Editor's note: This is the second part of a two-part look at the planned rollout of e-health records in the U.S. Part 1 is already available.
Hospitals and physicians have four years to deploy comprehensive electronic health records (EHR) systems and the technology needed to support them if they hope to snag some of the billions of dollars the federal government has earmarked to reimburse them for the work. That's why they're already scrambling to figure out how to set up what are likely to be costly and complex systems.
The government has established "meaningful use" criteria that will determine whether best practices guidelines are being met. But many facilities are unaware of the standards or how to achieve them.
Experts cite these five key factors for successfully implementing EHRs at hospitals and doctor's offices:
• Know what you already have.
• Get departmental and executive-level involvement and ongoing support for the rollout.
• Verify that vendor products are certified.
• Make sure technology can be integrated facilitywide.
• Ensure that staffers are well trained and certified to use the system.
According to a Computer Sciences Corp. (CSC) survey of executives at 58 U.S. hospitals and integrated health delivery networks, hospitals are only halfway to qualifying for government reimbursements for their EHR plans.
The IT service provider's survey offers good news and bad for facilities now eyeing EHR technology. In many cases, CSC found that the hospitals can already support one of the most basic elements of an EHR rollout -- a computerized physician order entry (CPOE) system. In fact, hospitals may not even need to purchase new hardware or software to move ahead in that area. According to CSC, 70% of hospitals have systems that can support CPOE, although just 8% have such systems throughout their facilities where at least 75% of orders are entered by physicians.
The survey also found that while 89% of hospitals report on core quality measures, only half capture the majority of the required data from their EHR systems. Moreover, 98% have policies in place to limit the disclosure of protected health information, but only 52% use encryption to render data unreadable or unusable in case of unauthorized access. And 40% report broad awareness of the new civil and criminal penalties included in the American Recovery and Reinvestment Act. That's the measure, passed by Congress last year, that includes $36 billion in funds to reimburse U.S. doctors and hospitals for EHR rollouts.
Erica Drazen, a managing partner in CSC's healthcare group, said her company routinely asks prospective clients if they know where they are in their EHR rollouts. Most have no idea.
As a result, Drazen's advice for facilities hoping to meet the government's meaningful-use requirements is to start with a self-assessment of the systems already in place: Can they be certified as is? And are there any technology gaps that need to be fixed?
Find the technology gaps
Chuck Podesta, CIO at Fletcher Allen Hospital, a 500-bed tertiary care center and teaching hospital in Burlington, Vt., performed a gap analysis prior to choosing his hospital's EHR system, which went live last June. Fletcher Allen uses PRISM (Patient Record and Information Systems Management) from EPIC Systems Corp. in Verona, Wis.
Since the new system went live, the facility has achieved a rating of 6.02 out of 7 points on the Healthcare Information and Management Systems Society's (HIMMS) EHR Adoption Model. On the HIMMS scale, a zero represents a facility that largely relies on paper records and a 7 represents a facility where 100% of the EHR system is in place and fully integrated.
Podesta said there are two aspects to rolling out EHRs, one technical, the other practical.
For example, one objective that's included in the government's meaningful-use criteria is that hospitals maintain active medication and allergy lists for patients. To qualify for reimbursement funds, a hospital must prove that at least 80% of patients it admits have that data recorded in a structured format.
"It's one thing getting an electronic record in, and it's another thing getting clinicians to use it in a meaningful way," he said.
Podesta was able to roll out his hospital's EHR system in only 15 months at a cost of about $88 million. The good news: he expects to see a full ROI and an uptick in productivity. "We constantly get calls from physicians about their productivity, about how this has made life easier for them," he said.
Fletcher Allen's PRISM system will eventually connect virtually every key function in the hospital and has been key to creating a smooth workflow for clinicians and technicians alike.
Rolling out the servers and databases for the EHR system was the easy part, at least compared to training physicians and nurses to use it. Over a 10-week period, Podesta said his unit had to train between 5,000 and 6,000 medical staff members -- and it took anywhere from 16 to 24 hours to train each nurse. That was a priority, he said, because nurses tend to help train physicians.
Some of Fletcher Allen Hospital's training was performed using Web-based tools, but most was hands-on work in training rooms. "One thing we made sure of was that it was all [EPIC] certified. Everyone had to take a test and pass it before they got their certification codes. The day we went live... if someone showed up who wasn't certified, we took them to the training room and trained them first."
Focus on CPOE
Dr. Reid Conant, chief medical information officer at Tri-City Emergency Medical Group in Oceanside, Calif., said implementing a CPOE system is the best place to start on the road to EHR. He suggested that such systems should be set up in the emergency department first before being rolled out to the rest of the hospital.
"It's a highly visible microcosm," said Conant, an emergency department physician. Tri-City Emergency Medical Group has 395 licensed beds and 600 active medical staffers, and it treats 72,000 patients a year in its emergency department. It's the third busiest hospital in San Diego county.
