2 HIT Vision and Strategic Planning

Section2.5 Plan

Section 2 Plan—HIT Vision and Strategic Planning - 1

HIT Vision and Strategic Planning

This document describes a vision for health information technology (HIT) in nursing homes, including the purpose of implementing an electronic health record (EHR), along with a conceptual model of an EHR and suggestions for strategic planning.

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How to Use

HIT refers to the broad class of information technology that aids health care organizations in achieving efficient and effective care delivery. EHR refers to the specific application of HIT to capture data at the point of care, use the data in making clinical decisions, and share data as authorized across the continuum of care and with individual residents and/or family members in a secure manner. All HIT encompasses software applications and hardware, as well as requisite people, policies, and processes. It is unlikely that any nursing home will acquire all components of its vision for HIT at once, but having a vision and a plan to achieve the vision helps build momentum and reduces reactive buying that may result in costly mistakes.

Software Applications

Within HIT are many types of information system applications. In general, these include:

Financial and administrative systems that include, at a minimum, resident registration-admission, discharge, transfer (R-ADT) and billing systems. R-ADT includes the ability to: maintain an index of all residents you have treated; document their demographic, contact, and insurance information; manage the census of current residents; and other associated functions. Billing systems will support charge capture, accounts receivable, collections, trust accounts, general ledger, accounts payable, etc.
Departmental or ancillary systems that support the operations of various departments or types of staff. For a skilled nursing facility, these may include a clinical laboratory information system (LIS), radiology information system (RIS), nutrition and food services (N&FS), therapy department systems (e.g., rehabilitation, physical therapy, occupational therapy, speech and language therapy, respiratory therapy and others), human resources, time and attendance, staffing, materials management/ procurement and executive decision support. The minimum data set (MDS), if it is a standalone software system, may be treated as an ancillary system. Some nursing homes may also have health information management (HIM) functions that are automated, such as a master person index if not included in the R-ADT module, dictation/transcription and electronic signature, encoder, chart tracking, and deficiency analysis.
Clinical information systems that support health care professionals in direct care delivery. When these clinical systems work together, they are often described as an electronic health record (EHR) system. Clinical information systems in skilled nursing facilities may be all inclusive in a single suite of functions, or may be several distinct modules (which may not necessarily be implemented in a specific sequence). A suite of applications for nursing documentation may include nurse assessments, interdisciplinary care plans, clinical pathways, vital signs documentation and workflow support. More sophisticated clinical systems require significant connectivity with the departmental systems. These typically include electronic/barcode medication administration records (EMAR/BC-MAR) in skilled nursing facilities. Another more sophisticated clinical system not always found in a nursing home is computerized provider order entry (CPOE). Physicians who are ordering medications may use an e-prescribing system to do so. Although clinical decision support (CDS) is generally included in EMAR/BC-MAR and CPOE/e-prescribing applications related to medication management, more sophisticated CDS and point-of-care (POC) charting for providers applications frequently are implemented after most others. (Note that a more comprehensive discussion of clinical information system applications is provided in separate tools within this toolkit.)
Clinical data repository (CDR) is the means by which data from the various applications come together for various forms of processing. A CDR is essentially a database that is optimized to manage all transactions for each resident. Some examples include:

a.A CDR may enable the development of a graph showing a resident’s vital signs in comparison to medication administration. Clinical decision support is greatly enabled by a CDR.

b.When a drug to be administered for a given patient appears on the EMAR/BC-MAR, the drug can be compared with drug knowledge information and perhaps also to the resident’s lab results if all this data is present in a CDR. If the resident is allergic to the drug to be administered, or if it is contraindicated for that resident for some other reason, an alert will display stating the potential contraindication. This also occurs in CPOE and e-prescribing systems so that the ordering provider is alerted. The system may also suggest a lower dose, alternative drug or closer monitoring, as applicable to the situation. The ordering provider may accept the recommendation and the finalized prescription is then transmitted to a pharmacy. The recommendation may also be rejected, in which case the original prescription is transmitted to a pharmacy. The ordering provider may be asked by the CPOE or e-prescribing application to identify the reason for the rejection, which then is held in the CDR as part of the resident’s EHR.

