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EHR Resource Planning (3) – Estimating Task Work and Duration

Estimating the work effort is the third blog in the multi-blog series on estimating resources for an electronic health record (EHR) project. The first blog, Introduction, describes the basis for these blogs and the series of blogs that will follow. The second blog, Defining Resources, discuses how to create the tasks and designate the resources roles assigned to the task in a resource assignment matrix (RAM). The third blog will use the RAM created in blog two and add work, duration and resources to the tasks.

Let's take a look at how to use your RAM to add work and duration for each task. The RAM (Appendix 1) lists all the tasks and resources needed to complete the tasks. The tasks from the RAM should be copied into a project management software application, such as Microsoft Project (Appendix 2). An additional tool to assist with estimating duration is a risk register (Appendix 3) which contains the identified risks. A risk is a positive or negative event that may impact the ability to meet the project objective. For example, if a particular task has a high risk probability then the duration or work for that task may need to be increased.

There are several task duration and work estimating techniques however we will focus on three which include: expert judgment, historical performance, and three point estimating. Expert judgment is generally used when no historical data is available from past projects and involves requesting individual team members to provide work and duration estimates. The second estimation technique, analogous estimating, uses historical information as the source for estimating duration and work. The last estimation technique, three-point estimating, involves gathering three estimates for each task: most likely, optimistic, and pessimistic. The next step is to combine all three estimates to come up with one single value. The most common method of obtaining an accurate single estimate is by using the Program Evaluation and Review Technique (PERT). PERT uses a formula in Microsoft Project that places an emphasis on the most likely estimate but still takes into account the pessimistic and optimistic estimates (Appendix 4). Microsoft Project only supports estimating duration with PERT however you may create an Excel spreadsheet and average the likeliest, optimistic and pessimistic work estimates and enter that value into the work column in Microsoft Project. Three point estimates will be more accurate than single point estimation and is recommended for estimating work or duration for tasks without expert judgment or historical performance baselines.

The next step is to attach the resources to your tasks. In order to complete this step the resource sheet in Microsoft Project must be populated from the resource names in the RAM (Appendix 5). Once the resource names have been transfer to the resource sheet than attaching the resource to a task is easy. From the Gantt view click the cell below resource name and the list of resources from the resource sheet will present. Select a resource name the resource will be assigned to the task (Appendix 6).

At this point, the RAM has been used to populate tasks and the resource sheet within Microsoft Project. Three estimating techniques for work and duration were discussed and resources have been assigned to tasks. The fourth blog in this five blog series will discuss resource calendar and task relationships to finalize the EHR project schedule.

Appendix 1 – Resource Assignment Matrix (RAM)

Task	Clinical		Technical			Clinical W/Technical Skills			Administrative
	Tom	John	Sue	Terry	Bob	Carol	Susie	Nick	George	Brian
Establish VPN connectivity			A	C	R				I
Review EHR vendor statement of work	C		C			C	C	I	A	R
Finalize future state workflows	A	R	C			I
Finalize interface specifications			A	R		C
Test all Interfaces	S		A	R		S

Appendix 2 – Copy tasks from RAM into Microsoft Project and add Resources

Appendix 3 – Risk Register

Appendix 4: Adding the PERT Analysis Toolbar

Appendix 4a: PERT Analysis View

Appendix 4b: PERT Analysis with duration estimates

Appendix 4c: Calculate duration based on PERT Analysis

Appendix 5: Populating Resource Sheet in Microsoft Project

Appendix 6: Assigning resources to a task in Microsoft Project (Click the cell under resource name)

Transitioning from Paper to an EHR

Achieving a goal to become truly paperless is not realistic. Not all systems from all hospitals, clinics, imaging centers and laboratories that touch your patients are fully electronic, and even if they were: they don't all willingly or otherwise integrate with one another yet. Interoperability makes for interesting discussions, but demands a period of definition, evolution, more definition, acceptance and finally adoption before we see true interoperability. Paper (even if scanned) will continue to be part of the patient/ provider experience for quite some time. Phasing the implementation should be considered when guiding providers and clinical staff on their path to become paperless. The learning curve and initial productivity impact of a new system can be minimized by following appropriate plans unique and specific to your existing processes, tools and overall tolerance for change. When implementing an EHR, it is important to pick the right components at the right time to leverage synergies and improve adoption.

