.  A data exchange can be useful when regional providers of care use either different electronic medical records or EMRs where the database can be unilaterally altered. It’s value will be high in the short term when entities merely wish to view data, but will be limited in the future when those same entities wish to use the data to provide decision support at the point of care.

A few EMR vendors offer a standard data base across their user base. Separate health care entities can utilize these records and have an identical database structure allowing alignment of patient records.  The resulting structure can allow the data to drive decision support or common determination of clinical benchmarks. Since the database has a standard format, custom programs for decision support can be easily shared between users. Though more useful than an data exchange, this format is limited in that patients may not be uniquely identified in aligned systems.

A single common medical record with a single patient database used by independent regional health care entities provides the most robust structure to share medical data and drive decision support.  Governance can be a real issue but the improvement in patient care is worth the effort. Data can be packaged and presented to meet the needs of each individual user.

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Electronic Health Record (EHR) or Electronic Medical Record (EMR) 1.01

Think of an EMR as the equivalent of a patient’s paper medical record, the accumulation of one business unit’s information about the patient.  Typically, patient health care information is found in multiple paper medical records (or EMRs). Even in small isolated communities with a limited number of care options, records are kept in multiple locations. The hospital has medical records, most often organized as episodes of care. Even if all medical practitioners use the same outpatient medical record, dental and psychiatric records are often segregated. 

Some systems of care have taken the step of combining all the regional medical records; consider the result to be a combined medical record. The step involves considerable effort as each patient will need to be uniquely identified and the various health care entities will need to establish a common form and governance of the medical record, not an easy task.

If the system of care takes the concept one step further and embraces the concept that the medical record should be the complete record of the patient, they are on the path to an electronic health record.  The quest to obtain a complete record will never be finished as there will always be more information that can be gathered. However, the quest results in a record with ever increasing value to patients and caregivers.

An EHR is considerably more complex than a combined medical record because systems of care that are not directly aligned business units need to agree on common patient identifiers, common structures and governance. 

There are three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database.

I will discuss these types of EHRs in a future post

Our use of the term EHR, signified our intent to move towards a single health record for a patient. As you can imagine, the vision of having an EHR had major significance for selection of a vendor.

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Electronic Health Record 1.0

Where does one start on the EHR journey? At the beginning.  Where is the beginning?  The beginning should be squarely focused on the business needs of the organization.

Our journey grew out of series of strategic development sessions.  Our two major medical groups had been acquired within the past 10 years and each had developed a business model centered on a regional hospital.  Each regional business unit had developed the basics necessary for a functional EMR but there were no true links between the units.

A number of tactical initiatives grew out of our strategy sessions. We discussed how we might achieve the various initiatives and came to the conclusion a system wide EHR was a prerequisite.  

Lesson: The EHR (or any other initiative) has to be based on the business needs of the organization.

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