EXECUTIVE SUMMARY
Each year, HIMSS recognizes exceptional achievement in healthcare IT implementation, through its Nicholas E. Davies Award of Excellence. Find out what the healthcare IT leaders at Sentara Health System, Nemours Health System, and Miramont Family Medicine have learned on their path to clinical and operational transformation, and the lessons they have to share with the industry.
Every year, the Chicago-based Healthcare Information and Management Systems Society (HIMSS) salutes exceptional achievement in healthcare IT, through its Nicholas E. Davies Award of Excellence. By taking a look at the organizational winners, Sentara Health System and Nemours Health System, and ambulatory winner Miramont Family Medicine, some commonalities emerge that undoubtedly speak to common approaches to innovation. Not only do the organizations create a culture for change, they also embrace clinicians each step of the way to galvanize their information revolutions.
HOME SWEET MEDICAL HOME
Miramont Family Medicine in Ft. Collins, Colo., the ambulatory winner, is the very model of a modern-day patient-centered medical home (PCMH). “They really get the patient-centered medical home concept, where they try to perform as many services as they can at a one-stop shop for the patient,” says David Collins, director of health information systems at HIMSS.
The six-physician Miramont is always in the state of expansion, opening three new offices in 2008 and 2009. Not only does the four-clinic practice have an onsite dispensary, but they have a portable X-ray and state-funded labs in three of the four sites to limit return visits for patients.
Miramont needed increased clinical data and registry functionality to become a PCMH pilot practice in Colorado. So in 2007, its physicians went for broke and started using Austin, Texas-based e-MDs' EHR and practice management system, after using an inferior “DOS”-like product for a few years (it was the legacy IS of a nearby hospital system). Miramont had a relatively smooth go-live by scheduling the first three days at 50 percent to leave time for using the new system. The practice also had studied the software previously and selected a super user on staff to help as issues arose.
As a part of the transition to the new system, Miramont decided, against the advice of e-MDs, to go totally paperless since square footage for off-site storage was getting more expensive. This Herculean feat involved the scanning and subsequent shredding of 10,000 pages of medical documents. The shredding was done incrementally, and to encourage the process after each 1,000-page milestone the staff would have a celebration.
SHAKING OFF THE ‘70S
John Bender, M.D., believes one main decision that led to his practice's success was taking the calculated risk of investing $200,000 of personal capital in technology. Bender sought to combat what he said was the outdated '70s healthcare model-paper-chart practices that were inaccessible to patients (early closures, no after hours). “No one likes that anymore, and it's not convenient,” he says. “And patients are abandoning the model to go to retail clinics and emergency rooms. Consumers are revolting.”
With the generous IT investment, the practice has doubled its census to nearly 14,000 patients in the last three years, and has effectively paid off the cost of the IT closet. “The payback was a very robust return on investment that made us more efficient, safe, and faster, so we could see more volume,” Bender says.
With the higher volume of patients, collections for providers increased by $86,000. Miramont has also been able to garner $10,200 in Physician Quality Reporting Initiative (PQRI) incentives. Another major chunk of change, $56,000, has been realized through grants and other pay for performance monies. These pay for performance/quality improvement programs Miramont participates in address chronic disease and preventive care, such as Health TeamWorks, Improving Performance in Practice (IPIP), HCI3's Bridges to Excellence, and the Medicaid Colorado Children's Healthcare Access Program (CCHAP).
With meaningful use Stage 1 “in the bag,” according to Bender, some next steps for Miramont are getting its patient portal running to facilitate the sending of Health Insurance Portability and Accountability Act (HIPAA)-compliant emails. The family practice also intends to increase its participation in the Colorado Regional Health Information Organization (CORHIO).
Bender and his practice have reaped many rewards in its electronic environment from being courageous, what he calls the opposite of cautious. “We've had a strong signal from our federal government that they want us to make these investments, and I believe we'll be rewarded in the marketplace,” he adds.
