EHR Journey 1.2

Once embarked on an EHR journey, Ministry needed to develop supporting corporate infrastructure, tasks such as finding a Chief Information Officer (CIO) and Chief Medical Information Officer (CMIO). While those efforts were underway, we pulled together a team of clinicians and staff who were using or had used an electronic medical record in the past. This team gathered virtually on a regular basis to develop a joint vision of what practicing clinicians need in an EHR.

I have found clinicians who have used EMRs in the past possess unique insights as to how an EMR can be used to improve provision of care. Clinicians who have not used an EMR, tend to develop workflows duplicating their paper flows rather than finding new processes to leverage the technology.

We gathered over the noon hour once a week via a telephone conference. We generally talked about a topic and flushed out our functional specification.  Offline, we developed representative screen shots depicting the functionality we desired. Screen shots and functional requirements were shared using PowerPoint Presentations sent via our internal e-mail server. Today we would collaborate using WebEx as the communication tool.

 

By the time Ministry had hired a CIO and CMIO, the clinicians had formed a very clear vision of our functional specifications.

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Types of EHRs (1.02)

In a previous post, I stated there are there three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database

A data exchange provides a mechanism where information from disparate data systems is collected and then presented for viewing.  The data, while useful as a reference source, is of limited value because of a restricted ability to package the information in meaningful ways or be used as a driver of decision support. Patients are often not uniquely identified in the database resulting in duplicate records.  Some entities maintaining data exchanges do not adhere to the same patient confidentiality standards as the organizations that contribute the data. These exchanges are expensive and ongoing funding to support continued use has been problematic.  A data exchange can be useful when regional providers of care use either different electronic medical records or EMRs where the database can be unilaterally altered. It’s value will be high in the short term when entities merely wish to view data, but will be limited in the future when those same entities wish to use the data to provide decision support at the point of care.

A few EMR vendors offer a standard data base across their user base. Separate health care entities can utilize these records and have an identical database structure allowing alignment of patient records.  The resulting structure can allow the data to drive decision support or common determination of clinical benchmarks. Since the database has a standard format, custom programs for decision support can be easily shared between users. Though more useful than an data exchange, this format is limited in that patients may not be uniquely identified in aligned systems.

A single common medical record with a single patient database used by independent regional health care entities provides the most robust structure to share medical data and drive decision support.  Governance can be a real issue but the improvement in patient care is worth the effort. Data can be packaged and presented to meet the needs of each individual user.

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Electronic Health Record (EHR) or Electronic Medical Record (EMR) 1.01

Think of an EMR as the equivalent of a patient’s paper medical record, the accumulation of one business unit’s information about the patient.  Typically, patient health care information is found in multiple paper medical records (or EMRs). Even in small isolated communities with a limited number of care options, records are kept in multiple locations. The hospital has medical records, most often organized as episodes of care. Even if all medical practitioners use the same outpatient medical record, dental and psychiatric records are often segregated. 

Some systems of care have taken the step of combining all the regional medical records; consider the result to be a combined medical record. The step involves considerable effort as each patient will need to be uniquely identified and the various health care entities will need to establish a common form and governance of the medical record, not an easy task.

If the system of care takes the concept one step further and embraces the concept that the medical record should be the complete record of the patient, they are on the path to an electronic health record.  The quest to obtain a complete record will never be finished as there will always be more information that can be gathered. However, the quest results in a record with ever increasing value to patients and caregivers.

An EHR is considerably more complex than a combined medical record because systems of care that are not directly aligned business units need to agree on common patient identifiers, common structures and governance. 

There are three common structures for EHRs.

1. A regional data exchange
2. Aligned medical records using a standard database structure
3. A single common medical record with one database.

I will discuss these types of EHRs in a future post

Our use of the term EHR, signified our intent to move towards a single health record for a patient. As you can imagine, the vision of having an EHR had major significance for selection of a vendor.

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Electronic Health Record 1.0

Where does one start on the EHR journey? At the beginning.  Where is the beginning?  The beginning should be squarely focused on the business needs of the organization.

Our journey grew out of series of strategic development sessions.  Our two major medical groups had been acquired within the past 10 years and each had developed a business model centered on a regional hospital.  Each regional business unit had developed the basics necessary for a functional EMR but there were no true links between the units.

A number of tactical initiatives grew out of our strategy sessions. We discussed how we might achieve the various initiatives and came to the conclusion a system wide EHR was a prerequisite.  

Lesson: The EHR (or any other initiative) has to be based on the business needs of the organization.

