1.1 Implementing Systems Overview

1.1 Implementing Systems Overview

Section1.1Adopt - Assess

Section 1.1 Adopt – Assess – Implementing Systems Overview - 1

Implementing Systems Overview

Depending on your goals, health information technology (HIT) encompasses implementing a broad scope of applications, technology, and operational activities (1.1Visioning and Strategic Planning)(1.2HIT Goal Setting).This tool provides an overview of a typical implementation of an electronic health record (EHR) system for a chiropractic office.

Instructions for Use

Use this tool to understand the broad range of topics you will need to consider during EHR implementation.For each topic listed below, see specific tools in the toolkit for more detail.
(1.1 Overview of Toolkit)

Overview of Implementation

Although specifics related to an EHR implementation will vary by vendor and nature of acquisition (e.g., client/server or shared services – see 1.1Financing Resources), any implementation should follow a similar high-level structure:

  1. Project management
  2. Workflow and process redesign
  3. Detailed plan creation, including a plan for chart conversion
  4. Issues management
  5. Preparing for and installing hardware
  6. Network and telecommunications development/refinement
  7. Security risk analysis and controls
  8. Super user training
  9. Software installation and system configuration (system build), including report writing, interfaces, data conversion
  10. Testing
  11. End-user training
  12. Preparation for golive
  13. Golive
  14. Benefits realization and recognition, including earning incentives
  15. Optimization strategies

Project Management

EHR vendors vary significantly according to the level and type of project support they provide—support for which you are willing to pay. Regardless of the amount of support you receive from a vendor, designate a project manager from your office who will represent your interests, ensure that all tasks are completed to your satisfaction, and that information learned during the process is retained within the organizationfor future reference. (1.2 Project Management, 1.2 Project Manager Job Description)

Your project manager will be responsible for many activities:

Managing yourproject plan in coordination with the vendor’s project plan tomake sure all tasks are completed in the sequence necessary

Organizing staff resources

Team building

Ensuring equipment is acquired, installed, and tested

Delegating system build tasks

Managing interface development between your system and another

Facilitating decision-making

Maintaining the project budget and approving invoices

Keeping track of issues and escalating them to the appropriate person as applicable

Carrying out your communication plan (1.1 Communication Plan),reminding others to perform their required communications, and scripting communications for others if necessary

Handling a myriad of other elements to make sure designated tasks on the project plan are completed accurately, on time, and within budget

Workflow and Process Redesign

Ideally during the planning phases, you will map current workflows and processesto make adjustments, help initiate change management, create expectations to achieve goals, identify system requirements, and select the most appropriate vendor. Mapping current workflows and processes before acquiring an EHR may reduce work during implementation.This step is essential for configuring the system to your specifications and anticipating changes with the new system.

Not attending to workflow and process redesign during HIT planning and implementation canhamper EHR adoption and lead to serious consequences, such as neglecting to address or evaluate considerations unique to your office during system configuration. Some vendors strongly support workflow and process redesign, while others may view it as the organization’s responsibility. Whether your vendor supports workflow and process redesign or not, this activity has proven to be a critical element of success.(1.2 Workflow and Process Redesign)

Create aDetailed Implementation Plan

Every vendor will provide you with some form of implementation plan, which outlines the steps for implementing your system, including meetings and milestones. It usually identifies what the vendor will do, and when, what the vendor expects you to do, and when, and what is performed jointly.Complete the following important steps when you receive this project plan.Organizations often overlook some of the steps. Missing them may come back to haunt you.

Compare the plan with the contract you signed with the vendor to make sure everything you agreed to buy has been addressed in the plan and that nothing is in the plan that you did not buy.Most vendors use a standard plan and make adjustments for each client, which can lead to discrepancies in your contract.(2.1 Project Plan)

Review the plan thoroughly with the vendor’s implementation specialist, making sure any discrepancies are addressed. The implementation specialist assigned to your office may not have read your contract, so special aspects of the contract need to be reviewed closely as part of this process.Make sure you fully understand each item in the plan— especially those for which you will be responsible. Consider staffing and other resources you will need to complete activities in the time allotted.