There are many components that need to be considered, ranked and slotted in the rollout plan. Picking your battles and prioritizing are important while achieving implementation and "meaningful use" goals as quickly as possible.

The Components:

1. Data conversion options need to be confirmed. What historical data can be converted at what cost and in what time frame? How useful is the historical data and how far back do you really want to go considering storage and potential performance impact.
   
2. All potential real-time interfaces need to be confirmed and weighed based on clinical relevance, cost and resource availability to build and test. Which interfaces provide the biggest bang?
   
3. A decision needs to be made regarding the cost/ benefit of back scanning and whether to back scan at all using your own or third party resources. Third party resources tend to shorten the duration of a back scan project.
   
4. A Go-forward scanning solution of critical clinical patient information not available electronically needs to be defined.
   
5. Pre-population of current medication, problem, allergy and immunization list should be considered as well. Are there resources available to assist with this to ease the transition for providers?
   
6. Transcription – see previous blog entry regarding transcription options.
   

Contact us for more details regarding strategies that will help you align your short and long term focus with the most effective transition to less paper.

EHR "Meaningful Use" Planning

People are responding to the American Recovery and Reinvestment Act (ARRA) and the Economy in a similar fashion. Depending on the newspaper you are reading or TV channel you are watching, the Economy shows signs of recovery and then gloom. The uncertainty is causing people to freeze their assets and take less risk. Similarly, the definition of “meaningful use” seems to change as often. One thing is clear; it will require the use of an Electronic Health Record (EHR) to record and report on whatever elements are defined. We are starting to see two symptoms in the market. One is panic in those organizations that do not have an EHR in their five year vision. The other is demand for experienced resources to complete the work. It is not advisable to rush now as calculated decisions are necessary since time is no longer expendable. For organizations that are better prepared with an EHR, focusing on increasing adoption, scrubbing dictionaries, standardizing documentation, establishing firm clinical change management processes and refining reporting and business intelligence strategies will be key. While the definition of “meaningful use” is important it should not cause healthcare organizations to freeze but rather accelerate the organization's strategic plans. It will be a while before the Government and Software vendors have incorporated all the necessary elements for "meaningful use." In the mean time the time for action is upon us. A quote from Napoleon Hill sums up this state well, “Do not wait; the time will never be "just right." Start where you stand, and work with whatever tools you may have at your command, and better tools will be found as you go along.”

We will continue to follow the definition of “meaningful use” by the HIT Policy Committee as they refine the criteria. Download our "meaningful use" workbook to guide you through the recommendations and areas where your organization may need to focus. The current workbook includes the latest criteria published in July 09. Check back routinely for updates as the HIT Policy Committee progresses.

Right click on the link below and select "save as" to download the meaningful use planning workbook. Be sure to enable macros to assist with inpatient and outpatient measurement filter and read the instructions in the workbook. Meaningful_Use_Planning_Workbook_V2.xls

EHR Resource Planning (2) – Defining Resources

Defining the resources that are needed for an Electronic Health Record (EHR) implementation can be a challenging task. What types of resources are needed? What are their responsibilities? What are the required skill sets and job descriptions for each resource? Each EHR implementation is unique and therefore the answers to these questions will vary by project. A resource assignment matrix (RAM) is the tool that will assist your organization to assign work (responsibility) to the resources (role) for your project.

This process begins by requesting roles and the responsibilities documents and a project plan from the software vendor. This should be completed in the sales process to understand the operational requirements to implement and maintain the system in the future. The documents and project plans you receive will be in different formats. To organize and clearly define the work and the resource needed to complete the work the RAM is the best tool. Do not assume that the vendor has defined all the work and resources required. The software vendor has expertise implementing the product but not integrating it within your operational infrastructure.

