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Slide 1: 

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

Contents : 

Contents Acknowledgements List of Abbreviations Introduction The PMBOK Framework Framework of the implementation Lessons Learned – A summary Getting Ready Embarking on the Journey Continuing the Journey Summary Checklist

Acknowledgements : 

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

Abbreviations : 


Abbreviations : 


Introduction : 

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 : 

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 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) : 

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 : 

Roadmap & Guideline Process Phase 1 Phase 2 Phase 3

Key Lessons Learned – Getting Ready Phase : 

Key Lessons Learned – Getting Ready Phase

Key Lessons Learned – Embarking on the Journey Phase : 

Key Lessons Learned – Embarking on the Journey Phase

Key Lessons Learned – Continuing the Journey Phase : 

Key Lessons Learned – Continuing the Journey Phase

Ready : 


Slide 15: 

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

Importance of Change Champions (continued) : 

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.”

Slide 17: 

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

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.”

Slide 19: 

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

Whither an ECR Committee? (continued) : 

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.”

Slide 21: 

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

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 : 

Embarking on the Journey

Slide 24: 

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

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.”

Slide 26: 

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

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.”

Slide 28: 

“After 2 months of longer appointments, we went back to 20 minute appointments.” “As an incentive, we gave out awards for staff who had figured things out, created templates, etc.” “At the time of implementation we had a backup of 2.5 months due to physician training on software.” “At the time we brought it in, we allowed some extra time for physicians to get more used to working with Purkinje for encounters. Over time we got back to the pace we had been at previously.” “Electronic charting for the allied health professionals required a lot of up front work to build e-chart properly.” “Our management team reduced the number of external meetings our staff attended.” While the transition to an ECR is not easy, there are many measures that can be implemented to improve the process. Based on the interviews, the key was to ensure that the users of the software get an opportunity to learn the program easily without excessive pressures from the appointment commitments. All the centres increased their appointment times (e.g. from 20 to 30 minutes each) to allow for more time spent encountering using the CMS software. Centres which are policy-heavy did develop policies to support the change but this was not the case among centres light on policies. Some, though not all centres, have returned to their original appointment times following the initial roll-out. Easing the Transition 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) : 

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.”

Slide 30: 

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

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.”

Slide 32: 

“CHCs don’t have the rights for document tree security profiles, but they need them for the sake of the evaluation framework. Without them, QI and changes can't be suggested as they can't see data.” “Our individual physicians like their templates so we have a lot of them for practices. Group practices don't require templates.” “Providers use the text box to document SOAP; this means data is harder to extract.” “Some templates were imported from other centres to demonstrate their use and possibility.” “Templates are brought over to centre and presented to physician Champion first in order to determine usability within centre.” Because clinicians have such strong relationships and familiarity with paper charts having the electronic chart mimic the paper chart structure, helps them become more comfortable with the software. Three ways these centres found that this can be accomplished is through the use of templates, flow sheets, and a customized document tree. Templates designed should be built from existing templates created by early adopters, and those familiar with the CMS software, but tailored to the specific needs of the centre. Using flow sheets to track medications and diseases also provided buy-in. Creating an electronic document tree of forms and other documentation that resembles the setup of the paper chart (in the file room, etc), made clinician more comfortable. Templates/Flow Sheets/Document Tree 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/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.”

Slide 34: 

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

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) : 

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.”

Slide 37: 

“For 4 months we audited our labs information, and went 6-8 weeks without gap in the HL7 feed from our labs, which met our expectations.” “Our centre is not HL7. We have reconciled lab information. The main lab is CML, covering 70% of our lab tests.” “Some providers are changing the "labels" for lab results while some do not; we have to set a standard way of naming things for those who do re-label.” “The challenges with the HL7 issue is big because we can't control where people opt to go to get lab exams.” “We are an HL7 centre, but some of the information coming in is not from HL7 labs, so we store that information as PDF of the results.” “We don't audit our lab data, but we know that there are flaws still in how it's coming into the Purkinje system. We discover this when clients ask us about the information.” “We use 3 lab companies; some results are still coming only by paper.” Long-heralded as the strongest motivator towards adoption of an ECR, the labs module provides tremendous opportunities with an ECR. The centres that were visited, however, had not been successful in all theoretical capabilities of the lab implementations in general, and HL7 more specifically. 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. Some of the centres visited had not gone HL7, and the rollout of the Labs module had therefore simply become a tracking device. One of the labs had audited its lab information and seen zero errors in lab data, but has since encountered flaws in the information. Labs 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 chart, early adopters recommend that the roll-out of the module be included in any implementation plan.

