Making many systems into one

Silver Hill Hospital unites disparate business and specialty platforms under an open-source EHR and database solution

A farmhouse until 1930, the Patricia Regnemer Main House is the centerpiece of the Silver Hill Hospital campus in New Canaan, Conn.

About five years ago, Silver Hill Hospital was looking for a new electronic medical record solution. “We felt that we needed a psychiatric system and, at the time, we found that a lot of the systems that had strong behavioral health features were big on billing and outpatient items but short on the diagnostics, charting elements, rating scales, and other things we need for inpatient work,” says Sigurd Ackerman, MD, the president and medical director of Silver Hill.

The search ultimately led them to an EMR-really an “electronic charting program” that the medical staff really liked, says Ackerman. It won rapid acceptance and use among the hospital's 230-plus clinical staff, who work with patients in a number of separate buildings on a 45-acre campus in New Canaan, Conn. One favorite feature: “If you had a patient with major depression-it would provide for a drop down list of diagnostic symptoms-based on the DSM,” he explains. In addition to being well liked and accepted, he adds that “it wasn't very expensive-as these systems go.”

At the time, the new EMR was simply added to a growing cluster of specialized systems on the Silver Hill campus. “We for some time have had a perfectly functional business system-Eclipsys-a laboratory system which was also working just fine, and a pharmacy program, which was actually outsourced, that was working effectively.”

The goal was to blend the EMR into a seamless information system that, at the time, was already about “80 percent” paperless. This would entail a series of modifications to the EMR that would add computerized physician order entry (CPOE) as well as an interface to allow for the upload of business system data-recorded during admission and stored in the Eclipsys system. The vision was to link a series of separate systems-laboratory, pharmacy, dietary, and the clinical/EMR into a shared database so all operations could share information in real time and become completely paperless (see Figure below).

Deciding to “bite the bullet”

But alas, the plan didn't work as planned. The EMR would not accommodate the addition of a home-grown order-entry feature and the vendor's timetable for adding the feature was uncertain. The common database proved difficult to build. Ackerman and his colleagues realized that despite its attractive features, their two-year old EMR might just have to go.

“We got a lot from that system-training, acceptance, experience,” says Ackerman. But, faced with the hospital's longer-term IT vision, “we decided … that we would just bite the bullet, scrap the whole thing, and go to one system that would enable us to become paperless. We ultimately accepted that we had made a choice with some limitations that we couldn't deal with over the longer term.”

Quickly a project steering team was formed and project goals took shape. The new EMR would have to:

  • Interface with the existing Eclipsys business system to receive key demographic, admissions, administrative, and billing data.
  • Support CPOE and paperless operations.
  • Include functionality that would replace existing laboratory, dietary and pharmacy systems.
  • Provide attractive, usable behavioral health features, including assessments, scales, and function- or population-based order sets.
  • Robustly support a range of clinical and patient care requirements, while offering flexibility to make site-specific modifications.

After considering alternatives for several months, Silver Hill decided to adopt Medsphere's OpenVista, an open-source version of the well-known VistA system initially developed for use in Veterans' Administration hospitals across the United States. It was a system already well known to a number of Silver Hill's physicians who had used VistA during military or civilian residency programs.

The product selection team found that OpenVista offered a lot of the backbone functionality that they needed-a robust and proven database, built-in CPOE capabilities, and a proven EMR solution. Just as important, it offered the flexibility to work with the business system that Silver Hill already owned.

“The VA's system, VistA, has been around for over 20 years and is very robust,” says Ackerman. “It's not all that fancy or slick-it's not Windows based, for example-but it works very well.” Surprisingly, he explains, the psychiatry features of OpenVista “were pretty limited.” But this time, that wasn't a major concern, says Ackerman. “We had a commitment from the company selling OpenVista that they would work with us to develop what was needed. I believe that the reason that they were able to offer this support was because of the open source structure of the system. If we worked with them to develop a key component for psychiatric facilities, we could use it and they could offer it to others who could use it as well. Conversely, if another group [contributed a feature], we could be the beneficiary of that.”

A fabulous creative process

This collaborative approach-what Medsphere calls a product “ecosytem”- struck a chord with the Silver Hill team. “It was appealing that we could contribute beyond our hospital something useful to others.” They got their chance.

After working with an EMR with limited modification potential, developing new features for OpenVista opened the door to “an exciting creative process,” says Lisa Benton, Silver Hill's director of quality improvement and risk management and a member of the project steering committee. As it turned out, the implementation would not only require development of a series of specialized clinical tools-including things like a suicide assessment scale, a drug/alcohol detox symptom scale, and a structure for multidisciplinary treatment plans-but also offered the opportunity of a top-to-bottom reassessment of critical processes and workflows throughout the organization.

“We decided, as a hospital, that we weren't going to ask Medsphere to just make screens that looked like our paper forms,” says Ackerman. “We were going to rethink things from a workflow perspective … that was very important for us.”

To that end, Benton says, “we spent six to nine months in a fabulous creative process looking at what [the hospital] needed … eliminating redundancies, improving workflows. It was exciting to have a product that allowed the flexibility to configure the work to our setting.”

One early workflow-improvement candidate was the hospital's admission process, which Benton says “starts with a phone call before the patient gets here, and continues until the patient reaches the unit and is assessed by the treatment team.” Improving this workflow involved understanding “who needed information, including when and why, and how to get that into the system so that it was available when it needed to be.” And, it required a multi-disciplinary team, consisting of a physician leader, a nursing leader, admission clinicians, and nurse managers from the unit. “We reorganized the process from beginning to end,” says Benton. “The thing that was beautiful was being able to configure it to ensure that key pieces of information-from a safety and regulatory standpoint-were where they were supposed to be. So, it was really comprehensive, from soup to nuts.”