Conant stressed that while vendors may offer software and systems that have the required meaningful-use certifications, hospitals must still be careful to implement them in a way that meets the government's standards and qualifies for reimbursements. That often means modifying the systems.
"For example, if you implement an application but you don't design it to meet the five rules for clinical physician support, the hospital won't meet the measure," he said. "A lot of this will come down to customization of these applications."
Conant said computer applications should help physician and nurse workflow, not hinder it. "We have seen many CPOE implementations go very well on Day One, but we have also seen many clients who had been struggling for months with an incomplete build."
CPOE system providers need to have adequate order sets or care plan content. Those are bundled sets of orders for patients; they could include orders to check vital signs, diet restrictions or pain medications. Physicians pick and choose which orders to include.
"This also allows for standardization of care across providers within a department," Conant said. "Just yesterday, I cared for a patient with an acute onset major stroke. I used our "Code Stroke" order set, which allowed me to enter approximately 25 orders within about 15 seconds, based on our Code Stroke protocol."
Conant advises CIOs to deploy a user-friendly and intuitive folder structure by leveraging custom departmental folder structures that exist in most EHRs. It's also important to include ancillary alerts that can immediately notify staff of order requests.
"We have built our system to immediately auto-page ancillary staff, immediately notifying EKG technicians, respiratory therapists, X-ray technicians, and phlebotomists," he said. Such a system cuts turnaround times and lowers the chance of error.
Conant and other industry experts also recommend identifying departmental and organizational provider champions -- high-level staffers or hospital executives -- to take part in the design, building, testing, training, implementation and maintenance involved in a CPOE project. These champions will need analyst and clerical support, and they should be compensated for their time, since they will be taken away from their clinical practices, Conant said.
The nonprofit Certification Commission for Health Information Technology (CCHIT) is currently the only organization accredited by the U.S. Department of Health and Human Services (HHS) to certify that EHR systems in use at private physician practices and larger healthcare facilities meet meaningful use criteria. The HHS's Office of the National Coordinator is currently working on new rules for accrediting other organizations to certify EHR systems.
"Until that happens, there can be no final certification of products that physicians and hospitals can rely on," said Sue Reber, marketing director at the CCHIT. "So it looks like it's being pushed pretty far back, and that creates a problem. If you're a physician and you've already rolled out EHR under a previously accredited vendor... then all you have to do is get the product updated with the vendor's newly accredited software [and if you] have fair amount of patient data to work with, you'll be in pretty good shape."
For hospitals, EHR certification is even more complicated. That's because hospitals don't rely on all-inclusive bundled systems like the ones that smaller practices purchase. At hospitals, technology is rolled out piecemeal and requires integration. Since many hospitals won't consider ripping and replacing existing IT infrastructures, they're forced to integrate new documentation systems, CPOE systems and relational databases with existing technology.
Most hospitals began using health information technology far earlier than smaller physician practices, but they purchased that technology department by department. A hospital, for instance, may have a patient admission system for its front office; a different patient transfer system for other departments; separate administration systems for the emergency room, the laboratory, the pharmacy and the radiology departments; and separate physician order entry systems. And all those systems may have come from different vendors.
The CCHIT, which has been certifying health IT systems since winning a federal government contract in 2006, is currently developing a program to be launched this summer called "Site Certification." The program and accompanying services allow inspectors to check a hospital's systems over the Web in order to certify them for meaningful use.
Until then, according to Reber, the most definitive source for information on "Meaningful Use" rules can be found on the HHS's health IT Web site.
The EHR payback
Denver Health, a health care group that serves some of Denver's poorest, uninsured residents, has recovered more than $28 million in revenue over a five-year period by digitizing its manual patient-tracking and claim-submission systems.
Gregg Veltri, CIO at Denver Health, said the ROI goes far beyond the money. For example, in his organization's pharmacy, a physician order used to take almost an hour and a half to process using a paper-based system. Once the EHR system was in place, that time dropped to 7.3 minutes.
"If you're on an antibiotic for a raging infection, the difference between 84 minutes and 7.3 minutes is a big difference. Or if you're in pain, 84 minutes is a long time," he said.
The CPOE system also cut down on mistakes. "It's legible," said Veltri, who used EMC Corp.'s consulting business to help with the rollout. "There is no, 'Is it penicillin or ampicillin?' As we all know, doctors' handwriting is interesting."
Far from being disheartened, most health care IT pros are looking forward to the progress they'll be able to make on patient care through the use of more highly integrated systems. "It's nice walking up to a unit and seeing a nurse or physician use the system and seeing it change the way we care for a patient," Podesta said. "To me it's very satisfying, as opposed to being a CIO in the banking or insurance industry. I can't impact the quality of someone's life in the same way there.
"In health care, it's a great time to be a CIO, even though there are lots of challenges," he said. "You need to embrace it and know you're making a difference and leaving a legacy behind."