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Application Management & Support Best Practices
- 1. Reducing Costs and Gaining Operational Efficiencies and Flexibility APPLICATION MANAGEMENT & SUPPORT BEST PRACTICES
- 2. ABOUT US
- 3. Confidential © 2016 Galen Healthcare Solutions OUR VENDOR EXPERTISE
- 4. Confidential © 2016 Galen Healthcare Solutions EHR Application Environment Roles & Connectivity Application Support Team Coordination Onboarding Methodology Application Support Transition Help Desk, Resources & Best Practices Data Quality & Integrity Considerations Changes that Impact the Application TODAY’S AGENDA Confidential © 2016 Galen Healthcare Solutions
- 5. Confidential © 2016 Galen Healthcare Solutions Max Stroud Lead Consultant, Field Services 10 years of healthcare IT experience Max has worked on a variety of projects as a Project Manager, Implementation Consultant, Upgrade Consultant and a Meaningful Use subject matter expert. http://www.himssconference.org/session/don-t-you-know-me-interoperability-patient-narrative TODAY’S MODERATOR Max is also founder of Doyenne Connections, a social network designed to foster opportunities for women in health IT. She is a HIMSS17 Social Media Ambassador and will be presenting at the conference: Confidential © 2016 Galen Healthcare Solutions
- 6. Confidential © 2016 Galen Healthcare Solutions TODAY’S CONTRIBUTORS Kim Baxter Senior Consultant Laura Gold Senior Consultant Sara Whittaker Consultant Kathryn Halliwill Senior Consultant Cece Teague Consultant Tracy Kimble Senior Consultant Confidential © 2016 Galen Healthcare Solutions
- 7. Confidential © 2016 Galen Healthcare Solutions KNOW OUR ENVIRONMENT Server Diagram • Needs to show what flows in and flows out • Look for connections/interfaces • Spreadsheet with all identifiers (IP, Host Name, etc.) • Database servers – understand per server which databases exists • Don’t forget Test, Train, Dev and Live systems
- 8. Confidential © 2016 Galen Healthcare Solutions What falls under your umbrella? KNOW OUR RULE Downstream Applications Patching New Build Upstream Applications Customizations Interfaces New Implementations Upgrades Remote Connections
- 9. Confidential © 2016 Galen Healthcare Solutions How are you going to connect to systems? Citrix RDP VPN VDI How do you connect to users? VNC Join Me Skype Make sure your organization and client are capable of meeting these needs (licensures, etc.) CONNECTIVITY SECURELINK for Vendors Quick Connect Alerts Reports Robot LOG STATS INFO
- 10. Confidential © 2016 Galen Healthcare Solutions Who do we interact with? What other specifics we need from the client • Change control policy • Committees – Physician – Steering Committee – IT Leadership • Policy on Urgent Break/Fix Releases • Setup on Vendor sites for support WHO’S WHO Staff Providers System Admins Security / Privacy Desktop / Device Support Vendors
- 11. Confidential © 2016 Galen Healthcare Solutions Customized onboarding process • Allows for the opportunity to build efficiencies into the onboarding of our staff • Makes the transition process smoother and more efficient for our customers ONBOARDING METHODOLOGY
- 12. Confidential © 2016 Galen Healthcare Solutions Background Checks • 7-year history • County, State and Local checks and include sex offender registry searches Drug screening tests • 9-panel urine drug screen Health Screening • TB Screenings • Flu Shots • Other immunization IT Agreement • Rules for confidentiality • Details concerning access to a client’s information technology and computer systems ONBOARDING Drug Screenings Health Screenings Background Checks IT Agreements