Align the vendor’s plan with your own. The vendor’s plan only identifies those elements the vendor is directly or indirectly responsible for. You may need to conduct additional activities, such asthe following: hiring staff or contractors, selecting a company to host your servers, finding ways to release time for specific staff members to work on the project, encouraging certain individuals to learn computer skills, conducting a dress rehearsal prior to go live, remodeling an area to add workstations, and adding backup connectivity to the Internet.

Issues Management

Every project encounters some issues—large and small. Tracking issues is critical. Many vendors maintain an issues management website for their clients to use. Use the vendor’s website and keep your own issues list to track both internal and external issues, such as a person who is consistently late completing tasks, an end user who has failed to master training after several tries, a team that seems dysfunctional when a certain individual is present, or a printer with ongoing problems. Many small issues will occur. If project managers don’t write them down, the issues get lost and often are not resolved.

Preparation for and Installation of Hardware

Many small organizations hire a contractor to prepare and install hardware, or outsource hardware to a hosting company, especially for a large data center.As with project management and issues management, do not abdicate all responsibility for hardware. You need to understand enough about the hardware to anticipate problems and pinpoint issues. In the future, you will have to address maintenance and replacement issues, even when a remote data center is used. (1.1 Visioning and Strategic Planning, 1.1 IT System Inventory, 1.3 Input Device Planning, 2.1 Space Planning)

Selecting input devices is a major factor in implementing clinical information systems. Study and evaluate the options and evaluate in advance. Assumptions are made about input devices that often prove false. (1.3 Input Device Planning)

Even though printing to paper will be minimized, some printing is still needed. Scanners are used extensively, especially early in the migration path toward an EHR system. Scanning paper chart forms is essential to filling gaps when electronic applications have not yet been implemented.(1.2 Chart Conversion Planning)

Network and Telecommunications Development/Refinement

Most offices have some form of network infrastructure, but this often needs to be upgraded as clinical information systems are adopted. Wire and wireless network infrastructuregoes hand-in-hand with input device choices. Usability and security also are major considerations. Wireless can be slower than a wired network and prone to drop-offs, but enables greater portability. Wireless requires more attention to security, although protection standards are improving. In addition to the network within the facility, connectivity becomes an increasingly important issue as more HIT systems are adopted.

A remote connection will be required for otheroffices, hospitals, commercial labs, and accountable care organizations, as well as the e-prescribing gateway, and a health information exchange organization. Remote connection also will be required forelectronic data interchange (EDI) for claims, eligibility verification, and other transaction standards as they are updated and enhanced with standard operating rules, which make them easier to use.While, many chiropractic offices outsource the design and installation of connectivity, understanding the basics is critical to future troubleshooting.

If an organization is acquiring EHRvia an application service provider (ASP) or software as a service (SaaS) mode, connectivity becomes critical. This is one area you cannot skimp on. Slow response time discourages more staff from using technology than almost any other factor.Downtime can be disastrous to the trust users place in the new system, and to your bottom line if patients sense disruption in your service capabilities.

Security Risk Analysis and Controls

All security measures must be addressed when acquiring HIT and EHR(1.1 HIT Security Risk Analysis). The public is much more aware and concerned about security and state and federal data breach notification laws have become more stringent. As youroffice acquires more critical systems (backups, disaster recovery, etc.), contingency planning becomes critical. As the Health Information Technology for Economic and Clinical Health (HITECH) Act increases HIPAA requirements for privacy protections, stronger access controls and audit logging capability will be necessary. In addition, the Drug Enforcement Administration (DEA) recently issued interim regulations for e-prescribing related to controlled substances.(2.1 Security Risk Analysis and HITECH Requirements).

A security risk analysis, required to earn meaningful use incentives, accomplishes the following:

Identifies threats with respect to confidentiality, data integrity, and availability of data with changes such as the introduction of new HIT and EHR.

Identifies vulnerabilities or gaps in controls to address threats, including where your systems, policies, and procedures are weak or lacking security. Carrying out documented policies and proceduresis essential to remediating weaknesses and to supporting security service level decisions.

Considers the likelihood that a threat will exploit a vulnerability and considers the level of impact from exploitation. In cases where particular vulnerabilitiesare unlikely to be exploited or the levels of impact are not significant, you may find suitable lower-cost alternatives, policies, and other ways to address the gaps.

Considers cost of controls and capabilities to implement them. The bottom line of the security risk analysis is to identify the security controls most suitable for your office. The HIPAA Security Rule does not require every business to apply the same controls.