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We Have Announced Our EHR Selection

We have been on a two year journey to select our EHR product, Marshfield Clinic’s CattailsMD^TM .  My intent over the next few months is tell the story of our journey and provide details of the work ahead of us. I hope this work will be of value to others. Governor Doyle’s press announcement is below.

 

 

 

Friday, June 20, 2008

Contact: Carla Vigue, Office of the Governor, 608-261-2162

Governor Doyle Announces Creation of Largest Patient Database in Wisconsin

 New System Will Improve Safety and Health Care Quality for 2.5 Million Patients

Governor Jim Doyle announced today that Ministry Health Care will begin using an electronic health record (EHR) software suite developed by Marshfield Clinic - CattailsMD^TM - for the majority of its hospitals and Ministry Medical Group, creating the largest patient database in Wisconsin.

“This is an important step forward in our efforts to reduce medical errors, increase patient safety and decrease health care costs,” Governor Doyle said. “With better use of information technology, we can transform our health care system to improve the safety and quality of health care.”

“We are confident this significant IT investment will meet the health care needs of the patients we serve in northern and central Wisconsin,” said Nick Desien, president and CEO of Ministry Health Care.

“I am gratified that the longstanding relationship between Marshfield Clinic and Ministry Health Care has been further strengthened by this agreement to extend our CattailsMD^TM system to Ministry facilities, which will also greatly benefit our shared patients in the region,” said Karl Ulrich M.D., M.M.M., president and CEO, Marshfield Clinic.

More than 1,000 providers in the Marshfield Clinic system, at Ministry Medical Group and Ministry hospital locations will share access to 2.5 million patient records. Implementation of the EHR for Ministry will occur over three to five years.

The EHR makes all patient medical information immediately accessible via computer to medical personnel involved in a patient’s care regardless of where they are located. Currently, paper charts cannot be viewed by more than one person at a time and often need to be physically transported from one location to another, wasting time and adding cost.

Not only will the EHR improve access to patient records, it will provide clinicians critical information in an easy-to-read format.  The EHR will also be more secure. It will allow access only to those providers involved in a patient’s care, as well as track what information was accessed when and by whom.

As part of this agreement, Marshfield Clinic will provide planning, project management, implementation, training, customer service and technical support services to facilitate the installation of these clinical software applications.

Marshfield Clinic’s Cattails MD^TM is the first provider-developed ambulatory EHR in the nation to achieve Certification Commission for Healthcare Information Technology (CCHIT) certification.  It is used daily by more than 13,000 providers and support staff.  For more information about Cattails MD^TM, go to http://www.cattailsmd.com.

Widespread implementation of EHRs has been a top priority of Governor Doyle since he took office. In 2005, he created the Wisconsin eHealth Care Quality and Patient Safety Board, which is charged with developing an action plan for the statewide adoption and exchange of electronic health records. Governor Doyle has provided millions of dollars in tax credits for automating medical records and he ordered Act 108 to reduce barriers for providers to access electronic health information, while still maintaining appropriate privacy measures.

e-iatrogenesis

I recently had the opportunity to listen to a presentation by Joan Ash, PhD, MLS, MBA; Associate Professor of Medical Informatics and Clinical Epidemiology at Oregon Health and Science University in Portland, Oregon.  She has been part of a long term effort investigating computerized physician order entry (CPOE).  You can review the result of the work done by this team at http://cpoe.org. If you are considering CPOE, the website is well worth the effort of review.  If you know the experiences of others, you will be better prepared to minimize or mitigate the inevitable surprises of implementation.

Dr. Ash and her team have found asking users about their surprises rather than the unintended consequences of CPOE will result in a richer discussion.  She has also discovered that if you want to know how a process is working, go to the source and observe it.  Observing and asking questions results in far more accurate data than sitting in an office and reviewing the results of surveys.

I did learn of one specific example of a CPOE surprise that was new to me:

 

 http://www.timesonline.co.uk/tol/news/uk/health/article753765.ece

It seems as if there were no complaints from patients who had received Viagra in error.  Perhaps their thoughts of smoking were transformed into something else.

Please do not consider all surprises to be negative.  When we implemented electronic Rxs in my outpatient office, patients could actually read and interpret our prescriptions.  They became empowered in the process, read the Rxs,  pointed out address errors, asked for greater quantities  and even asked for more refills.

Any new useful technology solves old problems but introduces new ones.  A term has been recently coined, e-iatrogenesis, to label any patient harm caused at least in part by the application of health information technology.  

