VOLUNTEERS IN MEDICINE:

CLINIC OF THE CASCADES

EMR IMPLEMENTATION PROJECT PLAN

Prepared by VIM-OHSU Group

Marie Brandt, Project Manager Greg Forzley, MD Greg Fraser, MD

Monte Masten, MD Glen Stream, MD Amy Y. Wang, MD

Version 1.0 June 9, 2003

1 INTRODUCTION 4

1.1 PURPOSE 4 1.2 DOCUMENT ORGANIZATION 4 1.3 BACKGROUND AND RELATED DOCUMENTS 4

2 MANAGEMENT SUMMARY 5

2.1 A GROWING NEED 5 2.2 MEETING THE NEED 6 2.3 OVERALL REQUIREMENTS 7

2.3.1 PHYSICIAN ACCEPTANCE 7 2.3.2 SYSTEM FUNCTIONALITY 8 2.3.3 ACCESSIBLE HARDWARE 8

2.4 PROBLEM AREAS 9 2.4.1 PROFESSIONAL ISSUES 9 2.4.2 INFORMATION FLOW INTO AND OUT OF THE CLINIC 10 2.4.3 SOFTWARE LIMITATIONS 11

2.5 SCHEDULE: SUGGESTED MILESTONES 12 2.5.1 COMPLETED STEPS 12 2.5.2 SIX MONTHS PRIOR TO OPENING 12 2.5.3 FOUR MONTHS PRIOR TO OPENING 12 2.5.4 THREE MONTHS PRIOR TO OPENING 12 2.5.5 TWO MONTHS PRIOR TO OPENING 12 2.5.6 ONE MONTH PRIOR TO OPENING 12 2.5.7 ONE WEEK PRIOR TO OPENING 12

3 MANAGEMENT AND ORGANIZATION 13

3.1 PROJECT MANAGEMENT AND ORGANIZATION 13 3.2 CLINIC PERSONNEL 13

3.2.1 BACKGROUND 13 3.2.2 PHYSICIAN CHAMPION 13 3.2.3 VOLUNTEER MEDICAL STAFF 14

3.3 TRAINING AND DEVELOPMENT 18 3.3.1 INTRODUCTION 18 3.3.2 CHALLENGES 19 3.3.3 ASSESSMENT OF COMPUTER LITERACY 20 3.3.4 BASIC TRAINING 20 3.3.5 APPROACHES TO TRAINING 21

4 TECHNICAL SECTION 23

4.1 STATEMENT OF WORK AND SCOPE OF WORK 23 4.2 WORK BREAKDOWN 23 4.3 RESPONSIBILITY ASSIGNMENTS 24

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4.4 BUDGET AND FINANCIAL SUPPORT 24 4.5 TESTING 24 4.6 CHANGE CONTROL PLAN 25 4.7 QUALITY PLAN 25 4.8 WORK REVIEW PLAN AND CLINIC PROJECT MANAGEMENT 26 4.9 DOCUMENTATION 26 4.10 IMPLEMENTATION 27

4.10.1 INTRODUCTION 27 4.10.2 EDUCATION 27 4.10.3 PRELOADING OF DATA 27 4.10.4 STEPWISE APPROACH 28 4.10.5 SECURITY, PRIVACY, AND CONFIDENTIALITY 30 4.10.6 WORKFLOW 30 4.10.7 PHYSICIAN INPUT 32

4.11 JUSTIFICATION 33 4.12 UNCERTAINTY AND RISK 35

4.12.1 FUNCTIONALITY 35 4.12.2 USER ABILITY AND ACCEPTANCE 35

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1 INTRODUCTION

1.1 Purpose The overall purpose of this project is to achieve successful implementation and user acceptance of a clinical information system that includes an electronic medical record (EMR) system into Clinic of the Cascades, a health care facility that is being established by Volunteers in Medicine (VIM).

1.2 Document Organization Section 2 Management Summary provides an overview of the project and introduces the need for the clinic and the EMR, hardware and software features of the system, key challenges of the implementation, and major milestones of the project. The remainder of the document provides detailed information and recommendations for successful completion of the project.

1.3 Background and Related Documents This document was prepared in three phases, each phase generating a series of documents which were used to help prepare this project plan. Phase 1: Background research on EMR issues and barriers to adoption

• Professional Issues • Literature review on paper records EMRs • Hardware and network selection and structure • Physician characteristics

• Product Evaluation • Literature review on e-MDs topsChart • Evaluation of software features • Rationale for selecting topsChart

• Office issues with EMR information flow into and out of the office Phase 2: Barrier Analysis

• Techniques to remove identified barriers • Physician and staff training and support • Migration planning: preparation for incoming results and communications

Phase 3: Preparation of final project plan

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2 MANAGEMENT SUMMARY

2.1 A Growing Need Access to affordable health care is a clear and urgent need in the United States. More than 40 million Americans do not have health care insurance. Of these, almost 8.5 million are children. As of the year 2000, it was estimated that nearly 420,000 Oregon citizens were without health insurance, a statistically significant increase from the previous study finished in 1998. Deschutes County is located in the heart of Central Oregon. It includes the municipalities of Bend, Redmond, and the City of Sisters. The county has a population of approximately 126,500 residents. Of importance is the fact that as of the year 2000, 12.5% of the residents in this county were without health insurance. The majority of the uninsured tend to be male and Hispanic, have a household income at or below 200% of the Federal Poverty Level, do not possess a high school diploma, and belong to a single parent household. While regional differences do exist, Deschutes County possesses one of the highest rates of uninsured citizens in Oregon. 75% of adult uninsured Americans are employed; the average cost of an employer-sponsored health care policy is $7035, a high cost that is one major reason that many of the uninsured are working Americans. 40% of personal bankruptcies in this country are related to health care costs. The increasing number of uninsured Americans who lack access to health care places an unsustainable burden on this country’s health care system. The Clinic of the Cascades is being established to provide basic health care for a severely underserved population. The clinic will ultimately succeed. It has to. It is a vastly needed response to a growing health care crisis not only in Oregon, but the country as well.

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2.2 Meeting the Need Volunteers in Medicine (VIM) is constructing a new medical clinic in Bend, Oregon, to be known as Clinic of the Cascades. The clinic will be a volunteer-based medical facility designed to serve the medical needs of uninsured or medically underserved residents of Deschutes County. The Clinic of the Cascades is being developed under a $1 million grant on land donated by nearby St. Charles Hospital. Operations are scheduled to commence in January 2004. In addition to a salaried administrative and clerical staff of six or seven people, the clinic will be staffed by volunteer health professionals: family physicians, nurse practitioners, dentists, specialists as well as support staff consisting of nurses and medical assistants. The main focus of the clinic will be providing primary health care services, with the majority of care being delivered in the new facility. Patients will be referred to St. Charles Hospital for additional services. It is the intention of the Clinic of the Cascades to build a foundation based on an electronic clinical information system which will facilitate health care operations. The clinic will utilize Toshiba Protégé tablet PC’s running version 4.1 of the TopsChart electronic medical record (EMR) system, produced by e-MDs, a medical software company based in Austin, Texas. The decision to select the TopsChart software was based on an evaluation by the American Academy of Family Physicians. The clinical information system will be used for scheduling patients, documenting encounters into the EMR, and scanning in lab reports, x-rays, and other test results. The facility will go paperless from the outset. The Clinic of the Cascades will reduce administrative costs, improve operational efficiencies, and ultimately maximize the quality of medical care delivered to its patients by utilizing an electronic clinical information system. Costs will be reduced through lower transcription and copying costs, reduced malpractice premiums, reduction in duplicate testing, and improved coding. Efficiency will be significantly enhanced through less dictation time, reduced nurse intake time, and reduction in total overhead time per patient encounter, allowing health care providers to spend more time with patients. Quality will be improved through reductions in medication errors, increased compliance with preventive and treatment guidelines, and improved reporting and analysis of patient outcomes. The Clinic of the Cascades will ease, not solve, a growing problem of healthcare access in Central Oregon. A key element in the clinic’s long-term success will be successful implementation of the clinical information system. Although significant barriers exist, comprehensive planning, quality training, and a well-executed implementation will result in user acceptance and successful utilization of the system by the clinicians. With a solid organizational framework, unified mission to provide quality health care, adoption of strategies used successfully in other volunteer clinics, and anticipated efficient management of health information with an EMR system, the Clinic of the Cascades should prosper for years to come.

