EHR Role Models

Compiled by Ken Congdon, Editor In Chief, Health IT Outcomes

Implementing an EHR isn’t easy, but these three health systems have been trailblazers in this regard. Following their advice may help you achieve your own EHR success.

Panelists:

Bill Weyrick, Senior Manager of Information Systems	Michael Mistretta, CIO	Dr. Matt Eisenberg, VP of Clinical Informatics
Dartmouth-Hitchcock Medical Center	MedCentral Health System	MultiCare

For many health systems, hospitals, and physician practices, EHR is a four-letter word. The trials and tribulations of getting the technology installed and adopted can often drive providers to the brink, and for many, measurable results and Meaningful Use checks are still a long way off. Frequently, the problems encountered during an EHR implementation are not technological in nature, but rather the result of poor planning and execution. In these situations, inspiration can often be found in the advice of EHR role models — healthcare organizations that have “been there and done that.” Through the experiences of a select few pioneers, many other providers can finally discover their own path to EHR enlightenment.

MEET THE EHR ROLE MODELS
For this article, I had the opportunity to interview leaders from three health systems that many consider to be EHR role models — Dartmouth-Hitchcock, MedCentral Health System, and MultiCare Health System. What makes these health systems so special? Allow me to elaborate.

For years, Dartmouth-Hitchcock got by with a homegrown EHR it called CIS (clinical information system). However, with HITECH, the health system realized it couldn’t satisfy key Meaningful Use requirements using its existing platform. That’s when Dartmouth-Hitchcock embarked on an initiative some would call ambitious and others would call foolhardy — a transition from CIS to 15 Epic EHR modules simultaneously. This flash cutover was completed in April of last year, and the scope of the project was unprecedented. Several challenges presented themselves throughout the implementation (and some continue to arise), but for all intents and purposes, the project has been a success. In fact, Dartmouth-Hitchcock submitted its first attestation for Meaningful Use incentive dollars earlier this year.

MedCentral Health System, on the other hand, is no stranger to Meaningful Use. Using a combination of Siemens Soarian for inpatient and NextGen for ambulatory, this IDN (integrated delivery network) was one of the first health systems in the nation to successfully attest and receive payments for Stage 1 MU.

Similarly, as an early adopter of Epic, MultiCare hospitals were the first in the state of Washington to attest for Meaningful Use through both Medicare and the Washington State Healthcare Authority-directed Medicaid Incentive Program. To date, the IDN has received $8.8 million in hospital MU incentive payments and more than $2.5 in ambulatory MU payments. MultiCare also extends the capabilities of its Epic EHR technology to neighboring physicians and community provider groups as an ASP (application service provider). It brands this service MultiCare’s Care Connect.

I asked the EHR team leaders from each of these facilities to share their EHR challenges, best practices, metrics, and next steps in hopes that their words of wisdom could enlighten and inspire other healthcare facilities that may currently be struggling to find EHR success.

Q: What have been your biggest EHR challenges? How have you overcome them?

Weyrick: The infrastructure investment that’s been necessary has been a significant challenge. Not only did we need to purchase the Epic EHR software, but we also had to implement a Cintrix XenApp Virtualization platform so we could manage and update the software centrally, as opposed to updating thousands of individual clients throughout our facility. Unfortunately, there’s no quick way to overcome this cost hurdle, but the technology should provide a return over time.

Another challenge was handling the service management and call center activity that came as a result of the magnitude of our flash cutover from CIS to Epic. The sheer number of calls, reported problems, and incident reports was staggering. However, we anticipated this outcome and significantly augmented our command center and call center activity to address this demand. We established a technical command center manned by 100 Epic consultants and our own IT folks working in 12-hour shifts for the first two weeks after the go-live. We also temporarily expanded our cell center/help desk staff from 5 employees to 35 employees for those two weeks. The help desk was responsible for fielding calls and creating incident reports for the 100 folks in the technical command center. We also established an institutional command center and individual departmental command centers (e.g. nursing, hematology, oncology, etc.) to examine the impact of the project on individual departments and Dartmouth-Hitchcock as a whole. Finally, to ensure proper tracking and resolution, we ensured that all incident reports were entered and closed electronically in our Cherwell service management system.

Mistretta: Change management. Clinicians and physicians are scientists by nature, and scientists focus on reputable and predictable outcomes. Clinicians tend to develop standard processes that work for them to achieve desired results. With EHRs, you’re asking them to abandon their way of doing things and do things in a manner that fits the technology. There is a natural resistance to this change.

We’ve found the best way to overcome this challenge is to enlist as much participation from clinicians in the EHR process as possible. It’s better to participate in the change than have it done to you. We’ve developed a physicians EHR advisory board that consists of 10 hospital physicians from a variety of specialties. We also are sure to consider and address how the EHR will affect clinician workflow at every step in the implementation.

Q: What do you consider “best practices” for EHR adoption/implementation?

Dr. Eisenberg: At MultiCare, we believe in one patient, one record. We believe that application and workflow integration wins, and we feel the best way to achieve optimal integration is to take an enterprise approach to implementing EHRs rather than a best-of-breed approach. This philosophy has been validated by the results we’ve experienced since implementing our EHR.

Another best practice we lived by was to treat the EHR implementation as an organizational initiative, not just an IT project. We made sure we got input and buy-in on the technology from all levels of the organization before we installed anything.

Finally, we focused extensively on organizational EHR readiness. We developed “practice rooms” or “SIM centers” throughout our facility so that physicians, nurses, and other staff members could actually use the technology and see how their workflows would be impacted prior to go-live. We also provided specialty-specific training and performed 30-, 60-, and 90-day risk assessments.

