Charlotte Wray, RN, MSN, MBA is VP clinical operations and information systems and chief clinical and information officer at EMH Healthcare of Elyria, OH.
Tell me about yourself and the organization.
I’m the chief information officer and the chief clinical officer at EMH Healthcare. I’ve been in healthcare about 25 years, with probably the last 10 focused on HIT, and have been an executive at EMH for about three and a half years.
EMH is a medium-sized community hospital, about 400 beds. Like most other hospitals have a few sites, we have about 19 provider offices. We support a community of about 350,000 people.
How is the IT department structured?
The IT department has evolved given the investment that we’ve had to make in the clinical components. It has about 40 professionals of diverse backgrounds. We have a combination of business analysts and clinical analysts as well as your traditional technology experts. The group has evolved to become a service support area for the hospital and our target audience of end users, which are predominantly nurses, physicians, and technicians across the enterprise.
How has the Meaningful Use process worked? Do you think it was worth it, and would you do anything differently?
We embarked on the journey to implement a robust information system — clinical and financial systems — in late 2008. We entered the space in what I would call the sweet spot. We acquired the money to buy our solution. Meaningful Use wasn’t in the forefront of our thoughts.
Shortly after we began implementing, Meaningful Use became something that was more measurable and had a little reward with the risks. We aligned our information system strategy so that it was tightly integrated with the Meaningful Use requirements and the timing of those various activities. We attested in 2010, fiscal year 2011.
It was a huge change project for us. It was huge. We did not have clinicians of any kind using electronic record in a meaningful way. We had some niche solutions in cardiology, radiology, and pharmacy, but the bulk of our workforce was doing their day-to-day work on paper. It was an enormous clinical transition for our providers and our nurses.
I believe it was worth it. It helped us align with the government initiatives to try to improve healthcare. We tried to make it about more than just checking the box to get the money. There was a little bit of money there. It didn’t come close to covering the costs, but it certainly helped guide us to do things in a more prioritized fashion. We wanted to make sure that we weren’t just checking the box and saying we met the requirement, that we were really meaningfully using the various applications and the workflows that we were building.
I think it was worth it, but I think like anything else, the pain of change fades as you go live and move onto other projects. If you would have asked me right in the heat of it, I might have said, “Oh my goodness!” But looking back, it was definitely worth it.
Academic medical centers have it easier because their physicians are employed. I assume most of yours were community-based physicians who had not previously interacted directly with systems. How did you get them to use it?
At EMH, very few of them are employed. They are independent, they are entrepreneurial, they are primary care providers, and there’s about 400 of them. We had to have a very creative approach to managing that group of users.
We did an assessment of where they were. What we found was that a significant percentage of them had no access, no exposure previously to not only EMRs, but even basic computing functions. Many of them at the time didn’t have e-mail accounts. The closest thing that they had to interacting with some sort of a system was an ATM card. We had to build a lot of the fundamental blocking and tackling skills before we could even go live with our solutions.
We had to be very, very sensitive to their workflow demands. In an academic center, physicians are equally as busy, but they tend to stay in that center. In a community model, our physicians will go to two and three hospitals as well as maybe two or three free-standing surgery centers, and then they have offices in two or three locations. We had to build our solutions in a manner that was at least appreciative of their workflow demands and the competing priorities that they have with their day-to-day between the hospital space and the office space.
What kind of carrot or stick did you have to use to get them to take to CPOE?
It’s interesting. We used both carrots and sticks. They do definitely respond better to carrots.
We looked at the physicians. We profiled them, so to speak, informally, based on our knowledge of them. We knew who had a personality that was more change tolerant, we knew who was more tech savvy, we knew who would be more likely to just be engaged in activities that we would do. We focused on those first and put a number of our doctors together in a room. We had more of a critical mass of our doctors than we thought. For those guys, it was, “Hey, do you want to be one of the pioneers? You want to be one of the early adopters?” That motivated a lot of them.
Some of the carrots that we used were toys. We gave them some devices. They earned them if they were helping us build and design the actual product that we would be using. We did appropriately budget for and compensate them for their time with iPads. They could have easily asked for a check, but they were willing to do a lot of work because they would be entitled to a device if they gave us so many hours of their life. We found that to be very motivating. That helped us with about 40 physicians. That’s a lot of physicians to get working on a project with you.
We use the stick when we have to, although the stick doesn’t work very well. Physicians revolt when they see that. That doesn’t usually motivate them. We will use our medical staff channels to try to drive compliance, but that’s probably our last and least-effective strategy.
We leveraged the relationships we had with them. Being a community-based hospital, we know the physicians. We know them personally and professionally. We could leverage that existing relationship and call in some favors to help us drive the project.
I assume physicians who didn’t have e-mail accounts aren’t using much technology in their practices. Are they using EMRs and are you doing any connectivity outreach with them?
There’s been a lot of change in that space over the last few years. I don’t know the percentage so I would hate to guess, but we’ve seen a dramatic increase in the number of physicians that are using EMRs in their offices.
The challenge is a lot of them are using certified, free products. While that may be a short-term solution for them, I worry about them as we get into Stage 2 or Stage 3 and the viability of those solutions when they raise the bar for certification. A lot of them will be faced with having to migrate from one solution to the other.
