EHR Site Tracking Record

Make the decision to participate as an EHR site.

The most important step is the first one — deciding to transition to EHR. This is not a decision to be taken lightly, because of the implications for and impact upon the entire facility.

Ensure that organization leadership is committed.

Neither the decision to use EHR, nor the activities required to implement it, can take place without the full knowledge, consent, and support of an organization's administration and governing body (including Area Office officials), as well as local tribal leadership.

Ensure that medical staff are committed.

EHR is above all a clinical application, and its greatest impact will be on providers. While the medical staff do not need to be unanimous in their support for EHR, the transition will be more likely to succeed if influential clinicians are enthusiastic and energetic about EHR.

Organization leaders convey new vision, communicate core values, and increase their visibility.

EHR implementation is more than just installation of new software: comprehensive process changes are required throughout the organization if the potential improvements in patient safety and quality of care offered by EHR are to be realized.

Organization leaders and EHR Team develop change management plan to demonstrate their commitment to staff.

The implementation of EHR brings many changes to a facility. Many of the facility's business processes must be reviewed and possibly revised to better fit the use of an electronic health record.

Assign EHR project manager.

The project manager takes overall responsibility for the successful implementation of EHR at the facility and is the main contact person for the EHR Program.

Hire and/or appoint a clinical application coordinator (CAC).

The EHR Program expects all facilities to have a CAC. For most facilities, this will be a full-time, new-hire position. The typical CAC is a nurse or midlevel provider with strong computer skills who understands all aspects of the EHR graphical user interface.

Establish EHR Implementation Team.

Include: (a) CAC, (b) Pharmacy Package administrator, (c) Lab Package administrator, (d) Radiology Package administrator, (e) QA officer/GPRA coordinator, and representatives from (f) nursing, (g) HIM, (h) coding, (i) data entry, (j) business office, (k) medical staff, (l) other clinical departments, and (m) IT staff.

Develop CAC training plan.

Consider: (a) CAC Implementation Team, (b) site visit to EHR site, (c) FileMan, (d) PCC Outputs, (e) Lab Package, (f) Radiology Package, (g) advanced EHR trainings, and (h) basic site manager training.

Complete EHR site survey.

Submission of this survey to the EHR Program is required before a facility can be added to the EHR implementation queue.

Review the EHR website and sign up key staff for the EHR ListServ.

The EHR ListServ is the principal forum for discussion of EHR-related issues and has proven to be a valuable support and networking tool for EHR sites.

Attend an EHR "Lessons Learned" seminar.

It is highly recommended that facilities send staff to the EHR: Overview, Implementation and Lessons Learned course.

Perform Force Field Analysis.

Identify both "driving forces" and "restraining forces" for EHR implementation. Discuss ways to mitigate the restraining forces and use the driving forces to your benefit.

Identify clinical champions/super users from each clinical service.

Clinical champions are influential members of the medical staff with enthusiasm for EHR and a measure of technical skill who are likely to be the first EHR users.

Develop staff incentives.

Providing incentives to encourage committed and enthusiastic participation in the initiative can go a long way toward preserving staff morale throughout the transition.

Communicate with labor union (if applicable).

If any employees at the facility are members of a labor union, the EHR Implementation Team must discuss any potential changes in these employees' scope of work with the union.

Determine staff concerns and follow up.

On a regular basis, the EHR Implementation Team should discuss upcoming changes with the facility's staff and address any concerns in a timely manner.

Identify a subgroup of the EHR Implementation Team to ensure regular communication with employees and the community.

This committee might consider creating a pamphlet for the facility's patients that explains what EHR is and how it might affect them.

Create an EHR implementation plan and timeline.

The EHR Implementation Team should consider major milestones in the EHR implementation process and create an estimated timeline for these milestones.

Attend EHR CAC/Implementation Team training.

Most facilities should be using Pharmacy 5/7 for at least one month prior to attending CAC training.

Provide Area Office with a copy of the implementation plan.

Publicly promote the EHR initiative.

Use newsletters, community meetings, local newspaper, fliers, etc. The community should be aware of upcoming changes in business process and clinic flow.

Identify baseline measures and metrics.

Evaluation is a critical component of the EHR Program, both locally and nationally.

Identify the first go-live clinic or location.

This decision may be influenced by hours of operation, patient volume, physical layout, the presence of computers and network connections, and the specific clinical and nursing staff in each location.

Ensure that all EHR Implementation Team members and key clinical staff have viewed an EHR demonstration.

Develop training plan for new software packages (PIMS, Radiology, Pharmacy, etc.).

Design an implementation plan.

Consider: by provider, by clinic, by function, or a combination. Determine if rollout will proceed "tab by tab" or "provider by provider."

Perform productivity risk assessment and develop mitigation plan.

Sites implementing EHR can expect to see a decline in provider productivity for the first several weeks, and possibly lasting as long as two to three months.

Develop contingency plans for system down time.

Procedures must be developed for rapidly identifying and correcting the cause of failure, and for continuing to provide patient care while corrective measures are being applied.

Review CAC User Guide and Clinicians Guide user manuals.

Perform work flow analysis and business process review for EHR.

Implementation of an electronic health record forces a broad range of business process changes in a variety of departments.

Determine which consults must be set up in EHR.

Begin planning for EHR quick orders.

A quick order is a single order or a set of orders that is predefined in the system, allowing providers to choose it with a minimum amount of clicks.