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2.3 Overall Requirements

2.3.1 Physician Acceptance A medical clinic cannot survive without medical professionals. In order to operate the clinic and utilize a clinical information system successfully at the outset and long-term, the Clinic of the Cascades must recruit and retain quality health professionals, train them adequately in the use of information technology, address their concerns about workflow, and identify physician champions to promote user acceptance. These important steps are summarized here and described in greater detail in Sections 2 and 3.

2.3.1.1 Recruitment In order to assure success, the clinic must recruit and retain a highly qualified volunteer medical force. It must attract committed physicians and address issues such as unfamiliarity with the clinic, the clinic’s working conditions, and the legal concerns with regards to volunteer medical care. In order to recruit and retain a volunteer staff capable of utilizing a paperless clinical system, it is essential that the clinic administration identify the factors that motivate volunteers to remain, the obstacles to physician adoption of the EMR system, and ways to increase acceptance. It is critical that the volunteer staff adopts and supports an EMR system that will promote improvements in patient care and clinic operational efficiencies that will help achieve long-term viability of the clinic.

2.3.1.2 Training Implementing an EMR system at a volunteer clinic is a large undertaking involving users with varying needs and levels of comfort with information technology. User apprehension and resistance are normal and to be expected, but are not insurmountable. Quality training and support will be key factors in the acceptance and success of the EMR system at Clinic of the Cascades. By considering potential challenges and user needs and by using proven training approaches, it will be possible for VIM, in conjunction with the vendor, e-MDs, to design and implement a training program of sufficient quality, timeliness, and flexibility in order to allow each physician adopt and use the topsChart EMR system successfully.

2.3.1.3 Workflow Involving physicians and other clinic staff members in workflow assessment is vital to a successful EMR installation. Physicians who participate in the entire

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process, from workflow assessment to implementation, are able to voice their concerns, provide valuable input, and feel vested in the process. Their feedback can help implementers customize the system to meet their specific workflow needs. The success of the project will be largely dependent on managing the stress of the major change in the clinical workflow and hinges on the perception that sufficient value is gained from the change to justify the costs.

2.3.1.4 Physician Champion Finally, and perhaps most important to success will be for the Clinic of the Cascades to identify and promote a physician champion for the EMR system, who can greatly increase user acceptance of a clinical information system. A champion can motivate other physicians about the project and facilitate communication between administrators, implementers, and physicians.

2.3.2 System Functionality The selection of topsChart for use in the new Clinic of the Cascades was determined based upon a study of practice management software by the American Academy of Family Physicians (AAFP) published in 2002. The study included comprehensive technical, financial, task and functional components evaluations and pricing considerations. It presented a comparison of all systems with regard to these issues and calculated individual and composite scores for each product. The study excluded customer satisfaction because the number of respondents in this area was small and varied. In that report, topsChart demonstrated high marks for functional features and actual physician customer satisfaction. The technical features of the software received acceptable marks when compared to other programs. The topsChart system also was priced within the clinic’s budget. Based on this report, it was determined that topsChart contains many of the features that will be required by the physicians and staff at the Clinic of the Cascades. 2.3.3 Accessible Hardware The electronic medical record software for Clinic of the Cascades will be installed on tablet computers and connected via a wireless network. Each physician will have access to a computer either during or after each patient visit. The overview of the plan for the hardware and network configuration, as well as system security and HIPAA compliance, is a work in progress at this stage of the project. With that in mind, all of the business and cultural issues that have been identified appear at the forefront of the vision for the VIM Clinic information technology (IT) requirements.

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2.4 Problem Areas The critical barriers specific to use of an electronic record in the Clinic of the Cascades need to be identified, so that techniques to remove these barriers can be developed. While these are discussed in more detail in other sections of this report, summary considerations are shared here. 2.4.1 Professional issues

2.4.1.1 Barriers to EMR Adoption The current use of electronic medical records nationally falls far short of a recommendation made by the Institute of Medicine over a decade ago that 100% use be attained by the year 2000. While physicians are gradually adopting computers to automate some aspects of the patient encounter, such as appointment scheduling and billing, they have been reluctant to adopt the use of an EMR system for documentation. Several potential barriers to physician acceptance of the EMR have been identified. Among these are loss of physician autonomy, time constraints, privacy issues, effects on the patient encounter, necessity of the EMR, computer familiarity and skills, and potential workflow disruptions.

2.4.1.2 Computer Literacy Many physicians perceive themselves to have poor computer literacy. These physicians will need to acquire or further develop basic computer skills beyond those of using the Internet prior to learning to using an EMR system. The goal is to develop a program which trains the doctors on basic computer and EMR skills most efficiently and successfully.

2.4.1.3 Physician Buy-in Experience has demonstrated repeatedly that users of a clinical information system will reject the system unless there is sufficient buy-in. The decision to implement an EMR system, specifically e-MDs topsChart, was made largely by administrators, not by health care professionals. The health professionals are not purchasing the system and may have no financial interest in seeing it succeed, especially if they do not understand the benefits. The importance of educating users about the benefits to the clinic and the local community of using an EMR system cannot be underestimated.

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Health professionals also will not accept a new technology if they feel that it is being imposed upon them without their input. They need to feel that their input is valued for implementation, training, and support, and that any concerns or suggestions will be promptly addressed. Although the clinic will not mandate use of the EMR interface for documentation, the goal is that fifty percent or more of patient encounters will be documented using topsChart. In the beginning, the remainder will be able to dictate their notes, with medical transcription students from the local community college entering the information directly into the topsChart interface. While this is a creative solution which gives physicians the option of using a familiar technology in lieu of using the EMR, the physicians may become so comfortable dictating and using the transcription service that they are even more reluctant to begin learning and using the EMR system. It will also be helpful for the clinic to have a plan in place to encourage health professionals to make the transition from dictation to direct EMR data entry. Physician perception of value and ultimate acceptance of the changes in workflow caused by an EMR system are heavily influenced by their levels of computer literacy and the ease of use of the software. They will form strong, lasting impressions early on about the system based on their personal experiences with how the EMR impacts workflow and efficiency in patient care. These factors highlight the importance of early, timely, adequate, and high-quality basic computer and application-specific training. Medical software implementations rarely fail because of problems with the technology. The vast majority of system failures are due to people and organizational issues. All clinic personnel, especially the project and clinic leadership, must be fully committed to successful implementation of the EMR system. If a system is installed and the users are not given the motivation, support and direction from the top that they need, they will inevitably perceive that the system is not of sufficient value and begin to lose interest. Users who are no longer engaged will not put forth the effort required to make a new project succeed. Strong organizational support is essential for creating an atmosphere that encourages adoption of the workflow changes necessary for a successful EMR implementation. 2.4.2 Information Flow into and out of the Clinic The collection, storage, and retrieval of patient information are central to the practice of medicine, whether the information is recorded in paper charts or in an EMR system. Health professionals need methods and tools for readily documenting, organizing, and accessing large quantities of complex health information. Patient information must also be transmitted to outside entities to adequately coordinate patient care among multiple care providers.

