Roadmap to electronic health record dr roohullah shabon 2008

Community Health Centre CMS Roadmap & Guideline
Learning from 5 Early Adopter CHCs

Contents

1. Acknowledgements

2. List of Abbreviations

3. Introduction

4. The PMBOK Framework

5. Framework of the implementation

6. Lessons Learned – A summary

7. Getting Ready

8. Embarking on the Journey

9. Continuing the Journey

10. Summary Checklist

CMS Roadmap V1 January 2009 Page 2

Acknowledgements
The AOHC would like to express its thanks to the following organizations and persons, without whose help
and valued contribution the realization of the Roadmap & Guidelines for the CMS Adoption Project would
not have been possible:
 The 5 early adopter CHCs, their EDs, DMC, Providers and Administrative staff who met with the team
• Anne Johnston Health Station
• Country Roads CHC
• Langs Farm Village CHC
• London Inter-Community Health Centre
• North Hamilton CHC
 The CHC Information Systems & Technology User Group (ISTUG) for guidance and help.
 The Training & Change Management Sub Working Group.
 The Community Health Centre e-Health Committee (formerly the ISC).
 CHC ISS.
 PSTG Consulting.
 All the CHCs who participated in the ECR Readiness survey.
 The AOHC Executive Director Adrianna Tetley for her guidance and leadership and the AOHC Education &
Development Team for developing this document.

This document is a dynamic and living resource and we will continue to add to it. For comments and suggestions please
contact:
Roohullah Shabon, Director of Education and Development
The Association of Ontario Health Centers
416-236-2539 ext. 231
Roohullah@aohc.org


Abbreviations

ABBREVIATION MEANING

AOHC Association of Ontario Health Centres

CHC Community Health Centre

CHCeC Community Health Centre eHealth Committee (formerly ISC)

CMS Clinical Management System

CNT Clinical Note Template

CPP Cumulative Patient Profile or Summary

DMC Data Management Coordinator

ECR Electronic Client Record

ED Executive Director

EHR Electronic Health Record


Abbreviations

ABBREVIATION MEANING

HL7 Health Level 7
ISTUG CHC Information Systems & Technology User Group
IT Information Technology
LHIN Local Health Integrated Network
MOHLTC Ministry of Health and Long Term Care
PLG Program Learning Group
PMBOK Project Management Body of Knowledge
QI Quality Improvement
SOAP Subjective Objective Assessment and Plan
WFA Workflow Analysis


Introduction

While many CHCs have been considering the transition from partial to full ECR, the lack of a structured
process that detailed the preparation, challenges, opportunities and successes has caused many to hesitate
to take the next step.

The AOHC, its member CHCs, along with the MOHLTC and other stakeholders, recognized this need and
embarked upon the journey of developing the resources to address the gap. This Roadmap & Guideline is
one result of that journey and its purpose is to provide all CHCs with a significant tool to make the transition
from paper to paperless.

The Roadmap addresses the change in three high level phases:
 Getting Ready: Detailing the important steps and discussing the decisions to be made in planning for transition.
 Embarking on the Journey: Details of the pitfalls, success tips and vital Business Continuity decisions to be made
during the transition.
 Continuing the Journey: Details on ensuring that the Journey does not have an end-state but is one of
continuous improvement in process, data and clinical quality management.

The Guidelines give details and elaboration on each of the above phases.

NOTE: This Roadmap & Guideline will be reviewed and fine-tuned as part of the Post-Implementation
exercise


Purpose

Those Centres who have moved forward with ECR adoption have within them knowledge and experience
that would be helpful to other Centres. However, developing a Roadmap & Guideline is not simply a matter
of collecting tips and tricks from front line users or the DMCs; instead, it is important to understand the
context in which the ECR project operates and the factors that lead to a given practice working well in a
Centre and not working in another Centre. This context helps to explain why Centres have chosen different
implementation approaches and is an important element of analysis so that other CHCs can evaluate
whether a particular approach is likely to be successful in their Centre or if a particular issue is likely to arise
in their environment.

By interviewing a range of staff within five early adopters CHCs (see page 2 for the list of CHCs) , it became
clear that the maturity of centres along the road to having a fully integrated system varied, and that each
had further to go. This Roadmap summarizes the findings of these interviews, and provides the necessary
context for future ECR adopters to learn the lessons of those which came before them.


The PMBOK Framework to Project Management

The Project Management Body of Knowledge (PMBOK) is an internationally-accepted framework for taking
an organization through many different types of projects, including change management projects such as the
ECR adoption transformation within the CHC sector.

While the PMBOK breaks a change into the phases of Initiating, Planning, Executing Monitoring and
Controlling adapted to the process of transition from Paper to Paperless, we find it useful to change the final
phase to Continuing the Journey with a focus on Quality Improvement. This conveys the fundamental fact
that the transition to full ECR is indeed a cyclical journey of continuous improvement.

Following the interviews it became clear that such a rigid project management framework for a change such
as this one is only partially applicable to a continuous journey such as this one and may not be the most
appropriate means of communicating the lessons learned from the early adopters of the ECR. This is
because the context in which each centre operates has a tremendous impact on its strategy towards
implementation and its success in roll-out.


PMBOK (Continued)
In order to develop a project plan, and a clear roadmap, direct, linear steps must be clearly laid out that
trace a plan from start to finish. However, with each centre operating within different parameters, such a
framework cannot be constructed. Each CHC follows a different flow as its decisions are driven by different
circumstances and parameters.

Of greater value is to synthesize the information into discrete, granular data points which readers can use to
determine the best implementation plan under the specific and unique conditions in which their centre
operates.

This Roadmap & Guideline breaks the implementation of the ECR adoption process into three over-arching
phases: Getting Ready, Embarking on the Journey, and Continuing the Journey. Each of these phases is
broken down by sub-category to identify major considerations at each phase along the road. A summary
highlighting the key lessons learned in each of these sub-categories is provided; however the reader should
be well advised that there are many ‘nuggets’ of wisdom in the verbatim along the way that should be
studied closely.


Roadmap & Guideline Process

Phase 1

Phase 2

Phase 3


Key Lessons Learned – Getting Ready Phase

Lesson Learned
Having a Champion in each of the clinical staff, the management team, and the data management groups
is critical to the success of implementation.

Despite challenges with the software, none of the centres felt that they would go back to paper charting.

