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Out in the Denver/Boulder, CO, market, a comprehensive computerized clinical information system has enabled Kaiser Permanente to rid itself of paper charts entirely. In Boston, a computerized physician order entry system saves Brigham and Women’s Hospital $5 million to $10 million annually. Meanwhile, Miami Children’s Hospital has the scanners working overtime as part of the implementation of a new imaging system. And now in Knoxville, computerized care plans are well integrated into the operations of East Tennessee Children’s Hospital, thanks (at least in part) to some well thought-out in-house promotion work.
While at first glance, the nation’s health care industry as a whole may look like it’s still drowning in a sea of forms, there’s actually a lot of progress being made in numerous organizations toward getting rid of the paper that’s (seemingly) forever been the bane of the caregiver’s life. In this month’s issue of Healthcare Benchmarks, we take a look at some of the success stories in the industry’s quest for the electronic patient record system. If your organization is behind the curve in this area, you need to read on, be informed, be inspired — and then get to work.
The numbers alone are impressive. At last count, there are about 4,000 computer workstations located within Kaiser Permanente’s 22 medical office, community hospital, administrative, and mental health facilities in the Denver/Boulder marketplace. More than 3,000 practitioners and support staff use these workstations daily, tapping into the more than 1 million patient records stored within the Kaiser Permanente clinical information systems (CIS).
The scope of the system is impressive as well. "We use the CIS to track everything," says Marianne Gapinski, PhD, regional services administrator for Kaiser Permanente. "The system supports more than 40 different specialties, from primary care to neurology to cardiology to general surgery, and all of our care providers do all their documentation on the system."
The Kaiser Permanente CIS contains all progress notes and family and social histories. It communicates with all ancillary systems, allowing providers to submit all orders by communicating electronically with the pharmacy, laboratory, and radiology departments, according to Gapinski. It also is linked to Kaiser Permanente administrative departments, she adds, including the organization’s human resources unit.
Information is easily accessed
Good things happen when all encounters with patients are documented electronically, says Gapinski.
"What that means to us, from a quality point of view, is that the information that our doctors and nurses need to take care of our patients is at their fingertips 24 hours a day, seven days a week, at every one of our locations. No matter where or when one of our patients shows up, with or without an appointment, the record is there," she says, "and that means that our clinicians no longer have to operate with one hand tied behind their backs because they are without patient information."
Implementation of the CIS has probably resulted in an increase in Kaiser Permanente’s real estate facilities costs — after all, staff needed to find somewhere to stack all those old charts that weren’t needed any more. "We pulled all the old paper charts out of our medical offices and put them in a central storage facilities, where they are still accessible for historical research and, if needed, information purposes," says Gapinski.
The paper chart has served medicine for many years, she says. "But, it also introduces a lot of inefficiencies and inconveniences for both patients and providers — the kind of problems that electronic systems do away with." In the Denver/Boulder market, "[Kaiser Permanente] has done something here that I believe is unique," adds Gapinski. "We have actually retired’ the paper record, which to my knowledge no other implementation of an electronic medical record has accomplished."
Getting a comprehensive electronic patient record system like that rolled out and fully implemented was a major undertaking with a lot of challenges to overcome. "It took a remarkable, focused effort over a long period of time," she says, "with literally everyone in the organization pulling together to make this happen — because this is not the kind of thing a project team can pull off on its own."
The first challenge was dealing with the highly variable levels of computer sophistication and skills among personnel in Kaiser Permanente and all other health care organizations. "Historically, most medical training programs, both for nurses and physicians, really don’t emphasize interacting with computer systems," notes Gapinski.
Increasingly, thanks to the technology revolution overall, younger physicians are more likely to have been exposed to computers in general, she says. "But as of yet, actually introducing the concept of an electronic medical record directly into medical training programs hasn’t happened."
As a result, the CIS project team initially faced the challenge of getting Kaiser Permanente personnel comfortable with interacting with computers. A number of approaches were utilized, she notes.
"Our overall philosophy in implementing the system was that it was our responsibility to do everything we could to help each and every one of our staff and physicians successfully make the transition from paper to computer record," says Gapinski. "So, we offered classroom sessions dealing with the new system. We had laptop PCs loaded with several CIS tutorials floating’ throughout our facilities for individuals to use when they could. We created what came to be known as super-user groups in all of our offices, taking advantage of the expertise of people who were already familiar with computers and were enthusiastic about our move toward an electronic medical record."
