Building The Perfect EHR For Community Hospitals

Compiled by Susan Kreimer, contributing editor

Four community hospital leaders share their EHR wish lists — outlining the performance strengths of their existing solutions and identifying areas for improvement.

As explored in the previous story, Are Community Hospitals Behind The Health IT Curve?, EHR adoption and implementation is currently the top IT initiative at most community hospitals despite significant financial and resource limitations. With this in mind, community hospitals need to make wise decisions when it comes to their EHR technology purchases. The clinical, workflow, and reporting needs of a community hospital are very different from those of a larger health system, and the EHR solution in use at a community hospital should address these unique needs effectively. Health IT Outcomes interviewed leaders from four community hospitals — St. Claire Regional Medical Center, Grande Ronde Hospital, Forrest General Hospital, and Ellenville Regional Hospital (all of which have successfully attested for Stage 1 Meaningful Use [MU]) — to gain a better understanding of the EHR features they find most valuable, where EHRs fall short in satisfying their demands, and how EHR use is impacting their organizations to date.

Q: What EHR features are most important for a community hospital and why?

McCleese: Many community hospitals offer the full range of healthcare services, so an EHR that provides a longitudinal record is extremely helpful. When services such as primary care, acute care, specialty care, and homecare operate on the same platform, it makes the job much easier for caregivers and technical staff alike. These requirements may be different for a larger healthcare organization. In larger hospitals and health systems, various provider groups (e.g. hospitals, specialty clinics) attend to specific needs. This alleviates the necessity of having one organization deliver the full scope of services.

Kelley: Larger health systems typically have big budgets and can afford to purchase a lot of equipment and hire systems people. They’re more likely to buy in-house systems and maintain their own data centers. As the CEO of a small hospital, I don’t want to be in the IT business, and I don’t want high EHR overhead. That’s why we selected an ASP (applications service provider) solution from HMS. Our vendor has the main system, software, and applications. We employ an in-house IT staff consisting of a systems expert and an applications person who trains others. Buying the entire package from one vendor also spreads cost across hundreds of hospitals on the same system, and there’s also less aggravation. In the long run, I think that model is the pathway for smaller hospitals. The elements of EHRs — while different in layout, ease of use, and capabilities — basically perform the same tasks.

Q: How has your current EHR improved operations and care in your hospital?

McCleese: Our current MEDITECH EHR has not yet excelled in these areas because it is a relatively new installation. Some of the components for outpatient functions have not yet been installed. All components — revenue cycle, clinicals, and ancillaries — have been installed in the acute-care environment. The revenue cycle components were installed in medical group practices. Our EHR is expected to go live in the medical group practices in early 2014. The system is beginning to show some promise, as users are starting to realize how their ambulatory records can provide a basis for the acute-care environment. The benefits we have realized so far are minor, but with the revenue cycle installation at the group practices, we are beginning to see the flow of data between the systems, which allows us to manage the patient’s record much more easily. This will undergo further enhancements when the EHR goes live and caregivers begin to utilize the data as it flows through the system.

Sattar: Our main McKesson EHR at the hospital has an integrated single database. This makes it relatively more expedient and less expensive to own and operate. It has allowed us to focus on numerous other challenges in healthcare IT, rather than concentrate primarily on the EHR product. The affordability also made it feasible to invest in additional systems, resulting in a more complete toolset available to the clinical team.

Kelley: Our experience with our EHR has been remarkable thus far. We’ve successfully made the transition from a manual paper-chart environment to a digital one that provides a great deal of automation. As for enhancing operations, our EMR has been a great asset. With CPOE, the possibility of transcription or communication errors has been virtually eliminated. Our EHR also provides us with tools to help physicians with dosages and metrics for conversions, so we don’t over- or undermedicate patients or prescribe medications that cancel each other out. This is especially important when several doctors are caring for one patient. Furthermore, providers have remote access to patients’ charts from their offices and homes, which is much more efficient and convenient. Also, having access to the primary EHR in the emergency department has saved lives.