The use of steering /guiding committees in implementation was not consistent across the centres
interviewed, and the decision to create one or not should depend on a CHC's culture and use of
committees in general.

Having clinical buy-in is critical to the success of the implementation and should be thought of as a
prerequisite to moving ahead with the process.

Conducting a workflow analysis to determine the CMS configuration changes needed to accommodate the
CHC workflow is a key element in this phase.

It is important to determine the training gaps and make plans to ensure that they are addressed prior and
post implementation.


Key Lessons Learned – Embarking on the Journey Phase

Lesson Learned
The timelines or phases to adopt the ECR varies based on the circumstances of each centre.

There is no best practice with respect to dealing with old paper charts. Money spent on scanning paper
charts should be done carefully; charts scanned and then never accessed by providers is a wasteful
endeavour. Data input can also be costly, but is more likely to be of use down the road.

In order to accommodate the learning curve of the users, appointment times should be extended during
the early days of implementation, but they should be returned to original times after the transition period
is complete.

Ongoing training in the form of short sessions (one hour or less) being led by clinicians from the CHC and
from other adopters is the best approach, provided there is strong support on the technical side from the
DMC and the software provider.

One highly useful practice was to import templates and other tools from early adopters and then
customize them to the centre’s needs.

The time spent considering the technical requirements for implementation is of critical importance. There
are many aspects of the implementation to consider, and each should be looked at on a cost/benefit
basis.

Integration between the ECR and the labs holds great promise, but current challenges with the lab module
and the integration means this promise is as yet unfulfilled.


Key Lessons Learned – Continuing the Journey Phase

Lesson Learned
The early adopter centres are achieving value with the system, however there is still further to go to
realize the full advantages of the ECR, particularly in use for quality improvement.

Milestone achievements are reason for celebrations.

Even the centres that are highly mature in the ECR adoption recognize the need for further and
continuous training (e.g. Program Learning Groups).

Room to improve exists in terms of using the ECR to drive QI measures, to integrate with other healthcare
providers, and to improve the quality of the technological support systems.

The challenges posed by the CMS software are numerous and wide-ranging. Although there have been
some improvements to the software over the past year, the hostility amongst providers within the CHC
community towards this system is the biggest risk to successful buy-in and adoption.


Ready

CMS Roadmap v.03 December 2008 Page 14

Ready

Importance of Change Champions

One of the most significant factors cited by all the early adopter Centres “DMC and clinical team comprised the Champions of the
was the need for mechanisms to build and maintain support for the change.”
initiative. While approaches varied, there was a consistent message
“ED support is obviously critical to success.”
across the board, namely that all centres needed a cross-functional
team from across the centre to drive and champion the change. “Having a highly competent DMC is critically important. They
have greater expertise in the software and understand what
can be done in different roles within the clinic.”
 All five centres could identify a physician Champion for the project,
without whom the project would not likely have proceeded as quickly “Ideally, the Champion of the change process is the DMC.”
or as well. While non-physician clinical Champions were also noted in
several of the Centres, the need for clear physician leadership was “It is absolutely essential to have an 'expert' on site to run the
striking. implementation.”
 All five centres noted the importance of having an Executive Director
who drove the change and supported those who wished to see the “It is critical to have the ED pushing towards ECR. The top-
down approach drives the organization.”
change happen and helped facilitate the process.
 All five centres had a DMC that could see the long-term vision of the “It would have been devastating to the process if any of our
ECR, who brought in-depth, technical knowledge to the process and Champions had left in the midst of the transition (this includes
acted as Change Agent. our finance guy, the ED, DMC, and our Champion physician).”

The change Champions were valuable in terms of creating the requisite
appetite for the change to take place.


Importance of Change Champions (continued)

“Our DMC and his support person are full-time, and are highly competent in terms of IT.”

“Our DMC championed the whole process, supporting everyone, leading the training.”

“Our DMC has 12 years of experience and was very comfortable with Purkinje, both as a user inputting data and in the extraction
process. Our DMC also had a good relationship with Purkinje, York Med and ISS, as well as a trusting relationship with our staff.”

“Our DMC was the Champion of the process.”

“The board was informed of our decision to make the change to ECR , but the ED had the authority.”

“The DMC is key to make the change happen through training and creation of templates.”

“The DMC role is insufficient to champion the implementation. The requirement is to have an IT-savvy team who can spearhead the
implementation process.”

“The management team within the CHC was very trusting which was instrumental to the success of the project.”

“To make it work it is critical to have champions as DMC, ED, and Physicians. DMC does reports, not the implementation. The
Champion overall needs to be an internal change management leader with strong support.”

“Having a strong DMC was critical to the process, as well as having lots of support from management.”

“We had the faith of our clinicians, which helped immensely.”

“ED leadership was critical.”

“The DMC led the implementation project.”


Ready

Making the Case

The justification for going towards full ECR is based on both theoretical
e-health concepts and on the experiences found in the five centres “At the outset we were using Purkinje just for encounters to
visited. Many of the motivators were foreseen ahead of time, while play the numbers game and follow the evaluation framework.
We found, though, that our Purkinje codes lacked
others were only realized after implementation. The message coming consistency.”
from each of the five centres was that while there were challenges to
the implementation, none would go back to paper charting now. “Lots of our data was of very poor quality, showing males
getting PAPs and so on.”
 The use of the CMS software prior to the moving to full ECR has been “Paper charts were growing.”
limited to tracking encounters, which often led to frustration within the
centre as to its use and relevance. “Paper charts would go missing for 1.5-2 weeks, which posed
 The paper charting, combined with the highly complex care many CHC a lot of problems for our interdisciplinary work.”
clients receive, led to some very large paper charts often with poor
legibility and less than fully complete documentation and files.
 The benefits to the collaborative model of care -- thanks to the use of
the internal referrals module – were unforeseen but justified the change
process further.

Although there are strong cases made showing the justification for the
implementation for the system, many centres spoke of the challenges
associated with the software that made the process difficult.


Making the Case (continued)

“The biggest reason for centres to go that way is that other centres that are going towards an ECR are getting much better data, and
most people have come around to the idea, and often adamantly so. The principles of e-health benefits are valid.”

“The use of the software for internal referrals (i.e. collaborative model) was a big sell for the group.”

“To be 'fully ECR' means to be totally paperless, to use electronic charting as legal chart.”

