Donn R. McMillan
One health system managed its organizationwide patient health data exchange by first gaining input from clinicians and working cooperatively with competitors.
At a Glance
Implementing an electronic health record (EHR) system that links medical facilities in three states taught PeaceHealth these valuable lessons:
- Establish clinical standards.
- Talk to clinicians early on.
- Look for an EHR with clinical decision support capabilities.
Implementation of an electronic health record (EHR) system is a long and challenging (yet ultimately valuable) process. Although health systems have been slow to implement EHRs, the significant financial incentives being offered by the federal government-in the form of $30 billion in stimulus funds to support hospital implementations over the next several years-are rapidly shifting the EHR from an optional improvement to a near-mandatory initiative.
Fifteen years ago, PeaceHealth envisioned implementing a comprehensive community health record to collect and share patient information with providers inside and outside its health system, including competitors. The goal was not merely to streamline processes, but also to improve patient safety and quality of care. Today, PeaceHealth has 2 million patient records in its database that are accessible to more than 20,000 care providers and staff, and the health system has earned high marks from independent evaluators for the quality and safety of the care it delivers.
The lessons PeaceHealth learned regarding how to overcome barriers to EHR adoption-and how to successfully engage physicians and clinicians in this initiative-could help other organizations achieve success in their EHR implementations.
Assessing the Situation
At PeaceHealth-a multistate health system with seven hospitals and dozens of medical groups and healthcare joint ventures in Alaska, Washington, and Oregon-we have long embraced a philosophy of leveraging our considerable IT investments to improve decision making,lower costs, and improve outcomes. As a result, the EHR has played a central role in our organization for many years.
Our EHR strategy was founded in the early 1990s when our governing board charged us with deploying healthcare IT to pursue our overarching mission: safe, evidence-based, and compassionate care-every time and every touch. Our goal for EHR implementation was to seamlessly deliver high-quality patient care across the PeaceHealth continuum, from the hospitals and clinics to the homes of our patients in the communities we serve. We recognized that accomplishing this goal would require a sophisticated IT infrastructure and an EHR that would reach our entire community. The challenge was how to secure buy-in from hospital physicians and clinicians for a project that would present an entirely new way of coordinating patient care.
Implementing a Solution
Many health systems about to embark on their own EHR journey will be tempted to focus on the financial return to justify the decision, particularly because an EHR initiative bears a considerable cost over an extended period of time. However, our primary goal for adopting and implementing an EHR was to use it to improve patient safety and enhance the quality of clinical outcomes.
In many of the communities we serve, we are the only large-scale healthcare facility. We viewed the addition of an EHR as an important proactive step in increasing healthcare accessibility, quality, and affordability in these areas. Yes, process efficiency was certainly welcome. After all, by ordering tests and writing prescriptions, physicians drive 80 percent of the cost of the care that's delivered. But clinicians would not support an EHR if it didn't first and foremost promote better patient care. In fact, we believe that an EHR investment can never be justified solely by reducing the use of paper records or boosting productivity.
In 1996, we implemented our first EHR at St. Joseph's Hospital in Bellingham, Wash., and over the next four years, we automated all of our hospitals and clinics (more than 500 providers). Each patient room had workstations where clinicians could access patients' medical records. Using these workstations, caregivers enter orders, vital signs, patient notes, prescriptions, and more. They can also review laboratory results, view X-rays, read historical notes, and perform computerized provider order entry (CPOE) in some areas. Ninety-five percent of all nursing documentation on non-critical-care floors is fully captured at the point of care using these workstations.
Although we have a long way to go, we have made tremendous progress over the past several years in creating a true community health record. Our system has increased efficiencies for physicians and clinicians by providing instant cross-provider access to comprehensive patient health information, from test results to prescriptions.
Challenges Along the Way
It would be disingenuous to paint a picture of EHR implementation as a pain-free, straight-line process. Any such endeavor will inevitably give rise to varying levels of short-term pain and unexpected complications. For PeaceHealth, the EHR implementation process was particularly challenging in the beginning stages.
Resolving initial complications. During our first deployment, we stumbled initially by taking on too much in a short amount of time. We halted the project for about a year to regroup and identify our next steps. Stopping was never an option. Learning and moving on were the only choices. After completing the initial deployment, we quickly rolled out the EHR to our other four regions much more easily.
