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Implementing an EHR to Connect a Rural Health Network (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 19, 2009, John O'Brien made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (28.5 MB).

Slide 1

Implementing an EHR to Connect a Rural Health Network

John O'Brien
Marcia Ward, Douglas Wakefield, Jean Loes

Slide 2

Presentation Objectives

  • Describe EHR10/Genesis, Mercy Health Network-North Iowa, and the collaborative partners.
  • Describe key aspects of readiness and major challenges for a Critical Access Hospital

Slide 3

What Is EHR10/Genesis

  • Integrated Health Information System shared between participating Network Hospitals, Mercy Medical Center-North Iowa, and Trinity Health.

Slide 4

Collaborative Effort-supported by the Agency for Healthcare Research and Quality, grant # UC1HS016156

EHR10 Hospitals
Trinity Health
University of Iowa

Slide 5

Mercy Health Network - North Iowa

A schematic map demonstrates the far-reaching geography of Mercy Health Network-North Iowa, including nine affiliated and contract Managed hospitals of Mercy Medical Center-North Iowa (the referral hospital), the wholly-owned clinics, and Physician-Hospital Organizations and their affiliated Clinics. The seven participating EHR10 sites include:

Palo Alto County Health System, Emmetsburg, Iowa; Kossuth Regional Health Center, Algona, Iowa; Hancock County Memorial Hospital, Britt, Iowa; Franklin General Hospital, Hampton, Iowa; Ellsworth Municipal Hospital, Iowa Falls, Iowa; Mercy Medical Center - New Hampton, New Hampton, Iowa; and Mitchell County Regional Health Center, Osage, Iowa.

Mercy Medical Center - North Iowa, Mason City, Iowa is the referral center for these rural hospitals and is situated centrally.

Mercy Medical Center-North Iowa is a ministry organization of Trinity Information Services, Farmington Hills, Michigan.

Slide 6

Collaborative Effort

  • Mercy Medical Center-North Iowa
    • MMC-NI Project Support Team
  • Trinity Health
    • Build
    • Testing assistance (integration, system, user acceptance, stress/load)
    • Cutover assistance
    • Future maintenance and upgrades to software solutions
  • Network Hospitals
    • Readiness Teams
    • Work Teams
    • Super Users
    • Trainers

Slide 7

Strategic Vision

  • Collaboratively transform care delivery processes to improve health care quality and operational efficiencies by incorporating evidence-based practices and best practice business designs with state-of-the-art technology.

Slide 8


  • Excellent Patient Experience
  • Patient Safety
  • Excellent outcomes
  • Improve quality
  • Improve efficiency
  • Seamless care for all our patients in North Iowa
  • Improved care coordination between all providers
  • Patient Satisfaction

Slide 9

EHR10 Conception

  • Network Strategic Plan (FY2005-2007)
    • Develop an Integrated Information System
  • Planning: funded by AHRQ Grant, # HS015396-01
    • Network Steering Team
      • All Network CEOs
      • MMC-NI Leadership
      • IT and HIM Professionals from MMC-NI Network
      • Public Health Nursing
      • Network Physicians
    • Educate, identify goals, assess organizational readiness, review infrastructure, prepare care delivery, develop implementation plan
  • Implementation: supported by AHRQ Grant #HS016156
    • Network CEO Leadership, Mercy Leaders, Trinity Health, U of Iowa

Slide 10

EHR10/Genesis Components

  • Healthland Patient Management/Patient Financial Systems
  • Cerner Clinical Systems:
    • PowerChart
      • Clinical Data Repository
      • Clinical documentation
      • Provider Order Entry
    • PharmNet: Pharmacy Information System
    • RadNet: Radiology Information System
    • FirstNet: ED System
    • CareMobile:Barcode scanning for medication administration
  • Fletcher Flora/LabPak: Laboratory Information system
  • Chart Script: Transcription system

Slide 11

EHR10 Health Information Technology

Slide depicts the Health Information Technology proposed by Trinity Health at the start of the project. The shape of a house is used to illustrate the building blocks of HIT, which includes a clinical data repository, results viewer, enterprise master patient index as the foundation, rules engines and alerts, Zynx Clinical Content Database as second tier, e-signature, Pharmacy Information system, nursing documentation, medical records applications as the next level, radiology information system, ED application, use of Computerized physician order entry system at a fourth tier, and bedside scanning at the bedside for medication administration at a higher level (tier 6). At the highest tiers are physician and patient portals, community networks, and finally, the Infrastructure to share data nationally.

Slide 12

Being Connected

Slide shows schematic of information systems at the seven hospitals and their interfaces at the start of the project, along with interfaces that would be developed through the project in order to "connect" the seven hospitals.

Slide 13

Best Practices - Trinity Mercy Bural Hospitals

Picture depicts the different information systems, technology, and infrastructure that impacts care at the bedside:

IT support, Pharmacy information systems, Automated medication dispensing cabinets, Radiology information systems, PACs, Laboratory information systems, Health Information Management systems, hardware, connectivity, and wireless infrastructures that supports the use of evidence-based care at the bedside.