The RAM tool contains tasks down the vertical edge and resources across the horizontal edge (See example below). Start with compiling a list of tasks, from the project plan, and populate the vertical edge of a spreadsheet. Next, along the horizontal edge create a list of resource types. Finally, for each task identify the resource and their role. Keep in mind that one activity may need more than one type of resources.

The next blog will focus on using the RAM to define the work or effort for each task and estimating the project schedule.

Example Resource Assignment Matrix

Task	Clinical		Technical			Clinical W/Technical Skills			Administrative
	Tom	John	Sue	Terry	Bob	Carol	Susie	Nick	George	Brian
Establish VPN connectivity			A	C	R				I
Review EHR vendor statement of work	C		C			C	C	I	A	R
Finalize future state workflows	A	R	C			I
Finalize interface specifications			A	R		C
Test all Interfaces	S		A	R		S

 

Role	Description
Responsible (R)	This role conducts the actual work/owns the problem.
Accountable (A)	This role approves the completed work and is held fully accountable for it. There should be one and only one A.
Supportive (S)	This role provides additional resources to conduct the work or plays a supportive role in implementation. Optional.
Consulted (C)	This role has the information and/or capability to complete the work. Two-way communication (typically between R and C). Optional.
Informed (I)	This role is to be informed of progress and results. One-way communication (typically from R to I). Optional.
Verifies (V)	This role checks the work to ensure that it meets all defined criteria and standards. Optional.
Signs (S)	This role signs off on the completed work. Optional.

EHR Physician Adoption

Physician documentation is a major component of practicing medicine. Complete and appropriate documentation can be time consuming and costly. Traditional dictation incorporating manual transcription remains an option for many practices. A host of alternatives exist in the EHR (Electronic Health Record) world aimed at increasing efficiency and reducing costs. Assessing these alternatives and implementing the best set of solutions is a critical step to help physicians make the transition to an EHR. Successful adoption demands careful consideration of multiple options that can be chosen by the community of physicians in your practice depending on the nature of the visit, physician tolerance for change, and more appropriate technology match for the physician and their personality. Whatever the solution: cost, productivity, reimbursement, patient safety, patient and physician satisfaction should all be considered carefully.

Options for physician documentation include:

1. Leverage telephone or voice recorder devices to dictate the entire note for manual transcription. Solution can be accomplished with or without an interface.
   
2. Leverage telephone or voice recorder devices to dictate while taking advantage of macros on the back end to reduce dictation and transcription effort. Solution can be accomplished with or without an interface.
   
3. Leverage telephone or voice recorder devices to dictate while taking advantage of back end voice to text technology to assist transcriptionists and to reduce transcription effort. Solution typically requires an interface.
   
4. Leverage dictation markers to minimize the portion(s) of the note that need to be dictated and transcribed. Solution typically requires a bi-directional interface.
   
5. Leverage front end voice to text software to remove need for transcriptionists. Solution requires no interface.
   
6. Leverage point and click templates to build the documentation for the visit. Solution requires no interface.
   
7. Leverage text templates or macros to build the documentation for the visit. Solution requires no interface.
   
8. Physician manual typing
   
9. Provide physicians patient worksheets (piece of paper) that can be marked up and handed off to support staff member for entry into the EHR.
   

There are pros and cons to each of the options. Assessing the options for your organization, choosing the best matches and implementing the solutions correctly, is critical to your success. You will need to arrive at a subset of these options that best supports adoption while remaining supportable.

For more details on how to select the best options, best practices for implementation, training and support, contact us for additional information at information@projectnavigation.com.

EHR Resource Planning (1) – Introduction

You just signed a contract to implement an electronic health record (EHR) at your organization. The vendor has been engaged explaining that the implementation is a partnership and they will be there to lead your organization through the process. In order to start the project, the vendor suggests that you staff your team according to their roles and responsibilities (R&R) matrix. Based on the vendor's R&R matrix you feel that you have most of the staff in house and will be able to start the project within the next month. This is a common scenario healthcare organizations encounter in an EHR project. Without even knowing it you just started the implementation with a considerable risk unless you define the staffing requirements for the implementation as well as long term support.

This series of blogs will discuss how to define your resources for implementation, outline the work for each resource, define project schedules, and the operational plan for long term support.