From Allscripts to OnBase: A Migration Story

In healthcare, it’s about the patient’s chart, tests, and results, which all starts in the quality of the information extraction from Allscripts. Of course, when you move from one solution to another, people tend to get in the way. What I mean by this is that there usually needs to be a consultant to broker between each sides of the transfer.

Information

Requirements gathering is only as good as the person’s experience who’s managing it. A third may boast many years of experience, however, chances are good that there are a few key internal architects that need to be involved and listened to from the get-go. The mapping of patient data, doc types, and workflows are all fundamental to the success of the migration. The sizing parameters will have to be detailed, such as, number of files, average file size.

Execution logistics

As the “what” questions are answered, inevitably, new ones come up, such as “What transfer batch size should we use?”, “How long will it take to transfer each batch?” and “When will we shut down access to Allscripts?”, etc. A “who/what/when/where/how” matrix will help sort out the details. The transfer batch will depend on how many document pages are extracted and will entail multiple folders and file naming convention.

Testing

Testing and its organization are a litmus test of how well the project is managed. Hopefully all of the application’s SMEs are involved and designated Users are scheduled to test. Testing ADT scenarios and OnBase scanning and indexing are essential. Also, testing the backfill of accounts and demographics has to be done at least twice to get all of the pieces validated.

Extract

The Allscripts extract index will be delimited and should have all of the metadata needed to import into OnBase. It should have a pointer to the scanned files. These files will most likely be extracted pages, so there will need to be a unique number to be able to build the document before importing into OnBase. You’ll need the following:

Patient Demographics – enough information to validate and tie back to the ADT patient record.

Master Patient Index – the corporate medical record number to identify the extract as it is imported to OnBase

Document types – each type must go through HIM for validation. If Allscripts was used for ambulatory sites, chances are good that the naming of doc types will reflect this. You may want to just keep all the source names and prefix them with a value that allows for easy recognition. These should also be set up in a new doc type group if there are a lot of them. The “go forward” strategy of scanning should include only the unique doc types that were not already in the Onbase system.

Document formats – there may be some formats that surprise you. Import formats have to be identified and set in the OnBase import process.

List of file pointers – this list tells OnBase the page’s file system locations. If there are thousands of pages, the pointer will most likely have a folder in it that changes as the batches are imported. The filing naming convention will have to be unique and could be extracted from Allscripts’ unique file naming.

Data Manipulation

Between any focused information management system there are bound to be idiosyncrasies. For example, the patient medical record numbering scheme will be different, the rules around naming conventions of metadata, and many other conventions specific to the infrastructure of the source system.

Registration, EMR and interface

With different naming conventions of patient metadata between the source and target systems, the issues of data integrity could be compounded. During testing all sorts of issues can come up from ADT messages not having correct patient data, to patient corporate numbers being duplicates. Quality control and validation as a separate can help fix issues before they go into the target system.

Import

As we know the quality of the import starts with quality of the extract. As the patient data issues get mapped and fixed, the actual importing will have to be achieved through a third party tool or customization. Every difference that is not accounted for in the design or development will definitely show up as errors during testing of this process. Using the tool to look up values in the target system based on source values should be part of the tools requirements. The tool should be able to handle errors gracefully by logging them and queueing them for reimporting.

People

The human factor cannot be overlooked with any migrations. Both sides will have feelings though they may be hidden behind professional facades: some were comfortable with the old system and others are not happy about the new responsibilities of the new one. These feelings will show themselves with delays in development, or show stopper issues during testing. If everyone is complaining about the project manager then you know the culture is old school in that the walls of knowledge continue to be fortified, that sharing only occurs when show stoppers force everyone to open up and help each other if only for just that moment…

ECM Matures Beyond the Models

Gartner’s ECM Maturity model from 2012 shows the simplified journey of an ECM implementation into a company through time. The trail followed is well worn into the trained minds of solution providers. What typically happens with this methodology mantra is that it infiltrates and pervades, then when fully dependent upon the software solution that touted it, the company buys more modules, more licenses, more storage, etc.

How mature is mature?

ECM implementations reach the goals put forth be the company’s director in charge of operations. Each time a “nice to have” is overlooked or pushed to further phase, it may reach a dead end. These dead ends accumulate, but are not factored into the overall implementation; they fester and show up again when the next cycle of solutions/consolidations/open source evangelists sweep in.