Slide 14

Phase I 9/1/06 - 07/01/07

Applications and Infrastructure included in Phase I:

  • Install common lab system at two additional sites
    (Fletcher Flora)
  • Update Dairyland & Fletcher Flora to use the Trinity Std. data elements and charge description master
  • Evaluate Wide Area Network Security
  • Update Dairyland to store and transmit patient identifier
  • Install ADT & Result Interfaces (Dairyland - Cerner)
  • Power Chart - EHR Result Review

Slide 15

Phase II 07/25/07 - 9/05/08

Applications and Infrastructure included in Phase II:

  • Rules & ADE's
  • Profile - Chart Deficiencies, Physician Inbox
  • Discern Explorer - Reporting
  • Cerner Clinical Applications:
    • Power Chart - EHR
    • Power Orders - computerized physician order entry (CPOE)
    • PharmNet - Pharmacy
    • RadNet - Radiology
    • CareMobile-point of care med administration device that uses bar code scanning technology-Deployed February and April 2009.

Slide 16

Readiness Process: Why Do We Need It?

Slide 17


An Operational Plan:

  • Comprehensive work plan
    • Tracked through a web-enabled work plan tool
    • Addresses: People, Process, Technology, Operations and Culture
  • Assessments to monitor progress (Cultural, Clinical, Training, etc.)
  • A series of Executive meetings designed to promote and support key strategies (Physician and Clinical Adoption plan, Communication, Revenue Management)

Progress tracked and reported with a comprehensive Readiness Dashboard that includes:

  • Work plan progress to critical milestones
  • Competing priorities
  • Watch List (risk items)
  • Operational indicators
  • Executive deliverables status

Slide 18


A Structure

  • EHR10 Steering Team (Oversight)
  • EHR10 Integrated Operations (Readiness) Team
  • Genesis Executive Steering Team - Trinity Health Executives

Key Roles

  • Executive Leadership - Mercy Health Network-North Iowa, Home Office and TIS
  • Readiness and Oversight Teams - supporting members include DONs, physicians, liaisons, MMC-NI Project Support Team, TIS
  • Operational Project Management - Readiness Facilitator, Senior Readiness Project Manager
  • A cast of thousands!

Slide 19

EHR10 Readiness Structure

Organizational Chart showing the structures to support readiness activities, the top phase being the EHR10 Steering Team, made up of Network hospital CEOs and led by Senior VP of Network Integration.

Slide 20


  • Project Milestones:
    • Understand Current State
    • Define Operational Impact
    • Operational Build
    • Validate Build and Process Decisions
    • Train
    • Deploy Computer Devices
    • Finalize Activation Support Processes
    • Activation (Go-Live)
    • Transition to Operations

Slide 21

Define Operational Impact (Standardize)

  • Standardize Formulary
  • Select orders and ordersets from standard catalog
  • Review standardized documentation forms & flow sheets
  • Adopt Best Practice Design Workflows
  • Select rules from catalog
  • Develop comprehensive training plan
  • Map to Trinity Standard Charge Description Master (from Cerner)
  • Map end users to Cerner Security positions

Slide 22

Validate Build & Process Decisions (Internalize)

  • Testing
    • Unit Testing
    • System Testing
    • Integration Testing: 2 rounds
    • User Validation Testing
    • Process Simulation Testing: 2 rounds
    • System Charge Testing

Slide 23

Train (Internalize)

Trainers, Super Users, & End Users

  • Trainers (107)
    • PowerChart Trainers: 40 + hours
    • Physician Trainers: Additional 8 hours
    • FirstNet Trainers: Additional 16 hours
    • CareMobile Trainers: Additional 6 hours
  • Super Users (93)
    • Up to 40 hours of training
  • End Users (779)
    • PowerChart : ~20 hours, plus practice
    • FirstNet
    • CareMobile
    • RadNet
    • PharmNet
    • Physicians

Slide 24

Challenges to CAH

Process Workflow Gaps

  • Patient Management/Patient Accounting
    • Lack of 24/7 real-time registration process
    • Need of an encounter strategy to delineate care provided at each level of care for patients whose primary carrier is Medicare
    • Patient Identification using bar coded wristbands

Slide 25

Challenges to CAH

Process Workflow Gaps

  • Clinical
    • Lack of 24/7 presence of many roles requiring the need for more than one department to receive notification (Respiratory Therapy, Laboratory, Social Workers, Dietitians)
    • Other departments performing functions typically provided by another ancillary department (example, EKGs performed by Lab)
    • Medication Administration using barcode scanning at the point of care

Slide 26

Challenges to CAH

Process Workflow Gaps

  • Pharmacy
    • Standardizing formularies
    • Lack of 24/7 pharmacist for order review and medication dispensing
    • Purchasing practices intended to minimize number of items stocked in pharmacies (due to limited shelf space, costs, and concerns about shelf life)
    • Billing process for Medicare patients whose level of care changes during one episode of care: impact to orders, review, dispensing, charging and crediting.

Slide 27

Phase II Live!!!!

July 26, 2008
Franklin General Hospital-Hampton, Iowa
Kossuth Regional Health Systems-Algona, Iowa
Mitchell County Regional Hospital-Osage, Iowa
September 8, 2008
Ellsworth Municipal Hospital-Iowa Falls, Iowa
Hancock County Memorial Hospital-Britt, Iowa
Mercy Medical Center-New Hampton, Iowa
Palo Alto County Health Systems-Emmetsburg, Iowa

Slide 28


  • Complex, but necessary
  • Resulted in Network-wide collaboration and integration to reduce variation and improve quality
  • Front-end pain will result in back-end gains
Current as of December 2009
Internet Citation: Implementing an EHR to Connect a Rural Health Network (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


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