“We eventually chose to go with Purkinje because we felt that the potential efficiency gains outweighed the challenges.”

“We have three satellite centres plus the one main centre. All of these locations run off of one server.”

“We moved towards the idea because we weren't using the data we were putting in, and felt that labs and meds would make Purkinje
more useful.”

“We were duplicating our efforts by keeping a small chart to support the larger one.”

“We wish to inform our LHINs of information that can help in their decision-making process.”


Ready

Need for Transition Committee

The use of a committee to help implement an ECR can lead to greater
buy-in from different groups, and is often thought of in the literature as
an essential tool to creating the necessary framework to successful “Our Champions committee comprised 2 physicians, 1 NP, 1
implementation. However, not all of the five Centres developed an ECR Clinical Manager, an Administrative lead and a DMC. It was
committee – these centres tend to operate without using committees chaired by the clinical manager.”
very often, and as such implementing one would have complicated the
“There was no ECR committee; the lack of a committee is
process unnecessarily. If a Centre chooses to establish an ECR consistent with the "non-committee" culture of the centres.”
committee, it should be composed of not only the Champions of the
change management group, but also of the ‘disbelievers’, in order to “We created a team to address issues as they came up which
help gain buy-in from all staff. met every 2 weeks.”

 The group should meet regularly, and must have representation from
management, clinical, and IT staff in order to be able to capture all
issues.
 Outstanding issues should be tracked, and resolution to them should be
a target before the next meeting.
 The use of the committee as an opportunity to train employees on the
use of the CMS software and its capabilities is an option that should be
explored.


Whither an ECR Committee? (continued)

“We did not bother with a Champion committee because we didn't feel we needed one.”

“We had a committee that Championed the process at each area within the CHC. These committees helped resolve issues.”

“We identified a group of experts to take a lead in each discipline within CHC.”

“We met monthly with admin staff, data team, provider Champions, management to address issues and to mitigate and solve
problems. We strongly recommend doing this. The open lines of communication is critical to the success of the implementation. Our
data guru ran these meetings. The whole group was passionate about what was happening.”


Ready

Building Clinical Support
“2 of our new physicians who were using labs and meds
previously and were very computer-savvy helped drive the
The clinical staff are the key users of the software, and are in the most
centre's culture towards adoption.”
advantageous position in terms of witnessing the benefits of the
implementation therefore it is absolutely critical to gain their support. “At the time we began the implementation, more than half of
The users who are being forced to ‘learn on the fly’ are the most likely our physicians were opposed to the initiative.”
to encounter challenges and difficulties and therefore can pose great
“Early on, we hired some new physicians who were
risk to the success of the implementation.
comfortable with ECRs, and this helped change the culture
towards ECR.”
 Having at least a few physicians who were comfortable with IT ensured
a smoother process and peer assistance availability for those less “Gaining clinical buy-in was critical.”
familiar with computers and technology.
“Having a physician Champion is critical at the beginning, but
 Some, but not all, centres lost physicians and other clinical staff who becomes less important over time throughout the process. It
were unfamiliar with the CMS software and were unwilling to learn. is, however, important that the Champion physician doesn't
 Due to their strong relationship with paper charts, it can be challenging change.”
to get clinical support to the change to an electronic chart, however
clinicians interviewed felt they would not go back to paper now.

Ironically, a common sentiment was that electronic charting needs to
mimic paper charting; therefore a key to getting physician buy-in is to
demonstrate the use of an ECR keeping the best of paper charting
while providing an opportunity to develop further improvements
beyond this.


Building Clinical Support (continued)

“Our physicians previously had a 'relationship' with paper as their medium of choice for charting.”

“Our physicians treated their paper charts like their security blanket, and had a lot of reluctance towards changing the system.”

“Physician Champion presented to board to support buy-in from board. Having a physician Champion do this was good move.”

“The joint relationship between the clinician community within a centre and the centre's management team is critical.“

“To get physicians interested, we looked at what business area we could improve and identified lab turnaround time. ECR allowed us
to take 7 day process down to 24 hours.”

“We had a Champion physician who got buy-in from existing staff, being capable of describing the new capabilities of the ECR.”

“We had a physician who was the Champion of the change process.”

“We needed a 'hook' to get physician interest.”

“We took the opportunity of introducing the ECR to also update our clinical protocols.”


Embarking on the Journey


Embark

Timing and Phasing of Adoption
“Before we started, we were encountering for the Ministry,
but the data were ‘useless’.“
Trying to create appropriate timelines and phases of the implementation
is difficult to do in this exercise. This is due to the fact that each CHC “Everyone has to make the change simultaneously.”
encountered different challenges from its own unique set of
circumstances, and dealt with them very differently. The consensus, in “Labs and meds were the first thing we introduced.”
terms of what the ideal approach to phasing in the full ECR across the five
“Once we had implemented labs and meds, our physicians
centres was, that a simultaneous roll-out is more effective thus
began to see the potential of the software, which created a
introducing as much of the centre to the software all at once, rather than 'pull' towards going ECR.”
in a disjointed, phased approach.
“Our Champions group began meeting 6 months prior to
rolling out the ECR. After the rollout, these meetings
 Beginning to meet and discuss the issues 6 months or more in advance continued for another 6 months.”
was beneficial to the Centre.
 Most centres agreed that a firm ‘adoption date’ was critical to the “Our outreach workers didn't use the charts before, so there's
success of the project, and not to let that date change. no need for them to use Purkinje.”
 Besides implementing all modules simultaneously, the consensus was
that implementing the ECR amongst all CHC staff at once was best.

While a firm ‘go live’ date was seen to be best, technical issues around
satellite centres and/or system capabilities must be well considered prior
to the actual date.


Timing and Phasing of Adoption (continued)

“Piece-by-piece implementation is less effective than one big move, including labs, meds, charting, and connection with front desk.”

“Previously, we used Purkinje for tracking encounters only.”

“Prior to the introduction of Labs and Meds we had been working with encountering only.”

“The first implementation step was the labs. Inputting to ECR then became more necessary to providers, and improved quality of
encounter substantially.”

“The transition to the meds module was not nearly as big as we had been concerned it would be.”

“We rolled out the ECR to social workers at the same time as the clinical staff.”

“When a date is set to make the change over to electronic, stick with that date.”

“When we brought in the meds module we encountered some difficulties.”


