Getting PFTs into the EMR Lessons learned Kevin McCarthy, RPFT Manager, Pulmonary Function Laboratories Cleveland Clinic
Getting PFTs into the EMR Lessons ^ being learned Kevin McCarthy, RPFT Manager, Pulmonary Function Laboratories Cleveland Clinic
Maximizing the Tools Available PFT techs get good at getting quality test results Difficult work Technical Maintaining instrumentation and assuring accuracy of Interaction with databases, EMR and PATIENTS Software can help or hurt you Any tool that can save time for the tech or the doctor should be explored
PFT Labs often orphaned from Tools Limited budget and resources Low volume = low pressure to integrate into EMR Scanned reports are a common interface to the EMR TAT often lengthened by HDS desire to exclude scanned preliminary reports from the EMR Can result in lengthy (weeks) delays
Consider the Customer Inpatient testing for assessment of operative risk leaves inadequate time for efficient access to data Long delays to access to results for Outpatient testing results in an inefficient operation. Interpretation Only reports are inadequate unless specific results are in interpretation. Lack of graphics data withholds diagnostic and quality assessment Trending of important parameters not possible
Cleveland Clinic PFT EMR 1985 PFT Lab moved to a new building; lab wired for networking testing systems (4 rooms) 1996 - Entire operation consisted of 6 full PFT systems, 2 spirometers, ABG analyzer and 1 CPET unit. Interfaced a simple HL-7 text report to our EMR (LastWord) Two reports: Preliminary (sent within minutes) Final (should be sent within 24h)
2010 Assessment Many of the docs needs were not being met No graphic data No trends Unable to police the 24h turnaround time TAT was 3+ weeks at some sites No electronic signature labor-intensive workaround Logging/billing were time consuming Operation had grown: 8 full PFT systems, 4 spirometers, ABG analyzer and 1 CPET unit 6 Satellite Labs (full PFT systems) 8 hospital-based PFT labs Growing pulmonology practice in region
Post-Test Workflow CMS Electronic Signature Requirements Not Met Post-test processing: After preliminary report sent, report available in que for electronic review Fellow interprets test All reports printed next morning with interps Edits hand-written on reports by interp MDs, other reports signed Edits made in PFT text file Edited reports printed for signature Tech looked up appointment that report represented and printed a barcode label Label affixed to report Labeled reports sent to HDS Labeled reports scanned into EMR
Plan Get software that will do all I want
Cleveland Clinic s Future State Graphic data (flow-volume loops) Trend data Paperless review True electronic signature 24h TAT Ability to monitor workloads and reallocate studies Billing and logging
Search Started with Our PFT Vendor All PFT systems in my labs came from one vendor (Jaeger-CareFusion) Timing was bad Vendor was migrating to new software platform Their solution was not sufficiently developed at the time
PFT Vendors 3 years ago, what was available was limited in its capabilities Vendor best when dealing with their own data Trending is simple when it originates from the PFT database Less robust when dealing with other vendors Can t edit/reselect data Trending will require discrete parameter reports (can be extracted from HL-7 reports)
Other PFT Vendors Medical Graphics nspire + Both had solutions that seemed good - Both required their hardware to enjoy all of the features
Internal Search Evaluated solutions used in other areas: Endoscopy - ProVation Radiology Syngo Peripheral Vascular adapted Syngo Approached each vendor to assess their interest in adapting their software: NO
External Search Middleware Epiphany Cardio Mainly Cardiology Recently adapted to PFTs Experienced with high volumes Hundreds of installations in US
Solution Selected! Epiphany would give us Order Entry Text PDF Trending Electronic signature Billing Order placed!
Purchase Order not Released! Legal review Took about 2 weeks IT review Committee review took several months Commitment of resources took months Total process - over 1 year
Purchase Order Released; When and How to Implement? Servers needed to be purchased and built All workstations had to be network ready All lab sites had to have an active network drop Software loaded on servers Some software needs to be built the interfaces * Some software needs to be built the interfaces
When to involve `IT YESTERDAY!
IT Collaboration Submit IT Project Request ASAP Get on their schedule! (if possible, before PO is obtained) IT should review the vendor s proposal Evaluate costs (server, PC upgrade, OS upgrades) Estimate IT involvement (possibly more $) Request a Project Manager!!!!!!!!!!!!!!!
