Carilion Health System - Large Scale Ambulatory EMR ...

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  • While adding nineteen physician was significant, the departure of fourteen resulted in a net add of only about five physicians. The location count is somewhat soft as we have several settings with multiple practices operating out of the same building. A good example would be Carilion Urgent Care which operates out of the Colonial Avenue practice location.
    Overall the specialty mix remained relatively constant with about eighty percent of the physicians in primary care. You can see however that we continue to add to the number of specialties managed by the practice.
  • Spend some time here talking about:
    1-Project steering committee
    2-Rollout meetings and team (discuss duties of each of these groups)
    IS
    NS
    Training
  • CMG set as a goal to improve care in 3 areas during 2003
    DM
    Anticoagulation
    Mammogram
  • Carilion Health System - Large Scale Ambulatory EMR ...

    1. 1. Carilion Health System: Large Scale Ambulatory EMR Implementation Brent Lambert, M.D. Carilion Health System
    2. 2. Thursday, January 29, 2015 2
    3. 3. Thursday, January 29, 2015 3 EMR ~15% of Virginia physicians use an EMR
    4. 4. Thursday, January 29, 2015 4 Carilion Physician Operations • Carilion Medical Group +/- 190 phys. • Carilion Medical Center +/- 90 phys. • Carilion Emergency Svs. +/- 50 phys. • Total Physicians Employed 330
    5. 5. Thursday, January 29, 2015 5 CMG Physician Characteristics • 117 Family Pract. • 29 Internal Med • 16 General Sur • 12 OB-GYNs • 8 Pediatricians • 2 Cardiologists • 4 Neurosurgeons • 1 Vascular Surg • 1 Dermatologist • 1 GYN-Onc • 1 Pulmonologist • 1 Gastro. 61% 60% 65% 71% 71% 15% 15% 14% 20% 29% 8% 10% 7% 6% 8% 6% 5% 4% 4% 4% 4% 1% 2% 1% 2% 1% 1% <1% <1% <1% <1% <1% <1% <1% <1% <1% <1% 2003 1999 1994 158 Phys 54 Loc 24 Phys 9 Loc 171 Phys 61 Loc 2004 188 Phys 62 Loc 2005 193 Phys 64 Loc
    6. 6. Thursday, January 29, 2015 6 About CMG • Practices from Woodstock to Wytheville on I-81 & down to Galax and Martinsville on the NC Border. • Electronic Medical Records in use since 1999 – one record per patient regardless of the location of care. • Single patient financial record regardless of the location of care. • Greater than 600,000 patient records • 950,000 patient visits a year.
    7. 7. Thursday, January 29, 2015 7 Ambulatory EMR • Carilion Medical Group began the role out of their ambulatory EMR in March 1999. • Completed the initial rollout about 2 years later.
    8. 8. Thursday, January 29, 2015 8 Carilion Medical Group’s Experience with EMR • Started the EMR project in 1998 • First practice to transition from a standard paper record to EMR was in March of 1999 • Initial roll out complete in 2002 • “No new paper” in 2002 • Interfaces from: – practice management system – reference lab – radiology reports – ED records, hospital transcriptions – document imaging system
    9. 9. Thursday, January 29, 2015 9 CMG’s Challenges • Database vs. Document Storage • Minimum usage standards – Current Problem List – Current Medication List – Current Allergy List – Immunizations • Takes more time initially – Learn new application – Working in 2 worlds For most of our physicians it took 9-12 months to get back to baseline production.
    10. 10. Thursday, January 29, 2015 10 CMG’s Challenges • Integration – Lab – both reference and office – Radiology – Practice Management – Transcribed Documents – ED Reports (from another EMR) – Document Imaging • Standard Vocabulary • Development of standards and clinical content – Determine what clinical standards to follow – Development of clinical content with clinical decision support tools • “Out of the box” the clinical content is very basic and clinical decision support is nearly nonexistent
    11. 11. Thursday, January 29, 2015 11 Carilion Medical Group Board • CMG board made decision to use an EMR • Board elected by physicians in group and consists mostly of physicians • Board made it clear that EMR was not optional
    12. 12. Thursday, January 29, 2015 12 EMR Selection • Board appointed a committee to select an EMR • Selection committee was made up mostly of physicians that were not on the board • Made several site visits where EMR was used • Selected Logician by Medicalogic
    13. 13. Thursday, January 29, 2015 13 Vendor Issues • Medicalogic – privately held company • IPO • Bankrupt • General Electric
    14. 14. Thursday, January 29, 2015 14 Pilot Site Chosen • Before final decision to move forward, the EMR was piloted • Pilot site went live and used EMR for about 6 months before any other sites went live • Pilot site used to fine tune project plan and scope • Pilot site used to define and refine rollout plan
    15. 15. Thursday, January 29, 2015 15 Key Project Decisions • Single database over a WAN • 100% thin clients • Device in every exam room • Limit printers as much as possible • Interfaces priority
    16. 16. Thursday, January 29, 2015 16 Rollout Begins • Order of rollout defined – Each site had the option to opt out once and move to end of list – Once an opt out site was reached for the second time they could not opt out • 21 week schedule for “kickoff” to “go live” – Site – Training staff – IS application staff – Network Services
    17. 17. Thursday, January 29, 2015 17 Chart Preload • Sites encouraged to “preload” problems, medications, and allergies • Sites free to preload other information • % of charts preloaded very important in success at go-live
    18. 18. Thursday, January 29, 2015 18 Interfaces • Practice Management System • Reference Labs • In-house labs • Radiology Reports • Hospital Transcription • ED Reports
    19. 19. Thursday, January 29, 2015 19 Enhancements • Faxing – Electronic prescription transmission • Required visit to Virginia State Board of Pharmacy • Still not allowed by DEA for scheduled medications • Document Imaging • Dinamap
    20. 20. Thursday, January 29, 2015 20 Provider Decision Support • “Out of the Box” – Medication interaction – Allergies • Developed – Diabetes – Anticoagulation – Immunization Reminders – Mammogram Reminders – Congestive Heart Failure – Ob Care
    21. 21. Diabetic Notification
    22. 22. Diabetic Assessment
    23. 23. Initial Anti-Coagulation Form
    24. 24. A-C Treatment Sched.
    25. 25. A-C Follow Up Form
    26. 26. Thursday, January 29, 2015 26 A-C Results • We think that through standardization of dosing we will ultimately improve results for patients across a large population. • Physicians and nursing staff like the documentation aids and efficiency
    27. 27. Consider Mammogram
    28. 28. Needs Mammogram
    29. 29. Visit Assessment
    30. 30. Thursday, January 29, 2015 31
    31. 31. Thursday, January 29, 2015 33 Customization • Both good and bad – “Out of the Box” our EMR is very generic – EMR allows considerable customization – Learning curve to customize is long and difficult – Limited outside sources for EMR content
    32. 32. Thursday, January 29, 2015 34 Future of Carilion EMR • More decision support • Orders with out bound interfaces – Lab – Radiology – Practice Management System • Reporting
    33. 33. Thursday, January 29, 2015 35 Lessons Learned • Difficult and painful process – but worth the effort for most • Provider productivity decreases (may not be all due to EMR) – At 18 months encounter/provider/workday down by 1.8 – At 30 months down by 0.4 • Few providers would ever choose to go back • We believe that patient care improves!
    34. 34. Thursday, January 29, 2015 36 Keys to Success • Total Commitment at the top • Physician leadership • Develop “in-house” skills • Development/customization team leaders must have clinical background

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