It’s easy to win with a Model

I’ve seen original solution documentation show this maturity model from the beginning. The instructions are outlined, budgeted, and milestones are set. All you have to do is do what it says to do and you will succeed. Any movement forward is seen as a win. Plus, you executed on the plan, never mind that dead ends were left along the way. You can’t please everyone!

The model is the model

The model’s steps of “Initial, Opportunistic, Organized, Enterprise, and Transformative” are exactly what happened to this model. It is an artifact of solution execution, but in the end it is just another way to sell product suites and Gartner products. This model matured. A new one is coming.

Implementation’s long tail

If you are looking at models make sure the last half the curve looks like a thick long tail. This shows the correct long term implementation of ECM. It takes mature team of people to fully realize its potential beyond initial expectations and bouts of disillusionment. Over time, if you are lucky there will be enough focus on the quality of information and its benefit to productivity.

ECM Moving Across the Silos of Information Management in Healthcare

Information silos are commonplace in every industry. They tend grow around concentrations of knowledge/experience collectors and “best of breed” applications. Because enterprise content management usually spans across these silos, we as ECM solution providers get a unique insight into how work.

Take scanning solutions in Healthcare for example, you get exposure into not only financial and HR applications, but EMR, interface, and lab apps. Once you have gained trust among the managers of these applications and have implemented ECM across them, you will begin to see the potential synergies. One potential synergy could be to combine Informatics, HIM, and ECM under one director to be able to fully realize the full patient information potential.

Let’s say for this example that Informatics is underfunded, HIM is well funded, and ECM is okay. By combining budgets and focusing on common goals, the patient as well as the hospital’s image will undoubtedly benefit. By providing ECM with a direction base on requirements coming from what patients need, the emphasis and objectives will be clear and hopefully funding will be well justified and measurable. 

Post ECM Modern New New

When John Newton, Alfresco CTO, talks about the “Modernization of ECM” he takes the biggest, most pervasive view possible of ECM at an organization. The issue I have with this view is that most solutions are point solutions which may be expanding into other departments, but are mainly focused on specific solutions, not necessarily solutions that impact the enterprise. He wants everyone to think big with “millennials” using “mobile” phones “collaboratively”, “sharing docs”, using “Instagram”, and “Snapchat”, etc.

Ok, great, CIOs think big, I get it, but what happens during the implementation? Did the big idea get implemented well, or are we blaming Users for “poor adoption”?  John says, “Employees don’t buy in because the systems are cumbersome, non-intuitive, or lack support for B2B sharing and remote access.” That type of statement side steps the many bad implementations made by his previous company’s professionals. You can’t leave a company, build a better solution, and then blame the old software for being inferior. For those of us who have seen their share of implementations, we know that ECM was first CM at many of these companies. The “E” depended on the professional services as much as the software.

The “extended enterprise” beyond the firewall concept has been around for over a decade. The issues of security and sharing information are evolving and involve way more than an ECM solution’s capacity and technology. The larger enterprise is under the gun here, not the content management system.

With the “Explosion of Digital Content” as quoted from IDC sources, the “big data” issue of finding and contextualizing content will always be an issue. The point should be that the “crap in, crap out” adage is the real issue, not the system. If you don’t take the time to add context to your content on the way in, the search results later, regardless of how heuristically brilliant the algorithm, will not be as accurate as you want or need.

There’s no doubt Alfresco has a head start with open technology, integrations, and UI simplicity. I just find it hard to believe that they still think ECM is everything to everyone when it comes to content. All applications have evolved to deal with content and metadata. ECM can help patch the holes and connect the dots, and even be everything to a small/medium sized company, but with large enterprises it takes many software solutions to deal with its content and information. Whether it be financial, human resources, healthcare, pharma, registration, etc., in each case there are specialty professional services and software solutions to fit the requirements. What ECM promises is to patch the hole when a leak occurs because a leak in the other solutions will eventually occur.

ECM Safety Net

The big promises of ECM solutions ten years ago could not have foreseen the importance of risk mitigation in today’s risk adverse business environment. ECM systems have turned into safety nets for many companies. Not that information or content is in free fall, but it is reassuring to know that the location and storage of content is safe.

Many ECM initiatives were underfunded or over-architected:

Underfunded Scenarios:  when a solution performs great, but does not have a disaster recovery solution. When the version you are on is four years old. When you have more paper be shuffled than when scanning started.

Over-architected Scenarios: when it takes a senior engineer to unpack a workflow. When there’s a custom solution that does close to what is out-of-the-box in the next version. When it takes an act of congress to change a form.

