Nine separate clinics have now gone live with eClinicalWorks in SMMC's health system since March, with four more to go (one being a multi-specialty clinic and another being a clinic with rotating family practice residents). Three major categories of problems have emerged in our voyage to digital conversion: ePrescribing, billing and user support.
ePrescribing issues emanate from a misunderstanding of provider workflow and eRx capabilities, an in-house pharmacy system that is older and not made with eRx in mind and eRx naive commercial, non-chain pharmacies. A focused team has been assigned to work through these problems. It is increasingly evident that ePrescribing is still in an early stage of development due to both legal and technical hurdles.
We are still trying to determine the correct strategy for electronic billing, so we continue to manually complete paper fee tickets after each encounter. Since our current financial system was originally developed for inpatient services, the customizations required for outpatient billing produce significant interface challenges. A specific and painful example is the requirement for an episode number (generated by a physical visit) to be linked to any lab/Xray order to initiate a charge. This was not anticipated to be a problem, until we realized that in the outpatient setting, labs can be ordered as a result of a phone call, or in the future for maintenance care, and they are not associated with a specific visit. Workarounds are being considered and development requests are being sent to the vendor.
Our support structure has now come under intense introspection as our centralized IT resources are being called to work on other projects within the medical center. User demand for support is higher than anticipated because we are not fully leveraging our superusers and have not instituted a triage desk to rank calls by priority. We are working quickly to remedy these shortcomings.
eClinicalWorks has been responsive to our needs in most cases, especially in those circumstances where patient safety is involved or actual use of the EMR is impaired to he point that workflow is disrupted. We have regular support calls with eCW staff, and if significant issues arise, then ad hoc groups quickly form from both sides and meet as needed to solve the problem at hand.
As the first clinic has been live for 3 months, we are beginning to entertain requests for changes to templates to optimize provider performance and satisfaction. Our system administrator will be a certified trainer for eCW, and we also have another eCW certified trainer on the IT staff, so ongoing training for new hires is possible. A sustainable support plan in our post go live existence is also being reexamined in the face of the new budget cuts.
One additional concept that we have overlooked and will be important for sustainability is IT system monitoring. With increasing frequency, we are being made aware of problems in the system by the end users, when it should be the support team that identifies the problem first whether it is the drive that is almost full, leading to performance degradation, or the fax server that stopped functioning or the sudden drop in normal eRx refill traffic. This has lead us to explore proactive monitoring solutions, many of which are open source (e.g. Nagios), that can put the support team on the leading edge of potential problems and avoid inferior performance or malfunction events.
The general attitude of all of SMMC has been positive, due to strong executive support and endorsement, and a commitment to improve the care for our patients. This will help take us to the finish line of our implementation and change the care processes of our organization.
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Mike -
Thanks so much for your update (I've been meaning to respond for a few weeks now...). I am particularly interested in two things you mentioned. The first is about the issues you have faced with ePrescribing. I wondered if you could elaborate on your comment that ePrescribing is in its infancy, specifically as it relates to the meaningful use criteria that will be required for Medicaid/Medicare incentives. I get the feeling that CMS sees eRx as "low hanging fruit" and you are not the first person to indicate this in not the case. [Perhaps I'll raise this to a higher level post for all to comment on.]
The second issue is that of pro-active monitoring; what a terrific idea! Once you get benchmarks for "normal" activity you can begin to develop a dashbord of monitoring indicators. Charles K. at Shasta also told us of a related activity: he runs a set of scripts every morning that look for outliers in various data fields. These are sent to the person who entered the data to correct or to verify. Please keep us posted about your evaluation and monitoring activities.
Congratulations on your efforts so far, hang in there for the home stretch. One never anticipates the thousand little things that can add up to big impediments. Writing about them here will definitely help others to think through some of these details.
SA
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