Building the network. One of our biggest challenges in building the PeaceHealth EHR was geographic: how to create a fully redundant, secure network to all facility sites in three states across more than 1,000 miles. Although many of our hospitals and clinics in Oregon and Washington are located in or near cities and towns with state-of-the-art communications networks, connecting our Alaskan clinics to our larger facilities presented a significant challenge. Several of these clinics are located in rural and even island communities without sophisticated IT infrastructures. To undertake the challenge of connecting to these communities, we applied for, and received, a grant to help install the network in Alaska. We used the grant to procure and install a secure IT network across Alaska, which was then seamlessly integrated with the PeaceHealth network. The level of connectivity in our most remote areas is now comparable to networks in any U.S. city or town, and we now have a single IT system that stretches from Oregon to Alaska.
Connecting to partner organizations. As we grew and broadened our reach into our communities, we encountered another challenge: Having a true communitywide health record required managing the exchange of data between PeaceHealth facilities and other local healthcare organizations (such as outpatient imaging centers and local laboratories) that, in certain instances, might view us competitively. As a result, we all needed to overcome issues of trust and confidentiality while increasing our focus on processes and procedures that would ensure the security of patient data. Over time, this partner network has grown to include independent physicians and clinics outside the PeaceHealth system. The patient benefits greatly outweigh any concerns of competition; physicians now have instant access to their patients' complete medical records from anywhere to help improve care coordination and offer the best levels of treatment.
Overcoming clinician skepticism. Any organizationwide IT implementation will have its pain points, especially in an environment with hundreds of physicians and clinicians who have different needs for their particular workflows. Care providers tend to view an EHR as representative of major changes to how they input and access data and an interruption in their workflows.
To ensure provider buy-in, we included physician and clinician leaders on the EHR adoption team. Having providers lead the initiative has accomplished the following:
- Continuous physician and clinician input ensures that EHR workflows will be designed to meet their needs.
- Physician leadership gives the whole organization confidence that the EHR is being designed from a physician point of view.
- Involving providers at every point in the decision process helps them to better tolerate difficulties along the way while keeping the goal of improved patient care in mind.
We learned some valuable lessons that may be useful for other healthcare organizations undertaking an EHR implementation.
Establish clinical standards. An EHR implementation encompasses much more than sophisticated IT technology. Before an EHR can be implemented, firm, high-quality standards for technology and processes need to be in place. The goal should be to use the data your system generates to continue to refine and iteratively improve the processes and workflows you're automating.
Although we still have work to do, we've become experts in clinical standardization, which we discuss virtually every day at PeaceHealth. We have created several task-force teams to evaluate and update the protocols that define our clinical best practices, which helps considerably in persuading their peers to conform. In addition, bedside clinical standards are rippling out to other areas of our health system. For instance, admitting processes or medication reconciliations must all be standardized to achieve a single system with consistent data and comparable results. For a multistate health system, that's a challenging proposition to tackle.
Talk to clinicians early on. One of the most important pieces of an EHR-how the data are presented-was developed as a result of our conversations with physicians and clinicians early in the implementation process. The EHR aggregates a massive amount of data from various health IT systems, and how the data are presented has a significant impact on their usefulness to physicians. From our initial conversations, we learned that simply giving physicians some printouts of tables of data wouldn't work. By having these conversations early, we were able to incorporate a series of visual reports and one-screen dashboards that show clinicians the important trends and highlight improvement opportunities in their clinical practices. By taking the time to listen to their concerns and discuss ways to incorporate their feedback into our EHR, we empowered our clinicians to help make improvements and adjustments that have a material impact on the care patients receive. Perhaps the best indicator is the fact that physicians and nurses are continually asking us for additional reports and specific new analyses.
Look for an EHR with clinical decision support capabilities. An EHR that is designed simply to keep records in a database is a vastly underperforming asset. One of the principal reasons we selected the specific EHR that we use was its ability to structure and automate evidence-based, standardized clinical interactions. Incorporating clinical decision support rules into EHR workflows can significantly improve the quality of patient care while saving time and money. For instance, EHR systems can alert clinicians to potential drug interactions or scan test results and issue alerts based on abnormal results.
