# Presentation: 523329

## Inpatient EHR Implementation andLessons Learned

- LCDR Robin Bartlett, PharmD, NCPS
- Clinical Applications Coordinator
- Cherokee Indian Hospital
- April 2008

## Objectives

- Provide overview of relationship between RPMS packages and EHR
- Review preparation required prior to Inpatient EHR Implementation
- Review Inpatient EHR Implementation Plan (phase 1 and phase 2)
- Discuss issues and lessons learned from Inpatient EHR Implementation

## Cherokee Indian Hospital Authority

- Located on the Eastern Band of Cherokee Indian Reservation.
- Enrolled Members
- 		= 12,669
- Hospital User Population
- 		= 10,842

## Cherokee Indian Hospital

- Cherokee Indian Hospital is a 29 bed facility that features a busy outpatient department and other services:
- Laboratory
- Radiology
- Pharmacy
- Physical therapy / wound care
- Dental
- Eye clinic
- Emergency room
- Contract health services

## Cherokee Hospital Affiliations

- Outlying Outpatient Clinics
- Snowbird Clinic
- Marble (Cherokee County) Clinic
- Cherokee Health & Medical Tribal Programs
- Cherokee Diabetes Program
- Cherokee Women’s Wellness Clinic
- Qualla Youth Teen Center
- Analenisgi Behavioral Health Center

## Mission Statement

- To continuously improve the health status of the Eastern Band of the Cherokee nation through a comprehensive health care system sensitive to the culture and values of the community.

## RPMS

- Resource Patient Management System (RPMS) as the database for patient information.
- Developed in the 1970s
- The Patient Care Component (PCC) and the Indian Health Service Electronic Health Record (EHR) are tools to enable the entry of patient data into the database.
- PCC developed in the 1980s
- A number of packages have been added to improve the functionality of the RPMS system.

## Slide 8

## EHR

**EHR**

## Preparation for Phase 1 Inpatient EHRImplementation

## Evaluate Current Process

- Important to evaluate your current process prior to inpatient EHR implementation
- ER Staff (Clerk/CNA/RN)
- Admits patient via Emergency Room System (ERS) in RPMS
- Process creates Emergency Medicine visit
- Inpatient Staff (Clerk/CNA/RN)
- Admits patient to Inpatient via Admission-Discharge-Transfer (ADT) package in RPMS
- When patient physically arrives on inpatient ward

## Emergency Room System (ERS) in RPMS

## Admission/Discharge/Transfer (ADT) in RPMS

## Inpatient EHR Preparation

- EHR Progress Note Template Development
- Import national inpatient EHR progress note templates from _[www.ihs.gov](http://www.ihs.gov/)__ website _
- Review EHR templates and alter to facility as needed
- Create Progress Note Titles (INPT...)

## Inpatient EHR Preparation

- Set up Parent/Child ID notes as desired
- Fort Defiance set-up
- Day shift RN note parent – drag RN notes each day
- MD notes remain separate
- Cherokee set-up
- INPT H&P – drag all MD notes
- INPT NURSE ADMISSION ASSESSMENT – drag all RN notes

## Phase 1 Implementation Issues

- Initially, progress notes were not consistently dragged into interdisciplinary folders
- Outpatient providers could not see previous outpatient visit notes at quick glance due to multiple inpatient notes
- Custom View of Progress Notes to sort by note titles or location instead of chronological is possible but our providers preferred chronological for tracking of patient visits throughout system
- Assign responsibility of note dragging (multiple tiers)
- Night Nurse staff during 24 hour chart check
- Day Nurse staff upon patient discharge (added reminder on INPT NURSE DISCHARGE note)
- Coder upon review/coding of inpatient chart

## Inpatient EHR Preparation

- Print Parameters (notes, orders)
- Quick Order Development
- Lab quick orders
- Lab AM Collect (LRZ LC)
- Immediate Collect (LRZ IC)
- Ward Collect (LRZ WC)
- Send Patient (LRZ SP) [Outpatient]
- Radiology quick orders (RAZ)
- Consult quick orders (GMRCZ)

