HISTalk Interviews Beth Raucher, MD, Chief Medical Officer, Lutheran HealthCare

Beth Raucher, MD is executive vice president and chief medical officer of Lutheran HealthCare, Brooklyn, NY.

Tell me about yourself and about the hospital.

I am a physician with training in internal medicine and infectious diseases. I’m the chief medical officer here. You can think of me as the doctor who represents both the medical staff, all the doctors in the hospital, and the administration. I have one foot in each door. I help the medical staff come to the hospital and move their way so they can do their patient care. I help the administration work with the doctors to meet their needs.

My role in the electronic health record was the lead physician on the project. I helped make some of the design decisions and work flow decisions, things that would work best for the hospital. I had previous experience doing that in another job before I came to Lutheran four and half years ago.

Yours is the largest hospital I’ve heard of that has implemented Medsphere’s OpenVista. You’re a teaching hospital, too. What parts of the system are you live on and how has it gone?

The part that we are on live now is order entry. All the providers — the doctors, the nurse practitioners, the PAs, the CRNAs, and anyone that’s allowed to write an order — put the order electronically into the system. The nurses pick up the order and the pharmacies pick up the orders through the system. Orders also go to the laboratory, radiology, dietary, and other ancillary services.

The other thing we’re doing now is that the nursing assistants are putting vital signs into the system. The doctors are seeing that in the system. That’s the patient’s temperature, pulse, blood pressure, and heart rate.

That’s a pretty impressive accomplishment going right up with full CPOE and closed loop to pharmacy. Most people struggle with those and save them until last. How did this project compare to the one you did previously at the other hospital and what did you learn from that?

What I learned there was that was a multi-hospital system. It was a little different because that project required us to get consensus in a couple of different hospital systems before we could go out there and train and implement it. But we used a lot of trainers and people who were on the floors super users and other people to help the doctors and the nurses at go-live.

We took that model that I had used successfully elsewhere and brought it here. We had a lot of super users, mostly from our own nursing staff. We had a few physicians.

In addition, we hired a bunch of super users from a training company who did the classroom training a couple months ahead of go-live. They were here at go-live and out on the floor, super users and the employees from the company, all wearing yellow vests. If you needed help, all you needed to do was look for someone wearing a yellow vest and you knew you had some help. They were there 24 hours a day, seven days a week for a full two weeks.

That’s an interesting approach. A lot of hospitals don’t understand that implementation is a hump that you need to get through, but then your labor needs go back down. Was using an outside company something you’d heard of elsewhere?

When we hired this company at my previous job, it was a relatively new company. I think that the chief medical information officer who I worked with at that implementation had done some implementations before using a lot of super users and possibly an outside company. I’m not sure. But he was very clear that you needed to have elbow-to-elbow support for the providers when we went live.

Between him and the leadership of the company, we figured out ratios of numbers of people we needed on each unit and super users. I was able to make a recommendation to do a similar type of thing here. It didn’t really matter to me what company, just that we had enough people. Go-live to me is the big show. You’re either going to make it or break it at go-live.

Did you replace other systems when you implemented OpenVista or was it purely paper to electronic at that point?

In the inpatient unit, it was paper to electronic. In the emergency room, we replaced their electronic system with this one.

What have you learned or what advice would you have for someone else trying to follow your footsteps in the CPOE journey?

You have to have great communication with your clinical staff. This was a long time in coming. From the time we signed the contract until we built everything and started training and implemented it, was about three years.

Medsphere was a young company. We were trying to figure out exactly what we needed to do when, so it took time. But you get the physicians on board in physician advisory committees. You get the nurses on board with nursing advisory committees. You keep them up to date.

This was probably a good time to do something like this because there’s no physician — unless they have their head in the sand — who would not know about electronic health records and Meaningful Use and the importance to the Obama Administration. In addition, a number of our bigger groups have already put these into their offices. It’s not like ten years ago when the physicians at Stanford said, “We’re not doing this.” That just wasn’t going to happen because timing is everything. This was the right time to do this. There’s no question about it.

We made it easier for the physicians. We gave the physicians three options for training. We didn’t put any pressure on them. We told them, “You decide what your skill level is and do what’s best for you.” We offered them Web-based training. We offered them classroom training with a proctor. We offered them true classroom training, where they went in sync with an instructor for four hours. They had their choice.

All of them at the end of their training had to do a validation test. About a half hour or 45-minute test where they had to go through some exercises and show an instructor in the classroom — even if they had done the Web-based training in their office or at home — that they could do the basic things, like log on, find a patient, make some orders, and things like that.

But we knew that the hard stuff — like some of the harder orders, like complex orders like IVs with additives in them, or insulin sliding scales — that was going to come with practice. That was something that the super users and other folks on the floor were able to guide them through the first time they did those things.