- 13. Confidential © 2016 Galen Healthcare Solutions Client Side Requirements • Network and Application Access • Electronic Health Record • ConnectR • PM Systems • Ancillary Systems • Laptop and Hardware Requirements • FBI Fingerprinting ONBOARDING
- 14. Confidential © 2016 Galen Healthcare Solutions Transition Process Methodology • Introduction to the organization - new employee orientation Interviewing staff on their day-to-day activities • Repositories of workflows • Set up or build work • Troubleshooting methodology Observing a client resource provides the consultant the opportunity to • Pose questions • Uncover information, workflows or assumptions overlooked by the organizations No business disruption01 Effective Risk Management02 Communication & Reporting 03 Effective Tools implementation04 Measuring Transition Effectiveness05 Effective documentation06 SeamlessTransitionTRANSITION
- 15. Confidential © 2016 Galen Healthcare Solutions New project Request(s) Evaluation Requirement SpecsGo ahead Detailed estimates End Release Planning Sprint Planning Story Reprioritization Sprints Delivery UAT/ Sprint Demo Transported to production Request for production No No YesYes THE WORK: RESOURCING & BEST PRACTICES Go ahead
- 16. Confidential © 2016 Galen Healthcare Solutions provider/practices/users daily/weekly/monthly helpdesk new duplicate go-live training share tasks support accounts Value+QualityPrograms credentialing flow work documentation THE WORK: RESOURCING & BEST PRACTICES
- 17. Confidential © 2016 Galen Healthcare Solutions Interview Observe Document INTERVIEW, OBSERVE, DOCUMENT
- 18. Confidential © 2016 Galen Healthcare Solutions IT Helpdesk and Support HELP DESK
- 19. Confidential © 2016 Galen Healthcare Solutions Hospital A Hospital B Patient ID 1 MPI 9876 Patient ID 2 MPI 9876 Healthcare System DATA QUALITY & INTEGRITY
- 20. Confidential © 2016 Galen Healthcare Solutions VALUE & QUALITY BASED INCENTIVE PROGRAMS
- 21. Confidential © 2016 Galen Healthcare Solutions CHANGES THAT IMPACT APPLICATION
- 22. Confidential © 2016 Galen Healthcare Solutions OPERATIONS SUPPORT
- 23. Confidential © 2016 Galen Healthcare Solutions OUR PHILOSOPHY
- 24. Confidential © 2016 Galen Healthcare Solutions Thank you for joining us today. To access the slides from today’s presentation, please visit: http://wiki.galenhealthcare.com/Category:Webcasts For additional assistance or to request information about our many services and products, please contact us through our website: www.galenhealthcare.com
Editor's Notes
- Our Team Best in KLAS – HIT Implementation Staffing and Support Clinical workflow and operations experts Average Staff HIT Experience: 12 Years Our company culture - Strive for success, you get the entire Galen team behind every project Cross-section of clinical and non-clinical healthcare application expertise 2.0MM Hours Healthcare Experience 280 Customers served in the last 2 years Boutique, healthcare-focused services & solutions company For over a decade, Galen has built a solid reputation of providing high-quality, expert level IT consulting services to health systems, hospitals and physician practices. The foundation of our growth and success can be attributed to our people. It’s what we care about as a company that makes us unique.
- Our Value Proposition: We transform data into actionable, profitable information Provide world-class Technical & Professional Services to healthcare organizations that interoperate, aggregate, convert, harvest and optimize clinical patient information within their multi-vendor systems portfolio including Practice Management, Electronic Health Record & Health Information Exchange. Deliver a suite of fully-integrated Products that enhance, automate, and simplify the access and use of clinical patient data within those systems to improve cost-efficiency and quality outcomes.