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In order for the clinic to successfully use an EMR from the outset in lieu of paper records, physicians and staff need to be engaged in the concept of a paperless environment. The clinic must manage the flow of electronic information into and out of the clinic in order to maintain a paperless environment. Health care requires the importing and exporting of documents in order to facilitate patient care among different health care providers. Although EMR systems may help reduce the use of paper in a practice, “paperless” does not mean a lack of documents. EMR systems may be created with features that aid practices with the inward and outward flow of paper and electronic documents. Information into the medical record during the actual patient visit is expected to be handled primarily through direct computer entry using the robust array of clinical categories and templates available within the topsChart application. Although dictation and transcription will also be available, the eventual goal is for all health providers to enter their own notes directly into the EMR system. Much of the information that enters into an EMR from outside consists of diagnostic test results, letters, and outside records. Using the TaskMan and DocMan features in topsChart will help establish and maintain a paperless environment by effectively alerting physicians to new and important incoming information, managing the everyday efficiency of patient flow throughout the office, and importing and organizing paper documents sent from outside the clinic. In addition to the need to bring information into the electronic record, there is also the requirement to produce or send information that is captured in the chart in order to respond to various needs, such as for prescriptions, orders, and referral letters. An evaluation of the topsChart has demonstrated that the system contains the necessary utilities for generating documents that are to be sent out from the clinic. 2.4.3 Software Limitations As noted, topsChart was selected on the basis of a study of practice management software published in 2002 by the AAFP. While it performed poorly on financial features, this element was considered less important since the Clinic will be a free walk-in clinic. Some features that can be considered key to workflows and efficiency (such as central ‘inbox’ features of TaskMan, the ability to query records for medication issues, etc) need further clarification through demonstration and testing of the software by the Clinic personnel. This is important since it may cause changes in the workflow within the Clinic, as well as general user acceptance. The EMR system currently is not fully compliant with federal privacy and security rules. According to the vendor, this deficiency will be corrected in an upcoming version of topsChart.

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2.5 Schedule: Suggested Milestones A detailed project schedule is outside the scope of this plan, but it would appear that there is adequate time between now and January 2004 to complete the tasks necessary to ensure successful implementation of the clinical information system. In the context of the recommendations contained within this analysis, it is believed that the following milestones are worthy of consideration: 2.5.1 Completed Steps

• Selection of EMR software • Establishment of Clinic Project Manager • Consideration of volunteer and employed staffing, volunteer physician

recruitment and physician champion 2.5.2 Six Months Prior to Opening

• Identification of Physician Champion(s) 2.5.3 Four Months Prior to Opening

• Completion of initial recruitment of volunteer medical staff 2.5.4 Three Months Prior to Opening

• Completion of assessment of clinicians’ basic computer skills • Completion of installation of computer training lab

2.5.5 Two Months Prior to Opening

• Completion of clinician training in basic computer skills 2.5.6 One Month Prior to Opening

• Completion of workflow analysis • Commencement of clinicians’ application-specific training

2.5.7 One Week Prior to Opening

• Final completion of installation of hardware and software • Final completion of clinicians’ application-specific training and evaluation

of the adequacy of training

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3 MANAGEMENT AND ORGANIZATION 3.1 Project Management and Organization The clinic will have an executive management team composed of an Executive Director, a Medical Director, and a Board of Directors of sixteen. Christine Winters, the project manager, is overseeing the entire EMR implementation. Doug Ritchie is the project sponsor who is providing technical expertise for the project. He will also design and implement the training program for the EMR. Additional team members will assist with the project. 3.2 Clinic Personnel

3.2.1 Background The clinic will employ six or seven full-time employees, with the remainder of the clinic’s staff comprised of part-time volunteers. Approximately 23 physicians of varying specialties will staff the clinic; their ages range from the 50’s to the 70’s, with roughly 25% still in active practice and 75% retired. The support staff will include nurses, nurse practitioners, and medical assistants. Local medical transcription students and volunteers from the community will also provide assistance to the clinic. Although a formal alliance has not been formed, the Clinic of the Cascades will be physically in close proximity to St. Charles Hospital in Bend, Oregon, on land donated by the hospital, and will utilize various ancillary services through St. Charles.

3.2.2 Physician Champion An important early step will be for the Clinic of the Cascades to identify and promote one or more physician champions for the EMR system. Ideal champions would be individuals who are enthusiastic and optimistic regarding EMR systems. They will have had much experience with computers at home and at work. By virtue of their previous experience they will understand the benefits and shortcomings of EMR systems. They will then be able to educate others on the value of EMRs and advocate their use. Physician champions must tolerate change well and be excellent listeners and communicators. If a physician EMR champion cannot be identified among the volunteer staff, it may be necessary for the clinic to find one through community and medical resources who can volunteer time, not to see patients, but rather to support the implementation and training requirements for the EMR system. Besides computer literacy issues, one reason why physicians are reluctant to embrace technological changes such as EMRs can be traced to the physician

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culture. For the most part, the physician culture is conservative and reluctantly shares decision-making and managerial power with outsiders (i.e., non-physicians). The physician cultural characteristics may reflect a self-centered, narrow-minded, and shortsighted worldview. However, these traits dominate many physicians’ minds and can’t be dismissed. A physician champion can help the EMR implementation succeed by bridging the professional, cultural, technological, and managerial differences between physicians, staff members, administrators, and technical personnel.

3.2.3 Volunteer Medical Staff Critical to the success of the Clinic of the Cascades is the recruitment and retention of a qualified volunteer medical staff which supports the necessity and value of an EMR system. Most, if not all, of the volunteer medical staff at the clinic will be retired physicians who most likely will have spent the majority of their clinical time in the private practice setting. Many of these physicians will have had no prior experience with an EMR system. Appropriate training will help accustom them to using computers and EMR systems. In order to recruit and retain a high-quality volunteer staff capable of utilizing a paperless clinical system, it is essential that the clinic administration identify ways it can attract new volunteers, the factors that may motivate volunteer staff members to remain, and barriers to physician recruitment and retention. Successful recruitment of volunteers requires that physicians know about the clinic. Perhaps the most effective method to recruit a volunteer medical staff is to utilize current volunteers, preferably physicians, to speak directly to potential volunteers. Physicians who represent the clinic should be known and respected in the provider community. These individuals can describe their experiences at the clinic to interested volunteers through presentations to professional societies or individual physician groups. Their presentations can also be recorded and incorporated into short recruitment videos which can be sent out to physician practices, hospitals, and medical societies. By using physician lists available from hospitals and medical societies, the clinic can send letters of invitation to actively practicing and retired physicians who are licensed in the state. Media coverage, in the form of articles in mainstream and medical publications, television and radio interviews and features, or coverage of fund-raising activities will also raise clinic exposure, improve the clinic’s credibility in the community, and help attract qualified volunteer candidates. The Clinic of the Cascades is not the first volunteer medical clinic to come on the horizon, and it will most certainly not be the last. It also will not be the first medical clinic to be based entirely on an electronic clinical information system. The trailblazers have succeeded. Thus, it is important to look at how others have succeeded in this joint venture between a volunteer medical staff and an EMR based operational system, and perhaps model some aspects of the clinic’s