LIVING IN THE FUTURE
The crux to Sentara Healthcare's successful eCare Health Network was getting physicians involved during the earliest stages of IT implementation. This early buy-in at the Norfolk, Va.-based Sentara system, which has a total of nine acute-care hospitals and 1,935 beds, led to the ease of subsequent innovations. The Sentara eCare program was five years in the making. Originally, the health system wanted to implement an EHR in the late '90s, but the market wasn't deemed ready for what Sentara's “mad scientists” really wanted. But by 2005, hospitals around the country were implementing computerized physician order entry (CPOE), and that year, Sentara sent a slew of representatives to HIMSS to gather ideas to create their integrated system.
To select their electronic health record (EHR), Sentara's leaders didn't go the traditional request for proposal (RFP) route. As Senior Vice President and CIO Bert Reese describes it, Sentara “had to create an environment where [clinicians] could actually live in the future as we were starting to build it around them.”
To do that, Reese had the two finalists, Cerner Corp. (Kansas City, Mo.) and Epic Systems Corp. (Verona, Wis.), do live demos with a clinical scenario his clinicians created. The scenario was quite complex: the fictional patient started off in the emergency department, then was admitted to med/surg, then to the intensive care unit, afterwards the operating room; then the patient went home and had homecare; then went to their primary care physician; then went back to the emergency department. Reese invited clinicians to watch the live EHR demonstrations of the scripted clinical scenarios. As Sentara is a nine-hospital system, naturally not all the physicians could see the demos live, so they were videotaped. Both scenarios were put side-by-side, so clinicians could easily compare the patient's record in both environments. DVDs were pressed and shipped to all hospitals and practice groups for comments. By the time the final vendor was recommended to senior management, 3,000 people, of which 1,000 were physicians, had viewed the live demo or seen the DVD. “We did something that was really different,” Reese says. “We thought that if you're going to do something this big-we believe that you have to lead from the future.” Epic ended up being Sentara's final choice.
THE eCARE TEAM
Sentara's Director of Information Technology, Miller Trimble, got physicians involved in a physician advisory group during the organization's initial system configuration, in order to gather their input on design decisions. “I think it was absolutely key that we had that group fully engaged to make the design decisions upfront,” he says. “And they became champions, so when they went out to their areas of practice and talked it up, they also brought back their colleagues' complaints, so that we could make further changes.”
Reese, Sentara's CIO, took an innovative approach to embedding IT knowledge into his organization through staffing the eCare project. Reese describes it as a casting call of sorts to be on the implementation team. Instead of singing a show tune or reciting a Shakespearean sonnet, clinicians had to teach the IT department how to make something, be it tapioca pudding or a knitted scarf, during tryouts, so Reese could get a feel for the person's teaching skills and charisma. After the audition, 189 full-time employees were added to the implementation team and went to Epic's boot camp in Wisconsin to get the necessary training. “What's interesting about that model, is that when I do an upgrade for Epic, I recall those people from operations to help define the upgrade and support it when it goes live,” says Reese. And that, he says, “means I don't have to keep an IT staff as large as at other organizations.” Reese also points out that these staffers also know what they want upgraded since they live in the environment.
Physician adoption was further encouraged by a self-imposed mandate from the medical staff that in order to practice at Sentara, staff had to complete training modules to gain access to the EHR. Greg Hafer, director eCare operations and a nurse executive by trade, developed a competencies checklist for staff to make sure they clearly understood the critical workflows and demonstrated them before go-live. “It made our adoption rate and our turnaround time to get a hospital up and stable decreased radically when we did that,” Hafer says.
Trimble notes the physician advisory group, with representatives from physician practices, surgeons, emergency department doctors, anesthesiologists, was extremely successful in gaining staff acceptance. Compensated for their time, the team now meets every other week to bring feedback and complaints to the group for modifications to the system. Hafer also adds that with 300 subject matter experts brought into the mix from the ambulatory and acute care settings, adoption was driven by sound decisions made around software and workflow changes.