Continuing the Journey : 

Continuing the Journey

Slide 39: 

“All of our prescriptions are input to Purkinje and then printed at the clinic.” “Approximately 10% of our appointments now involve a chart pull.” “Clinicians are very happy with the ECR now. Centre feels that in hindsight it was the right thing to do. The culture definitely wouldn't' t go back to paper now.” “Data extraction leads to more reasonable benchmarks and requirements for our staff and team. We use it to set benchmarks for how many appointments our physicians have in a month, and how this compares to our centre's average.” “Digital imagery usage in electronic charting is fantastic.” “Importing digital photographs (e.g. wound care) is very helpful.” “Management is using the ECR as a decision-making tool.” “Other health professionals (e.g. social work) noted that there is less face to face interaction with the MDs and NPs.” The centres interviewed have achieved a tremendous paradigm shift with respect to the ECR. While the challenges faced due to the issues with the CMS software created some disdain towards ECR, the answer 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 greater appetite for the improvements, as the vision can be more easily seen within the Centre. Some centres are using the reporting tool to inform management decisions regarding practices and programs. Most centres now regard the CMS chart file as the legal chart. Chart audits are now being performed in one centre to track quality of care rather than quality of charting. Achievements The culture change that has occurred in these centres has without question been met with a sense that while ECR is a very good concept that can truly improve clinical care, the challenges with the CMS software are very frustrating.

Achievements : 

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) : 

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).”

Slide 42: 

“A part of our orientation package now is learning the system.“ “Every 6 months we hold refresher training for our staff.” “Other doctors and nurse practitioners help new doctors become familiar with ECR when we hire someone.” “Our training program depends on the discipline.” “Some information needs to be standardized in tip sheets.” “We hold 'tip sessions' for group learning purposes.” “We need more dedicated IT support including more money for training and a dedicated DMC specifically for assistance with Purkinje.” “We need to give feedback to providers to get buy-in.” “We were prepared to hire physicians who were less tech-savvy, and train them later.” “We would like it if Purkinje would provide regular training to our staff on a refresher basis.” In order to ensure that new staff are well acclimatized to the system, many centres have introduced training as a part of the orientation package. It became clear over the course of the interviews that interactive, less formal training sessions, being led by CHC staff rather than by the software vendors has been the most effective means of communicating information to providers. Refresher training ensures that providers are developing new skills, rather than simply relying on the transactional capabilities of day-to-day activities. The CMS vendor’s assistance in training during new roll-outs is of great value. Provided a candidate seems willing to learn the system, many of the centres would hire a candidate who was unfamiliar with the CMS software or with ECRs in general. Need for Support and Training 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.

Slide 43: 

“Advocacy work is needed to convince LHINs of importance of ECR.” “Consistency of input is still not where it needs to be. This is next big improvement measure for us.” “In order to drive quality of care improvements, we need to train our clinicians on querying their data and understanding what's extractable, how to look at the data, or else DMC must do it.” “More time needs to be spent figuring out what providers want with the program and what to pull out to drive quality care.” “Our system still cannot talk to other health centres.” “Providers do not access Purkinje at home - this is a technology constraint and not a policy constraint.” The ECR journey is not one with a defined end-state. There were a number of long and short-term opportunities defined by the centres interviewed that will be pursued in due course. These opportunities range from technical improvements in terms of speed of the system and remote VPN access, to QI drivers such as practice, quality assessments and integration with other health care centres including hospitals. The use of VPN access could allow for home visits, on-call work, or ‘homework’ by the provider. 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 visit. The centres feel that going forward there should be greater involvement by clinicians in the development of the finer details of the ECR to ensure usability and relevance. Looking forward 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) : 

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.”

Slide 45: 

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

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) : 

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 : 


Slide 49: 

 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

Slide 50: 

 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

Slide 51: 

 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  CELEBRATE – a Milestone has been reached  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  CELEBRATE – a Milestone has been reached  2nd Round training and support delivered Checklist

Slide 52: 

 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  CELEBRATE – a Milestone has been reached  3rd Round of Training and support delivered Checklist

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Inventory of Resources

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Inventory of Resources

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Inventory of Resources

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Inventory of Resources

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Inventory of Resources

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Inventory of Resources

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