## Inpatient Quick Orders

## Lab Quick Orders

## Radiology Quick Orders

## Consult Quick Orders

## Consult Template (Nutrition)

## Inpatient EHR Implementation Phase 1 - April 2007

## Inpatient EHR Implementation Phase 1 – April 2007

- Physician Coding Documentation
- Purpose of Visit
- Evaluation and Management Codes
- Inpatient Progress Notes (MD, RN)
- Inpatient Provider Order Entry (Labs, Radiology, Consults)
- Medication Reconciliation (PCC+)

## Inpatient EHR Implementation Phase 1 - April 2007

- Physician Documentation
- Purpose of Visit
- Selected from patient Problem List, patient Historical POVs, or Inpatient POV Picklist (contains most common admission diagnosis from QMAN search of inpatient visits)
- Progress note template field added to pull POVS into history and physical, daily physician progress notes, and discharge summary for consistency

## Inpatient Purpose of Visit Picklist

## Phase 1 Implementation Issues

- Purpose of Visits
- Inappropriate codes/incomplete documentation common when provider selected POV from problem list and historical POVs
- (i.e. DM type 2, NOS vs. controlled or uncontrolled;  Alcohol dependence vs. abuse, chronic vs. in remission)
- Entire admission documented with incomplete diagnosis since POV was being pulled into daily progress notes
- INPT Coding progress note developed for deficiencies and clarifications to assist with communication with inpatient physicians and nurses
- Sometimes POV crossed over to business office prior to completion of visit in ADT by coder  ?mystery?

## Inpatient EHR Implementation Phase 1 - April 2007

- Physician Documentation
- Evaluation and Management Codes (Superbill)
- Inpatient ward admission – E&M codes entered
- Initial Hospital Care
- Subsequent Hospital Care (daily)
- Discharge Hospital Care
- Observation visits – E&M codes entered
- Selected from Superbill Picklist vs. E&M tab due to incomplete list

## Inpatient E&M Documentation

## Observation E&M Documentation

-   Observation E&M Codes (E&M tab list incomplete)

-   Observation E&M Code Superbill Picklist Developed

## Phase 1 Implementation Issues

-  Evaluation and Management Codes
- Difficult to determine event date since only inpatient admission date shown
- May Edit narrative to include date in parenthesis assist in determining intended date without looking at visit detail

## Inpatient EHR Implementation Phase 1 - April 2007

- Nursing Documentation
- Vital Signs
- Immunizations
- Health Screenings
- Tobacco Use
- Alcohol Use
- Domestic Violence
- Depression Screen
- Patient Education

## Health Screening Documentation

-   Health Factors
-      – Tobacco Screen

-   Exams
-      – Alcohol, Domestic Violence, Depression Screens

## Patient Education Documentation

## Phase 1 Implementation Issues

- Nursing staff documents vitals and immunizations/skin tests on regular basis via EHR
- Immunization tab shows inpatient admission date vs. event date
- Inpatient Nurse Admission Assessment contains all the health screening questions but nurses often busy and forget to document on screening tab
- Inpatient coders can assist in picking up these codes and documenting via ADT after discharge
- Patient Education picklists developed for common inpatient admission, disease states, and discharge education topics
- Nurses often forget to document on Education tab but progress notes do contain information regarding education provided

## Inpatient EHR Implementation Phase 1 - April 2007

- Provider Order Entry
- Lab, Radiology, Consults
- Clerk, Nurse, and Chart Check Order Verification
- Inpatient Progress Notes
- Physician (H&P, Discharge Summary)
- Nurse (Admission Assessment, Shift Note, Problem List, CIWA/COWS, Critical Labs, Discharge/Transfer Note, etc.)
- Coding (Final Diagnosis Worksheet, Deficiency)
- Consult Service Tracking
- Complete/Update Consults (all services)

## Inpatient Quick Orders

## Order Verification

- Clerk verifies order upon updating cardex
- Nurse acknowledges order via verification
- Night nurse verifies order during 24 hour chart check