The improvements not only changed the admissions workflow, but made an impact on the patients as well: “There's a patient satisfaction issue involved,” states Benton. “If you're asking the same things over and over again it may sound like you're not communicating with each other,” she explains, noting that it's a factor patients can and do notice.


Silver Hill Hospital EMR implementation. (*ADT refers to admission, discharge, transfer information.)

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Order sets simplify patient management

To replicate the behavioral health specific functionality that was so well liked in the previous system, workflow teams also set about creating order sets specific to behavioral health. “These weren't just medication orders,” says Benton, “but laboratory, nursing, milieu, dietary, and others, all so that [working groups] could have function-specific auto-order sets. We even took it to the point where a group of physicians could have their own order sets. For example, for physicians who work with an eating disorder population, there were specific order sets that they would be likely to want to use but that could always be modified on the spot if need be.”

Ackerman elaborates: “Let me give you another example of the efficiency of an order set. We see a fair number of substance abusing patients. We use the Clinical Institute Withdrawal Assessment (CIWA) scale, which requires the nursing staff to monitor vital signs as well as certain other signs and symptoms on a regular interval during an alcohol detox. In the order set, one can point and click to a nursing order, for example: ‘Evaluate patient for CIWA signs and symptoms every two hours.’ And one can also point and click to a related medication order, for example: ‘lorazepam, 2mg PO Q1H, PRN, for CIWA of 8 or greater; not to exceed 24mg in 24 hrs. Hold if pt is lethargic, light-headed, has BP less than 90/60 or pulse less than 60/min.'.

“You can see how if you put 10 of those [customized order sets] together, it becomes much easier to admit and care for a detox patient and to manage that patient than if you have to develop and record all of the proper orders every time, for every patient, as we used to do.”

Benton points out that while auto-order sets help to set up a framework and consistency in treatment, “there's nothing there to preclude a physician who sees something out of the ordinary from saying, ‘I'm going to change this; I'm going to modify that.’ So, it in no way limits the clinical judgment or decision making of the physician, but is a guideline that facilitates accurate preparation of very complicated and labor-intensive orders for these tapers.”

Completing an entire implementation in just over 11 months is quite an accomplishment. But you'd wonder-wasn't it a strain on the staff and the IT resources?

“From the IT standpoint, what you have to know is that the end result was a much more efficient workflow,” says Benton. “Where we had once been worrying about all of these different interfaces with the other systems, we have now rectified that situation by replacing many legacy systems-laboratory, dietary, pharmacy-with those included in OpenVista.” Because OpenVista does not have a business system, we retained our business system and interfaced it, allowing data to be uploaded into the OpenVista database, where it would become available for patient management, administration, and billing functions.

Despite the load of work to do, Silver Hill decided to do a “big bang” implementation of the new OpenVista EHR, database, and integration, instead of a phased, multi-step approach. For Ackerman, the single database was the deciding factor. “We couldn't run two clinical record applications at the same time, especially if we were implementing CPOE.” While he admits that “it was hard to calibrate the risks of that approach, we could see that it didn't make much sense to do things separately.”

As Silver Hill's team worked to simplify and automate their workflows as part of incorporating existing dietary, lab and other legacy systems data into the new OpenVista installation and database, a new barcode medication administration system, or BCMA, was also introduced. The system uses barcode scanners for medication administration and matches medications by means of barcoded patient wristbands. While Ackerman says that BCMA is “one thing that we could have done later,” the team decided to go ahead with it as part of the 11-month system implementation because of “a groundswell of commitment and enthusiasm” around all aspects of the new system.

“We decided to charge ahead while we had the focus, the resources, and the support of the vendor,” says Ackerman, who acknowledges startup difficulties-such as with the BCMA system-which some staff found difficult to work with, at least at first. “It took a while for us to catch on to that issue and work it out, but we're talking about a matter of weeks, not much longer.”

“There were some glitches,” Benton acknowledges, “but with anything that's going live, you have to get in and fix them quickly. Because it's all integrated, glitches in the pharmacy package would impact the BCMA but again, we figured that out quickly because there was this intensive, 24/7 focus on getting the system going.”

As the system neared completion, training and support became critical to the transition. In addition to “practice” computer terminals made available to clinical users, Silver Hill began an intensive training process. Over a three week period, some 230 clinical staff were trained on two shifts, along with about 20 on-duty physicians. Then, for weeks following the March 2010 go-live date, key members of the interdisciplinary implementation team and a highly trained group of super users were present day and night both on the units, and via 24/7 help lines to provide continuous support.

In the 11 months between system selection and the go-live date, “We went from seven or eight systems that didn't talk to each other to two systems that did,” says Ackerman. “We got the order entry, pharmacy, dietary, and clinical systems all working from a single database to eliminate redundancies and opportunities for error.”

With all data now “coming from the same place, we can do things like consider drug-drug and drug-food interactions. For example, the CPOE system now informs the dietary system immediately if someone gets put on a specific medication, say an MAOI, and there's a dietary issue, for instance.”

“In terms of patient safety, having all systems speaking the same language and coming from the same place is paramount.” And, despite a large campus that contains 15 different buildings and frequent moves of patients from one level of care (or building) to others, he asserts, “We've got a very tight, instantaneous communication loop around the patient, with access to all information for all caregivers at all times.”

Click on Behavioral Healthcare to access the original article on Silver Hill Hospital.