- Webcast Homework: Read My Blog: http://blog.galenhealthcare.com/2016/04/19/more-than-backfill-how-will-you-ever-fill-that-chair/ I’m a story teller by nature and the intent of this webcast is to share our collective story of application management & support – the lessons we’ve learned, the best practices we’ve accumulated and the insights we’ve gathered. Once, the key person at a client I had worked with before went out on medical leave, and I was asked to “be them” for a few weeks. More recently, I have been asked to play this role as the lead admin is preparing for a conversion and implementing a brand new software product. The organization cannot afford to not have her on the new implementation…but to say filling her shoes is “Tier 2 support” is an understatement at best. When you have an enterprise application that is used by hundreds of users a day, connects with multiple ancillary systems via interfaces, is responsible for the delivery of healthcare for individuals, and drives billing operations, you can’t just hire a temp. You need to find someone who is not only an expert in the applications that you are using, but also someone who understands relationships and how to work with a team
- Laura Gold St. Luke’s Help Desk, Tier 3 Support, ancillary & pms application expert TouchWorks configuration, end user training and support Sara Whittaker St. Luke’s Help Desk, Tier 3 Support, ancillary application expert Acute Billing and Coding expert Training, implementation, and onsite application support
- One of the first things to managing the support is to know the environment well. Not just how the applications work. We need to know everything about the architecture of your server farm. This allows us to see what feeds into and out data flows out of the applications we will be supporting. Many times during this review, we find one-off applications, interfaces or other connections that have been overlooked in the initial scoping of the project. Also a spreadsheet that lists all the servers, what resides on the servers, IP addresses of servers and clusters, and the System Environment Specifications of each can be a very helpful resource when troubleshooting with vendors. On this sheet it is also very helpful if we understand on the database servers if there are more databases that reside on the server or cluster. This alerts us that we need to take into consideration any specifications for those vendors as well. Don’t forget, we need to know all this information not only for your Production environment but also any test, dev or training environments.
- Discussions need to take place to understand our role within your organization and within the IT reporting structure for your department. At a minimum we need to be mindful of shared duties for applications that overlap. For example – the Acute System has a patient portal and they have their own support team. The ambulatory also uses that portal and we might support only the ambulatory user / patient build, interfaces from our system into the portal, etc. However the other support team will handle all upgrades, patches and general troubleshooting. Understanding the boundaries of this support structure, who we will be interacting with and developing a working relationship with team for cohesiveness is imperative. The other caveat to knowing our role is to fully understand any and all downstream and upstream applications and if the support team has the responsibility of those applications as well These can be interfaces, remote connections, web-based, peripherals (Dragon, Speechmics)etc. How does the system handle future customizations, new build, new implementation upgrades, monthly patching?
- We need to work out the details of the best mechanism for our support team to have connectivity to any and all these systems. Do we access the primary applications via Citrix or VPN, Securelink or are we assigned a VDI? If we have need to access the servers directly will we have admin rights to do so? How do we reach users? Does the organization have a mechanism for us to view the users desktops? VNC, Join Me or skype screen sharing are a few ideas. Will we have admin rights to the users desktops for when we have to add an icon or adjust IE settings, etc. If we have a device that needs installed such as a printer or scanner, do we support that or do we have a Device Support team that will do those things for us? Also make sure that there are licenses available to add our staff to those applications.
- Knowing our audience is also imperative. We need to know and be introduced to front line staff, Providers as well as our counterparts with in IT. System Admins, Security and Privacy staff, Desktop Helpdesk or Device Support. Understanding the role of those we work with and how the chain of command flows, what is the change control policy, how are requests for new build filtered through this chain of command. Are there any committees that we need to present issues, updates too. Are there specific forms or shared drives where we need to store monthly reports or project work? Also, we need to be introduced to the venders. Making sure that the vendors know who will be supporting their product is very important. Especially if you have assigned support people and they have been used to working closely with another staff person on your side of the house. If we need access to a vendor support portal then that will need to be initiated from your organization.
- A client’s onboarding process for a Galen Healthcare Solutions consultant at the start of an Application Management project varies from client to client. Our process depends upon the client’s needs and requirements. We go through a discovery phase with each client, prioritizing their needs and requirements, resulting in a customized onboarding process. Our customized onboarding process with each customer, allows us to build efficiencies into the onboarding process, and thereby making transitions smoother and more efficient for both our customers and Galen’s consultants. The following describes components of our onboarding processes that we use with our clients.
