HIM 3014 Health Information Technology Practicum EHR Assessment - Site Visit Questionnaire Student Name: Instructions: Schedule an EHR site visit and complete the following questionnaire by the date found in the course manual for HIM 3014. This is a broad questionnaire that will help you to assess a healthcare organization s EHR from strategic planning through to implementation. Listen to the designated lecture for supplemental information on completion of the site visit questionnaire. The goals of this assignment are: 1. Represent yourself professionally as an HIM student. 2. Develop interviewing skills to elicit information on EHR implementation, design build and maintenance at a healthcare organization that has a hybrid or true electronic health record. 3. Evaluate an EHR from a user s standpoint as to the overall efficacy of an EHR. 4. Create a report on your interview utilizing good writing skills. 5. Discuss and reflect on your EHR site visit experience. 6. Build on EHR learning by researching an unfamiliar EHR topic. 7. Create a workflow diagram depicting an EHR model. Site Visit Coordinator/Interviewee: Name, title (with credentials) and contact information Ideally this person should be an HIM professional, but in some cases this may not be possible. Make sure whomever is your coordinator has enough authority and responsibility within the healthcare organization to provide you with access to the information required for the assignment. Section I Introduction: This section will be due at the end of Module 2 of Health Information Technology Practicum (HIM 3014) as a separate assignment. You will research the EHR product and provide background information about the EHR vendor. You will also provide information on whether or not the product is officially certified and who certified the organization s electronic health record. In addition, you will provide a paragraph describing the healthcare Health Information Management Program. Page 1
organization that you visited, the type of healthcare organization, services provided, number of beds, physicians, etc. This same information will be turned in on your final questionnaire. Copy and paste from the Module 2 assignment to this questionnaire for the final questionnaire. Product Name: EHR Vendor/Company Background: Provide background information on the EHR product that you are assessing at your site visit as well as background information about the vendor/company who produces the product. Provide official certification of the product (CCHIT or other) and a working link to the site where you obtained the information for the vendor. Healthcare Organization Background: Provide background information on the healthcare site that you are visiting. Provide a working link to the site where you obtained the information for the healthcare organization. Section II: Site Visit Information EHR Selection, Design/Build, Implementation and Ongoing Maintenance Instructions: For each of the sections below provide answers to the questions following each question. Use complete sentences as well as correct grammar and spelling. Address/answer each question do not leave any questions blank. Be sure to explain any abbreviations used the first time you use them in the questionnaire. A. EHR History: Provide a brief paragraph or two on the history of the electronic health record at this organization. How long the electronic health record has been in place? Is this the first generation or second generation EHR at the organization? Additional questions might include: Who was on the EHR project team? Was HIM represented? Who was the project leader (department and title)? What were the goals for the EHR implementation? What was the request for proposals process? B. EHR Configurations: 1. EHR Specifications: Create a table and insert here to address the questions below. Make sure the table answers the questions posed by each item. a) What platform does the system operate on? Example: Windows platform Health Information Management Program. Page 2
b) What type of database does the system use? Example: Oracle c) Did the EHR system require the healthcare organization to purchase any additional proprietary software? If so, identify the type of software. d) Based on the product selected did the healthcare organization utilize standardized design features of the product or did they have to customize the EHR to fit their organization s particular needs? e) Does the EHR use HL7 interfacing/messaging standards? f) Certified EHR Modules -- Specify the modules that are certified and by which certification organization. Example: SureScripts LLC. g) Does the EHR include capability to upload digital files and pictures? What format? Example: PDF h) Does the EHR lend itself to a totally paperless operation? If not, does the EHR allow the capability to scan reports? Was the healthcare organization able to use the document imaging system it already had in place or did it require the purchase of a different system? i) Is the facility able to revise its own documentation screens/templates, or is this assigned to a vendor technician? j) Are physicians able to access the system from any internet connection or does the system require the use of Citrix or other central login functionality? Describe physicians internal and external access procedures. 2. EHR Components: List and describe all the clinical and administrative components or applications. a) List and describe the clinical components of the EHR: b) List and describe the administrative components of the EHR: c) List and describe any other components of the EHR that don t fit into the categories above. Health Information Management Program. Page 3