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strategy on earlier successes. The first step is to identify factors that may hamper the successful recruitment and retention of a volunteer medical staff. If the staff is not committed to the clinic’s underlying mission, then the successful implementation of an EMR system is moot. One major barrier to successful physician recruitment and retention is physician unfamiliarity with the clinic. Having most likely spent the majority of their time in a non-volunteer practice setting, these physicians will face the challenges of adapting to a new environment. There will be new faces, new equipment (or perhaps lack of such), geographical issues, and so on. By establishing a clinic setting that is inviting and familiar, the administration can help physicians to feel more comfortable in the clinic. Offering the staff small meals, snacks, and sodas saves time at breaks and can help clinicians “unwind” before sessions begins and throughout the day. Not dispensing controlled substances helps limit physician exposure to patients with drug-seeking behaviors. A dedicated committee can be established to promptly handle physician requests for supplies, equipment, or additional services and frequently update physicians on the statuses of their requests. In a busy medical practice, it is all too easy to be caught in the whirlwind of constant activity and forget about the time and effort put forth by the volunteers. A clinic can make a concerted effort to show all staff members its sincere gratitude for all volunteer contributions. For examples, Volunteers might be recognized annually at a banquet or party with awards such as an “Extra Mile” award or a “Shining Star” award, and publicly acknowledged in local newspapers and hospital newsletters. Doctors might be recognized for their contributions on Doctors’ Day with a hand-delivered gift. These measures may seem trivial, but recognition of the volunteers’ hard work and dedication can serve as a powerful motivating force. The clinic must also establish good working conditions in order to recruit and maintain the volunteer base. It is important for equipment such as otoscopes, ophthalmoscopes, etc. to be available and working properly. Nothing turns off volunteers more than outdated or poorly working equipment. Also, competent staff members who can maintain the front reception area, assist clinical and administrative personnel, and update the patient database, are essential. It may also be important for these individuals to be fluent in a foreign language, depending on the patient demographics. These personnel can help minimize unnecessary clinician interruptions and serve as interpreters, facilitating workflow. The Clinic of the Cascades should form strong relationships with local hospitals, providers of ancillary services, social support services, government agencies, and local medical societies so that volunteers will feel as if they have the adequate tools and resources to give their patients the best care possible. Clinic security issues should be addressed in detail. Ample lighting at entrances and parking areas will enhance the feeling of security among the clinic’s staff. If it

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is deemed necessary, the presence of a security guard may also provide an added sense of security at the clinic site. Patients who cause disruptions should not be tolerated. If patient or family members cause trouble for the clinic’s staff members, they should be summarily discharged. If a physician recommends discharging a patient from the practice, the chart should be flagged with a description of the reason for discharge. For many physicians, concern about exposure to medical liability risk is a significant barrier to providing volunteer care. While charitable immunity laws make it harder for volunteer physicians to be sued, there is no guarantee that it cannot happen. Fortunately, current laws in some states may offer some protection for volunteer physicians. As of October 1, 2000, 42 states and the District of Columbia had some type of charitable immunity legislation. Most of these laws provide statutory immunity by raising the standard from simple to gross negligence for volunteer physicians, or by indemnifying them with liability protections granted to state public employees. In 1997, Congress passed the Volunteer Protection Act (VPA), giving some liability protection to all volunteer physicians. Under the VPA, a licensed volunteer physician in a nonprofit organization acting within the scope of his or her duties is protected from liability for simple negligence. That is provided the alleged act does not represent a crime of violence or hate, a sexual offense, a civil rights violation, or an act committed under the influence of alcohol. In events allegedly due to gross negligence, a physician can be held liable. While the VPA does not limit economic damages in such cases, it does significantly restrict punitive damages. The clinic should resolve liability concerns to the satisfaction of the volunteer clinical staff and educate them on the protections afforded to them by law. The costs of malpractice insurance also may constitute a significant barrier to physician recruitment. While tail insurance would cover the volunteer physician for alleged negligence prior to retirement, he or she will need insurance to cover the volunteer work, which would not be covered. Particularly in today’s era of increasing jury awards and malpractice premiums, this could represent a financial barrier to physician participation in the clinic. Physicians in active practice may need additional coverage if their current malpractice policies do not cover clinical patient care performed outside of their regular practices. Fortunately, some companies do offer discounted malpractice insurance to volunteers, including retirees. Local medical societies may also offer discounted premiums to retired volunteers. Regardless, concerns about malpractice insurance costs should be addressed openly in any recruitment materials or discussions, specifically addressing the efforts the clinic has undertaken to resolve the issue. Retired physicians may especially be concerned about the cost of maintaining and paying for an active license to practice medicine in the clinic after they have

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retired. It may also be necessary for them to pay to maintain their Drug Enforcement Agency (DEA) numbers. The clinic could subsidize these costs in whole or in part for the physicians who maintain a certain number of annual hours at the clinic and meet certain continuing medical education requirements. The suggestions mentioned above will help the Clinic of the Cascades in its efforts to recruit and maintain a committed medical staff to serve its patient base. But if the true goal of the clinic is to ensure its long-term viability by utilizing and capturing the financial and operational advantages of an electronic clinical information system, the clinic will need to go further. Transitioning an older physician group to an electronic system will undoubtedly raise issues with physician autonomy, time constraints, privacy, physician-patient interaction, clinical workflow, and integration of systems. It is also important to provide the volunteers with proper training, which will be described in the next section.

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3.3 Training and Development

3.3.1 Introduction For many health professionals, the EMR is a new and unfamiliar technology. Many who will be working at the clinic have established routines for documenting patient encounters on paper. They may perceive EMRs as onerous and devoid of value. They may have concerns that they do not know computer basics, let alone understand the complexities of an EMR system. The training staff should solicit comments and suggestions from the users throughout the training process, and respond promptly to user concerns and feedback. A well-designed, ongoing, and intensive training program will help overcome significant challenges of an EMR implementation. The topsChart training provided by e-MDs will be augmented by an in-house training program that Doug Ritchie will design and implement. The software vendor will provide:

• Offsite training in Texas after purchase, at a cost of $1500/day. • Onsite training after purchase, at a cost of $1500/day. • Computer-based multimedia tutorials, of which VIM has received three to

date. • 242-page user guide in Portable Document Format (PDF).

VIM is also setting up an off-site computer laboratory for extensive training that will be available on an ongoing basis after the clinic opens. In addition to the training laboratory, the clinic may need additional computers available for training within the clinic. The clinic will be able to take advantage of the six-month lead time before the final go-live to conduct pre-implementation training. However, once the clinic starts seeing a large volume of patients, there may not be enough computers in the clinic for on-site post-implementation training. The EMR system will be installed in the off-site training laboratory and loaded with a mock patient database, but there are currently no plans to connect the training laboratory to the clinic’s live network. There may be value in installing extra workstations in the clinic which are connected to the live patient database. A physician encountering difficulties with the EMR can then be shown, while working with actual patient records, how to use the application correctly. The training can be conducted at a suitable pace, perhaps on days when that particular physician is not seeing patients. Training is more likely to be meaningful and be remembered if it involves real patient data than if it occurs through tutorials or mock databases Training must be thorough, adequate, and well-timed; training that is inadequate or poorly timed (e.g., too early or too late) is frequently cited as a major cause of system failure. As discussed in greater detail below, basic skills assessments should be completed three months before the go-live date and basic skills training should conclude two months prior. Application-specific training should