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Plan For the Future

One important duty for a leader is planning for the future. When we first implemented Practice Partner (see my previous post Business Needs Should Drive Technology Solutions) we installed a single user workstation.  It served our needs at the time but it was not hard to see the need for a multi-user system and the desire of the nursing staff to document their phone conversations electronically.

We were at a time before Practice Partner had templates and before anyone in our local area knew anything about networks or stringing cable.  At about the time I had finished design/testing phone documentation templates and found a source to help us network, staff made a plea to allow more nurses access to the system at one time and document their phone calls.  Because of planning, we were able to deliver a solution when the business needed it.  The nurses were happy to learn how to log on to the system and learn how to use templates.  As they used the system, we made a series of improvements  further advancing  their workflow. Had I pushed implementation, there would have been resistance. Had I not planned, we could not have been as responsive to our business needs.

As I have taken on larger responsibilities, the need for planning remains. It is just a bit more complex, time consuming and requires greater vision into the future.

Business Needs Drive Technology Solutions

My personal journey towards electronic health records (EHR) began as a search for a solution to a business problem. We were a growing and very busy primary care medical practice founded on the principle that everyone who needs to be seen today, is seen today.  Need was determined by either the patient or the medical practice.  A major issue we faced was a large volume of phone calls and the resulting need to obtain the medical record. Despite our best efforts we simply could not access a patient’s health information fast enough. Typically we would have to take a message and call the patient back.  The patient was often not available during our call back and when they in-turn called us back, we still had trouble laying our hands on the information since it was written on a single piece of paper sitting on someone’s desk.

At that time (1989) computers were not common place in small business but we did have a computerized billing system.  We dictated our patient visits, but the notes were transcribed onto paper.  We realized if we could transcribe the visit and have an electronic copy, we could later retrieve the electronic copy at moments notice. We could answer patient issues with the first phone call rather than play frustrating rounds of phone tag.

We looked at various document management systems (I wasn’t even aware of the concept of an EHR) none of which seemed to meet our needs.  I became aware of a product called Practice Partner that had been developed for medical practices.  We implemented the product and we were able to solve our business problem.

We were successful despite using cutting edge technology in a setting where not a single clinical individual had any computer skills.  It worked because technology solved a business problem that had been clearly defined. Since then IT has become a major part of my life.  I am constantly reminding myself that IT does not drive the Business, it is the Business that drives IT.

Communication is More Than a Communication

I was having a discussion with the senior most sister-leader at Ministry Health Care regarding effective communication.  I had been thinking of communication in only a very concrete sense but she reminded me communication is also about process and organization.

As Executive Sponsor of the EHR, I spend about 25% of my time doing heads down work, the other 75% is dedicated primarily to communication.  Here is a partial list of my communication efforts:

• Travel at least a thousand miles a month in central and northern Wisconsin
• Conduct in-person presentations to 20 or more groups of clinicians, staff or administrators  every month
• Present to each regional and campus administrative team quarterly
• Participate in countless virtual meetings (both via telephone and WebEx)
• Send out a monthly e-mail update to all clinicians and respond personally to every question posed by clinicians and staff
• Post all previous updates and FAQ on an intranet site
• Present at any clinician meeting when requested to
• Present at regional clinician meetings
• Spend time in various doctor lounges in our hospitals to seek opinions and answer questions
• Include EHR updates in local, regional and system newsletters

Even with these efforts, 6% of our surveyed clinicians (see the previous post Survey Your Clinicians and Staff) believe our communication is poor and another 20% are neutral.  As I was trying to find additional ways to communicate with our clinicians, Sister reminded me communication is not just a piece of communication, it is also process and organization. How your organization engages clinicians and seeks input going both up and down the organizational structure will have an impact on effective communication. We are about to transition from planning to design of our EHR.  As we engage more and more clinicians, it will be interesting to see if our communication is judged to be more effective.

One of the benefits of attending the Physician Executive MBA Program at the University of Tennessee, is the opportunity to participate in an individualized Leadership Development Program. As part of my LDP, I will be spending some time learning how to use organizational process and change management to improve communication.  Stay tuned.

Survey Your Clinicians and Staff

If you want to know what people think, ask them.  If you are in a small group, asking opinions is relatively simple and straight forward.  In a large geographically dispersed organization, the task is more difficult. One tool we have found helpful is Web Surveyor.  The tool is hosted internally.  Our staff author the survey.  We send an e-mail to clinicians and staff asking them to participate and provide a link to the survey. A separate link allow administrators an opportunity to view the tallied and graphed responses.

We recently used the tools to judge the opinions of our clinicians regarding several EHR issues. This is the response to a question regarding how well we are communicating EHR progress.