Mistretta: We also opted for an enterprise EHR approach rather than a best-of-breed. This strategy helped to streamline vendor management. In other words, by working with one vendor you avoid a lot of the finger-pointing that goes on when working with multiple systems and vendors. Furthermore, the built-in interoperability between applications is a huge benefit. There is a trade-off here, though. We do sacrifice functionality in some areas of our health system because the enterprise system doesn’t cater to each and every discipline. This is a price we’re willing to pay because an enterprise approach allows us to share data across the continuum of care easier and at a fraction of the cost.

I also think it’s crucial to start any EHR implementation by outlining the goals and objectives you’re trying to achieve with the technology. This will provide you with a benchmark with which to measure your ultimate success. For MedCentral Health, our ultimate goal was always to develop a longitudinal patient record for the community.

Weyrick: Adequate EHR workflow testing is crucial. This is a lesson we learned during our transition to Epic. When we used CIS, clinicians carried assigned laptop computers from room to room to enter preappointment vitals, patient notes, and orders. However, Epic’s ambulatory workflow for clinic visits is designed for use with a fixed device in every exam room. When using this fixed device, the software allows for nurses and physicians to quickly log in and out to enter their portions of the patient record. However, this “fast user switching” doesn’t work properly when mobile devices are leveraged, which is exactly what we tried to do during the transition. For example, if a nurse didn’t log out of the patient record when they entered the preappointment vitals, then the record was locked when the physician tried to pull it up on their laptop. This record-locking issue frustrated clinicians and hurt us from a productivity standpoint for a while.

Q: What measurable results have you realized as a result of EHR use?

Dr. Eisenberg: MultiCare has achieved an 85% CPOE rate (i.e. percentage of orders entered directly by the provider relative to all orders requiring licensed independent practitioner authentication) in the inpatient settings and 100% CPOE in ambulatory settings. We’ve also achieved 95% medication barcoding compliance. We’re tracking the effectiveness of our EHR initiative at multiple levels and are seeing significant results. Here are a few examples:

• 72 adverse drug reactions were avoided in the first 2.5 months of CPOE.
• There was a 30% reduction in transcription volumes.
• Our average length of stay dropped 3.35% from 4.28 to 4.14 days.
• Our net accounts receivable (AR) days improved from 51.6 to 46.6.
• Our average operating margin increased from 4.2% to 8.8% in the first three years after our first hospital implementations.
• Our average medication error rate decreased by an average of 26.5% across our four hospitals.

In addition, we’ve seen marked improvements in lab and imaging result turnaround times. The cumulative effect of all these improvements will allow us to break even on our EHR investment in 2013. More importantly, however, the quality of patient care has significantly improved. We have also begun to leverage our enterprise data warehouse to provide key performance measures and outcomes related to hospital management of sepsis and heart failure. We’ve already seen significant reductions in risk-adjusted mortality in sepsis patients.

Q: What’s next on your facility’s EHR road map?

Weyrick: The next step for us involves mobility. For example, Epic has a number of mobile device applications, such as Haiku for the iPhone and Canto for the iPad, that we need to add to our environment for nursing, physicians, and pharmacy. These applications will help provide our clinicians with mobile access to key electronic health data while on the move. We are also looking into adding Epic’s financial system to provide us with a fully integrated system from patient registration through billing.

Mistretta: We’re currently in the process of getting our emergency department up and running on Siemens Soarian. Once that phase is completed, we will turn our attention to getting our surgery department and some of our outpatient facilities operational on the software.

We will also start an initiative soon to integrate medical devices (e.g. infusion pumps, patient monitors, pulse oximeters, etc.) with our EHR software. There are three reasons for this initiative: 1) These devices are often a source of error, and integrating them with the EHR will help us identify these errors; 2) these devices can cause productivity issues for nurses that EHR integration can help alleviate; and 3) there are Meaningful Use reimbursements tied to this activity.

After that, we will turn our focus to Stage 2 Meaningful Use. We made it a point to overachieve in regards to the criteria established for Stage 1. For example, we figured Stage 2 would require incremental increases in CPOE. So, instead of simply achieving the 60% CPOE required by Stage 1, we continued progressing and now achieve more than 75% CPOE in all areas of the health system. Therefore, from a progression standpoint, we feel we’re positioned pretty well to capitalize on Stage 2 incentives.

The one aspect of Stage 2 we will need to put a lot of work into is the patient engagement requirement. However, I think CMS (Centers For Medicare & Medicaid Services) is missing the boat a bit with its proposed rule in this area, and I said as much in my comments on Stage 2. I don’t think patients want to carry their own records around with them. I think they desire a process similar to the financial industry where they either personally (or through another healthcare facility) put in a request for their health record and it is transferred electronically. Think about it: You don’t go to an ATM, take out $100, and then walk down the street to deposit it. This is basically the way the patient engagement piece is designed to function under the current rule, but hopefully that will change.

Dr. Eisenberg: We are focused on completing our Stage 1 Meaningful Use initiatives and preparing for Stage 2. A key component of this phase will be HIE. MultiCare currently has a robust and active HIE strategy with CareEverywhere, Epic’s embedded HIE module. This module allows us to exchange information with other Epic users regionally and nationally.

MultiCare has also become just the fourth private institution in the country to partner with ONC (Office of the National Coordinator), the Department of Defense, and the Department of Veterans Affairs for HIE. We are using CareEverywhere to share patient data with the VA and DoD, and vice versa as part of the Virtual Lifetime Electronic Record (VLER) project.