Providing this kind of introduction to the system was an integral part of successfully implementing the CIS, she adds. Support, training, and especially learning time are crucial. "You have to give people time, above and beyond training classes, so that they can figure out how they are actually going to use a new system that represents a huge change for them to go through," says Gapinski.
There was a high level of enthusiasm among Kaiser Permanente personnel about learning the new system, thanks to efforts by the system developers to gain buy-in from the start. "We decided to build the CIS ourselves, because there was no system in existence that could do everything we needed in an integrated care organization like ours," she says. "And from the very first day, we involved the people who actually interact with patients — doctors, nurses, physicians’ assistants — in the design of the system. And we asked them what an electronic medical record needed to do in order to help them do a better job."
Upfront, intensive involvement on the part of the people who were going to be users of a new system is essential. Without that, system workstations are likely to wind up being little more "than a lot of large paperweights scattered about," she notes.
Reaping the quality benefits
Kaiser Permanente’s CIS was fully implemented in Denver/Boulder in 1998. The health care giant plans to take the system nationwide shortly, says Gapinski. Quantification of the benefits of the system has not yet been performed, but the anecdotal evidence of improved care has been compelling, she notes.
"Only a week after we first installed the system in our emergency department, we heard clinicians talk about the old world they used to operate in — flying blind with no information on patient health status, history, etc.’’ says Gapinski. "Now, they are talking about the fact that within 20 seconds of when the patient comes into the emergency department, they are able to pull up a medical record and have a complete medication history, get all lab results, all imaging studies, as well as progress notes from the physician who just saw the patient that afternoon in a medical office."
Other benefits abound. "An internist in one of our medical offices can call a cardiologist in another, and the CIS enables them to simultaneously pull up the same patient’s chart, and confer about that patient’s care with all pertinent information available to them," says Gapinski.
Also, when a specialist sees a patient while doing a consult for one of Kaiser Permanente’s primary care physicians, "literally within seconds of completing that consult, a note goes back to the primary physician, letting them know what the status of the patient is." The CIS has made a huge difference in the way medicine is practiced, she adds, "and has dramatically changed the kind of quality we can provide to our members."
Saving the big bucks
Implemented in 1993, a computerized physician order entry system has enabled Boston’s Brigham and Women’s Hospital to save between $5 million and $10 million on an annual budget of $500 million, according to David Bates, MD, medical director of clinical and quality analysis.
"These savings are directly attributable to the system, and have taken place primarily through its ability to help physicians in reducing the incidence of adverse drug events, avoiding redundant testing, and in following clinical pathways," Bates says.
All physician orders at Brigham and Women’s are written on-line, promoting both efficiency and safety, he says. When physicians order medication, for example, "the system is structured so that physicians have to provide dosage, route, and frequency."
As part of a decision-support component, the system displays guidelines about the medication that is being ordered, as well as providing information on possible complications from drug interactions and patient allergies, he explains.
Implementation of a physician order entry system is no easy task. "It represents a major change in the workflow of providers," adds Bates. When Brigham and Women’s system was first put in place, "the percent of the physician’s time spent using a computer jumped from 2% to 12%."
Make it snappy!M
And when you have doctors spending that much time at a computer, it better be fast. "The thing that we’ve found users care the most about is speed — that is absolutely pivotal in system development," says Bates. "People really want subsecond screen flips; that is the benchmark they use for system performance."
Bates has several other tips for health care organizations considering implementing a physician ordering system. "You need to have very strong support from both clinical and administrative leaders. You must get them involved from the beginning and make sure they are definitely on board," he says. Physician involvement is obviously also crucial, as well as "responsiveness to users and a constant focus on improving the system."
Be careful about trying to make wholesale changes to existing organizational processes when embarking upon implementing a computerization project, he adds. "Most processes have a number of significant problems associated with them, and there is nothing like a computerization project to put them in the spotlight." Don’t try to fix all of these problems until you’ve got your system in place, says Bates. "If you try to solve them all at the same time you are doing your automation, you will tend to get stuck."