When you choose OpenVista, what other systems did you consider? What led you to make the decision that you made?

I wasn’t here then. I had just come when the final decision was being made. But I know that they did go to other hospitals that had rolled out some of the bigger programs like Cerner, Epic, Eclipsys, and Mediware. I think they did do their due diligence in the two years before that with all those companies.

OpenVista was a funny story. The CIO apparently learned about VistA through some technology newsletter that he got and realized that you could download it free of charge. I think you could buy it for $17 or something like that because it was in the public domain. He downloaded it and realized we couldn’t do a thing with it [laughs]. It was too complicated. Then I guess Medsphere got out there and started to advertise. They met with them and decided to go with it.

Eclipsys and Epic all of those are probably, I don’t know, three or four more times expensive then what we’re paying for OpenVista because it is open source. What we’re really paying for is the support, the interfaces, and obviously the hardware we would have had to pay with any system. The training cost we would have paid no matter what system. It was something we could afford.

What parts of it do you plan to implement?

We’re going to implement all of it. We’re likely to go to medication bar coding next. Then, to full documentation, clindoc, with notes from the doctors and the nurses. The ED already is everything. They have clindoc and they have order entry. They replaced their system in full. Otherwise, it would have been taking a step back for them. That’s the likely scenario, but it’s not in stone yet.

Are there other key clinical systems that you use outside of OpenVista?

We went with their radiology system. Right now, we’re still using our interface to our laboratory system, which is Sunquest. We’re using their pharmacy system.

I think the reason we didn’t go with the laboratory system was because our system actually was more sophisticated and better then the one that the VA had. Theirs was sunsetting and they were going to be moving to one of the commercial laboratory systems anyway.

Do you have physicians who learned VistA at the VA and are happy to have a system that they already know how to use?

There were a couple of residents that rotated through the VAs as medical students when we announced that we were going to be using OpenVista. A couple of people had used or had read about it and heard that it was a great system. So that was very positive. There’s been a lot of national press about the VA’s system.

You mentioned Meaningful Use earlier. What are the hospital’s plans for it and how are you doing?

Just by going live the way we did, we basically have completed the option of CPOE. That’s one indicator we don’t have to worry about. On Day One, we were at 93% acceptance by the physicians. The other seven percent was only because there are physician extenders that enter their orders and it’s only measured by physicians. But in reality, 100% of our orders are being entered into the OpenVista system now.

The other parts of Meaningful Use – we’re looking into the software and we’re working with the company. Medshpere expects to be certified for Meaningful Use sometime in January, I believe. A lot of the validation for Meaningful Use for us will be in the clindoc part of the system. That’s where we’ll be able to get the data from to show Meaningful Use. We have some of it now, but we still have to go into that phase to be able to show the first stage of Meaningful Use. We’re hoping to do that before the end of 2011.

Many hospitals are concerned about their ambulatory strategy and exchanging information with employed or affiliated practices. What are you doing along those lines?

Our ambulatory practices were already up on another health record called eClinicalWorks. Our strategy now is to try to interface both systems so that we can share basic information like medications, allergies, previous visits, and those types of things. Which you know is very doable, and that’s working well. But they were way out ahead. They did a project with the City of New York and so they’re using that software very successfully.

What about interoperability? Are you working on projects involving health information exchange or any data sharing with outside facilities?

Yes, we’re working with a couple of other Brooklyn facilities on RHIOs and health information exchanges both. We’re working with a visiting nurse service and a number of the local community-based health programs. So yes, we’re actively involved in that.

Organizations will need data to prepare for Accountable Care Organizations and other reimbursement plans. What thoughts do you have about that?

You’re absolutely right. It’s going to be critical. We’re looking at everything that we build to make sure it’s discrete data and we’ll be able to get it out in a usable form. We have been doing chart review for some of the indicators that we have to do for CMS core measures for care of patients with heart attack, heart failure, and pneumonia. There are a bunch of indicators they look at to see what kind of care you’re giving and they publicly report those indicators.

Up to this point, it was chart review and we did that by hand. Now we’re trying to figure out how to use the electronic health record. As we build our screens, notes, and templates, we’re making sure we can get that information out in an electronic way and hopefully make life much easier for the data abstractors.

Any final thoughts?

So far, so good. I was very proud of our staff here. I really was. They just took it all in stride. We went live late on a Saturday. Those who came in on Sunday thought it was great. The masses came in on Monday and it was just a regular day. Challenging for everybody, but nobody stormed my office. It was great.

Click on LMC on HIStalk to read the original interview with Dr. Raucher and Mr. HIStalk.