Q: How do EHRs need to improve to better address the needs of community hospitals?

Sattar: There are many areas needing improvement, but above all, what’s lacking is the ability to share data across the continuum of care. The biggest contributing factor is the absence of a standard across the board. All vendors need to adopt the same standard for data capture. Then, no matter which system originally captured the data, this information would still be accessible when patients move among providers. This would enable patients to have better access to their healthcare data. Also, it would allow clinicians to focus more on patient care instead of struggling to incorporate past and current information from patients into the clinician’s toolset.

Kelley: We need more standardized interfaces between modules and health equipment. Our radiology equipment has the same format, so any PACS system can pick up data. But we don’t have this capability on our laboratory equipment, cardiac monitors, and blood pressure machines. The government should mandate standards and facilitate data exchange. Standardized interfaces would enable any provider to search for elements about a particular patient from any EMR in the country. At the moment, without uniform protocols, a common exchange for all applications seems somewhat elusive.

Q: Do you feel the MU program provides larger hospitals/health systems with an advantage over community hospitals?

McCleese: Yes, most large hospitals and health systems have sufficient IT and other functional staff for specialists to be groomed more easily. Staff in community hospitals generally work on a broader range of assignments and have little time to become experts in a specific area. Generally speaking, experts can accomplish things more quickly than generalists. Also, a larger staff permits the workload to be spread among more people, including clinical workers.

Jones: The type of system that can be implemented at a stand-alone, small, rural, or community hospital varies greatly from a system that would be appropriate for a large community or academic facility. These stand-alone hospitals can’t justify employing staff to build and maintain highly customizable and complex EMRs. Therefore, these hospitals tend to implement either a hosted solution or one in which the developer provides most of the technical support. In addition, these systems usually meet all information technology needs for a facility, including payroll and accounting functions. The MU incentives earned by smaller facilities tend to cover the initial investment for implementation of the EHR, whereas the payments received by larger hospitals do not.

Kelley: I don’t think so. We were able to reach the MU proficiency benchmark in 27 days. Then we completed our 90-day attestation. We worked hard to achieve this goal and are proud of our staff ’s dedication and execution.

Q: What changes would you recommend to the MU program to make it a more level playing field for community hospitals?

McCleese: One of the biggest changes would be to extend the amount of time organizations are allotted to achieve Stage 2 MU criteria. A lot of changes are required in Stage 2, and concern has been voiced over whether there is enough time to make the systems perform the necessary functions without interfering with patient care. Healthcare workers have a duty to cause no harm, and they need time to ensure that implemented systems are adequately tested before using them to record data about a patient’s care.

Sattar: Critical-access hospitals should be allotted more time to adopt the significant changes that MU mandates. It would help to utilize the incentive funds for resources toward implementing the MU changes. Otherwise, community hospitals will try to implement the big changes without investing in additional resources, and they will end up struggling even further. CMS could provide greater assistance in the MU change implementations, on top of what the Regional Extension Centers are already doing. These centers are utilized more by physicians’ offices than hospitals because hospital administrators generally feel their management is ready to handle such changes. Unfortunately, management may not be prepared, and when CMS turns a blind eye, the transition isn’t as effective as it ideally should be.

Q: What’s next on your EMR road map?

McCleese: There are several items in the project pipeline, such as ICD-10, ambulatory system installation, current EHR system optimization, and preparing for MU Stage 2.

Sattar: Among other goals, establishing a clinical and business intelligence program across the organization is our next major undertaking. We are also working to unify our EMRs into a single chart-based system, so that no matter where the patient is seen within our organization (ER, inpatient, ambulatory, etc.), the same electronic chart will be visible. Integrating biomedical device data, such as vital signs, into the EHR is also on our road map.

Kelley: We will reach Stage 2 MU without gigantic steps. Another priority consists of developing and refining management dashboards. Each department’s manager has a dashboard with meaningful indicators to measure on a daily, weekly, monthly, and year-to-date basis, establishing operational and financial volumes.