Secrets to EMR success

A CCRC shares implementation and selection tips

Aging services providers generally lag behind hospitals and medical pracJL A. tices when it comes to purchasing and using electronic medical records (EMR) systems, in part because government incentives-and penalties-weren't implemented with them in mind. As the government and other health system sectors increasingly recognize the vital role that entities traditionally serving seniors play in the care continuum, however, the necessity of EMRs in long-term care (LTC) settings is becoming a reality. One continuing care retirement community shared its EMR selection and implementation experience with those attending a recent Long-Term Living webinar.

The Jewish Association on Aging (JAA) realized that an EMR system could bring benefits to its CCRC, said Deborah WinnHorvitz, MS, president and CEO. Among the advantages: enhanced coordination of care thanks to a seamless flow of patient/ resident information across its service lines; improved availability, accuracy and reliability of data to enable decision-making and reporting; and enhanced efficiencies leading to cost savings-all resulting in improved quality of life for patients/residents and job satisfaction for staff members. The changing healthcare landscape and requirements related to ICD-10, the IMPACT Act, healthcare information exchange, new payment models, an increased focus on length-ofstay rates and rehospitalizations and other factors converged to convince the CCRC that the time had come to select and implement a system, she added.

Four main challenges

"Funding was a big challenge for us," Winn-Horvitz said. The Pittsburgh-area CCRC is a nonprofit, faith-based organization that includes a 159-bed skilled nursing facility; an outpatient rehabilitation center; two personal care facilities with a combined 120 units and including independent living; hospice, palliative care, home health and adult day services; and Meals on Wheels and other community resources.

JAA sought grants from local foundations * and contributions from individuals to cover some of the cost of system selection, purchase and implementation, Winn-Horvitz said, and operations will cover some of the cost. Support from the organization's board was critical, however, she added.

"It's going to be very important from the beginning to have board participation, so when it comes time for you to be in front of your board asking for support for the EMR, they will have a vested interest in this and have an understanding as to why it's so important," she told webinar attendees. Because the JAA board was involved in planning from the beginning and had been educated about the project, she added, members permitted funds from its endowment to cover much of its costs.

A second challenge, Winn-Horvitz said, was ensuring sufficient information technology (IT) support. Before implementation, JAA had outsourced its help desk function to one person. "We really needed to put some type of infrastructure in place," she said.

At the beginning of the project, the CCRC hired a full-time project manager who had an IT background. As implementation loomed, JAA hired an EMR nurse clinician. "One of the looking-back lessons learned is, I would have hired that EMR nurse clinician earlier in the selection process as opposed to waiting until implementation," WinnHorvitz said. The Pittsburgh Regional Health Initiative and Pennsylvania REACH, a federally funded regional extension center (REC), provided assistance as well, she added. (JAA was one of the first LTC providers to benefit from REC services, she said.)

A third challenge related to JAAs EMR journey, she said, was upgrading the CCRC's hardware and networks. What JAA had was "bare-bones minimal and clearly not adequate to support the implementation of an EMR," Winn-Horvitz said. "And so we ultimately rolled that cost up into the entire implementation."

Actually selecting the system was a fourth challenge. "We knew what our core components were of our IT strategy," the CEO said. "We had an idea of what we were looking for-there are, of course, a number of systems out there on the marketplace-but we really didn't know where to begin in terms of the selection process."

The LeadingAge Center for Aging Services Technologies (CAST) electronic health records system selection tool also was a "tremendous resource" for discovering systems and analyzing their capabilities, she said. JAA also contracted with a consulting company that specializes in EMR selection. "For the spend that was associated with their assistance, it was very, very insignificant compared with the spend for the whole EMR system," Winn-Horvitz said. "It was a very worthwhile investment for us."

JAA sought a system that was sustainable, high-performing and compliant with the Health Insurance Portability and Accountability Act. The system had to have mobile accessibility, too, because "physicians prefer to access information either on-the-go or from their offices when they're not here physically rounding in our facilities," WinnHoritz said.