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begin approximately one month before the clinic opening date and conclude about one week before the go-live date. The training should be completed just before go-live because new users tend to forget things easily if they don’t apply what they have learned right away. Additional training will take place after implementation has been completed and the clinic has opened and begun seeing patients. The most important training occurs during the first few weeks of actual usage of the application. It will be important for full-time trainers to be on-site during the first few weeks of operations. Although the Clinic of the Cascades intends to allow its clinicians to participate in EMR data entry in a variety of ways, it is important that all users are trained to a level of competence that allows them to be able to access and utilize a patient’s entire record without frustration. An important part of the training system should be a means to evaluate and confirm that adequate training has taken place. Adequate time needs to be allotted for training. It cannot be done overnight. Training should begin early, with training sessions occurring at frequent intervals. It is probably safe to say that there is no such thing as too much training. The providers in the clinic should have sufficient time learning basic computer skills and the EMR system so that by the go-live day, it is boring for them. It should be a relative non-event because they will have spent so much time with the system. However, training should be available on an ongoing basis after the clinic opens. Periodic review sessions will keep information fresh and introduce the users to new features in future versions. Prior to starting at the clinic, new volunteers will need to complete a full training program. The clinic must allocate time for periodic post-implementation training so the training does not place undue and unexpected burdens on the clinic staff.

3.3.2 Challenges Health professionals have busy schedules and are thus leery of anything that may rob them of their precious time. Documenting patient encounters with an EMR system may take longer than documenting on paper. Many physicians have the perception that using an EMR system wastes time and disrupts workflow without worthwhile benefit. Health professionals have valid concerns about system reliability, downtime, security, privacy and confidentiality. They also may be concerned that the new technology will hamper their communication with patients, adversely affecting the physician-patient relationship. These perceptions can seriously hinder acceptance of the EMR, increasing the chances for failure. Personnel providing training must address these concerns, educate users on the unique benefits of EMRs, and provide systematic, adequate training of high quality so that health professionals can learn to use the system efficiently. Busy schedules also make it difficult to set aside adequate time for training programs. The volunteers at Clinic of the Cascades may work as infrequently as

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two days per month at the clinic. Retirees with frequent travel and family commitments may not always be in the local area during their days off from working at the clinic. If large group training sessions are planned, it will be difficult to schedule times when everyone will be present. This will not be a major constraint if most training is to be done in small groups or individually. Physicians and staff members will also accumulate less experience using the EMR system than if they were working more frequently. As a result, the physicians and staff members may be less familiar with the EMR and more likely to forget portions of their training, requiring periodic reviews and updates. Perhaps the greatest challenge will be to overcome physician resistance of EMR applications due to lack of familiarity with computers and EMRs in general. A disturbing fact is that most physicians over the age of 35 have poor typing skills and are computer illiterate, and are therefore intimidated by technical systems. Thus, the considerable instruction and time required to learn these skills is a barrier to technology adoption by physicians. Most physicians can turn on a computer and surf the Web; however, their abilities beyond that are severely limited. They do not readily embrace new technologies such as EMR systems. Many physicians with an EMR system already in place may utilize basic functions such as billing, scheduling appointments, and generating patient referrals and form letters, but not valuable functions such as entering patient visit notes or using decision support tools. Older physicians, who will comprise virtually all volunteer physicians at the clinic, tend to be the most conservative, apprehensive, and resistant to using information technology.

3.3.3 Assessment of Computer Literacy Users will differ in their computer experience, familiarity, and level of comfort. Clearly, assessing their skills and preferences is essential in order to provide a customized training program. It is likely that many users will require basic training on the use of PC hardware, the Windows operating system, and commonly used applications such as word processing programs and Web browsers. Even experienced users may require basic skills training in the use of tablet PC’s, and may benefit from instruction on the network structure and other hardware issues. Initial basic skills assessments, which ideally should be completed approximately three months prior to the clinic opening date, will help instructors to determine baseline skill levels, determine areas in which to concentrate their efforts, and develop an appropriate training program.

3.3.4 Basic Training Basic computer skills training should be completed approximately two months prior to the clinic opening date. Basic computer literacy classes are available through local high schools, community colleges, and universities. Special

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programs which introduce physicians to hardware fundamentals, basic software applications, operating systems, the Windows interface, word processing, multi-media applications, the Internet, and Internet medical resources are offered by hospital libraries, universities, and medical societies, often for CME credit. In some cases, hospital librarians will, by appointment, bring a laptop computer to the physician’s office to demonstrate the use of computer skills. One key to training physicians to use computers may be to start simple. Physicians can learn basic computer skills and have fun at the same time by playing computer games such as Solitaire. Introducing physicians to electronic mail so that they can send messages to their children or grandchildren can also help spark their interest.

3.3.5 Approaches to Training Training using a hands-on approach with real or simulated software demonstrations should occur early and frequently. All training should be designed around physicians’ needs and work schedules. Application-specific training should not take place so soon prior to the implementation that skills could be lost, nor so close to the start date that adequacy of training cannot be evaluated. Initial basic skills assessments should be completed three months prior to the implementation date and basic skills training two months before. Application-specific training should begin one month before and be completed about one week before the clinic opening date. Although group training facilitates rapid distribution of basic information to larger numbers of students, one-on-one training is ideal for physicians, who have varying levels of computer literacy and learn at different paces. Physicians may prefer to work in private settings, where their specific questions and concerns can be addressed. Training can also be customized to accommodate the needs of different specialties. Although the one-on-one approach may require more training personnel, it is much more effective than group sessions. Individual approaches include one-on-one demonstration-interaction sessions, tutorials, and instructional videos.

Another approach to physician EMR training would be to utilize Web-based training. Given that training health care professionals is not an easy task due to characteristics such as shift work, moderate to high employee turnover, and the difficulty in obtaining the commitment of clinicians to attend group training sessions of any length, Web-based training systems may be a reasonable alternative. Web-based training has numerous advantages. For example, this method of training is associated with reduced time and costs needed for training, with the possibility of new types of materials including simulations being introduced, and with automatic record keeping about trainees. Unlike a live

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instructor, whose schedule and location must be coordinated with the student’s, a Web-based training system is always available. U.S. Army studies have shown that students trained with Web-based tutorials complete the lessons faster, have improved comprehension, and have better retention than with more traditional methods. Web-based training system also allow for self-pacing, active learning, variety, record keeping, and timeliness. While progressing at a comfortable pace, the learner remains engaged because frequent responses are required when information is presented. Multisensory techniques incorporating computer with animation or graphics keep the experience interesting, and statistics can be kept on a learner’s progress. Web-based training provides other advantages including easy accessibility, simple distribution, rapid content development and updating, the ability to perform automated user evaluations, and user familiarity with the Web interface. Clinicians can access Web training from anywhere at any time. Program administrators can make changes to tutorials anytime from the server side and develop and make updates. Databases can be maintained and analyzed to determine usage and effectiveness. Many users find the Web training more interesting and intriguing than lectures delivered in a classroom. Also, Web-based training is nonjudgmental and nonthreatening. It provides a privacy that reduces learners’ embarrassment about doing remedial work or making mistakes. In order to ensure that physicians actually complete the training program, a policy can be instituted that requires that they complete the program before access to the EMR system is granted. Because the system can keep record of the physician’s training sessions, it can provide confirmation that a physician has demonstrated mastery of essential material. Whatever training protocol is chosen, flexibility and customizability are paramount. Physicians and other clinicians may need to be trained in an “ad hoc” style, with a knowledgeable trainer “on call” for sessions that may vary from 30 minutes to several hours. Some physicians may want several lengthy sessions; others may only want initial training on what they perceive as their most pressing needs. The selection of the training model will ultimately be influenced by factors such as the number of users, the flexibility in scheduling clinicians, the availability of a classroom facility, the functionality to be implemented, and the cost.