## Inpatient Progress Note Templates

## Final Diagnosis Worksheet

- *********************************************************************
-                  "Official Attestation for Billing Purposes"
-                     Cherokee Indian Hospital Authority
-                             Cherokee, NC 28719
- *********************************************************************
- |PATIENT HRCN|     |PATIENT SSN|
- Name: |PATIENT NAME|     |CURRENT WARD-ROOM|
- DOB: |PATIENT DATE OF BIRTH|   Age: |PATIENT AGE|   Gender: |PATIENT SEX|
- Admission Date: |VISIT DATE| {FLD:DATE}
- {FLD:CIH TRANSFER/DISCHARGE} {FLD:DATE}
- Length of Stay: {FLD:CIH TEXT 6} days
- Initial Impression:  {FLD:CIH DRG IMPRES}
- |ADMITTING DX|
- Principal Diagnosis:  {FLD:CIH DRG PRIN DX}
- Secondary Diagnosis
- Procedures: {FLD:N/A}
- Out-of-Facility Procedures / Consults: {FLD:N/A}
- I certify that the narrative description of the principal and secondary
- diagnosis and the procedures performed is accurate and complete to the
- best of my knowledge.

## INPT Coding Deficiency List

- _Provider Deficiency_
- Provider:
- Coding Worksheet: Complete (date)
- Review for Principle Diagnosis
- Additional Diagnosis Required:
- Additional Diagnosis Required:
- Additional Diagnosis Required:
- Complete Level of Care
- Sign A-Sheet   Sign
- Procedure Documentation Required:
- Discharge Summary Narrative Required Complete (date)
- History I, II, III Complete (date)
- Progress Note Complete (date)
- Discharge Follow-up Records Complete (date)

- _Provider Deficiency (cont.)_
- EKG   Sign
- PCC / ER Record Complete (date)
- Physical Examination Complete (date)
- Orders Complete (date)
- Procedure Consent Complete (date)
- _Nurse Deficiency_
- Nurse:
- Admission Note Complete (date)
- Progress Notes Complete (date)
- Discharge Note Complete (date)
- Missing?

## Consult Service Tracking

## Phase 1 Implementation Issues

- Delayed orders not set up properly during inpatient EHR phase 1 implementation
- Work around developed
- Physicians ordered inpatient lab, radiology, and consult orders, and documented history and physical (INPT H&P) progress note prior to patient arrival on the floor under the Emergency Medicine Visit created by the ER check-in RPMS package (ERS)
- Manual print of inpatient orders required since print parameters only set-up to print orders under inpatient location
- Orders missed/delayed due to inconsistent order printing
- Changed process for physicians to create a new Emergency Medicine visit with In-hospital type to assist in identification of visit so that it could be physically merged into Inpatient visit by inpatient coder
- Difficult to do in real time – manual print of orders still needed

## Inpatient (Phase 2) EHR Implementation and Lessons Learned

- Mary Lambert, CCS
- LCDR Jonathan Dando, RPH, NCPS
- LCDR Robin Bartlett, PharmD, NCPS
- Cherokee Indian Hospital

## Preparation for Phase 2 Inpatient EHRImplementation

## Inpatient EHR Preparation

- Quick Order Development
- Pharmacy quick orders
- Inpatient Medications (quick order type)
- Unit Dose Meds (PSOZ)
- IV Piggyback Meds (PSJIZ)
- IV Medications (quick order type)
- IV Admixtures/Infusions (PSJIVZ)
- IV Fluids (PSIVZ)

## Pharmacy Quick Order – Unit Dose

## Pharmacy Quick Orders – IV Piggybacks

## Pharmacy Quick Orders – IV Infusions

## Pharmacy Quick Order – IV Fluids

## Inpatient EHR Preparation

- Quick Order Development
- Nursing quick orders (ORZ)
- Generic Nursing quick orders (ORGXZ)
- Standing admission order sets
- VANDALISM Acronym
- V – Vitals
- A – Allergies
- N – Nursing orders
- D – Diet
- A – Activity orders
- L – Labs
- I  – IV Fluids
- S – Special orders (Imaging, Consults, etc.)
- M – Medications