- Background Checks - Handled through Galen Healthcare Solution’s Human Resources vendor Include criminal checks – 7-year history, based on employee’s SSN. County, State and Local checks are run and include sex offender registry searches. Are not typically delivered to the client unless specifically requested. The documentation is kept on file by Galen and available if requested or needed as per an audit. Drug screening tests A clear 9-panel urine drug screen. Like the background checks, these are not typically delivered to the client, but we confirm that we have the tests on file for our consultants. Health Screening TB Screenings, Flu Shots and other immunization records are common requests for consultants who are working on-site, specifically in clinics . IT Agreement An agreement on the rules for confidentiality and access to a client’s information technology and computer systems applied to all non-public patient and business information
- Network and application access Per the IT Agreement and the needs for each consultant, the client provides the required system accesses. The length of time it takes for access to be granted to a consultant varies depending upon a client’s internal processes. We set clear expectations that our ability to begin work for our client depends upon having system access. Laptops and hardware requirements Client requirements dictate which computers and other hardware a Galen Healthcare Solution consultant will use. Consultants can always use Galen’s own securely protected computers. FBI Fingerprinting Some clients require a Galen consultant to have in-state fingerprinting completed. This is usually a step that is contingent on preliminary steps being satisfactorily finished. Galen consultants may do this while on site working the first week.
- Once the required background information is completed and distributed as required, the actual transition of work responsibilities can start. Galen’s approach for transitioning to managing applications is flexible and agile in meeting the needs of the client. It depends upon the client’s team that Galen is taking over and their plans to transition off team members and/or leave some to work with Galen consultants. Typically, we develop the transition plan with a “Lead” Galen resource who will help manage this transition. The lead resource helps to ensure that the Galen team have all the resources and information needed to do the work as effectively as the current team. Based on what the client wants impacts who on Galen’s team does what and how many are needed to eventually manage the application. However, it is important to note, we stress the need for some overlap time with the existing client team and to have clear expectations of how long those team members will be available to the Galen team during this transition. We will be discussing this requirement in more deteail later in the webcast. While it can be a lengthy, involved process, Galen has developed some proven methodologies to smooth the process. Most clients start with an introduction to the organization, similar to new employee orientation. Interviewing staff that are shifting off the project to discern their day to day activities is probably the preferred method. Most organizations will also have repositories of workflows, documentation specific to set up or build work and troubleshooting methodology. Links to or copies of this documentation are very helpful while they ease and speed up the process. Many times, sitting with a client resource while they are working through an average day or more provides the consultant the opportunity to pose questions and uncover information, workflows or assumptions overlooked by the organization. I would add that as we develop the transition plan that we generally have one Galen lead who will help manage the transition with the client team and ensure that we have all the resources and information we need to the job as effecivly as the current team. It is important to have some overlap time with the existing team and to know how long they may be available to the Galen team. Then add that we will talk about this more in depth later in the webcast (or that Laura will)
- Resourcing and Best Practices to provide a better level of service than you received prior to engaging in staff augmentation Our Goal: For the level of service that you receive to be better than prior to engaging staff augmentation services. We want you and your end users to have a superior experience and not even know or be aware that there has been a ‘change of staff’ responsibility. This goal is accomplished by investigating current practices and workflows, keeping an open line of communication between organizational leaders, managers and support staff and having a clear understanding of where organizational responsibilities lie, with existing staff or newly created staff, leaders You may say and think to yourself “Our organization is not going to allow any changes to existing/legacy system..… but this is not a realistic statement. There is one thing we know to be a constant in life and that is CHANGE. Things change. When you look at the timeline that is in place when the decision to change EHR Vendors is made thru final GL implementation a process that is known to take often 2+ years anything could happen. Reporting standards could change, patient safety issue present, equipment needs to be replaced/updated, vendors leave the work space, key personnel may unexpectedly take a medical leave of absence. We will be reviewing some of the area to be aware of and plan for.