ECM is also a good place to land when political maneuvering in the company causes paralysis with some solutions, or budgets get swept leaving your great idea with no funds. Catching the falling projects and at least saving them for complete disaster is at least admirable. It may not push forward the mobile agenda, but it will soften the blow when it’s budget is slashed in half.

When your system has an outage and you have to resort to paper

The more we computerize our work, the more difficult it will be to recovery from unanticipated down times. In a hospital situation for example, when your system goes down, every task done on the computer goes into manual “paper” mode. Work is done and forms are used. At some point when the system is back up, you have to deal with the pile of paper that accumulated during the outage. This paper pile could consist of notes, orders, assignments, referrals, medication list, etc. What do you do with this stuff?

Did you plan for recovery from paper?

Everyone plans to recovery, but the real question will it go as planned? Did everyone follow the downtime documentation procedures accurately? For example, was the account number written on the form? Can barcodes be printed after the outage?  

Scanning

Automated scanning with barcodes for indexing paper can be a life saver, however with an outage there no barcodes, which can be a major hassle from which to recover. Also, what if the accounts are still caught up in the content management system?

Processing

If you have an automated workflow for coding diagnoses or approving invoices, is there a paper alternative for this, or do you just go home?

Overtime

To recover a system by back loading information from paper, it might take a temporary surge of contractors. This unexpected budget hit should be noted as a risk in your outage plan.

Fixing data

Sometimes during an outage, only one system is down, leaving up or downstream systems running. Users could go about their normal routines without knowing for a while. Data entry could get queued up as the integration is broken. So, one process is using paper and another one is still using a computer. When the outage is over, some data might have been corrupted. For example, a patient is registered and is being seen by a nurse. The nurse fills out the patient’s drug allergies on a paper form. The patient goes in for surgery and is recovery. A physician checks the EMR for allergies and sees none. The paper form for allergies is in the chart, but the physician assumes the system is up-to-date…

The Need for recoveries of recovery

Chances are good that the downtime procedures cover what should happen and are in compliance with the auditors, however when your system goes down and the paper comes out there are many more chances of mistakes. Of course the answer is a plan for system redundancy, however, this comes at a hefty prices that not every hospital or entity can justify. 

How to Triage ECM slowness

Who’s the first team a User calls when the ECM application slows down? The ECM team of course. But, nine times out of ten, slowness is caused by effects of other systems. Whether it’s the database, network, or the User’s open applications, sluggish performance has many sources.

Question: who’s working on what client, in what environment, and where?

Network: we were fixing something

From Who: multiple sites simultaneously, or one building?

Large companies with multiple buildings most likely have networks that are somewhat patched together leaving some Users with networks that are performance subpar. Also, some areas of the company may be hugging bandwidth with applications that are dragging the whole network down.

Database: This won’t impact the application…

From Who: All applications that use that db server, or one application?

Typically, the database server is a shared environment thanks to our buddies who consolidated individual servers at the expense of “decoupling”. This shared environment could at the mercy of reporting for BI initiatives slowing it down. If it’s an Oracle RAC, sometimes the nodes don’t reboot as advertised. The shared environment of tier 1 applications, could put the other lower tiers at risk because the lower ones will not be the priority if there’s a business outage.

Backups: we were trying to restore another application

From Who: One application or many?

Backups might happen late at night during “off” hours, but there’s still a performance hit on databases and file stores. There’s also the possible wave of activity after a recovery that clogs all downstream applications.

Security: we were hacked

From Who: One app, or many?

With new layers of security applied comes extra processing thus potential for slowness. This is usually agreed upon at the design stages, but complained about after implementation.

Virus protection: half of our share drive files are encrypted

I’ve had many times when I’m looking for causes of slowness on my PC or on a server, only to find out that the task manager is showing a huge percent of CPU being used by the virus protection software. Hint: Double check when the full scan is scheduled.

User’s 5k open applications: who me?

If one User complains, log onto their PC and check out what applications they are running (assuming they didn’t close some while they waited for you). Try closing and opening Outlook. What’s in their startup folder? Check their browsing history for views and downloads.

Service Desk: this is a routine patch

Even when the Service Desk is being proactive with mandatory testing of patches to Windows or IE, there are always issues, especially with interaction of multiple open web browser (“no footprint”) applications.

Upshot

When you get blamed for slowness of your ECM application have a script of questions to ask to triage the issue. Check the possible larger issues first and move toward the User at hand. Slowness happens because everyone wants information faster, that is, in our zealousness to always get faster we stumble occasionally.