We did develop an outreach strategy with the physicians. We offer them a turnkey solution to purchase licenses and services for the ambulatory EMR that we use in our employed positions. If they’re an employed physician, we have a solution that they can use, but if they’re non-employed physician –a community based physician — we will allow them to buy from us that same solution. It’s much more economical to buy it from us than to go out on their own and try to buy it from XYZ vendor. That’s been pretty successful.
What systems are you using on the physician side?
Our employed physicians are using Allscripts Enterprise. One of our physician groups has been using it for many, many years over the various naming conventions of the solutions themselves.
Allscripts Enterprise is a very robust system. It tends to be a lot of system for small practices, and sometimes I believe it’s outside of the financial reaches of the practices. We’re able to offer that to small and medium-sized groups at a very reasonable rate because we’re basically just repackaging what we’ve already built and putting it in the appropriate silo. They can do their business in the same application in a manner that’s respectful of privacy and various regulations surrounding privacy.
What are you using for inpatient clinicals?
We are using Siemens Soarian solutions for clinicals and for financials. We still do have a few niche solutions in some of our other areas. The emergency room uses Allscripts and we’ve got a combination of solutions for PACS. Agfa PACS was the legacy radiology system. Whenever possible, my goal is to try to migrate everybody to core solutions and get rid of those niche solutions whenever possible. It’s just a nightmare, as you noticed, to continue to support those things.
Do you bring in outside help?
Like a lot of hospitals, there’s been so much change in a short period of time that we have needed to bring in some expertise. Either because we didn’t have enough bodies to do some of the basic work or we didn’t have the insight and experience do some of that higher-end work. We’ve used consultants – Stoltenberg, specifically — in the ambulatory space as well as the acute care space. We have used them to help us develop some strategies. We’ve used them the help us with basic building. We’ve used them as for staff augmentation and also to expand the skill set of our workforce based on their experience in doing these implementations in other facilities.
I find it as a very good interim solution to the resource constraints that we have. When used appropriately, I think it can be very effective.
The health system has achieved HIMSS EMRAM Level 6, which is impressive and unusual for a community hospital. Have you seen care improvements from that?
I believe we have. We went from Stage 2 to Stage 6 two years.
The most measurable improvement that we’ve seen is in the area of a closed-loop medication management system. We use a solution called MAK for barcode medication management. What we know is that we have dramatically reduced the adverse events surrounding medication management when it’s specific to giving the right patient the right med. Human beings in a busy environment make mistakes. Sometimes the best nurse, the best doctor can make a bad decision about which patient gets what. Barcoding the medication and the patients against the orders has eliminated almost all of those verification errors.
That closed-loop medication solution gives us a lot of insight from the near misses. We didn’t always get a good amount of detail about near misses because nurses and doctors didn’t know they almost made a mistake. When they did, they didn’t likely report it. The system tracks and captures all of that near-miss data. We can drill down into that and develop remedies to trend what we’re seeing.
Where people are working around the solution, undermining the solution, we can develop a strategy for that. If it’s basic education about a functionality that they may not be aware, of we can drill down into that. If it’s a process issue, if we’ve got an issue with bar codes or specific workflows, we can drill down into that, which has been very, very meaningful for us. I think that’s been the biggest bang for our buck.
What we’re starting to see ROI on now are clinical decision support queues that we have built. Compliance with simple things is very complicated in a hospital. When it takes 87 steps to get a medication to a patient or to give an immunization to somebody that needs a pneumonia vaccine, it blows up for a lot of reasons. We’re trying to use decision support in a meaningful way, not to try to overwhelm the nurse and the doctor, but to try to guide them where we know that they tend to make omissions. We know we can, with great certainty, improve a process by putting some decision support and team workflow behind it to remind and nudge and nag the providers to do all of the things that they’re supposed to do.
Obviously when you see decreases in variations and care, it’s going to improve clinical outcomes. I would daresay that we are improving clinical outcomes, but the measurement of that is still rather new. It’s probably a conversation for six months from now. Using the tools to drill down with the data to make changes in care based on what you’re seeing — that’s what we’re focusing on now, because that is what I think is the cool part of having these solutions in place. You can really make changes to care delivery and improve clinical outcomes.
What are your biggest IT-related challenges and opportunities?
The challenges and opportunities are enormous. I think in the immediate future, it’s balancing the financial investments against all of the other competing priorities. We are a hospital. How many years in a row can you invest greater than 50 or 60 percent of your capital into IT? We have to balance it against the other needs of the health system. I think those challenges are growing, and it’s getting more difficult to continue to fund these significant investments.
I think the other challenges are, how do we really use the tools to improve care? How do we really get the right information into the hands of the providers so they can make better decisions about patient care? That is optimizing what you’ve put in and really making it as functional as possible so that the nurses and the doctors are getting what they need out of that system.
I think patient engagement and getting patients to be accountable and engaged in their healthcare management is an enormous challenge for not only EMH, but for the country. That’s going to be something that’s going to evolve dramatically over the next couple of years.
Lastly, the evolution of accountable care and the ability of health systems to work together tightly or loosely across the continuum so that we can do a better job of caring for patients across that continuum. That’s going to be an enormous challenge, especially for hospitals like EMH because we’re an independent hospital. We’re going to need to align ourselves with tertiary providers, community providers, and skilled nursing facilities. We will have to be able to do business across the lifetime of a patient, and that’s a whole new territory for everybody.