DETAILED DASHBOARD
One of the major innovations that impressed the Davies judges was Sentara's ability to collect metrics into a dashboard for executive management to evaluate progress and performance. “Their dashboard in particular is very advanced,” says HIMSS' David Collins. “They actually push and pull data to their senior executives and staff.”
The Key Performance Indicator (KPI) dashboard is located on the Sentara Intranet and pulls data from the finance department and the eCare Network to display more than 40 different metrics for management. Some KPIs the hospital system focused on ranged from emergency department turnaround times to Centers for Medicare and Medicaid (CMS) core measures. Since the dashboard was implemented, reductions in length of stay, medication errors, and time to first dose have been realized. Also average order time decreased from 132 minutes to 4.5 minutes. “Just by our pretty high CPOE adoption rate, we dramatically decreased the cycle times for implementing interventions to patients,” says Hafer. “We saw that radically reduce within the medication administration component.”
When Sentara Leigh Hospital in Norfolk, Va. first went live in 2008, that facility's staff held daily meetings to discuss the metrics so problems could be identified and operations streamlined before bad habits became entrenched. Gradually, the meetings were less frequent, and eventually were phased out entirely and replaced with a monthly ROI scorecard to measure performance. “The level of standardization that we have across the company-we've been able to achieve more with our metrics and our KPIs than others,” says Miller.
This deep data dive also gave Sentara the ability to standardize its EHR deployment system-wide. The implementation staff would debrief periodically with clinicians throughout the implementation at each facility. “At the end we'd formally go over with leadership from that site what the key lessons learned and that really drove the priority of the decisions for the next facility,” says Hafer. Other initiatives that smoothed implementation were level one and two action plans, as well as creating achievable milestones.
EMERGENCY MEDICINE AND BEYOND
Bert Reese is not only excited about how physicians have adopted the new technology, but by how patients have as well. Currently, 36,000 patients are using Sentara's patient portal MyChart to electronically dialogue with physicians, get education based on their problem lists, and schedule appointments.
Other happenings on the horizon will be the next facility, Potomac Hospital in Woodbridge, Va., going live on the Epic system in fall 2011. The seventh facility, Sentara Obici in Suffolk, Va., recently went live in September.
Reese is excited to be pioneering the usage of the eCare system by ambulances in Virginia Beach. EMTs affiliated with Sentara currently use the EHR to enter critical information directly into the EHR while patients are in the ambulance, so when the patient arrives inside ER, doctors already know what happened onboard.
LONG MARCH TO SUCCESS
As Bernie Rice, Nemours' chief of information technology puts it, it isn't really about the project his system did last April transitioning the system's Cerner inpatient system to Epic that won the Davies award, it's about what the Jacksonville, Fla.-based children's hospital had been doing over the past 10 years. “It's been our march to where we are now and the vision of our board and executive management to get to where we are,” Rice says.
Indeed, creating Nemours One, an EHR with all clinical and business applications from Epic, and spreading it across the system's four states-Delaware, Florida, Pennsylvania, and New Jersey-was quite an undertaking. “What was compelling about Nemours is their leadership and culture and the way they've been able to get everyone's buy-in and make decisions at the corporate level for all four states,” says HIMSS' Collins.
THE ENTERPRISE APPROACH
With 15 children's clinics and 11 pediatric offices operating the Epic outpatient system, and Nemours' flagship Alfred I. duPont Hospital for Children in Wilmington, Del. on a Cerner inpatient system, interoperability was difficult, to say the least. The organization's leaders wanted to create an Epic Enterprise system with “one record north and south” to diminish the interfacing currently needed and to improve long-term interoperability. The time for change presented itself in April 2009 with a new hospital in Orlando scheduled to open 2012. “[It was] the fact that we were poised to essentially double in size, which would have basically doubled the magnitude of this problem,” says CMIO David Milov, M.D., who is an attending in the division of pediatric gastroenterology. “There's actually a very favorable ROI for switching over to a single vendor over time.”