Super User Training

A super user uses an application full time and has a special interest in the potential value of information technology. Super users receive the vendor’s super user training to assist in system configuration and helping other end users learn the system. Training may occur anytime from signing the contract to just before system configuration. Depending on the application being implemented and size of your office, you may have several super users. In general, super users are provided some release time to perform their super user duties, from 20 to 60 percent time during system configuration to 60 to 80 percent time while preparing for and during golive. (2.1 Training Plan)

Software Installation and System Configuration

Software installation is the act of loading software onto your hardware (e.g., server) for it to run. If you are using a shared service model, installation refers to establishing a specific version of the software within the host’s servers that will then be configured with your specific requirements. Although software installation may take place immediately after you have signed the contract for the software, a large part of the total implementation process relates to the configuration of the software, often referred to as system build. (2.1 System Build)

System configuration includes setting up the various system parameters that are unique to your office, such as filling database tables with the names of your chiropractors and employees who will be using the systemand their user log-in processes; patient locations (e.g., patient exam roomsnumbered 1 through 5, etc.); inventory of equipment and supplies; diagnostic studies and preferred providers.Building templates, order sets, clinical decision support rules(2.1 Incorporating Clinical Decision Support), and reports are other system configuration activities. While most vendors supply standard sets of templates, order sets, etc., most officesreview, approve, or modify them to some extent,such as adding the name of the organization. Once designed, these components are loaded into the master files and tables that make up the underlying database of the application. System configuration also includes writing interfaces that connect disparate applications and conducting a data conversion if an existing information system application is being retired.

If your office is acquiring a general-purpose EHR, you may have to perform more configurations than you would if you were acquiring an EHR designed specifically for your specialty. This is not necessarily a bad thing, as it may give your office a great deal of flexibility. However, it will likely cost more and require more time to implement.

While some configuration is essential for the system to operate properly in your environment, resist the urge to modify moststandards provided by the vendor. Vendors now have considerable experience and have created templates and standard order sets based in scientific evidence and workflows that have been well-implemented by numerous organizations. Too much modification is costly because a change in one template or function has a ripple effect, which impacts other templates, functions, reports, etc. Tracing change throughout the workflow and making necessary adjustments is tedious and can result in errors. Often organizations find that their users urge modifications that essentially result in returning workflows and processes to the old manual—comfortable—way of doing things, which does not achieve the intended goals of the project.

Testing

As system configuration is performed, unit testing is needed—checking that the specific table, master file, template, screen, or other elements have been built as desired. Just as super users are critical to system configuration, they are usually the primary people engaged in unit testing along with the vendor and should be expected to sign off on each of these tests. As interfaces are built, their ability to integrate data needs to be tested. This may only be from an existing practice management system (PMS) to the EHR if your office is not also acquiring a PMS with its EHR. Finally, the overarching system workflow and processes need to be tested. This may be done with the team of super users or with the end users after they have been trained in a rehearsal mode. Not all vendors support much testing. Understanding the different types of testing and identifying how you want the testing to be performed provides reassurance that the system will be ready to go at golive. Some organizations prefer their end users not be system testers. They expect a rehearsal to be focused on the end users needs and reassurances, not fixing system configuration glitches. (2.1 Testing Plan)

End User Training

End user training should be performed in a just-in-time manner.For this to work successfully, end users need to be ready to accept training. Continued communication and engagement of end users throughout the entire EHR selection and implementation process is required, including during system demonstrations, goal and expectations setting, change management, computer skills building, system configuration review, and more(1.1 Communication Plan). Training is greatly aided by having the new workflow and process maps handy to illustrate changes as well as having tip sheets, screen shots, and other devices available.End users must be reassured during training that direct support will be available during go live.Many offices develop a training plan that encompasses all elements of training and checks off completion of each phase throughout implementation.(2.1 Training Plan)

Preparation for Go Live

Golive is the day end users use the system for the first time to accomplish actual work. Preparation should be as carefully orchestrated as any significant event. Develop a checklist, validate it, and conduct a dress rehearsalthe day prior to golive. Many new users have concerns about how they will use the system in front of patients. The dress rehearsal allows users to play a role (e.g., chiropractor and patient, registration clerk and patient), receive feedback on the experience, and decide what can be done to make the experience more comfortable.(2.1 Go-Live Checklist)