3. Integration of EHR Modules: Describe how the EHR modules interface or integrate with one another. a) Does the clinical program interface with the financial program? How do the programs interface (i.e., Registration/ADT, ADT/clinical, clinical/coding, coding/billing)? b) Does the clinical/financial program interface with Pharmacy s software program or PACS? c) List any other software applications that require integration with the EHR. 4. Workflow: Create a workflow diagram of EHR Components listed in #2 above and based on the integration you described in #3. Copy and paste from the Module 4 assignment to this questionnaire for the final questionnaire. If the workflow diagram was provided by the vendor or healthcare organization, provide an appropriate reference. C. EHR Implementation or Upgrade: 1. Roll-out and Turnover Strategies: Describe the Roll-Out Strategy and Turnover Strategy utilized for implementing and/or upgrading the EHR. Use appropriate terms as discussed on pages 406 411 of the Electronic Health Records (Amatayakul) text. 2. Preparedness: Explain the infrastructure preparedness for the EHR system Go Live or EHR system annual update by answering the questions below: a) Process What type of workflow analysis was performed and were new workflows implemented based on the features of the EHR? Provide one workflow example such as population of demographic data in clinical documentation. b) People Describe the type of training methodology that was utilized such as Train-the Trainer or Super Users. Explain how employees were selected to be trainers. Were onsite trainers provided from the vendor? How was training provided? In class, online, other? What was the average training time required to train clinical staff and what was the average training time required to train non-clinical staff? How is training handled for new employees or agency/contract staff? c) Data Conversion: Explain the data conversion plan the organization utilized prior to Go Live d) Testing Describe the system testing that was performed by the healthcare organization prior to Go Live. Was HIM involved in the testing process? Who created Health Information Management Program. Page 4
the test plans and what was considered a successful test? Provide an example of one test item. e) Timeframes - How long was the system implementation from purchase to Go Live? Explain any significant delays in system implementation. D. EHR System Documentation: What department maintains all the documentation for the EHR? Examples: user manuals, practice guidelines, decision support rules, and system documentation. List the title of the person(s) who maintains the documentation and their department. Is the information readily available to the entire organization and how is it available? Example: stored on a shared drive E. Ongoing EHR Maintenance: 1. Describe the type of support that is available on a 24-hour basis. Is it internal or external? Are there additional costs for external support? 2. Describe how support is provided. What is the expected turnaround time for response? What is the actual turnaround time for response? What are the qualifications of support personnel? 3. How frequently are software updates provided by the vendor and how often does the healthcare organization install these updates? Does the healthcare organization utilize a team to assess whether the updates should be installed or not and what impact the updates will have on current workflows/processes? 4. What are the required or scheduled down times? Are there downtime procedures for EHR documentation in place? How does the EHR get updated after a downtime? Describe the downtime procedures. 5) How are change requests for the EHR managed? Are changes a centralized or decentralized process? How are changes communicated throughout the organization? F. Budget/Costs EHR Project: What was the projected budget for the EHR project? This can be a ballpark number. Did the costs of the implementation exceed the original budget? What contributed to budget overruns, if any? Estimates of costs or budget will suffice. Health Information Management Program. Page 5
SECTION III: Demonstration of the EHR Instructions: For each of the sections below provide answers to the questions following each question. Use complete sentences as well as correct grammar and spelling. Address/answer each question do not leave any questions blank. Be sure to explain any abbreviations used the first time you use them in the questionnaire. A. User Interface: You will assess the actual performance of the EHR product via a demonstration. 1. Are the EHR documentation screens visually appealing? Are the screens easy to maneuver? Does data move easily from one screen to the next? Example: Do patient name, DOB, and medical record number populate new forms upon their creation within the patient encounter? Describe your impressions as an end user. 2. What is the method of data entry? List all that apply: mouse, keyboard, touch screen, voice, bar code, other 3. Does the EHR use template notes, narrative entries or transcribed reports? Does the EHR product include SmartText or Smart Phrases? Are data entered via electronic forms with dropdown boxes or selected from columns similar to a spreadsheet? Describe the process for creation of a progress note by a clinician within the EHR addressing the questions above. 4. Does the EHR include an electronic co-signature capability? How does this impact the workflow for chart completion? Describe the provider signature process. 6. Is decision prompting available? Are electronic alerts and drug counter-indication notifications available? If so, provide an example of one or two alerts a clinician may see. Health Information Management Program. Page 6
SECTION IV: Other EHR Considerations Instructions: For each of the sections below provide answers to the questions following each question. Use complete sentences as well as correct grammar and spelling. Address/answer each question do not leave any questions blank. Be sure to explain any abbreviations used the first time you use them in the questionnaire. A. Security: 1. Passwords/Access Audit Trails a) What are the security features of the EHR system? b) Does the system provide EHR security rights by password? c) How often are passwords changed and what are the parameters of the change (password strength)? d) Does the EHR have a biometric capability? e) Which department maintains the security to the EHR within the organization? Include titles for security positions. f) Are there access audits available from the system and who monitors these audit trails? g) How are mobile devices such as smartphones, IPads, etc. monitored in terms of security of data? Does the organization have a policy in place regarding the use of mobile devices? Explain. 2. Editing the EHR/Erroneous Documentation: a) What edit functions are available to end users during the documentation process? b) Can notes be appended and/or changed and does this impact the physician signature process? c) How is an entry error corrected? Who is responsible for correcting errors within the EHR? d) Does the healthcare organization have a copy and paste policy regarding EHR documentation? If yes, briefly describe. If no, why not? Who within the organization is responsible for monitoring the copy and paste functions within the EHR? 3. External Reviewers: a) What is the healthcare organization s process to accommodate surveyors during regulatory inspections and accreditation surveys where log-on and access to the EHR is required? Health Information Management Program. Page 7
