Most long-term care facilities use a hybrid medical record, part paper and part electronic, with the percentage of paper varying greatly among facilities. But by 2014, everyone will need to be ready for a national electronic health information infrastructure. So as you update your five-year plans, a critical goal should be to move to an electronic medical record.

In this current transition period, the facilities that are actively moving toward an EMR have taken one of three general approaches: maximizing their current software and hardware, staying current with technology as it becomes available, and making a total change from the ground up.

MAXIMIZING THE CURRENT SYSTEM

Some LTC facilities are preparing for the future by making full use of their current software and hardware to reduce paper. They are making workflow changes that improve efficiency in the MDS process, care planning, progress notes, physician orders, and other assessments and worksheets. Making these changes now reduces time-consuming tasks and improves communication. And a hybrid medical record that is closer to an EMR will make future changes easier.

STAYING CURRENT

Another approach is to acquire software and technology as it becomes available, such as the eMAR/eTAR for point-of-care medication/treatment charting and e-prescribing for electronic communication with pharmacies. These progressive organizations are reaping the benefits of an EMR today, including increased revenue and efficiency, improved quality of care, reduced risk and better communication.

STARTING FROM SCRATCH

A third approach is to install a whole system as one project. Partners Healthcare of Boston, recently implemented a new clinical and billing software system by following the principles set out by the Project Management Institute. Partners Healthcare is an integrated health system founded by Brigham and Women's Hospital and Massachusetts General Hospital. The skilled nursing facilities that implemented the new system are The Boston Center and The North End Center for Rehabilitation, part of Spaulding Rehabilitation.

To begin, Partners addressed the project's schedule, scope and budget. In most health care projects, the budget is the fixed element and if adjustments need to be made they are usually to the project's schedule or scope, explains Colleen Rougeaux, project specialist.

They then set up a series of teams:

• An oversight committee reviewed changes in schedule, costs and resources.

• Decision teams reviewed and chose forms and reports, and addressed administrative issues.

• Project teams helped design the software and train the staff.

• The data-entry team worked with the project team to enter data, including capturing data from the previous system if the conversion did not pull the information over.

All of the team members worked together to address organizational culture, stakeholders' interests, regulations (policies and procedures), communication and patient care.

Partners diagrammed the workflow of the areas the software took over. For progress notes, the paper workflow began with nurses registering patients with paper documents. The documents were then copied and distributed. During the resident's stay, nursing staff handwrote notes and the unit secretary filed the notes in a paper chart.

After the software was implemented, those tasks were either automated or eliminated. Now resident information is entered in the system at admittance. Nursing retrieves data and enters notes online. At discharge, the patient's record is already stored electronically.

KEEPING TRACK

The project manager used online tools to keep track of all aspects of the implementation. For the initiation phase, she used a culture documentation tool, a project charter, the organization's policies and procedures and workflow diagrams. During the planning phase, she maintained a communication plan, a risk management plan, and a work breakdown structure document that defines the work of the project and how it meets the project's objectives.

"Planning takes time," Rougeaux says, "but it saves in the long run because less re-work will need to be done."

Another important element is measuring performance. "For clinical projects, we measured productivity before and after implementation," she adds. "We also measured success according to what's important to the sponsor and the department affected. I maintained a simple grid that showed each task and its status. It was useful at team meetings to keep everyone on the same page."

"We did a lot of preparation so the execution phase ran smoothly," continues Rougeaux. "For the physician orders implementation, we used spreadsheet software to list medication profiles, indications for use, time codes and most-commonly ordered medications. When we had it all on paper we could see how it related to the software profiles and could all agree on how to proceed."

For each application, the Partners teams gathered all the reports everyone was using to make sure the information would be available with the new system. The software vendor's manuals were downloaded, modified for Partners' procedures and put on CDs to give to each staff member.

WORDS OF WISDOM

Rougeaux shared some lessons learned from software implementation projects:

• Document, document, document.

• Have a central area where all the project management tools reside so you can communicate well with staff and sponsors.

• From the beginning, make sure everyone has a chance to participate. This encourages a sense of ownership for the new EMR process.

• Communicating to the staff should be fun and informative, and should not increase workload. When the project work is completed, the staff that must maintain the systems and ensure their efficiency and effectiveness.

CHOOSING THE RIGHT PATH

We are in a transition period now with the goal of electronic medical records in view. Besides the many benefits EMRs offer to facilities, the government and other external influences are directing skilled nursing toward an EMR as a prerequisite to a nationwide Electronic Health Record. Now is the time to choose the path your facility will take.

Matt Walker is applications systems manager, Keane Care, Redmond, Wash. DISCLOSURE: Keane Care provides software to the long-term care market.