Embark

What do we do with the old paper charts?
“At the time of implementation, we were working partially off
The old paper charts contain not only the legal documentation of the of the paper chart and partially off of the electronic system.”
clients, but also much of a client’s medical history. There were
“Having a firm date for chart pull cut-off is a great way to
conflicting opinions around the best approach to dealing with this
stop the use of paper charts.”
historical information, with some centres scanning all information,
others scanning some of the information, and still others that input the “In inputting the information, the admin assistant had to
information from the chart into the CMS chart. Most centres had guess at some of what was written for legibility reasons.”
stopped pulling paper charts for clinicians to use during appointments.
“It took us 52 man-days of work to input 400-500 charts,
which included the allergies, the past medical history, the
 The time, resources and costs associated with scanning make it a less social history, the surgical procedures to date, prescriptions,
than ideal option, unless otherwise necessary. immunizations, and family history.”
 Inputting the information from the chart into the CMS software has “Our scanned charts are not used very much, if at all. This
substantial costs and must be input by someone who is clinically may have been a waste of time.”
literate and then validated by the physician.
 Most centres agreed that the time, energy, and money spent scanning
and storing old information may not be worthwhile as it is seldom
accessed by clinical providers once it’s there.
Despite the costs associated with making use of the historical paper chart,
the inclusion of it in the CMS software may be a necessary step in order to
gain physician acceptance of the software system.


Paper charts

“Our physicians were responsible for populating the summary information.“

“The first six months after implementation we would pull charts and clinicians would use both the paper and electronic as needed.”

“To discourage physicians from using the paper charts, we eased off of the administrative time spent pulling the paper charts such that
the docs had to do it themselves or just use the software.”

“We did not scan old information, but entered manually. Then Physician would review electronic charts and sign off on changes. This
helped with buy in for providers.”

“We didn't perform any scanning of documents which we feel saved time and money. Rather, we picked a day, and said that all
encounters were to be done in Purkinje as of that date.“

“We hired someone to populate CPP information, history of family, allergies, etc rather than scanning. This was a good idea.”

“We keep microfilm copies of all of our old, archived charts.”

“We scanned paper charts going back 1 year initially, but in the end wound up scanning the entire file in the end.”

“We scanned some of the charts.“

“We spent approximately $40K on scanning of documents.”

“We used an RN to move chart information to electronic.”


Embark

Easing the Transition “After 2 months of longer appointments, we went back to 20
minute appointments.”
While the transition to an ECR is not easy, there are many measures
“As an incentive, we gave out awards for staff who had
that can be implemented to improve the process. Based on the figured things out, created templates, etc.”
interviews, the key was to ensure that the users of the software get an
opportunity to learn the program easily without excessive pressures “At the time of implementation we had a backup of 2.5
from the appointment commitments. months due to physician training on software.”

“At the time we brought it in, we allowed some extra time for
 All the centres increased their appointment times (e.g. from 20 to 30 physicians to get more used to working with Purkinje for
minutes each) to allow for more time spent encountering using the encounters. Over time we got back to the pace we had been
CMS software. at previously.”
 Centres which are policy-heavy did develop policies to support the “Electronic charting for the allied health professionals
change but this was not the case among centres light on policies. required a lot of up front work to build e-chart properly.”
 Some, though not all centres, have returned to their original
appointment times following the initial roll-out. “Our management team reduced the number of external
meetings our staff attended.”
Due to the increase in appointment times, one centre commented that a
delay of 2.5 months built up in the appointment waiting list. Centres
must be prepared to deal with this issue should it arise during the
implementation process.


Easing the Transition (continued)

“The change management work required a lot of focus to ensure we were progressing in the right direction and not encountering
problems.”

“Use of reporting led to great buy-in from providers. The first thing we were reporting was no-show attendance.”

“We changed the clinic schedule to add more time for providers to document in the electronic record; this change was permanent.”

“We did not develop any new policies to adopt the change, but we are not a policy-centric CHC.”

“We discussed the Purkinje change over at every staff meeting, and sent out emails when issues were being addressed.”

“We increased appointment times up front, but are back to other schedule now.”

“We increased the appointment time for our physicians from 20 to 30 minutes each when we rolled out the Labs and Meds.”

“We lost some staff (1 NP and 1 Physician) due to lack of comfort with an ECR, and who didn't want to adopt change.”

“We made our appointments longer at the time of implementation, but never went back to our original schedule.”

“We needed our clinicians to spend time outside of their clinical responsibilities to deal with issues and line things up.”

“We toured other early adopter Centres in advance.”

“We used clinical staff to develop solutions and to customize the ECR for our use.”


Embark

Need for Support, Training and PLGs

To ensure that the clinical staff are well prepared for the rollout, strong “At the time of implementation, York Med was on site for 2
training must be put in place beforehand, and throughout the change to days. This was a big help as they provided lots of support.”
ensure competency continues to improve. Some centres opted to use
“Having follow-up training with York Med was a very good
training from the CMS vendor, others from York Med, and still others idea to allow for complex questions to be answered.”
from early adopters, which sent clinicians to the centres to help
providers who needed it. “It is critical for our IT team to be onsite at all times to provide
answers to questions from staff.”
 The use of clinical staff from other centres provided a great “It is important to provide feedback to providers in order to
opportunity for providers to speak with their peers and troubleshoot improve data quality/ standardization within the Centre.”
the sorts of problems the software provider was unfamiliar with.
 As full day sessions were seen as ‘information overload’ it became clear “Our DMC and his support person had no other commitments
that frequent, short training courses were a better use of time. at the time of implementation.”
 Investing in quality training up front pays dividends in the long run.

Most centres felt that even in the best of times there was only so much
learning that can be done in a ‘classroom’ setting. Working with the
program and learning by trial and error is a necessary, though difficult,
part of the learning process.


Need for Support and Training (continued)

“Providers need hands on training - not just a classroom session. Giving training in smaller chunks was much more useful than a day
long session with too many topics.”

“We brought Miriam Wiebe to train / support the providers.“

“We brought Purkinje in to support physician practice first and foremost.”

“We brought Purkinje in to train - this went well.”

“We had training sessions with a single topic every 2 weeks as a refresher for the first while; we stopped that but are now feeling that
we need to bring them back.”

“We worked quite closely with York Med throughout the change process.”