Some EHR vendors fully integrate their clinical components with a CDR. This is generally true for some nursing home EHR vendors, though not necessarily all do this. If you buy different applications separately from the same vendor, you might inquire if there is a CDR that integrates the data from the applications—as this helps improve both clinical decision support and reporting functions. If you have to buy different applications from different vendors, you may be faced with buying a CDR from a third party or managing multiple interfaces between the applications. Although a CDR is primarily designed to integrate structured data, some repositories also include pointers to documents and images.

Electronic document management system (EDMS) is often used where a bridging strategy is needed to achieve a paperless environment during the time clinical systems are being implemented. EDMS allows document scanning and indexing to archive documents until all data collection aspects of the health record are automated. Later, EDMS supplements the EHR when external documents are received in paper or digital form (e.g., email, e-fax, or digital dictation).
Portals are another important application that are used to connect different providers to one another, such as physicians to your facility or your facility to a hospital or multiple hospitals. Patient portals allow a resident or family member to complete intake forms, retrieve copies of their health record or summaries of their care, and perform other functions directly from your facility’s applications. In general, a portal is a Web interface that serves as a secure door to related sets of data and services. For example, a physician from a home or office may gain access to the nursing home’s EHR, obtain a resident’s vital signs, and enter orders.
Data warehouse is a database that has been optimized to collect and manage data on which complex queries and analysis, such as data mining, can be performed. Such databases may also be called translational or analytical databases. While you can do some analysis and reporting from any database, including the databases in individual applications or the CDR, very complex analyses on large quantities of data will significantly slow down the system. Most skilled nursing facilities contribute data to external data warehouses, such those as held by the Centers for Medicare & Medicaid Services (CMS), their corporation, or various other payers, quality registries, etc.
Telehealth, personal health records (PHR), and health information exchange (HIE) services are yet other forms of HIT which are rapidly evolving and being adopted by large and small health care delivery organizations. Many small and rural communities have extensive telehealth implementations, connecting to their closest tertiary care facility or reaching out to very remote areas for patient monitoring and to supplement care delivery. Skilled nursing facilitieswill certainly find using a referral management system that reaches out to a variety of other organizations to be advantageous. PHRs are just starting to be recognized as important adjuncts to health care delivery. Several health plans (including a number of Blue Cross Blue Shield plans) are promoting use of PHRs. The U.S. Department of Veterans Affairs has created myHealtheVet, a PHR systems for veterans. Some vendors are supplying various forms of PHRs. Some of these are in form of patient-friendly summaries of care; others provide access to lab results and even self-administered medical history systems that reduce the documentation burden for providers. Many families of chronically ill patients or elderly residents in nursing homes find that PHR is the only way they can keep track of all the medications, physician visits, etc.
Middleware is another type of software that is important to include in HIT. While often not a concern to end users, various report writing applications, presentation layer utilities, interfaces, database management systems, and other software is required to make all of the end-user applications work.

Hardware

Hardware includes the various processing devices and servers to run the applications.

1.Data entry requires various input devices (e.g., desktop computers, tablets, personal data assistants [PDAs], speech microphones, etc.) and output devices (monitors, display screens, printers, fax machines, speakers, etc.).

2.Data also must be archived, so storage functionality is needed. This may be provided byvarious storage devices, each with its associated media (magnetic disks, optical disks, flash drives, etc.). A variety of storage area networks and storage management systems are used to manage large volumes of archived data. As the HIT becomes more mission critical, backup storage and redundant processing devices are necessary, often with middleware applications to provide automatic failover.

3.Hardware devices and servers must connect to one another in a network.

a.Within a given facility, a local area network (LAN)—which may be wired, wireless, or a combination of the two—requires various network devices and their associated media (including various forms of cable for wired networks and wireless network capability).

b.If you are connecting across disparate organizations (such as with your vendor, a hospital, physicians, pharmacy, etc.) you will also need a wide area network (WAN) and WAN services. Trunk lines may be purchased through a telephone company for a point-to-point connection over a virtual private network, or you may use an Internet Service Provider for an Internet connection.

Conceptual Model of EHR

This diagram illustrates the many HIT components described above. While this diagram may seem overwhelming, it is designed to show that as clinical computing requirements are addressed, the complexity of applications, technology, and operational elements to support them increases, as does the skilled nursing facility’s ability to use the resulting information and knowledge.