The CCRC narrowed its choices to six, then three, then two products, aided by the LeadingAge CAST tool and information gathered by the consultants. "We did very, very detailed site visits for both of those vendors," visiting providers that were using the systems, Winn-Horvitz said. The scrutiny also included calls to additional facilities geographically less convenient to visit as well as examination of responses to a request for information.

The consultants calculated the five-year total cost of ownership for the two finalists, including software, hardware, incremental staffing and consulting costs for the implementation, the cost of keeping the CCRC's current system operating during the change, costs for training the project team during the selection process and training all system users during implementation, costs to convert existing patient/resident data into the new system and costs for interfaces to systems not being replaced.

"Some of these are things that we would not have thought of," Winn-Horvitz said, "so they were able to put together a very, comprehensive picture for us of what that total cost of ownership would be for the systems that we were considering."

Ultimately, JAA chose the HealthMEDX EMR. The company "had a really great track record in terms of a rollout that was pretty standardized at this point in their life cycle, and that really made it much easier for us," Winn-Horvitz said.

Overseeing the project

At the beginning of the project, she said, JAA and its board established guiding principles and goals for the project as well as committees to see it through. The executive steering had oversight at the highest level and included some board members with IT or project management experience as well as the president/CEO, the chief financial officer and the project manager. The system selection committee included heads of all of the lines of business as well as staff members from the front lines.

"We included CNAs, and we included some LPNs and RNs, because we knew that they were going to be critical not only to helping us understand their challenges on a day-to-day basis but also critical in terms of adoption," Winn-Horvitz said. "If we were to select a system without them and then kind of force it on them, then that clearly would not go over well." Remember to include the medical director in the process as well, she advised.

JAA began implementing the EMR in the first quarter of 2014, and the system went live in the skilled nursing, personal care and independent living areas in July. "It was really a very efficient six-month implementation process, and we were able to go live on time," Winn-Horvitz said. "We're scheduled to go live with our home- and community-based services by the end of this calendar year."

The implementation phase has included several forms of oversight: an executive committee of senior managers; the initial oversight committee from the selection process, which included some board members; an implementation team, including representatives from all levels of the organization; an administrative work group that included staff members in business functions such as billing and collections; a project team, led by the project manager, which addressed technical issues; and clinical work groups.

Going live

"We formed the clinical work groups at the time of go-live and have continued them in those areas where we've gone live," WinnHorvitz said. "They meet on a biweekly basis right now to continue to refine workflows, make changes to the system and work with our vendor partner to continue to refine."

The clinical work groups also identify where retraining is needed. "It's not enough to train everyone just once," WinnHorvitz said. "You have to tell them, and then tell them again and again."

As the rollout was set to begin, JAA tried to create a sense of excitement and enthusiasm among all staff members, making it "more than just an IT project," Winn-Horvitz said. "We actually gave a name to the project. We called it J Care, and we were counting down the days to the launch of J Care at the organization. We had signs up. Everyone knew it was coming."

The organization identified "super users" who could troubleshoot issues and help their co-workers learn the new system, and everyone knew in advance who the super users were. On the go-live date, those super users wore bright green T-shirts so that they were easily identifiable. "We asked them to wear the Tshirts for the first week of go-live so that if anyone had a problem anywhere, they knew where they could find a super user," WinnHorvitz said. "All shifts, all over the organization."

The contingency planning the CCRC had completed ended up being useful during implementation, she added. "When you're going live with an EMR, everyone knows there's a chance that something could happen, and as fate would have it, we actually ended up having some issues with our power. We had a number of unplanned power outages probably two weeks into our golive."

But one of the most important lessons JAA learned in the entire EMR selection and implementation process was the importance of communication, Winn-Horvitz said. "You cannot overcommunicate," she said. "It's so important to include individuals from all levels of the organization. It makes everyone's job much easier if everyone really knows what's going on.'

The CCRC already is reaping rewards from its implementation to date: improvements in quality measure scores; access to real-time information; improved workflows in admissions, finance and nursing; and accelerated cash flow due to full electronic claims submission and payment processing.

The organization identified "super users" who could troubleshoot issues and help their co-workers learn the new system, and everyone knew in advance who the super users were.

BY LOIS A. BOWERS, SENIOR EDITOR