“When our full time DMC is on vacation, we contact him if we are having serious problems. Minor problems are dealt with by our
assistant DMC, but our DMC is still available if needed.”


Embark

Templates/Flow Sheets/Document Tree
“CHCs don’t have the rights for document tree security
profiles, but they need them for the sake of the evaluation
Because clinicians have such strong relationships and familiarity with framework. Without them, QI and changes can't be
paper charts having the electronic chart mimic the paper chart structure, suggested as they can't see data.”
helps them become more comfortable with the software. Three ways
“Our individual physicians like their templates so we have a
these centres found that this can be accomplished is through the use of lot of them for practices. Group practices don't require
templates, flow sheets, and a customized document tree. templates.”

“Providers use the text box to document SOAP; this means
 Templates designed should be built from existing templates created by data is harder to extract.”
early adopters, and those familiar with the CMS software, but tailored to
the specific needs of the centre. “Some templates were imported from other centres to
 Using flow sheets to track medications and diseases also provided buy-in. demonstrate their use and possibility.”
 Creating an electronic document tree of forms and other documentation
“Templates are brought over to centre and presented to
that resembles the setup of the paper chart (in the file room, etc),
physician Champion first in order to determine usability within
made clinician more comfortable. centre.”

The most frequent request heard throughout the discussions with the
centres was for e-forms which can populate from the client’s chart. When
this module is released by the software provider, it will create a much
wider acceptance for the CMS software.


Templates/Flow Sheets/Document Tree (continued)

“Templates can be lifted from other centres, but must be modified to meet specific needs of providers.”

“Templates were built by our DMC, with some being built by Purkinje, and others by clinicians.”

“We attempted to make our electronic document tree mimic the physical paper chart.”

“We created a document tree that was colour coded to match the paper documents we had used previously. This worked well.”

“We created fillable PDF that the providers would fill out (with some auto-populating fields such as client's name, etc) that are added
to the client's chart.”

“We created flow sheets for various processes to orient clinicians. The process of creating these was customized for our centre, and
they generated a lot of feedback from the clinical team.”

“We found that building templates was very valuable, and helped getting buy-in from physicians.”

“We mapped the document tree to mirror the paper chart, which was an iterative process to get it right.”

“We used customized templates to improve data entering methods - our physicians were showing a lot more evening appointments
than were actually having, so we de-selected that as the default and saw a great improvement.”


Embark

“A risk management approach is needed in order to have a
contingency plan in place for dealing with downtime.”
Hardware and Technology Considerations
“DMC performs 1.5-3 hours of preventive maintenance every
day to reconcile servers, information.”
The technology demands placed on a centre’s IT infrastructure when an
ECR is implemented increase dramatically. Therefore, a centre must “In terms of layout of the exam rooms, we did the best we
carefully consider the requirements to upgrade the existing system to could, but we wound up with a layout where the physician still
accommodate the increased demand (and the inherent costs) before has his/her back to the client when encountering in Purkinje.”
making the choice to become fully electronic.
“It is a good idea to overestimate the IT needs for
implementation in terms of software/hardware capabilities
 Backup servers , and strong IT support must be in place, and a thorough rather than underestimate. Minimal requirements won't cut
contingency plan with a risk analysis should be developed. it for very long.”
 All centres visited had installed a desktop computer in each
“It is critical to have stable hardware as a part of
examination room, most had prescription printers there, and others implementation.”
had experimented with the use of laptops (however there was a high
risk of theft associated with laptops that should be considered). “Slow computers, switches, internet/intranet are real
 Centres with satellite locations developed secure VPN access as well as problems and pose a serious risk towards implementing ECR.”
high speed DSL lines to ensure continuous access to client records.
“The cost of running the system is in the $5000-$7000 range
to cover licensing and maintenance costs.”
There was a wide spectrum in terms of maturity of IT capabilities across
the five centres, and as time goes on the centres will all continue to grow
their capacity with such future additions as Dragon (voice
recognition/dictation software), remote access for on-call clinicians and
integration with local hospital EHR.


Hardware and Technology Considerations (continued)

“The ergonomics of the equipment were critical; we solved this using Centre funds because we saw it as vital.”

“The tactile relationship between the patient and physician is hurt by physician encountering on computer due to less eye contact. The
use of tablet laptops could help.”

“To allow us to use remote access for our staff we have upgraded to a more expensive Cisco VPN that has encryption system. We got
a discount on it because of a not-for-profit allowance by Cisco.”

“Using a thin client in exam rooms was a bad idea.“

“Voice recognition using Dragon Dictate Medical works well and providers who don't have great keyboarding skills use Dragon as their
standard method of entering info into text boxes.”

“We added computers and printers into each exam room.”

“We are able to do charting from the work we do at a shelter, but this involved a $1200 cost, and have spent another $4000 to upkeep
this over time.”

“We are looking for fibre-optic hook-ups but there are costs that may prohibit this.”

“We bought a redundancy server for $25K as a backup.”

“We bought new hardware for exam rooms.”

“We considered putting a single printer in a central area, but we had geography limitations and didn't want to make our physicians
get the prescriptions or other documentation printed.”

“We do not have a mirror server. When our server quits or when the DSL slows down, we have some problems to deal with. We
recognize that this is a potential risk.”


Hardware and Technology Considerations (continued)

“We felt that we needed the mirror server once the text boxes were being used more.”

“We had to install computers and printers in each exam room.”

“We had to reset our servers frequently at first.”

“We have a backup, redundancy server, which was purchased using year-end money and came to approximately $25k.”

“We have a disaster recovery plan and have tested it.”

“We have very little disaster recovery capability.”

“We initially started with laptops but they were stolen. Now we use non-ergonomic desktops that take up a lot of space but that won't
get stolen.”

“We needed a special printer for prescriptions.”

“We recognized that we needed to spend some money to upgrade our servers.”

“We store our redundancy server out of house.”

“We upgraded all of our monitors to 22" screens and provided a printer in every examination room.”

“We used end of year funds to buy a mirror server which updates every 15 minutes.”

“We used laptops at the start, but had a problem with theft of them; we now use desktops.”

“We went one year without a redundancy server, which was due to the costs.”

“When we brought the new server in, we had some minor issues, but nothing serious.”


Embark

“For 4 months we audited our labs information, and went 6-8
weeks without gap in the HL7 feed from our labs, which met
Labs our expectations.”