- We really, really like the word cloud!! If it can be kept, perfect, if you can make it better AWESOME!! Helpdesk, work flow, training, documentation, go live support, new provider/practices/users, daily/weekly/monthly tasks, credentialing, duplicate accounts, value and quality based incentive programs. There's a lot to think about when you are turning over your IT baby to a new team What applications will we be assuming responsibility for? EHR, PMS, Phone software (Televox), messaging services Help Desk- how many applications are being supported by the help desk? Tier I vs Tier II support SLA (service level agreements)EHR, PMS, Phone system…. Workflows- operational chain of command, who does what? New Providers/Practices/Users transfers, New hires, closing practices. Go Live support for new practices and providers number of support staff on site, length of support 2 weeks, 3 weeks? Follow-up site visits Daily, Weekly, Monthly operational tasks EOM, Credentialing- DEA, license, Insurance carrier Value and Quality Based Incentive Programs MIPS, PQMH/PCSH, CQS…reporting information gathering Training- for new sites, programs, etc Documentation- Internal where is it stored, Drives, Shares, who has access to it? Interview, Observe, Document http://www.wordle.net/create ^^ use this website if we want to change collage, just add word and it randomizes it for us
- Hear it, see it, write it The best WAY to find out how a team is currently producing is to sit with that team observe their workflows and interview them as to when, why, where, how and who of their daily work life. What do you consider are the challenges and current struggles in your day to day work life? Often coming in with a fresh perspective and the experience of having worked in multiple systems with multiple approaches, we maybe able to recognize areas of process improvement. Interview and Observe: I can not stress this enough, your new augmentation team will only be as good as the support documentation that is available to them. It is imperative to factor in time to allow your augmented staff the opportunity to interview your existing staff in their day to day functions. The interview process should take place over at least a week, longer if it is at all feasible to cover every day of the week. If you have a large organization with many moving parts and roles/responsibilities that are going to be assumed this process would need to be longer. For good measure interview more than one person in the same role as often person A and Person B may have the same role but may be responsible for different aspects of that role. EXAMPLE: (remove actual names) You may have an organization that has a team of trainers……..possibly use Kelsey/Ron vs Megan/John.. both trainers for staff, but one are in Allscripts, and one are in idx? And what level are they training? Are they training basic workflows or more in depth of each application _____________________________ The observation process allows for discovery in the real time work environment, with practical real time scenarios. It also allows for workflows to be observed that may not be documented well within the health system. In anticipation of an augmentation staff coming on board, you probably created an outline of ‘All” of the duties that are performed by the various departments with your organization. BUT I can guarantee you that your users/staff they are doing work for you, work that needs to be done, but it is not documented ANYWHERE, as to how it is done, when it is done and perhaps even why it is done. EXAMPLE: Error Queue ( different clients utilize different department to address errors, lab, interface, how are they divided up? __________________________ This is the benefit of the observation process…..you see what is really being done. And if it was not documented previously it will be now. You know why? Because your new staff augmentation people are going to create that documentation, so 3, 7, 11 months from now when that weird thing comes up that has to be done once a quarter that only Beverly did, they will know about it and do it. It will save everyone time and heartache and allow service to run more smoothly without undo interruption EXAMPLE: __________________________
- Interview, Observe, Document Help Desk How many applications are being supported by the help desk? EHR, PMS, Phone system, third party add on application such as midmark, phreesia, etc…. What is considered a Tier 1 vs a Tier 2 ticket? What is the current SLA (service level agreements) expectation? What is the On-call expectation? Is it a 24/7 shop or are certain applications unavailable at specific times, daily down time for back up? Ticketing priority, response times, escalation process, breached tickets. Will your augmented IT team have access to all of the systems or is there an access limit to a certain members of the IT team? Example: We’ve worked with clients that have separate IT teams for Ambulatory care practices and Hospital based care. The Hospital system is the source of truth for MRN, medical record numbers. Prior to merging duplicate accounts in the Amb Care setting, the Hospital database needs to be checked to confirm the correct MRN. If your Ambulatory IT team does not have at least view access to the Hospital system database, another resource will need to be engaged to verify those accounts, thus slowing the process of correcting a patients medical record . How are end users access the HelpDesk? Are they calling a Help Desk phone #, are the able to access the ticketing system in a self-serve format and enter tickets on their own behalf? This is important as often users CALL into the other help desk those staff get more of the critical information we need to investigate the problem, rather than when staff log their own service now tickets. Do you have a dedicated Line for providers to call with application issues? If so, how is that managed and what is the