July 25, 2011
Bridging the Gap Webinar Q&A
July 19, 2011
Participants
Mike Doyle, Medsphere President and CEO (moderator)
David Whiles, Director of Information Systems, Midland Memorial Hospital
Sigurd Ackerman, MD, President and Medical Director, Silver Hill Hospital
Q: David, how did you achieve such a strong rate of clinical adoption?
A: Whiles: Thanks, Mike. That could probably be a whole seminar in itself. Let me just go through a few items that we did that got the buy-in and the engagement. I mentioned earlier, first and foremost, this was really put together as an organizational effort; it was not an IT effort.
When we had that first encounter 18 months before we signed a contract with Medsphere, we organized an internal review committee. That committee consisted of all of our executive staff, which was our chief executive officer, chief financial officer, chief nursing officer… also included several nurse managers; it included representatives from lab, pharmacy, radiology, respiratory therapy. It also included our chief of medical staff who was serving at the time, so that committee actually went through 18 months of self education and roll-out or sales, basically, of this system to the staff—both the physician staff and the hospital staff.
Early on—again, before we signed the contract with Medsphere—we had what we called a demonstration project as opposed to a product demo. You know, we’re all used to vendors coming in and they’ll do their dog and pony for two or three or maybe even four hours, but you really can’t see and can’t understand the full thrust of the product during that time. We took a complete week and rotated our hospital staff, in two-hour increments, through education sessions and introducing them to the system. We also had three different sessions during evenings that we put together for physicians. We had a total of about 30 of our physicians that attended those sessions.
During all the sessions—physicians and hospital employees alike—we passed out a brief survey and had them fill that out as they left. From the hospital staff, we had about 80 percent very favorable ratings—they really felt that this was a good way to go and bought in to the project. On the physician side it was a little bit less—it was somewhere between 66 and 70 percent—but, still, that’s good for the really positive comments and feedback we got from that physicians. That early, early engagement and continuing engagement was a big part of the buy-in.
After we signed the contract with Medsphere and began the implementation, as we brought it online and got the pharmacy department online and laboratory systems online, as we brought up the clinical units, we actually crafted—of course, this was the time when Stark legislation was a little bit more strict than it is now in terms of physician relations—but we crafted a contract that the physicians signed where they would be reimbursed up to $1000 for sitting through the training of the new OpenVista system. In order to collect that $1000 they had to demonstrate that they were actually using the system by signing 100 percent of their documentation for a full month electronically, and also that they would meet a threshold of 40 percent of all their orders entered personally by them. That was part of the contract, again, for a full month. We had somewhere between 70 and 80 physicians that collected on that money, so that was a good investment of our time and money to get the physicians onboard.
We do recognize that it’s time consuming and that it takes time out of their practice and time out of their day to really sit down and learn how to use the system.
Some other things we did—I call it stalking the physicians. After we were live … I have about 8 or 9 clinical analysts that are on staff in the IT department, they are all from nursing backgrounds, the majority have RNs, and that’s basically who supports the OpenVista system at our organization today. During that period, we would run reports on a weekly basis, which gave us the utilization by physician in terms of their documentation, in terms of their order entry statistics, etc. We would identify those that were low utilizers and we would pick them out and pay them a personal visit. One story I had from one of my analysts, she was coming down the hall and one of the physicians that was one of our low utilizers came around the corner at the very end of the hall and saw her and immediately turned around and started going the other way. She literally ran and caught up with him and I think had a good training session with him a little bit later. A lot of one-on-one training, a lot of handholding with physicians during that period … we started out basically one-on-one and later on offered classes where we tried to get groups of physicians in to try and improve our teaching efficiency, and that worked out better than we expected.
Probably the last item I wanted to mention would be … we’ve spent a lot of time customizing the physicians’ templates to their specific needs and requirements—all the way from post-op surgical notes to their daily progress notes to history and physicals—we crafted many of the documentation templates specific to those physician practices. The same thing for order sets—we’ve spent a great deal of time in setting up order sets, in creating orders, which are basically a way to allow a physician to make an order that he does all the time basically with one click, and it completes the order it’s ready for him to sign. So, those efficiencies really helped to create buy-in from the physician standpoint.
Q: Can you clarify the certification process with folks like Drummond or others, and what is the deadline to register for meaningful use criteria for 2011?
A: Doyle: There are a number of bodies out there that certify, and they follow the same process. Medsphere actually got certified by InfoGard, and as we understand it the process is similar across the spectrum. We do know that if you want to get Stage 1 meaningful use payments, you actually have to attest for a 90-day period of time, and the last time you can do that is the fourth quarter of 2012.
You have to attest for 90 days beginning on October 1 through December 31. If you don’t meet that criteria by then you’re not entitled to Stage 1 meaningful use, and what’s significant about that is that’s 50 percent of all the meaningful use dollars available during the process.
If you want to get paid in 2011, you actually have to have started 90 days before the end of the fiscal year, which is October 1 by the federal government’s standards. I just wanted to make that clarification.
Q: Dr. Ackerman, how did you build clinical workflow improvements to your EHR implementation?