“Our centre is not HL7. We have reconciled lab information.
Long-heralded as the strongest motivator towards adoption of an ECR, The main lab is CML, covering 70% of our lab tests.”
the labs module provides tremendous opportunities with an ECR. The
centres that were visited, however, had not been successful in all “Some providers are changing the "labels" for lab results
while some do not; we have to set a standard way of naming
theoretical capabilities of the lab implementations in general, and HL7 things for those who do re-label.”
more specifically.
“The challenges with the HL7 issue is big because we can't
control where people opt to go to get lab exams.”
 Centres that were HL7 are not receiving all lab results in HL7 form and
accordingly must do some manual entry to populate the client chart. “We are an HL7 centre, but some of the information coming
 Some of the centres visited had not gone HL7, and the rollout of the in is not from HL7 labs, so we store that information as PDF of
Labs module had therefore simply become a tracking device. the results.”
 One of the labs had audited its lab information and seen zero errors in
“We don't audit our lab data, but we know that there are
lab data, but has since encountered flaws in the information.
flaws still in how it's coming into the Purkinje system. We
discover this when clients ask us about the information.”
While the HL7 lab information and the lab module has not led to a
tremendous increase in the quality of information in a client’s electronic “We use 3 lab companies; some results are still coming only
chart, early adopters recommend that the roll-out of the module be by paper.”
included in any implementation plan.


Continuing the Journey


Continue

“All of our prescriptions are input to Purkinje and then printed
at the clinic.”
Achievements
“Approximately 10% of our appointments now involve a chart
pull.”
The centres interviewed have achieved a tremendous paradigm shift
with respect to the ECR. While the challenges faced due to the issues “Clinicians are very happy with the ECR now. Centre feels that
with the CMS software created some disdain towards ECR, the answer in hindsight it was the right thing to do. The culture definitely
wouldn't' t go back to paper now.”
to the question of whether they would go back was met with an
unequivocal ‘NO’. What is more impressive is that there is now a “Data extraction leads to more reasonable benchmarks and
greater appetite for the improvements, as the vision can be more easily requirements for our staff and team. We use it to set
seen within the Centre. benchmarks for how many appointments our physicians have
in a month, and how this compares to our centre's average.”

 Some centres are using the reporting tool to inform management “Digital imagery usage in electronic charting is fantastic.”
decisions regarding practices and programs.
 Most centres now regard the CMS chart file as the legal chart. “Importing digital photographs (e.g. wound care) is very
helpful.”
 Chart audits are now being performed in one centre to track quality of
care rather than quality of charting. “Management is using the ECR as a decision-making tool.”

The culture change that has occurred in these centres has without “Other health professionals (e.g. social work) noted that
question been met with a sense that while ECR is a very good concept there is less face to face interaction with the MDs and NPs.”
that can truly improve clinical care, the challenges with the CMS
software are very frustrating.


Achievements

“Our chart audits have been changed to be more effective. Rather than tracking the number of 'legible' charts, we look to see if family
history is being populated.”

“Our data is slowly improving as data input improves.”

“Our social workers and dietitians do use Purkinje.”

“Performing chart audits are now easier, as they are more legible and can be found easily.”

“Reporting has not been used as far as it could be; analysis is a challenge.”

“Reporting is used for program evaluation. We make decisions on program effectiveness.”

“The internal referral capability is a great feature and we use it heavily - more so since we went ECR.”

“The nurse and psychologist are using the data, which shows that there can be a big benefit once people get through the learning
curve.”

“There are some documents that we must keep hard copies of, so that is the extent of our physical documentation. Otherwise it is all
electronic.”

“There is paper charting of home visits, however we aim to be using laptops with VPN remote access soon.”

“We are not yet using the ECR for clinical quality improvement - although we have started to look at our compliance with clinical
guidelines in a couple of areas.”

“We don't have as much face to face time between social workers and physicians because of the ECR.”


What have we achieved so far? (continued)

“We have gained a lot of efficiencies using this and feel that practices are improving. At the satellites we see continuity of practice.”

“We have seen an sharp increase in legibility - we love that!”

“We no longer refer to a paper chart, and our electronic chart is our legal one.”

“We would certainly not go back to paper charting now.“

“We would not go back to paper (noted by ED and providers).”

“We would not hire a physician who is not willing to use the ECR.”

“We wouldn't hire a physician now who wasn't familiar with ECR.”

“We've found a great improvement in legibility of the chart, and we feel that it has given us an opportunity to improve the quality of
care for the collaborative care model.”

“Charting of youth clients is all electronic. Some paper comes in, but it's all scanned into Purkinje system.”

“Other health workers at our centre use Purkinje too. The information being input is likely only being used by them and not by other
professionals in the team (i.e. no benefit to the collaborative model).”


Continue
“A part of our orientation package now is learning the
system.“

Need for Support and Training “Every 6 months we hold refresher training for our staff.”

“Other doctors and nurse practitioners help new doctors
In order to ensure that new staff are well acclimatized to the system, become familiar with ECR when we hire someone.”
many centres have introduced training as a part of the orientation
package. It became clear over the course of the interviews that “Our training program depends on the discipline.”
interactive, less formal training sessions, being led by CHC staff rather
than by the software vendors has been the most effective means of “Some information needs to be standardized in tip sheets.”
communicating information to providers. “We hold 'tip sessions' for group learning purposes.”

 Refresher training ensures that providers are developing new skills, “We need more dedicated IT support including more money
for training and a dedicated DMC specifically for assistance
rather than simply relying on the transactional capabilities of day-to-
with Purkinje.”
day activities.
 The CMS vendor’s assistance in training during new roll-outs is of great “We need to give feedback to providers to get buy-in.”
value.
“We were prepared to hire physicians who were less tech-
 Provided a candidate seems willing to learn the system, many of the
savvy, and train them later.”
centres would hire a candidate who was unfamiliar with the CMS
software or with ECRs in general. “We would like it if Purkinje would provide regular training to
our staff on a refresher basis.”
In order to truly benefit from the ECR and to be capable of extracting and
reviewing the information input to the system, a consistent input
method must be developed. Tip sheets are useful, but most centres wish
to see greater uniformity in the way clinicians encounter in the software.