b) Is anyone else outside of the healthcare organization allowed access to the EHR? How is this monitored and why? Does the healthcare organization have any type of Break the Glass function? B. Reporting: 1. Are end users able to run reports based on their job roles or are all reports run by Information Services? Explain. 2. Is HIM able to obtain the reports necessary for managing their work out of the EHR? Coding reports, chart completion rates, ROI reports, etc. If so, describe the types of reports that are generated from the EHR particular to HIM. If not, explain what workarounds are being completed in order to obtain the appropriate reports. Section V: Assessment of EHR Instructions: For each of the sections below provide answers to the questions following each question. Use complete sentences as well as correct grammar and spelling. Address/answer each question do not leave any questions blank. Be sure to explain any abbreviations used the first time you use them in the questionnaire. A. Healthcare Organization s Assessment a) How is the organization measuring EHR adoption within the organization? Identify and describe one tool that is being utilized to measure EHR adoption. b) What is the EHR Impact on patient safety, quality, and availability of care? Identify and describe one quality measure that evaluates the EHR s impact on patient safety, quality and/or availability of care. c) Has the EHR proven to provide administrative efficiency and effectiveness? How is this measured? Identify and describe one metric used to measure efficiency and/or effectiveness as such drop in accounts receivables. d) What is the history of Meaningful Use at the organization? Did the healthcare organization apply for the federal incentives attached to proving meaningful use? What pieces of meaningful use was the EHR certified for? How did this positively impact the facility financially? e) Does the organization participate with a Health Information Exchange (HIE)? What type of health information is regularly shared via the HIE? With whom is the information shared? Health Information Management Program. Page 8
f) HIMSS Analytics has created the EMR Adoption Model, an 8-stage model that allows a healthcare organization to track their progress against healthcare organizations across the country (himssanalytics.org). What is the EMR Adoption Model stage of this organization? B. Health Information Management s Assessment: a) What was HIM s contribution in regards to the EHR implementation? Was there HIM representation on the EHR Steering Committee? If so, provide HIM job title and HIM s role in the actual EHR implementation. If not, why? b) What new roles have emerged for HIM at the healthcare organization since implementation of the EHR? Describe the new roles and their typical job duties. c) What changes occurred within the different HIM areas (coding, chart management, transcription, ROI) as a result of the implementation of the EHR? Provide two examples. d) What type of coding product is used (3M, other)? Describe the coding process as it relates to the functionality of the electronic health record. How does the coding query process integrate with the EHR? e) Is HIM assessing or actively implementing any add-on products such as clinical documentation improvement software or computer-assisted coding? Describe the department s current status in regards to these products. f) Problem List: Describe the procedure utilized by coders for handling diagnoses on the Problem List. How is this list managed so that coders know which diagnoses to code for a particular encounter? g) What does the organization consider its legal medical record? Example: Do they release records from the EHR or from another source such as a laboratory or radiology system? Describe the documentation in place that outlines the legal medical record in this healthcare organization such as a Legal Health Record Legend, EHR Legal Health Record Policy & Procedure, etc. h) What types of automated workflows are available in the system? Does the system automatically check for key documents such as transcription or labs before routing to the coder or chart analysts work lists? Provide one example (if applicable). i) Has the department allowed any staff to work remotely as a result of the EHR implementation? Which positions? Explain. j) What is the process for allowing patients to review their medical records electronically? What is the process for allowing patients to amend their medical records electronically? Health Information Management Program. Page 9
k) Patient Portals: Is there a patient portal or personal health record (PHR) available through the EHR? If so, what information are patients able to obtain either through the patient portal or PHR? Example: lab results, diagnoses. Who educates patients regarding use of the patient portals? What role does HIM play in managing PHI within the patient portal? l) What were lessons learned from the implementation or what are some things the organization would do differently? Are there are major EHR process improvement (PI) initiatives in the works and is HIM involved in these PI initiatives? SECTION VI: Wrap-Up Instructions: Provide a paragraph (200-250 words) reflecting on the interview process; highlight one experience from this assignment that you believe will be helpful throughout your HIM career. Health Information Management Program. Page 10