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4 TECHNICAL SECTION 4.1 Statement of Work and Scope of Work The scope of the project is to plan and implement the EMR system and maximize user acceptance and successful use of the new clinical information system. The expected benefits to the patients and clinicians of the Clinic of the Cascades from implementing an electronic clinical information system are substantial. Improvements in quality of care, information management, practice efficiency, practice consistency, and cost structure will be the end-result of this project. The completion of this initiative will serve the mission of the clinic, which is to improve the health of the patients it serves. 4.2 Work Breakdown Work packages and tasks in this project include:

• Final planning and design • Finalize contract with vendor • Installation of EMR prototypes

• Hardware, including servers, computer workstations, network connections, input and output devices

• Software, including operating systems and applications • Loading of sample data • Testing • Go live

• Installation of EMR system in training lab • Hardware • Software • Loading of sample data • Testing • Go live

• Installation of system in clinic • Hardware • Software • Preloading of patient data • Testing • Go live

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• Training

• Initial skills assessment • Basic skills training • Group instruction • Initial training in lab, and then on-site after system is up in the clinic • One-on-one training • Web-based training • Solicitation of user input • Ongoing training as needed

4.3 Responsibility Assignments

• Project manager: Christine Winters • Project sponsor: Doug Ritchie • Physician champion(s): To be identified • Additional duties to be assigned to remaining project team members,

employed staff, and volunteer health professionals 4.4 Budget and Financial Support

• Estimated initial costs for EMR system • Software $35,000 • Hardware $10,000

• Annual cost for maintenance and support: $5,000 • Initial funds totaling $1 million have been donated to cover initial capital

expenditure and operating expenses at the clinic. • Grants and donations will fund the clinic in the future.

4.5 Testing Prior to beginning implementation, a schedule and plan for testing will be in place. Staff from the clinic and vendor will perform testing on the hardware, software, network, and preloaded data, preferably a complete database of real patient data. This will include testing the system’s security features. Testing staff will also conduct full evaluations of the application involving users to assess the computer and application configurations, as well as the user interface. Testing will also take place following any major modifications to the system.

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4.6 Change Control Plan Because changes can profoundly affect the project deliverables, there will be a formal process for managing changes to the plan. Proposals for changes to the scope of the project will be submitted to the project manager. The costs in time, personnel, and resources, and the expected benefits will be thoroughly assessed. Requests for modifications to the topsChart software itself will be submitted to the developing or distributing vendor. Project team members will evaluate effects of the proposed changes as well as alternatives before deciding whether to accept or reject the changes to the project. A version tracking system will be used to manage documents with multiple versions.

4.7 Quality Plan Because the clinic will not have operated in the same location prior to EMR with the same staff and physicians prior to EMR implementation, it will be difficult to make direct comparisons regarding cost, quality, and user satisfaction. The main objective of implementing an EMR is to improve quality. There are several methods of assessing the quality of health care in a medical practice:

• Aggregation, retrieval, and analysis of patient information – Using an EMR facilitates collection of patient statistics regarding demographics, diagnoses, treatments, outcomes, and medical errors, allowing one to determine compliance with current disease prevention and management guidelines. This information allows a practice to compare its practices and outcomes with those of similar practices in the region.

• Operating expenses can be compared to those of practices with and without EMR systems, including other VIM clinics. This information can be used to determine how resources are being used and provide information for grant applications.

• User satisfaction – Surveys are useful for assessing the level of satisfaction of administrators, physicians, staff, patients, and families. The results of the surveys can help provide an evaluation to the success of the implementation, identify areas for improvement, and track progress over time.

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4.8 Work Review Plan and Clinic Project Management Communication is a cornerstone of effective project management. To that end, the project team will develop a program of regular, frequent communication between project team members, physicians, staff members, and administrators. Measures to facilitate and encourage good communication include:

• An initial meeting with core members of the project team • An initial meeting with all project participants, including the project

manager, project team, project sponsor, volunteers, staff, and administrators

• Weekly status meetings of the project team • Weekly status reports describing project progress • Forums for users to submit comments, suggestions, and requests. This

may include outlets which allow users to submit feedback anonymously. A project team member will be assigned to monitor team health.

• “Quality circles” held when the clinic is not seeing patients, which invite clinic personnel to share their experiences, challenges, ideas for addressing difficulties, lessons learned, and areas for greater emphasis in training.

• Regular communication involving the project team, project sponsor, users, the vendor, and clinic administrators

• Periodic formal status meetings and reports to the project sponsor and administrators

• Formal review meetings and reports regarding the project between the project team and sponsor at the end of each major phase of the project and following the conclusion of the project

4.9 Documentation Documents to be generated during the course of the project will include:

• Specific IS requirements – Describing the hardware, network, software, and data components that need to be installed, tested, and confirmed operational before the clinic can begin using the EMR system for documenting patient visits.

• Staffing – Responsibility matrix defining the project organization, members of the project team, users, and the allocation of responsibilities.

• Implementation schedule – Gantt charts detailing the schedule of work packages, tasks, and milestones that need to be completed during the planning, implementation, and operational phases of the project.

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4.10 Implementation

4.10.1 Introduction Implementing an EMR is a major undertaking, even more so in a volunteer clinic. While some physicians will eagerly embrace an EMR, others will be “resistant” users. Health professionals who have worked for years employing firmly established methods of practice are understandably apprehensive. They are reluctant to abandon familiar methods, acquire new skills, and integrate new technologies into their daily routines. Many of them will be retired health professionals who are volunteering their precious time to serve others in need. Every effort should be made to remove barriers to an EMR implementation. The goal is to make the system as useful, easy to use, and user-friendly as possible. Important tasks during planning and design phases are: to assess the needs of the clinic, select a suitable EMR system, and map out the details of the implementation. Administrative, technical, and organizational issues will be identified and measures taken to promote project success. Much of this work has already been completed. The e-MDs topsChart system has been selected to meet the clinic’s information management needs.

4.10.2 Education Educating and training will help prepare clinic personnel using the EMR system. Many health professionals are resistant to change and fail to see the benefits of using an EMR. They need to be educated so that they understand the value of EMRs. Users are more likely to accept a system if it has high “perceived usefulness.” The initial educational program will emphasize the known benefits, including the time and cost savings, availability of charts, reduction of medical errors, reminders to improve compliance with guidelines, and decision support capabilities. If it can be arranged, a site visit to a nearby practice that is successfully using topsChart would be a valuable introduction to the system. Educational programs will also address user concerns about data integrity, security, and confidentiality. Training is discussed in greater detail in Section 2.

4.10.3 Preloading of Data Although sample patient data can be loaded into the system for testing, it is preferable to load a database of actual patient data. Often, systems are tested with “dummy” data, which do not adequately represent the volume and complexity of real data that will eventually populate the system. In addition to patient information, other useful information can be loaded, such as names, addresses, phone numbers, and fax numbers, of consultants, hospitals, ancillary

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services, pharmacies, diagnostic testing facilities, community services, and government agencies will help the staff to access these resources more easily.