Continue

Looking forward “Advocacy work is needed to convince LHINs of importance of
ECR.”
The ECR journey is not one with a defined end-state. There were a “Consistency of input is still not where it needs to be. This is
number of long and short-term opportunities defined by the centres next big improvement measure for us.”
interviewed that will be pursued in due course. These opportunities
range from technical improvements in terms of speed of the system and “In order to drive quality of care improvements, we need to
remote VPN access, to QI drivers such as practice, quality assessments train our clinicians on querying their data and understanding
what's extractable, how to look at the data, or else DMC must
and integration with other health care centres including hospitals. do it.”

 The use of VPN access could allow for home visits, on-call work, or “More time needs to be spent figuring out what providers
want with the program and what to pull out to drive quality
‘homework’ by the provider.
care.”
 The centres identified a desire to be able to integrate with emergency
rooms in order to be aware of changes in a client’s health prior to their “Our system still cannot talk to other health centres.”
visit.
“Providers do not access Purkinje at home - this is a
 The centres feel that going forward there should be greater
technology constraint and not a policy constraint.”
involvement by clinicians in the development of the finer details of the
ECR to ensure usability and relevance.
The key opportunity that was identified in the interviews was on the
quality improvement side. While there are some individual practitioners
using the CMS software data to drive improvement most are not as they
do not understand how to extract information, or what is even
extractable.


Looking Forward (continued)

“There are many barriers to interacting with hospitals and emergency rooms, however we have been investigating this possibility.”

“There is no end goal for the ECR roadmap.”

“We are not using data on an individual physician basis. No clinician is changing their practice based on query results due to the
already elevated sense of competition between clinicians and the feeling that the anxiety would be greater than the benefits seen.”

“We do not have remote access to Purkinje.”

“We don't have any connectivity with other health centres, hospitals etc. Ideally we will one day…”

“We feel that our on-call service will be improved using remote access.”

“We have a challenge supporting Providers who do home visits and are exploring several technology solutions.”

“We have begun clinical audits to look at quality of care measures, although this is just the beginning.”

“We have no remote access to our centre's Purkinje data.”

“We have not begun using the system to drive quality of care improvements yet, as we have thus far focussed on learning Purkinje.“

“We have remote access for managers. We are introducing remote access for our physicians.”


Continue

Comments/suggestions for improving the software “During 'down time' we can lose records, depending on when
the last server auto-save was.”
The challenges faced by the CMS software are numerous, and span a “During 'down time' we may lose lab information, but may
number of different areas. All centres complained that rollouts by the not know that we have lost it rather than simply not received
software provider which are intended to fix problems seem to create it.”
new ones.
“Electronic charting needs to be fixed within Purkinje before
other centres should adopt the software.”
 There is an enormous appetite for the e-forms module, which, if
implemented properly, will improve the role of the ECR dramatically. “Going forward it would be best to have clinically relevant
modules rolled out first by the software provider.”
 Although some changes to the software have been made to match
collaborative care CHC model, more are needed in order to capture “Health promotion capabilities are limited. The software is
more health promotion language. very medically-focussed. The terminology in the software is
 Incorporating a spell-check in the text box would improve the quality of very 'negative' in its language. In order to work in
data input further. promotions, there needs to be more positive language.”

“Investigative tables don't populate properly.”
While the shortcomings of the CMS software are well documented,
there is something to be said for the fact that the suggestions focussed
around the program rather than the utility of the ECR. Clinicians have
not developed an understanding of the differentiation yet.


Suggestions for improving the software (continued)

“It is critical that investigative tables be improved to populate properly, that end-to-end testing is captured, that lab data populate
correctly, and that upgrades to the software don't hinder improvements to date.”

“It would be nice to have spell check in the text box.”

“Lab data not coming in with high quality is a problem for us that is a risk other centres should keep in mind.”

“New rollouts are problematic to the process.”

“Our lab data is coming in with errors. We discover these errors by chance, without audits.”

“Physicians want paper charting on computer, but dealing with a counter-intuitive software means that training takes entire days.”

“Purkinje is a lousy program that needs massive improvements. Once these are achieved we will have great buy-in from the CHC and
start to really effect change.”

“Recalls needs improvement, as we are using an outside system for tracking PAPS, and have no electronic data exchang.“

“Reports are difficult to find, and we don't have a consistent labelling convention.”

“The actual capabilities of Purkinje are different from what the ministry thinks is possible.”


Suggestions for improving the software (continued)

“The clinical time is taxed because of the software use during the encounter.”

“The CHCs really wants the e-forms module as soon as possible, and hope that it will fix many of the problems.”

“The piece-by-piece implementation approach was a bad idea. Every subsequent rollout is feared by CHCs greatly rather than
embraced.”

“The primary limitation to capabilities is the software.”

“The process of dealing with the software takes longer than paper charting.”

“The software is where the most effort needs to be placed as Purkinje is an inferior product. Better data extraction would be nice to
capture dietitian data better and to allow for more informed decisions.“

“There are so many options for input that our data isn't of a high quality. This has caused a serious drawback by CHCs towards
adopting it as a tool.”

“We are keen to have e-forms module.”

“We would like to see greater audio-visual tools in charting to help physicians demonstrate to their patients. For example – ‘Your
cholesterol might do this if you can get your blood pressure to do this’."


Checklist


Checklist Ready

Champions have been identified
Select ECR Transition Committee or hold 1st ECR CHC Centre meeting
Roadmap, Guidelines and Toolkit reviewed
First draft of Project plan received
Argument made for transition (Clinical buy-in)
Final draft of project plan reviewed by committee or presented to staff
Workflow Analysis (WFA) conducted
Baseline data collected
Training Needs Assessment conducted
Report on WFA and Training Needs Assessment received
Project plan approved and ready for implementation
Configuration made to CMS to accommodate WFA


Checklist Ready

Labs contacted to set online delivery (ignore if already receiving labs)
Begin discussion how to deal with paper charts (scanning, populate Cumulative Patient
Profile (CPP)
Provider Champion begins task of selecting default Clinical Notes (CNTs) and determining
customization required
Begin work on Business Continuity plan
Set Go-live date
CELEBRATE – a Milestone has been reached
Organize Training date (1st Round of Training prior to Go-live)
Draft of Business Continuity plan received
Prioritize server/hardware changes/improvements that may be required based on WFA
Draft plan for scanning paper chart ( if required)
Create provider signoff document for scanned charts