expectation for service, the same as the originating SLA or different? What are the top 3 problem tickets your organization encounters and how are they resolved? I bet they are duplicate accounts, locked of the application and the system is running slow. Are you open to suggestions of changes in workflow that may help reduce costs or more evenly distribute work? Example: If locked out of the application tickets are handled by Tier II support, would you consider altering workflows, security and /or permissions to allow Tier I support to handle that? What are the daily weekly and monthly maintenance jobs tasks that need to be addressed? Examples: daily: PM system early morning status checks, monitoring error queues and addressing the errors either by refiling or building out the order code if you are monitoring a lab error queue, duplicate accounts/patient merges, monitoring inactive task lists weekly: what staff/department head meetings need to be attended? who will be responsible for budget forecasting of money and hours on the project, coordinating larger build projects, activating/inactivating orders sending off error queues to the interface team monthly: end of month checks and reports, upgrades, onsite support requirements for GL support or 1:1 training
- Duplicate, Incorrectly merged patient accounts PHI in the incorrect chart Start this slide with an assertive comment about the importance of data integrity and ensuring the quality of data. We will own this responsibility as much as your staff because at the end of the day it is about providing quality care and accurate records. What is the process when Duplicate accounts/charts are identified? Who is identifying and reporting them, end users, HIM, providers? Is this an IT responsibility to investigate and correct or is there another department those responsibilities fall to? Are there other systems or databases that need to be reviewed for duplicates, prior to corrections? For Example: referring back to the example discussed in previous slide where: The Hospital system is the source of truth for MRN, medical record numbers. Prior to merging duplicate accounts in the Amb Care setting, the Hospital database needs to be checked to confirm the correct MRN. We’ve observed the report of a simple duplicate account require system checks in 4 separate applications( IDX, EPIC, Allscripts, CMS Merge) and reviewed thru 5 different departments ( Site-End User, HelpDesk-IT, HIM, EPIC, IDX/Allscripts) prior to even being able to complete that request. What is the process when charts have been merged incorrectly resulting in two patients health information now residing in one medical record? Again, who is responsible for investigating and untangling the records? IT, HIM,? Does an incident report need to be completed? Documents scanned into the incorrect chart? What is the process for correction? Who is notified and how, email, ticket, internal system notification? Again the Interview, Observe and Document methodology will come into play here with all three of these scenarios as charting errors and duplicate accounts are a frequent re-occurring theme in most health organizations.
- Value and Quality Based Incentive Programs Which programs are you currently reporting to? How is reporting currently managed? Will that team remain in place during the transition? Is there a Value Based/Quality Team that meets on a regular basis. Who decides which measures to report against? Who is monitoring the reports and the measures for updates and changes. EXAMPLE: _______________________________ Are you currently doing site visits to review the program compliance and address concerns? If so, is it one person or more than one and how often and how long are the visits. (St Luke’s only has one person, Alison Gibson, and she would visit a site for about four hours. In the time I worked with her she was pretty much scheduled to do site visits everyday). If you are utilizing reporting services that have licensing fee requirements, such as Direct Messaging how is that service agreement going to be managed? Who will be responsible to request additional licenses and deactivating license for providers that have left your organization. This is a great topic to include. I would add in that if we are not taking this over that the relationship with the quality team is pivotal and indirectly linked with the day to day work in the applications and it is important to have an understanding of the overall plan
- When transitioning from one system to another, what will happen when the client hires new employees? Will they move immediately to the new system? Or be in a position to learn the old one before moving to the new one? Who will train them? Will there still be training classes for them or will all of those staff have moved onto the new health record system? When transitioning from one system to another, what will happen when the client hires new Providers? All of the items we previously discussed for new employees need to be addressed but also How are State licenses, DEA, NPI, Direct messaging managed, added and updated? How is Insurance carrier credentialing and provisioning addressed now and is that process going to remain in place? Will you be acquiring new practices during the transition period? If so which healthcare system will they be put on? What is the on site service requirement for on site support? When staff and providers leave what is the process? Do we inactivate them in the programs to leave them active? Who is responsible for the intake and output of the security forms (if security forms are in fact needed for new or terminations of accounts)
- Application Support Structure Legacy systems support and maintenance Helpdesk operations System & Application Upgrades Project management, needs analysis, staffing and support Training programs and initiatives End user, Admin, Super user
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