4.10.4 Stepwise Approach Physicians and other EMR users can be divided into several groups with regard to their computer literacy and readiness to using an EMR system:

• Regular users • Casual or infrequent users • Non-retired physicians using other systems or paper outside of the clinic • Resistant users • Other clinic volunteers with widely varying backgrounds

The clinic can accommodate these different types of users by encouraging all staff, including physicians, to use at least some features of the EMR, as well as provide staff who can train and support users of all levels of proficiency. Physicians who are comfortable with information technology may immediately immerse themselves in an EMR, using even the most complex features to the fullest extent. The “resistant” physicians, who are less familiar with computers, may try one or two functions or refuse to touch the system entirely. The clinic can encourage these “resistant” physicians to accept the EMR more readily by adopting a stepwise approach. A gradual introduction allows the physicians to “dip their toes in the water” and start with the few standalone EMR features having the most value or highest “perceived usefulness.” When physicians feel comfortable using a few features, they can add additional components to their repertoires. Ultimately, become more familiar with the EMR and recognize the value of the components they are using. At that point, adding the full use of the electronic SOAP (Subjective, Objective, Assessment, Plan) notes and templates will seem more convenient and less intimidating to them. The individual features of e-MDs topsChart are:

• Health Summary – A chart summary listing current problems, allergies, medications, and past medical history

• Chart View - Allows users to view patient visit notes • Immunization record • TaskMan – An “in-box” that collects inputs such as test results and

correspondence and organizes and displays them for the physician • Script Writer – Prescription-writing utility • Referral/Consult Letter Writer • DocMan – A utility for importing and organizing paper documents • Code Linker – Provides assistance in coding diagnoses and procedures

for billing • Curbside Consults – Research utility which allows physicians to reference

disease and drug information as well as current clinical guidelines.

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The first step in the stepwise approach is to rank the different standalone components in the order in which they contribute the most to improving patient care and save physicians the most time and effort. Another consideration is the level of complexity and ease of learning the different components. Because each physician may each rank the features differently, it is important to query them on their individual preferences. Different features can then be selected for initial adoption in response to the physician input. A good starting point is to teach all physicians and medical staff at the clinic to use the Chart View utility of topsChart, which allows users to review the contents of patient notes. Based on an evaluation of the EMR system, a list of the next three e-MDs topsChart standalone components was generated which can serve as a foundation for adoption of other EMR features:

1. TaskMan – In a traditional paper office, various inputs such as lab results, radiology reports, and letters of referral typically accumulate into large piles of paper, causing frustration, delays in processing, and unfortunately, lost information. TaskMan, which can be used alone or together with other topsChart utilities, organizes and manages these inputs, helping physicians to find, view, and process the information they need quickly, thus improving workflow and patient care.

2. Script Writer – Computerized medication prescribing improves safety by reducing medication errors by as much as 80% by eliminating illegibility, suggesting standard dosing regimens, and checking for allergies and drug interactions. Script Writer can be used alone or in from within a patient’s medical visit note. It can print prescriptions and also print medication information handouts to be given to patients along their prescriptions. Script Writer has high “perceived usefulness” and will greatly improve the quality of patient care.

3. Curbside Consults – The Curbside Consults utility allows physicians to improve their clinical knowledge by referencing information on diseases, medications, and practice guidelines. It can be used alone or accessed from within patient records. The information in Curbside Consults is updated regularly and will serve as an important resource when other references in the clinic may be limited or obsolete. Retired physicians who see patients infrequently will especially appreciate its value in helping them to stay abreast of the latest advances in medicine.

When physicians feel comfortable using these features, they can then begin learning to enter patient information into the EMR using the SOAP note format. Eventually, they will be ready to attend the full EMR training program and take on the rest of the topsChart EMR system. The stepwise approach facilitates EMR acceptance by gradually building the physicians’ skill sets, developing user confidence, and earning the physicians’ trust and buy-in regarding the EMR system.

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4.10.5 Security, Privacy, and Confidentiality With the entry of patient information into the system comes the responsibility to protect sensitive patient information from unauthorized access. Although the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may or may not cover Clinic of the Cascades from a legal standpoint because the clinic does not transmit information electronically for reimbursement, HIPAA is now the standard for health information privacy and security. Oregon law also protects medical records from unauthorized disclosure. Regardless of legal status, the clinic has a professional and ethical responsibility to protect patient information and must comply with these rules. A designated Chief Security Officer will have the responsibility of assessing the clinic’s information security needs, developing appropriate policies and procedures, monitoring compliance on a regular basis, and responding to lapses in security. Import procedures include but are not limited to the following:

• All clinic staff will be thoroughly trained in HIPAA regulations and clinic procedures to ensure compliance.

• The clinic will ensure that all EMR users have unique user IDs and passwords and that they do not share them with others. The system administrator will maintain appropriate access control so that providers only can view the areas necessary to perform their duties.

• Every time a provider accesses a chart, the system will make a permanent record of that access.

• Once a note is completed and authenticated, it cannot be altered or deleted. Similarly, entries in other areas such as the problem and medication lists cannot be deleted or altered. Old items can only be designated as inactive or incorrect and replaced by new entries.

• If a breach is detected, clinic staff will assess the extent and nature of the breach and take appropriate measures to prevent a similar breach in the future.

• The current version of topsChart does not fully meet HIPAA requirements; the software will be upgraded without delay as soon as a fully compliant version is available.

4.10.6 Workflow One of the greatest concerns of health professionals using a new clinical information system is that workflow will be disrupted. The topsChart system contains features that will improve workflow. The clinic will ensure that these are enabled and working and use them fully. If useful but not currently available features are identified, the clinic can request that the software vendor make additional modifications. Education and training are also important for dispelling misperceptions and helping providers use the system effectively. Workflow-enhancing features and procedures are described below:

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• Tablet PCs with wireless networks are portable and can be carried and used similarly to a clipboard, with minimal disruption of provider-patient communication. Generally, they are operated by stylus or touch screen, making them more acceptable to the majority of physicians with poor typing skills. On-screen or detachable keyboards are available to those who prefer typing. The clinic will establish a schedule for charging the batteries and servicing the units to ensure that they remain operational for patient care.

• Most of the volunteer physicians at the clinic will be over age fifty, when there is an increased incidence of farsightedness, cataracts, and other causes of decreased visual acuity. Brighter screens, glare filters, screen magnifiers, and adjustable font sizes will help them read the computer displays more comfortably.

• Because many clinicians are comfortable dictating charts, voice recognition is an area of great interest. Dictation directly into SOAP notes and templates is not supported in the current version of topsChart. However, voice recognition software which is already built into the Windows XP Tablet operating system can be used for free text entry. To ease the transition and avoid forcing providers to use the EMR before they feel comfortable with the system, the clinic will support the use of dictation for up to fifty percent of patient encounters. Medical transcription students from the local community college will transcribe the dictations directly into the topsChart structured format for no cost to the clinic. Hopefully, with time, physicians will become more comfortable directly entering data in the EMR and dictations will decrease.

• Patient information will be documented by non-physicians whenever appropriate and feasible, as is often standard operating procedure in practices without EMRs. When patients schedule appointments, they should be instructed to bring in any medical records with them to the clinic. Important information can then be scanned into the chart and will become part of the record. It will then be readily available for reference. Ancillary staff can enter patient information such as demographic information, current problems, past medical history, medications, allergies, review of systems (ROS), family history, and vital signs. Patients may also be able to enter some of their own information, perhaps while in the waiting room or even at home prior to the visit, if information entered into an electronic form or questionnaire can be imported automatically into the chart. Physicians can review and authenticate this information instead of generating it de novo. They will thus be able to spend more time seeing patients and making diagnosis and treatment decisions and less time documenting.