More than anything else, the anecdotal feedback has been emphatically clear: Caregivers appreciate having access to good clinical information. For instance, a physician can pull up a CT scan on screen, look at it with the patient, and review the radiologist's report, and the physician can immediately pull up a previous scan for comparison. Or instead of repeatedly asking patients what medications they are taking, a physician can simply bring up the medication record and confirm the information with the patient. The physician can also avoid ordering redundant tests, which not only saves money, but also reduces the time needed for diagnosis and treatments. And when a nurse contacts an on-call physician, the physician can securely log in from home and review patient records on the spot for faster and better clinical decisions.
Today more than 97 percent of physicians- both employed and external-working with PeaceHealth have adopted the EHR system, and new physicians are not permitted to join the PeaceHealth Medical Group without using the system for their practice. External physicians can upload their clinic results in the system as well. Considering the number of external physicians plus their office staff, PeaceHealth has far more non-PeaceHealth clinicians and staff securely accessing this information than its own employees. Network protections were put in place to maintain security and compliance with independent physician systems.
Our privacy and security processes for non-PeaceHealth providers and staff are twofold. The first set of processes takes place prior to receiving access, while the second set of processes consists of audits of the system.
As part of requesting access to the PeaceHealth EHR system, non-PeaceHealth providers and staff must read and sign a confidentiality agreement. The confidentiality agreement notifies the potential user of appropriate access and use. In addition, the user is informed of corrective action that can occur should the rules be violated. Users must read and sign this agreement annually to maintain their access to the system. Once a confidentiality agreement is signed, users receive training on how to use the system. This training includes privacy and security topics.
PeaceHealth conducts routine audits of the EHR system for appropriate use. These audits are performed routinely, randomly, and for cause. Violations are considered serious and dealt with using PeaceHealth's corrective action policies and processes.
As for a direct ROI analysis, we've consistently viewed the EHR as a means to improving patient care rather than cutting costs. On that score, we are achieving excellent results. For instance, the Joint Commission's 2008 survey of 73 health systems ranked PeaceHealth fourth in quality and safety. And Modern Healthcare recently named PeaceHealth one of the 50 best-performing hospitals for quality and efficiency. We also have a high degree of confidence that our efforts will qualify us for federal stimulus payments over the next several years that could reach tens of millions of dollars.
Industry studies have consistently demonstrated that higher quality care translates into lower costs. With an EHR, healthcare organizations can improve the quality of patient care while operating more cost-effectively and with better margins. The overarching lesson and benefit goes far beyond financial expenses and returns, however. EHR initiatives should be viewed as central to the clinical mission: to consistently deliver the best possible care across the health system continuum.
John Haughom, MD, is senior vice president of clinical quality and patient safety, PeaceHealth, Eugene, Ore. (firstname.lastname@example.org).
Skip Kriz is retired CFO, PeaceHealth, Eugene, Ore., and a member of HFMA's Oregon Chapter (email@example.com).
Donn R. McMillan is vice president of IT and chief information officer, PeaceHealth, Bellevue, Wash. (firstname.lastname@example.org).
PeaceHealth is a not-for-profit health system that operates seven hospitals and numerous clinics and outpatient facilities in urban, suburban, rural, and island communities in Alaska, Washington, and Oregon. During FY09, PeaceHealth had more than 53,000 admissions, 500,000 outpatient registrations, and 1 million patient encounters with its medical groups.
Fast Facts About the PeaceHealth EHR Implementation
PeaceHealth is one of the earliest adopters of digital records in the United States. Planning began in 1993-94 with a vision for seamless, effective care across hospitals, clinics, and communities. All of PeaceHealth's hospitals and the PeaceHealth medical group were automated between 1996 and 2000. The health system has spent more than $100 million on healthcare IT over past 15 years.
The electronic health record (EHR) system contains 2 million patient records. More than 20,000 care providers regularly use the system, including independent physicians, nurses, nursing home workers, and other providers in the communities PeaceHealth serves.
PeaceHealth expects to receive about $35 million to $40 million in federal stimulus payments.
Publication Date: Friday, July 01, 2011