What does a Project Manager do? Develops high level map of the route to get from here to there (now to future state) Recruits a team of IT specialists to develop, test and implement the interfaces Works with vendor s interface specialist Should be your first contact
What does a Project Manager do? IT size and hierarchy varies widely PM uses Project Management tools to keep track of all of the known tasks and the ones that develop Organizes teleconferences, remote access for vendor reps, keeps track of due outs from team members Keeps stakeholders apprised via touch-point meetings
How Much Will It Cost? Depends on: how many servers and their configuration What reporting options are chosen ADT (front end) HL7 text PDF Trending How many sites (testing workstations)
Costs Workstation upgrade PC?, OS?, PFT OS? Network drop for PFT workstation Dedicated server(s) needed Software Licenses IT costs for implementation (can be significant)
Sell the Plan Present plan (goals) to administration Patient care (immediate preliminary report, final interpreted report in 24h) Efficient for ordering physicians Efficient for interpreting physicians Efficient for lab Assist with standardization
How Long does it Take? Depends: Single system vs. multiple systems vs. multiple hospitals vs. multiple EMRs Single PFT vendor vs. multiple vendors Number and type of projects (ADT, HL7 report, PDF link, discrete parameters for trending, interpretation, electronic signatures, billing)
Phases may be necessary Dependent upon: Budget Development of EMR Software updates/upgrades from PFT vendors Bandwidth of IT resources
Wish List Front-end interface between EMR and PFT lab Import order info Laboratory log Show flow-volume and other graphic data On-demand trending of key PFT parameters True paperless post-test review Electronic signature Easy assessment of aging of reports (24h TAT) Ability to shift workloads between physicians Automate billing
1 st Step - Review of Workflow Don t Assume You Know all of the Details Watch and/or interview the therapist involved during each step of the process from receipt of order to generation of final report Show the entire process on flowchart Repeat the workflow mapping to reflect the future (desired) state Determine what change(s) need to occur to move from current to future state
Cleveland Clinic Current PFT Workflow Check - in Interpretation Verify Order Billing Med/Allergy Reconciliation Height/weight Chief complaint Reporting Workaround Administer Test
Workflows Current (TAT ~1 week+) Proposed (TAT < 24h) 1. Test ordered 2. Test scheduled 3. Order verified (chart review?) 4. Patient demographics entered/updated at time of test 5. Test completed 6. Report printed 7. Report picked up by interpreting MD 8. Test interpretation dictated 9. Reports and tape returned to lab 10. Dictated interp transcribed into file 11. Report w/interp printed 12. Report w/interp signed 13. Report scanned into emr 1. Test ordered (order ID created) 2. Test scheduled 3. Order verified (Order tab in Cadence) 4. Some demographic info from Epic transferred to testing workstations by Epiphany 5. Test completed 6. Preliminary reports sent electronically to Epiphany (PDF, discrete text), forwarded to Epic 7. Interpreting MD views test results online, applies interp, e-signs interp, final report sent to Epic
Multiple Sites? Don t assume review and map workflow Look for differences in current state Anticipate differences in future state
Reporting Options Text (HL-7) PDF Discrete data Electronic signature Inbox/email notification (ordering MD)
Preliminary Work Identify PC, OS, RAM to evaluate the need for replacement or updating Verify that current software version will be compatible with options chosen Identify/install network drop and activate Purchase PFT electronic interface software Identify key personnel in each lab to work with Epiphany staff at rollout
Are We There Yet? The Testing Phase Interfaces must be built and tested HL7 (text) reports tested If PDFs desired, how are they sent and stored? If Discrete Parameter reports used for trending, the translation must be tested
Testing Very time-consuming (can take weeks) Involves coordination of people from various areas within the EMR team (if not coordinated, can take months) Try to grow your own super-user
Training Change in workflows can be significant Minimal training generally required Super-user in lab can help field calls and provide guidance Enlist the aid of the EMR training staff and Communications
Communications Generally need 2-4 weeks to assess, plan and implement communication measures Emails Announcement page links
Ordering Physicians Easier access to the PFT order list Information column provides important info about the tests Timely TAT for the interpretation (<24h) Ability to trend key parameters on demand within Epic (prospectively only) Ability to review graphic data from Epic (PDF)
Appointment schedulers New order list is identical to the list of procedures seen by appointment schedulers Eliminates guessing which procedure matches the order No more write-in orders
PF Techs Can quickly verify orders using the ORDER tab in Cadence Import critical demographic data from Epic; list of scheduled procedures is available within the testing software (eliminates input errors) Training is minimal; interaction with Epiphany limited to importing demographic data and sending two electronic reports
Interpreting Physicians Can access the Epiphany software from any CCF terminal or can access remotely with 4 Corners Standardization of interpretation practices across CCHS (picklists) Can sign electronically; interp sent automatically to Epic to be appended to PFT report
Billing Embedded in this system is the ability to automate billing of the technical and professional components at the moment of completion
Cautionary Note Rapid appearance of PFT results in the EMR is a good thing Good idea to scrutinize report before releasing the preliminary report Errors are shared with the world with a click
Recommendations Involve IT at the start Evaluate workflow Decide on reporting options Strongly consider trending and PDF Start with your PFT vendor Get realistic costs up front no surprises! Bring PFTs into the big leagues where 24h TAT is the norm