Implement Adverse Reaction Tracking (ART) package.

Assign GMRA keys to data entry staff and turn on the ALG mnemonic. Only allergies and adverse reactions documented in ART will be included in order checks in EHR.

Define protocol ("standing") orders for nursing staff.

EHR requires standing orders to be very clearly defined. Ambiguous standing orders that may have been acceptable in the paper environment will not work in EHR.

Review notifications.

For each notification, determine: (1) Mandatory, Enabled, or Disabled? (2) Priority? (3) Who receives it? (4) What makes it go away?

Review order checks.

A site must determine when an order check will be applicable. The entire order checking menu must be reviewed before going live.

Review note titles.

Identify and revise note titles according to discipline rather than provider.

Design order menus.

The menu layout should be carefully designed and documented on paper prior to the National EHR Team's onsite setup visit.

Develop quick orders for medications, lab, radiology, and nursing.

Establish a medical records subcommittee for approval of Text Integration Utility (TIU) templates.

Prepare and obtain approval for general, clinic-specific, and provider-specific TIU templates.

Determine the effect of EHR on departmental policies and procedures, rewriting as needed.

Inform the community and staff of the EHR go-live date and what they can expect.

Go live with EHR Phase I (according to implementation plan).

Only very small facilities will be able to effect full-scale implementation in a single event. The majority will start with a handful of providers in a single clinic or ward.

Run and report follow-up metrics (1, 3, and 6 months; 1 year).

Perform stepwise, scheduled rollout of EHR to remainder of facility.

The EHR Program strongly recommends that a specific timeline for moving the application through all clinical departments be adopted in advance and followed.

Evaluate current hardware and network.

Includes: evaluation of RPMS hardware, server, and capacity; evaluation of facility network infrastructure; evaluation of end-user hardware needs.

Begin procurement process for hardware.

Evaluate IT staffing available to support EHR implementation and maintenance; hire additional IT staff if necessary.

Install new equipment.

Obtain and review VueCentric installation guides.

Perform RPMS package optimizations.

Set up a share drive prior to implementing EHR.

The share drive is where the EHR application files reside, and must be shared so that client computers can access the application. This must be done prior to installing the EHR GUI since creation of a shared folder requires administrative rights to the Windows Server.

Install remaining EHR components (including GUI files).

Prepare training database.

Set up EHR client on user computers.

Provide access to training database for exploration after staff attend CAC School and/or prior to EHR onsite setup.

Run XBEHRCK at the outset to identify and install required upgrades to existing RPMS software.

The XBEHRCK routine identifies deficiencies in RPMS application versions and patches. All required upgrades and patches must be installed before any EHR-specific applications are installed.

Run XBEHRCK again when Pharmacy is ready to upgrade to version 7.

Chief Pharmacist consults with OIT pharmacy consultants.

Perform pharmacist training for Pharmacy 5/7.

Perform Pharmacy 5/7 training, installation, and go-live.

Implement "Paperless Refill" option.

Perform pharmacy file cleanup and preparation for Pharmacy 5/7.

The revision process is estimated to require a full-time pharmacist a minimum of two weeks to complete.

Implement Ward Order Entry for Radiology (if not already in use).

Implement Radiology Reports within the Radiology Package (if not already in use).

Perform Radiology file setup and training for Radiology Package.

Perform Radiology go-live.

Set a date to stop printing paper reports.

Perform Laboratory file cleanup for Laboratory 5.2 (if not already in use).

Perform Laboratory 5.2 training, installation, and go-live (including most recent patch).

Implement Ward Order Entry for Laboratory (if not already in use).

Set up label printers and printers for reports and labels at clinics and in lab.

Set a date to stop printing cumulative reports.

Develop a system for bringing Point-of-Care (POC) labs into the Laboratory package.

Develop a system for bringing microbiology reports into the RPMS Laboratory package.

Develop a system for bringing reference labs into the Laboratory package.

Set a date to stop printing Reference Lab reports.

Review medical records policy and begin to define the legal medical record and its primary source.

Switching to EHR means facilities must update policies and procedures that outline the maintenance, use, disclosure, and retention of the medical record.

Perform Patient Information Management System (PIMS) training and go-live.

Discontinue use of appointment books in all locations. PIMS incorporates scheduling, admission/discharge/transfer (ADT), and sensitive patient tracking functions.

Set up ICD-9 pick lists by clinic and/or by provider.

Set up CPT superbill pick lists (usually by clinic or specialty).

Review the Provider File with input from CHS, Pharmacy, Nursing, and Medical staff.

Ensure that only active providers with appropriate affiliation and discipline are listed.

Perform utilization assessment and implementation of RPMS point-of-service package: Immunization.

Nursing staff should be using it exclusively for immunization entry and management of the immunization registry. Dependence upon immunization "blue sheets" must be eliminated.

Perform utilization assessment and implementation of the RPMS Diabetes Management package.

Ensure optimization of the Diabetes Registry, Visual DMS, and the Audit tools.

Perform utilization assessment and implementation of point-of-service package: Behavioral Health.

The integration of behavioral and medical information supports coordinated care and improved health outcomes.

Perform utilization assessment and implementation of Women's Health package.

Covers Pap smears, mammograms, breast exams, and biopsies. Several EHR reminders depend upon accurate data in the Women's Health package.

Perform utilization assessment and implementation of case management packages (e.g., Asthma package).