Strategic Planning

Planning the sequencing and nature of acquiring the various HIT components is very important. Rarely does any health care delivery organization acquire everything at once. Two key elements should be considered in planning. First is the sequence of components to be acquired and second is the manner in which the components will be acquired.

Migration Path

A migration path is a strategic plan for the HIT components that an organization plans to acquire over time. A migration path identifies:

□All current applications and applications proposed to be acquired over time. Plotting the applications to be acquired over time helps identify the various dependencies and interrelationships among applications. For example, many organizations begin with R-ADT/Census and Billing applications. For some organizations, the next move they might consider would be EMAR in order to address patient safety concerns. However, it is possible that an order entry or e-prescribing system may be needed prior to the EMAR in order populate the drug data in the EMAR application—otherwise nurses will have to manually enter drugs into the EMAR. Plotting application implementations over time also can help you identify gaps in applications or whether too many applications are planned to be implemented at one time. For example, in addressing the full range of EHR capabilities, a nursing home may be tempted to implement both an EHR and portal at the same time. This may overwhelm both IT and the end users—the staff who have to learn how to use the systems. Plotting out the prerequisites for the systems’ success also may identify critical, but missing, applications.

□Current technical infrastructure and all new technology needed to support the new applications. As your organization implements various new applications, it will clearly see that some new technology is required. For example, implementing e-prescribing may require more input devices at the nursing unit or at the point of care. Alternatively, if most physicians prescribe remotely, you may not need more devices but more connectivity capability. As you move toward point of care documentation and EMAR, you will need to determine the type of input devices and whether they will be wireless or hard-wired. Many small organizations find that they do not initially acquire the technology to optimally run their new applications. In many cases, the application vendor either has not known or not informed them about the technology needed, perhaps to avoid the sticker shock or because the vendor does not support the new technology.

□All operational elements—the people, policies, and processes that must be put into place for the applications and technology—are often considered the most important element of both strategic planning and successful implementation of an EHR. Some go so far as to suggest that the 80/20 rule applies, meaning 80 percent of the focus should be on operational elements and just 20 percent on applications and technology. Without appropriate change management, workflow redesign, training, and many other operational considerations, even the best software and hardware will fail.

A migration path template for plotting your HIT strategy is provided.

1.List all current applications, technology, and people-policy-process elements that you have in place to support the current HIT strategy.

2.Identify and record your high-level HIT objectives. In general, organizations have some sense of phasing for these objectives. Often, starting simple with e-mail applications or a portal to a hospital can be effective.

3.Identify and record the time period in which you believe each high-level HIT objective can be accomplished. Generally, this may be in one to two years, or more, per objective.

4.List all applications, technology and operational elements you believe are necessary to support each phase and high-level HIT objective.

5.Review and critique the migration path. Once you have plotted all of the elements on the migration path, step back and review the process with an eye toward determining if it is logical and feasible. Adjustments may need to be made, especially when there are dependencies between applications. Once you have identified the applications and technology, determine whether you need to expand the operational elements plotted on the IT plan.

6.In addition to making necessary modifications to the migration path, many organizations add other, more-detailed documentation to the migration path. You may want job descriptions for staff you need to add. You might want to add an information model to the migration path where you need to illustrate the need for an interface. Many other potential documents support the migration path.

7.Maintain the migration path. While the migration path is a high-level HIT strategic plan which should not be changed on a whim, changes will be needed over time. New regulations may require an adjustment in sequencing. The EHR meaningful use incentive program for hospitals and physicians significantly changed many organizations’ plans, which generally included adoption of EMAR before CPOE; however, the incentive program required that CPOE be implemented before EMAR. Vendor changes, products that are sunsetted, new applications, and new technology may require a review of the migration path. Internal factors such as a merger or acquisition also may require another look at the migration path. Changes in the migration path should be made with the consensus of all stakeholders and only for important reasons.

Migration Path Template

Timeline / Current / Phase I / Phase II / Phase N
High Level HIT Objectives
Applications

Financial/ administrative
Operational/departmental
Clinical

Technology

Database
Network
Business Continuity/redundancy
Security
Disaster recovery
Interfaces

Operations

People

–Leadership
–Clinical
–IT
–Governance
–Computer skills
–Training

Policy

–Transformational culture
–Adoption strategy
–Benefits realization

Process

–Communication/ celebration
–Goal setting
–Change management
–Workflow/process redesign
–Data quality and information management