## Inpatient Quick Orders

## Standing Admission Orders

## Admission Order Set

## Inpatient EHR SetupOffice of Information Technology (OIT) SupportNovember 2007

## Inpatient EHR Setup – OIT Support November 2007

- Inpatient Site Parameters
- Delayed Orders Set up
- Auto Discontinuation Parameters
- Order Checks
- Notifications
- Team List Management
- Print Parameters (pharmacy orders)
- Standing Admission Order Set Development

## Delayed Order Issues

- Process change after delayed orders set up properly
- Physician writes delayed inpatient admission orders released upon ADT admission
- Document INPT H&P progress note under Emergency Medicine visit created during check-in to ERS package
- After inpatient discharge, Medical Records can move note from Emergency Medicine visit into Inpatient visit

## Inpatient EHR Implementation Phase 2 - January 2008

## Inpatient EHR ImplementationPhase 2 – January 2008

- Provider Order Entry
- Order Verification / Nursing Order Completion
- Coding Documentation (via EHR)
- Final Diagnosis Worksheet
- A Sheet
- Medication Reconciliation (via EHR)
- EHR Progress Flag first dose medications
- Note (Admission, Transfer, Discharge)

## Inpatient EHR ImplementationPhase 2 – January 2008

- Provider Order Entry
- Standing Admission Orders (VANDALISM)
- Vital Sign / Accuchek Orders
- Nursing Orders
- Diet Orders
- Activity Orders
- IV Fluid Orders
- Medication Orders
- Order Verification / Nursing Order Completion

## Inpatient Quick Orders

## Coding Documentation

- E&M Code Documentation - back to paper
- Final Diagnosis Worksheet EHR note template
- Includes Present on Admission documentation
- Physician completed for awhile on patient discharge in addition to daily physician note and discharge summary – too many steps
- Combined into Discharge Summary template
- A Sheet EHR note documentation
- Copy and paste from ADT (RPMS) into EHR after coding completion

## Coding Issues

- Evaluation and Management Code Documentation
- Missed/duplicate E&M codes using EHR provider entry due to difficulty in determining event date (admission visit date appears with all codes)
- Business office often had to remove all codes and reenter in order to drop bill due to inconsistencies
- Date in parenthesis assisted but not all providers were consistent due to added steps to edit and training issues
- May revisit if visit date column is changed to event date in EHR display (enhancement request submitted)
- Business office scans paper E&M code documentation into Vista Imaging scanning software

## Original Final Diagnosis Worksheet

- *********************************************************************
-                  "Official Attestation for Billing Purposes"
-                          Final Diagnosis Worksheet
-                     Cherokee Indian Hospital Authority
-                             Cherokee, NC 28719
- *********************************************************************
- |PATIENT HRCN|     |PATIENT SSN|
- Name: |PATIENT NAME|     |CURRENT WARD-ROOM|
- DOB: |PATIENT DATE OF BIRTH|   Age: |PATIENT AGE|   Gender: |PATIENT SEX|
- Admission Date: |VISIT DATE| {FLD:DATE}
- {FLD:CIH TRANSFER/DISCHARGE} {FLD:DATE}
- Length of Stay: {FLD:CIH TEXT 6} days
- Initial Impression:  {FLD:CIH DRG IMPRES}
- |ADMITTING DX|
- Principal Diagnosis:  {FLD:CIH DRG PRIN DX}
- Secondary Diagnosis (Present on Admission):
- Secondary Diagnosis (NOT Present on Admission):  {FLD:N/A}
- Procedures: {FLD:N/A}
- Out-of-Facility Procedures / Consults: {FLD:N/A}
- I certify that the narrative description of the principal and secondary
- diagnosis and the procedures performed is accurate and complete to the
- best of my knowledge.