Rice saw the changeover as a way to make the clinical world simpler by eliminating the need for staff to maintain expertise in both clinical systems. “It's a lot of workload for them to stay proficient on each one of the applications, so that reduces their complexity by keeping it into one integrated system,” he says.
One choice that Nemours' leaders made to help facilitate the inpatient transition was to avoid a mandate for direct documentation by physicians. Physicians can choose to do handwritten, dictation, or direct entry for notes. With 10 years of experience on the Epic ambulatory product, Milov realized the benefit of letting his doctors choose their method of documentation, even if it came at an added expense of dictation costs. In his experience, this gradual phasing in of technology encourages adoption.
The Nemours go-live took place over a weekend to make the implementation easier. A command center was set up 24/7 for five days to ensure quality control while the IT staff handled tickets for service requests resulting from order conversion from one system to the other.
GETTING PHYSICIAN BUY-IN
There were many challenges in getting clinicians behind the inpatient changeover. According to Milov, a lot of clinicians had an emotional investment in the Cerner system. Milov's strategy was to identify the people who were emotionally attached and talk to them before the final decision was announced. “I would actually present the dilemma and say, ‘What would you do if you were me and had to support two pharmacy databases, two informatics teams, and maintain interfaces through every single upgrade of every application?” he says.
Another fear Milov sought to address was making sure there would be no loss of functionality in the new Epic system, as there was a high expectation to not take any steps backward. After a slight glitch in importation of blood gas data in a cardiac intensive care unit flow sheet, Milov got a hint of an “I told you so” attitude from physicians. Luckily, the issue was solved relatively quickly, and he continued campaigning for the new system.
Gina Altieri, vice president of corporate services, says the key to winning over her staff was tying the project to overall strategy and showing them what was in it for them and their patients. Many forums were held to show clinicians the benefits of the new integrated EHR. She also says everything was communicated so “nothing was a surprise,” and physician champions were selected early on to ease the process. “The change management aspect can't be ignored,” Altieri emphasizes. “As they say, ‘Culture eats strategy for lunch.’ Bad behaviors can sabotage any good plan.”
Bernie Rice also references communication as key for the success of NemoursOne. “You have to let people know what's coming,” he says. “You have to let them feel they're involved in it and that it's not being done to them. If they feel a part of it, then it's going to be more acceptable to them.”
Nemours also injected a little fun into the project by employing a NASCAR theme to garner excitement. The racing theme was referenced in signage, as well as holding “test drives” or practice sessions. The biggest challenge Rice noted was getting physicians' time for training, but a hard-line approach requiring training to receive a Epic system log-in helped ease that.
REDUCING NUISANCE ALERTS
For more than year, Milov has chaired the organization's clinical decision support committee, with the participation of physicians, pharmacists, nurse informaticists, and others. The committee meets monthly to make life easier for doctors in the NemoursOne environment. No. 1 on the agenda is to reduce nuisance alerts. Every month, a 3,000-page report charting every alert fired, including drug-drug and drug-dose alerts, is reviewed. Currently, the committee is developing a policy around black box warnings, as well as strengthening the drug-food allergy database, since there's less free text in that database.
One modification to the EHR that Nemours made that follows Nemours' agenda to fight childhood obesity was to add a body mass index (BMI) prompt. If a child has a BMI above the healthy weight range, an electronic clinical protocol gives the physician a hard stop, and they must counsel the family regarding healthy lifestyle choices, and provide educational materials.
PATIENT COMMUNICATION AND SAFETY
Besides building the new Orlando hospital, next steps for Nemours information technology journey include continuing to roll-out kiosks to ease sign-in at clinics and setting up MyNemours, the system's patient portal. Also, an innovative child security system is being researched to provide real-time patient location tracking. This will allow patients to find out their daily inpatient schedule, as well as prevent abduction.
“We couldn't be in a better position,” says Gina Altieri. “We made the investment, we were able to do it over time, and do it well. Now we'll hopefully reap some financial benefits of meaningful use and be recognized as a leader at a time where people are really looking to be led.”
Healthcare Informatics 2010 December;27(12):26-33