Checklist Embark

Appointments expanded by at least 10 min
If scanning – begin process or
Begin process of populating CPP
Ongoing provider signoff if populating CPP
Default CNTs customized and other CNTs work in progress
1st Round of Training delivered
Go-live
Ongoing monitoring of encounters for errors
Source, purchase and install server/hardware as required
Organize 2nd Round of training and support
Conduct mid-term evaluation and recommendations
2nd Round training and support delivered


Checklist Continue

ECR Transition Committee explores methods of how to use data to drive improvements to
client care
ECR Transition Committee determines other CHC quality improvements and programs
based CMS data
Determine if VPN/Remote access for physicians should be implemented
Organize 3rd Round of Training and Support
3rd Round of Training and support delivered


Inventory of Resources



S/N Documentation Use Source

1 Birth Control Prescription To input prescription for Birth Control medication for clients Anne Johnston
Form Health Station

2 e-labs/e-meds Workflow To detail the various steps taken by the CHC in implementing Anne Johnston
sheet the e-labs and e-meds modules. The document outlines the Health Station
changes and includes some examples

3 Transition protocol To provide instructions for many aspects of the clinical Anne Johnston
practice in terms of what changes under a paperless model Health Station

4 Prescription Process Flow To detail the process of encountering a new prescription or a Anne Johnston
sheet renewed prescription using the ECR Health Station

5 e-labs Unmatched Results To detail the process of addressing lab results that don’t Anne Johnston
Process Flow Sheet match in the ECR with the actual results Health Station

6 e-labs Lab Requisition To detail the process for requisitioning a lab test and the Anne Johnston
Process Flow Sheet associated steps therein Health Station

7 Scanning Process Flow To detail the process for scanning and validating information Anne Johnston
Sheet in a scanned chart once it is in the ECR Health Station

8 Internal Referral Process To detail the process for referring clients within the CHC Anne Johnston
Flow Sheet using the ECR Health Station

9 Contraception Sales Process To detail the process for forwarding completed prescriptions Anne Johnston
Flow Sheet for contraception medications to the appropriate desk such Health Station
that the client can obtain their prescription seamlessly and
confidentially

10 External referral Process To detail the process for referring clients to providers outside Anne Johnston
Flow Sheet the CHC Health Station




11 Diagnostic Cytology Form To input information for use by the Cytology department, Anne Johnston
outside of ECR Health Station

12 Next of Kin Form To track a client’s next of kin, supportive care providers, Anne Johnston
pharmacies, and external providers Health Station

13 Lab Test Requisition Form – To requisition certain laboratory tests for clients aside from Anne Johnston
MOHLTC the ECR Health Station

14 Clinical Practice Forms To lay out the document tree for the server for use by clinical Anne Johnston
staff Health Station

15 Document Tree To lay out the document tree for the server for use by all staff Anne Johnston
Health Station

16 Importing a text “.rtf” To detail the steps required to import a template file into the Anne Johnston
template document ECR Health Station

17 LVFA EHR Orientation Orientation Manual for new staff Langs Farm
Manual Village
Association

18 Clients folder structure Structure of document tree North Hamilton
CHC

19 Comparison Opportunity Comparison of Paper VS Electronic chart North Hamilton
Chart CHC

20 EHR 1YR Evaluation 1st Year evaluation questionnaire North Hamilton
CHC




21 EHR Presentation Presentation on move to EHR North Hamilton
CHC

22 EHR Proposal Proposal for moving to EHR North Hamilton
CHC

23 EHR Provider Signoff Signoff for providers North Hamilton
CHC

24 EHR Conceptual Concept of EHR North Hamilton
Architecture Roadmap CHC

25 IT Security Presentation on EHR Security Policies North Hamilton
CHC

26 Memo – Scanning Process Breakdown of scanning plans North Hamilton
and EHR Budget CHC

27 Memo System Security Details of suggested security policies North Hamilton
Option B CHC

28 Neverfail for SQL Server Vendor notes on backup alternative North Hamilton
CHC

29 North Hamilton CHC WFA on NHCHC workflow North Hamilton
Analysis Report CHC

30 Original Document to be List of paper documents held in chart North Hamilton
kept in client chart CHC




31 Toward EHR ISC 17-05-07 Presentation delivered on move to Full ECR North Hamilton
CHC

32 MDCHC Cheat Sheet Cheat Sheet for entering medication Merrickville CHC
Medication Revised
33 MDCHC Cheat Sheet Allergy Cheat sheet for entering allergies Merrickville CHC
Revised
34 MDCHC Cheat Sheet Cheat sheet on Dossier Dashboard Merrickville CHC
Dashboard Revised
35 MDCHC Cheat Sheet E Cheat sheet on eMessaging Merrickville CHC
Messaging Revised v2
36 MDCHC Cheat Sheet Cheat sheet on entering Historical data Merrickville CHC
Historical Data Revised
37 MDCHC Cheat Sheet Using Cheat sheet on stop dates versus duration Merrickville CHC
Duration to Create a Stop
Date in an Rx Revised

38 MDCHC ECR Pointer #1 Cheat sheet on current profiles Merrickville CHC
What Are Current Profiles
39 MDCHC ECR Pointer #2 Cheat sheet on documenting blood pressure Merrickville CHC
Documenting Blood
Pressure

40 MDCHC ECR Pointer #3 Cheat sheet on printing a scanned document Merrickville CHC
Printing a Scanned
Document




41 MDCHC ECR Road Map Merrickville CHC roadmap Merrickville CHC
07Jul26
42 MDCHC ECR Working Group Merrichville CHC working group Terms of Reference Merrickville CHC
TOR
43 NLCHC Cheat sheet for Cheat sheet for referrals North Lambton
referrals CHC

44 NLCHC Document Tree Example of a document tree North Lambton
CHC

45 NLCHC Dossier Dashboard Cheat sheet on Dossier Dashboard North Lambton
Inboxes CHC

46 NLCHC EHR DOCUMENT EHR Document list North Lambton
LIST CHC

47 NLCHC New Print Options Cheat sheet on print options North Lambton
CHC

48 NLCHC No Show Template Cheat sheet on a No Show template North Lambton
CHC

49 NLCHC Recall Process Instructions on NLCHC recall process North Lambton
CHC

50 East End CHC EHR Orientation manual for staff East End CHC
Orientation Manual


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