 Just Associates In The News
Industry Events
|
 |
 |
Articles
February 11, 2008 ADVANCE
First in the Nation
The Children's Hospital Of Denver Implements The Nation's First Fully Integrated Pediatric EHR
Vol. 18 / Issue 3 / Page 18
By Lynn Jusinski
It was a tall order. Back in the fall of 2002, The Children's Hospital (TCH) of Denver put pen to paper and inked a contract with Epic Systems with the end goal of having a fully integrated EHR. Achieving that goal would be no small featTCH has a main campus, 12 children's care centers in Colorado and more than 400 outreach centers that span three states, and all would communicate seamlessly come 2008.
A project this big needed a motivator that was larger than life, and e-REX, a two-armed, T-shirt wearing, stethoscope bearing dinosaur became a fixture at countless planning and design meetings. The dino made his debut in 2003 when the planning officially kicked off. The rollout was set to be complete in 2008, with an obvious goal in sightTCH was on the move. A new 1.4 million square-foot facility was constructed, and the TCH main campus was relocated in September of 2007. The old facility contained plenty of space to store cumbersome paper records, but the new facility was purposefully designed with the electronic environment in mindand therefore, very little room to store paper.
The EHR system went live in March 2007, and while some members of the staff admit that a few kinks still need to be worked out, the huge implementation was overall a roaring success. HIM and information systems staff members shared their story with ADVANCE, and they offered up some advice for readers who are getting ready to tackle their own mammoth EHR implementations.
Lots of Lessons Learned
Dena Somers, director of clinical information systems (CIS) at TCH, assembled a weighty PowerPoint presentation on the entire EHR implementation. In it is the all-important timeline: in early 2004 the CIS team began what Somers called a "stealth project," going into each clinic and implementing the EpicCare Ambulatory System, with that rollout ending in mid 2006. Document imaging came on board in early 2006, with clinical documentation going live in September 2006. Finally, computerized physician order entry (CPOE) went live in March of 2007, with 6 months to spare before the big move to the new campus.
Thus completed a whirlwind implementation, and TCH became the first free-standing children's hospital in the nation with a fully integrated pediatric EHR system, a feat that garnered TCH an award from KLAS. With the implementation a success, it was time to reflect on what went right and what could have been done better.
A Team Effort
Everyone involved in the implementation learned one huge lesson: "It takes more people than anyone tells you." With that in mind, don't be afraid to ask for help. At TCH, consultants were brought in to help clean up the master patient index (MPI) before go live, and approximately 5 years of discharges still in paper were moved to an offsite records center to be scanned, a project that will probably take another 2 years, according to Karen Proffitt, RHIA, CHP, HIM director. Applications coordinators were added to the HIM roster, and the coordinators train, configure and test, acting as IS resources that are in HIM. Automated scanning began in March 2006, and TCH scans approximately 1.1 million sheets of paper annually-and that certainly takes teamwork.
Having as many people as possible is important, but having all of those people work together is imperative to EHR implementation success. Proffitt and other staff members on the front lines of HIM came together during EHR work sessions and build sessions, helping to brainstorm and figure out the best course of action. Stepping out of their traditional roles challenged the staff members, according to Proffitt, and overall, they adapted well to the changes.
After go live, HIM staff members worked together in what Proffitt called "urgent meetings" every morning or so. The meetings would cover any problems HIM staffers were hav-ing with the new system in place, and the meetings also served to help iron out workflow issues that were cropping up in the department. Workflow roadblocks caused many headaches in the HIM department, and the meetings made the transition smoother. "There is just a huge conceptual paradigm shift to think about workflows being totally auto-mated vs. charts being routed around the department for work," Proffitt said. "That was the hardest thing to adapt to."
Communication Is Key
Meetings were held at TCH about how the system would be built. Teams met over 26 months to try to cater the ambulatory EHR system to each of the 45 different kinds of clinics that comprise TCH. Other groups came together in meetings to discuss cleaning up the MPI and scanning the records into the EHR. Meetings were numerous, staff members were in constant contact before and after the go live, but communication still appeared on the list of lessons learned: "No matter how much you communicate, it isn't enough."
While HIM had a prominent seat at the EHR tablemeeting with the orders team, the clinical documentation team and the clinicians to name a fewsurprises still cropped up. The HIM department helped with some of the build decisions, but Proffitt said that the impact of those decisions wouldn't truly be known until after the EHR went live. "I think the biggest challenge was our lack of understanding of the impact of some of those decisions, and how they would affect our workflows and our ability to produce the legal medical record," Proffitt said.