Imaging in Miami
Miami Children’s Hospital has historically been ahead of the curve when it comes to electronic medical records, according to the director of health information management Angela Korcok. The facility is now in the process of implementing a new imaging system to replace paper records generated by its emergency department, she reports, with other departments’ records slated for scanning beginning summer 2000.
"We are deploying workstations throughout the entire hospital that will enable providers to view and sign all records electronically, as well as allow multiple access to medical records at any given time," she explains.
Prior to joining Miami Children’s, Korcok put the same type of system into place at Florida Medical Center in Fort Lauderdale. Based on her experiences at both facilities, "the biggest challenges you have to overcome in implementing systems like these are technological," she notes.
New technology requires a lot of learning on the part of employees in most medical record-keeping departments. "Typically, these are places that have a lot of paper being shuffled," says Korcok, "as well as personnel who have never used a [Microsoft] Windows product. Going from paper-based to paperless record systems in situations like this requires devoting a lot of resources to training. "People have to learn how to use a mouse," she says, a first step in a process "that winds up changing the job description of everybody working in the department."
For a records-computerization project to be successful within the hospital setting, it is important to get the support and involvement of all involved, notes Korcok. In the case of the Miami Children’s imaging project, "We were able to get physicians to buy into the system by getting them involved and pumped up early in the process." At the same time, you also have to get the administrators involved, she says, and make sure their eyes are wide open.
"You need to be very frank with your administration," says Korcok. "Let them know about the savings that will come from use of the new system. But make it clear that they won’t be realized right away, because for some period of time you will still be generating paper and basically working with dual systems." And even though at "some point down the road" the existing medical records department may well be ripe for restructuring as a result of computerization, "make sure the administration understands that doesn’t necessarily mean they will be able to cut the staff in half."
There are also two more basic elements that need to be addressed when it comes specifically to imaging systems, notes Korcok. "Review all your forms to make sure the information they contain is indeed scannable." Also, make sure you have space for all the new equipment required for records scanning and imaging. "Imaging equipment takes up a lot of room, and there are always turf wars going on in hospitals when it comes to space."
TLC in Tennessee
When East Tennessee Children’s Hospital in Knoxville switched from computerized nursing care plans to completely computerizing its entire care documentation system, the primary barrier that had to be overcome was simply resistance to change, according to nursing information systems coordinator Rhonda Leeper.
"A lot of people still don’t like to use computers at all," she says. And when plans were first announced for expansion of the existing computerized system, "There were many who felt like their work would be slowed down."
Leeper and members of this project’s implementation team used a lot of patience, reassurance, and support to combat these attitudes. This TLC approach started out with an in-house "marketing campaign" built around the concept of "catching the wave" of the new technology being introduced. The team followed up with a series of classes introducing the new system to hospital personnel, accompanied by handouts and manuals for further study.
Then, "we actually put everyone who would be using the system at the computer they would be working from, and individually walked them through each and every screen utilizing information from a test patient," says Leeper. Every nurse in the hospital had to go through this four-hour session, she says, with aides required to take two hours of training.
At system rollout time, person-to-person training was followed by highly individualized support. "We had members of our team working in-house, 24 hours a day, standing right next to the nurses as they first used the system with the project leader always available by phone as needed."
Leeper has three main tips for those embarking on a computerization project. "Begin planning as early as you can," she says. Also, "bring everyone who will be impacted by the project in on the planning process from the beginning. And finally, she says, "get out there and market your new system and the benefits it will bring."
[For more information, contact:
• Marianne Gapinski, PhD, Regional Services Administrator, Colorado Region, Kaiser Perma-nente, 2550 S. Parker Road, Aurora, CO 80014. E-mail: firstname.lastname@example.org.
• David Bates, MD, MSC, Medical Director of Clinical and Quality Analysis for Partners Health Care, Division of General Medicine, PBB A3, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Telephone: (617) 732-5650. E-mail: email@example.com.
• Angela Korcok, Director of Health Information Management, Miami Children’s Hospital, 3100 S.W. 62nd Ave., Miami, FL 33155. Telephone: (305) 624-8406. E-mail: firstname.lastname@example.org.
• Rhonda Leeper, Nursing Information Systems Coordinator, East Tennessee Children’s Hospital, 2018 Clinch Ave., Knoxville, TN 37916. Telephone: (865) 541-8550. E-mail: email@example.com.]