A: Ackerman: Well, you first have to spend a lot of time looking at your workflow to see what it is. What we found in doing that is that there were many redundancies, many inefficiencies. We would have patients who came from admissions and onto the units who were asked the same questions they were asked twice before at admissions and they say, “This is the third time you’ve asked me that. Don’t you people talk to each other?” Well, the fact is that on paper we don’t talk to each other, but electronically, there’s no need to ask the same question three times. So, we spent a great deal of time going through what happens to a patient from the front door to discharge. What processes don’t we need? What processes should we smooth out? What processes can we improve on?
For those of you going from paper to an electronic system, the idea that you’re going to see your paper system on an electronic screen doesn’t really make sense—you’re not going to see your system, anyway. So, you may as well take advantage of the opportunity to create a better system—take advantage of the electronic potential to create a better workflow system. And that’s what we did. And it is well worth the effort—very time consuming, very labor intensive—but well worth the effort. And Medsphere helps with that.
Q: David, probably both of you could opine on this: What are the high level benefits of open source vs. traditional EHRs?
A: Whiles: Well, I think it took us a while to work into this. But, I think we’re seeing more and more benefit now from the standpoint of, number one, certainly the collaborative effort in the ecosphere, the Medsphere community, in terms of development and taking advantage of other’s work, but also simply being able to access the source code and making small tweaks, if required. You may have a specific routine that’s doing something … I work largely in interfaces, that’s where my expertise is. Needing an additional data element in an interface record, rather than having to go back to Medsphere or a vendor, typically, and go through their cycle time and what they’re going to charge you for modifications … some other vendors I’ve had even refused to make changes or customizations simply because that’s how they did business. Being able to tweak things like that, where you have real significant needs that are important but maybe very minor from a code standpoint is an unbelievable benefit. I’m still a firm believer that it’s the application that matters more than open source, but the benefits of open source as gravy on top of that are extremely important to us now and probably more important to us now than they were when we started this project.
Ackerman: I think one of the most obvious differences between a proprietary system and the open-source system is that, unlike a proprietary system, nobody owns this, no private company owns this. So, information is available to all users of the system. For example, we had some visitors from Vermont recently come down to look at our system and see what we’re doing. We had been working with Medsphere, in collaboration with Medsphere, we had been working on a multi-disciplinary treatment plan, which you need in psychiatry. This psychiatric hospital said, “That’s really wonderful. Do you think we could have that?” Well of course you can have that. Then, they’ve got some ideas about things they’d like to work on with Medsphere, and when they do that, we get it.
So, it’s of great benefit, and it’s actually very gratifying to think that the new work product that you’re developing is going to be available to other hospitals who will appreciate it.
Q: Have either of you heard from your patients about how the EHR has changed their experience?
A: Whiles: Yeah, we’ve had some feedback from our patients. It’s improved patient satisfaction tremendously from the standpoint of … I’ve walked down the hall and seen, in our orthopedics unit, where they will roll a mobile cart up and show patients their x-rays online. [Clinicians are] going through the chart with [patients] and showing them how their vital signs have changed over time, those kinds of things, where the patient can actually see their own record. It’s really been an interesting experience from that standpoint.
Our overall mortality rate has been reduced significantly. A couple of, again, real tangible benefits are … one of the stories that I was told by one of our nurse managers is that prior to VistA it was very typical that when a patient went from a unit on the floor to surgery and then back … the doctor, after surgery, orders their medication profile and, before we implemented VistA, the patient would get back to the nursing unit and maybe an hour or two hours later, the medications would show up on the floor. Typically now, when the patient gets back up to his room, the medications are waiting for him. More timely administration of medications, again, makes a difference downstream in the patient’s outcome and that’s just been a tremendous benefit.
Q: This question is for either one of you. What kinds of training challenges did you face in getting your clinicians ready to use the new EHR?
A: Whiles: The training challenges were not that great, really. The OpenVista product is really designed for end-user usability. Again, the VA has really put a great deal of human engineering and thought into the process. The record is actually designed very similar to a paper record that the physicians and other care providers are used to using and it’s really quite intuitive. It takes about an hour to two hours to really understand how to use the system, how to do order entry, how to look up lab results and find the information as well as documentation. So, the OpenVista system I see as being very useful.
B: Ackerman: We decided to go live with the entire system, throughout the many sites and programs of the hospital, all at once. This meant that we had to train a staff of about 300 users close enough to the go-live date and hour that they remembered their training and were competent users. We did this in the space of just a few weeks, had a team of trainers and help-desk "experts" on site 24 hours a day for the first 10 days after go-live and had "super users" at each of our clinical sites (10 in all) on each of the shifts for weeks after that. In all, it went smoothly.
Q: Dr. Ackerman, how is VistA, which was developed for acute care hospitals at the VA, appropriate and relevant for a psychiatric hospital like yours?
A: Ackerman: VistA is not particularly relevant for a psychiatric hospital, but I was impressed with how efficiently Medsphere could work with us to introduce the specific documentation elements that we needed to make the system relevant. We introduced enough documentation during the planning and preparation stages to allow us to go live and have continued to collaborate with Medsphere to create additional elements specific for psychiatry.
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