Release of Information (ROI) Manager Shandias Barnum, RHIA, noted that even with all of the planning, things can, and do, go differently than expected. A year after go live, there are still major configuration changes that need to be looked at for producing the legal record. Barnum recommended assembling a team to compare and see what's good to have, what can be ditched and what's missing in the legal health record. People from other areas and other departments help evaluate the legal health record at TCH, Barnum said, and it helps to get a different perspective on the legal health record. The ROI manager needs to be involved in the build process for the EHR, but if things don't go as planned, always have a plan B, Barnum advised. "It's really a matter of being patient, and making sure that you have all the groups that are involved," she added. "Really come in and have a good game plan, but then have a backup plan when things don't go as originally implemented."
Your Processes, Warts and All
Planning takes center stage in EHR implementation, but surprises will abound-and you might find that your facility isn't as perfect as you'd hoped. In the paper world you can work around broken or inefficient processes, Somers said. You end up knowing a lot more than you did before, she added. In the paper world, for example, you don't really know how many physicians' telephone or verbal orders were made. "It's just too onerous to go in and count them and figure out who's doing the bulk of them. It usually becomes a huge auditing process or anecdotal," Somers explained. "In the EHR, I can tell you every physician that wrote an order and whether or not it was a verbal order or they put it in themselves. So that sounds like a good thing, but all of a sudden we've got all this data that potentially makes us look better or worse than what we ever showed in the paper world."
That brings up the third lesson learned: "The EHR places a magnifying glass on every broken process," Somers pointed out, noting another inefficient processtaking care of incomplete medical records. "The process of counting those in the paper world was fraught with errors," Somers said. "In the electronic world, it's pretty darn accurate, so it's those kinds of things that you learn very quickly that any process that wasn't perfect in the paper world is really going to show up like a sore thumb in the electronic world And then all of a sudden the EHR's to blame."
The process of taking care of duplicate records and overlays, which are where multiple patients are registered on top of each other incorrectly or inappropriately, was something that needed to be worked on before the EHR go live. With lots of competing priorities, TCH didn't really get to accomplish a huge clean up of their MPI, Proffitt said. She estimated that there are still thousands of duplicates and some overlays in the systems, and they're brought to light through two systems-the EHR MPI and then another product by Initiate Systems Inc. that is integrated with the EHR and serves as the master MPI. The two indexes are out of synch for a lot of kids in the system, and Proffitt said that's the most critical thing to work on right now.
Some additional staff and a few outsourced consultants from Denver-based Just Associates are helping with the clean up, but in the electronic environment, repairing duplicates and overlays is more complex. A merge of duplicate records takes a little longer due to the re-labeling and scanning of forms, Proffitt said. Likewise, unbundling an overlay formerly took an hour or two. "Now it can be anywhere from 30-60 hours of staff time to fix those," Proffitt said. "Cleaning it up is important, but even more important is keeping it clean going forward and trying to reduce the creation of duplicates and overlays."
An Overall Success
After looking back on some lessons learned, the TCH staff can be proud of the overall success of their implementation. The big move to a new facility helped keep the implementation on track, and roll outs went off on schedule. Somers admitted there was "a little bit of fear involved" about not getting the implementation done in time, but overall, the move served as a great motivator. "Most organizations, given enough leeway, will tend to drag these projects out," Somers added. "At TCH, we didn't have a choice-we had to get it done before we moved."
Smaller victories popped up along the road to full integration, as well. Average monthly dictation minutes have significantly declined from 44,000 in 2003 to 21,000 in 2008. There are no medical record shelves or file rooms at the new facility-thanks to strict orders that no one was to move hard copy paper records to the new facility, with only a few exceptions. TCH is nearly 100 percent paperless today. Perhaps most importantly, physicians-very close to 100 percent of them-are using the new system. Somers admitted that some were excited about the EHR and some were less than enthusiastic, which became evident when the ambulatory care system was rolled out to the clinics. "Some clinics said pick me, pick me, do me next," she said. "Other clinics said don't come near my clinic."
Some are still slightly dissatisfiedbut physicians seem to be a hard group to please. Many embraced it, but no matter what the physicians' opinions on the EHR are, they're all using it. "We actually had very strong leadership that said, you can complain, and we'll do everything we can to make this work for you, but you can't choose not to use it," Somers said.
Somers expressed her pride that the physicians are using the EHR, but said she is most proud that the system is fully integrateda goal that TCH had its sights on from the beginning. While all the meetings on design, build and planning were going on, the staff at TCH had no idea that they would end up being the first hospital in America with a fully integrated pediatric EHR. "We really didn't want to be first at anything, but we found ourselves in that position," Somers said.
- Lynn Jusinski is an assistant editor with ADVANCE.
|
|