## Final Diagnosis Worksheet Combined with Inpatient Discharge Summary

- =======================================================
-      CHEROKEE INDIAN HOSPITAL --  Inpatient Discharge Summary
- =======================================================
- |PATIENT HRCN|     |PATIENT SSN|
- Name: |PATIENT NAME|     |CURRENT WARD-ROOM|
- DOB: |PATIENT DATE OF BIRTH|   Age: |PATIENT AGE|   Gender: |PATIENT SEX|
- Admission Date: |VISIT DATE| {FLD:DATE}
- {FLD:CIH TRANSFER/DISCHARGE} {FLD:DATE}
- Length of Stay: {FLD:CIH TEXT 6} days
- REASON FOR ADMISSION - See Admission INPT H&P progress note.
-   Initial Impression:  {FLD:CIH DRG IMPRES}
- |ADMITTING DX|
- DISCHARGE DIAGNOSES:
-   Principal Diagnosis:  {FLD:CIH DRG PRIN DX}
-   Secondary Diagnosis (Present on Admission):
-   Secondary Diagnosis (NOT Present on Admission):  {FLD:N/A}
- PROCEDURES PERFORMED:
-   Procedures: {FLD:N/A}
-   Out-of-Facility Procedures / Consults: {FLD:N/A}
- PAST MEDICAL HISTORY:
- |ACTIVE PROBLEMS|

- ALLERGIES:
- |ALLERGIES/ADR|
- HOSPITAL COURSE:
- SIGNIFICANT FINDINGS:
- STUDIES/LABS/CONSULTS PENDING AT TIME OF DISCHARGE:
- CONDITION:
- DIET:
- ACTIVITY LEVEL:
- DISCHARGE DISPOSITION:
- AFTERCARE PLAN:
- PATIENT EDUCATION:
- |V EDUCATION EVALUATION|
- DISCHARGE MEDICATIONS:
- |ACTIVE MEDS OUTPATIENT|
-             I certify that the narrative description of the principal and secondary diagnosis and the procedures performed is accurate and complete to the best of my knowledge.

## Dictation Discharge Summary

- Physician has option to dictate hospital course of discharge summary
- Physician completes EHR template under Discharge Summary tab with notation to see dictation addendum
- Transcriptionist makes addendum to Discharge Summary note with physician as author for dictation remarks
- Physician receives notification to sign addendum

## A Sheet EHR Documentation

- Inpatient Coder completes inpatient coding via RPMS ADT package as usual
- Copy and pastes “A Sheet” from EHR RPMS tab (allows to scroll up) into EHR progress note with INPT A SHEET title
- Identifies MD as additional signer to note
- Physician receives notification to cosign A Sheet EHR note
- Eliminates need for physician to sign off on paper copy of A Sheet

## Inpatient EHR ImplementationLessons Learned

- Interdepartmental Communication Important
- EHR Meetings every week (Thurs)
- Involve physicians, nursing, clerks, coding and business office staff with process updates
- Clinical Applications Coordinator should be available to assist with trouble shooting issues and adding additional quick orders during implementation

## Inpatient EHR ImplementationLessons Learned

- Staff Training Important
- Training manual developed for quick reference
- Multiple trainers ideal – train super end users that can reach night shifts
- Ideal training setting
- Group and/or one-on-one training
- Away from patient care activities prior to implementation
- Extra nursing staff coverage may be needed during initial implementation phases due to learning curve
- One-on-one medical staff training

## EHR for Inpatient Training

- EHR for Inpatient Training offered by Office of Information Technology (OIT)
- First training session April 21-25, 2008 in Albuquerque, NM
- Other training sessions TBA – additional training dates to be posted on _[www.ihs.gov](http://www.ihs.gov/)_
- Updated manuals now available on _[www.ihs.gov](http://www.ihs.gov/)_
- Inpatient EHR CAC Set-up Guide (Revised Feb 2008)
- Inpatient EHR User Guide (Revised Feb 2008)
- Join Inpatient EHR Listserve (_[EHRIP@LISTSERVE.IHS.GOV](mailto:EHRIP@LISTSERVE.IHS.GOV)_)

## Questions?