• Customizing the system also will help improve efficiency. All physicians are unique when it comes to expressing themselves in encounter notes; some prefer brief notes while others prefer detailed notes. Physicians can modify preexisting templates or create completely new templates to suit their needs. They can assemble lists of “favorites,” or frequently used

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items. They may wish to create templates that contain frequently used symptoms, diagnoses, combinations of symptoms and diagnoses, ROS and physical exam elements, medications, procedures, and patient education materials. They can also create their own templates for consult letters and notes that match their natural writing styles. Health professionals should be encouraged to experiment with the system and create custom elements that improve workflow.

• Remote access to the EMR system has significant benefits. It will encourage more regular and frequent use of the system. Some clinicians will be seeing patients infrequently, possibly not enough to become comfortable using the EMR. Accessing the system remotely may be important in helping to familiarize them with the system and maintain their skills. They can access the system to work on their own customizations when they are not seeing patients. Remote access also facilitates continuity of care and follow-up of patients seen in the clinic. Clinicians can easily access laboratory and radiology results and patient status at subsequent visits with other providers. They can also access patient information rapidly and easily when responding to medical emergencies that occur when the clinic is closed.

4.10.7 Physician Input No system can achieve user acceptance fully if the users do not feel motivated to work towards the success of the system. As mentioned above, education will help health professionals see the value. Physicians greatly value their autonomy. They will not embrace a system that they are forced to use without having any input in the implementation. They may perceive from the outset (correctly or incorrectly) that the decision to use topsChart has been made largely by administrators and for business reasons. It is important that they feel that they are involved in decision-making, that their feedback is sought and valued, and that their concerns are addressed. There should be a significant physician presence throughout the entire implementation process. If not done so already, one or more physician champions who are proficient using clinical information systems should to be identified. They will help advocate the use of the product and motivate the physicians using the system.

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4.11 Justification The completion of this project is vital to the survival of the Clinic of the Cascades, and in turn, critical to improving the health of the residents of Deschutes County. Workflow automation, information management, productivity, clinical decision support, provider and patient satisfaction, quality improvement, cost reduction, and grant and donation awards will all be enhanced by a successful implementation of a clinical information system. Specifically, costs will be reduced through lower transcription and copying costs, reduced malpractice premiums, reduction in duplicate testing, and more efficient tracking of resources and expenditures. Efficiency will be significantly enhanced through less dictation time, reduction or elimination of time spent hand-writing notes, reduced nurse intake time, and reduction in total time per patient encounter. Because eliminating paper charts reduces time spent assembling, seeking, pulling, and refilling charts, they may enable a practice to decrease the number of staff members who work with paper charts. Office space that might be used to store charts can be used instead as patient exam rooms, further increasing productivity. Quality will be improved through reductions in medical errors, better compliance with prevention and treatment guidelines, detection of practice patterns and monitoring of outcomes. Estimated costs for the e-MDs topsChart EMR system:

• Hardware $10,000 initial expense • Software = $35,000 initial expense • Annual cost for maintenance and support $5,000 per year • Assuming a depreciable life of 5 years straight-line, the cost of the system

is ($35,000+10,000) X 20% + $5,000 = $14,000 per year Estimated costs for paper charts:

• Average cost of a paper chart is $8.00 per chart • Average cost of a chart that has to be found is $15.00 per chart • Normal cost of transcription is $1,500 per full-time physician per month, or

$18,000 per year. • Assuming 20% of charts have to be found and relocated per year: • 6,000 charts X $8/chart + 6,000 X 0.20 X $15 = $66,000 per year • Cost of transcription = $18,000 X 4 FTE = $72,000 per year • Total cost of paper charts = $66,000 + $72,000 = $138,000 per year

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With the EMR implementation, costs for paper charts are eliminated and transcription costs are reduced:

• Cost of paper charts = ($138,000) • Reduced Cost of transcriptions/year, assuming maximum of 50% of

patient visit notes are dictated = $36,000 • Cost of hardware and software per year = $14,000 • Net cost savings per year = ($88,000) • Assuming that the net savings from using an EMR are too optimistic, and

that the actual savings is only $44,000 per year, the savings will exceed the initial investment in hardware and software in less than one year.

• The transcription costs may be reduced further because medical transcription students from the local community college will be helping to transcribe dictations for the clinic for academic credit, at no cost to the clinic.

The topsChart system was selected based on a highly favorable evaluation performed by the American Academy of Family Physicians. The system’s cost was also within the clinic’s budget. Evaluation based on demos and tutorials provided by the vendor have shown that the system will meet the clinic’s information management needs.

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4.12 Uncertainty and Risk

4.12.1 Functionality

• Implementation delays – may have numerous causes. The risk is relatively low now, given the generous lead time and time built in for prototyping and testing. If the EMR system is not ready at the time of clinic opening, notes can still be dictated or entered into other computer applications so that the clinic remains paperless. The medical transcription students from the community college can help transcribe dictations into electronic format. If necessary, the clinic can also hire professional transcriptionists.

• System failure – Failure may result from hardware, network, software, or data problems during or after implementation. All can result in significant clinic downtime. The risk management strategy includes using components that are known to be reliable, spending time and effort during the planning, installation, and testing phases, storing components in secure locations, and building redundancy into the system. Redundant hardware capacity, extra network connections, regular and frequent data backups, and storage of backups in remote locations will help to prevent system failures and data loss. Regular servicing and maintenance will help to prevent, detect, and repair problems with the system. Agreements should be made with the vendor so that components that cannot be immediately restored or repaired are replaced promptly. A well-designed, documented, and tested disaster recovery plan will help minimize disruptions caused by a system failure.

• Security, privacy, or confidentiality breaches – The risk is managed by developing policies and procedures for maintaining control of patient information from the very beginning and enforcing those policies. All usual and reasonable measures HIPAA applicable to paper records also apply to EMR records. One person will be designated as the Chief Security Officer to ensure HIPAA compliance. The clinic will mitigate the risks of unauthorized access and disclosure by fully training the staff in the HIPAA regulations and clinic procedures for maintaining compliance, using secure user IDs and passwords, controlling staff access to EMR areas necessary for patient care, and maintaining audit trails. The clinic will respond appropriately to unauthorized information access or release and take corrective actions to safeguard privacy and security.

4.12.2 User Ability and Acceptance

• User inability or discomfort with using computers – Described above, this risk has been anticipated and will be addressed primarily through training. Clinicians will initially have the option of using dictation instead of the EMR for documentation. Extensive training, including instruction in basic computer literacy, will help mitigate the risk. One-on-one and web-based

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training in the EMR system can be completed at the user’s own pace, accommodating novice and advanced users.

• Poor performance – Careful implementation and testing will help prevent and detect problems that contribute to poor performance. Testing the system with real patient data will help simulate performance and workflow that is representative of how the system will perform when the clinic is open and seeing patients. This allows the staff to develop realistic expectations about the system. If there is a significant slowdown, dictation is a backup documentation method that can be used while the problem is being diagnosed and corrected.

• Not meeting expectations, workflow problems – Realistic expectations must be established from the beginning. The system is not a cure-all for all of the problems which plague modern health care. Good training will help clinicians to use the system effectively and take greatest advantage of its features. It will be important to solicit user feedback on problem areas, so that problems can be evaluated and corrected promptly.

Users are the main customers of the product; their satisfaction is a major goal of the project. Their continued involvement will help keep them vested in the system and the practice. Their feedback will help drive the software developers and implementers to continue to improve the product. The project team will establish and maintain good communication with the users. Interdisciplinary collaboration and cooperation will ensure success throughout the implementation process and in the future.