12/19/04
EHR Tales from the Trenches
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: It continues to be a busy and productive year on the electronic health record (EHR) front. On Sept. 15, 2004, the Certification Commission for Healthcare Information Technology kicked off its work to develop an EHR product certification process. It is one of several national initiatives to accelerate widespread adoption of health information technology. The Certification Commission set a goal to begin certifying EHR products for physicians' offices by the summer of 2005, giving providers, payers and purchasers increased confidence that the products they buy will enable them to be part of the emerging national health information infrastructure (NHII).

Patty: The Certification Commission is a good example of how fast and how seriously the industry is taking up the key actions recommended in the "Framework for Strategic Action" announced by Tommy G. Thompson, Secretary of Health and Human Services (HHS), and National Coordinator for Health Information Technology (HIT) David J. Brailer, MD, PhD, just July 21st of this year.

Leslie: The commission is also a good example of how the private and public sectors are working collaboratively, without legislative mandates, to keep removing obstacles such as a lack of standards and financial barriers.

Patty: Is the commission a private effort?

Leslie: Yes it is Patty. The Commission was formed by the Ameri-can Health Information Management Association (AHIMA), the Healthcare Information and Management Systems Society and the National Alliance for Health Information Technology, all private industry organizations that volunteered to create a method to certify information technology products based on functionality, security and interoperability. Their work in turn will be informed in part by another private voluntary effort, the HL7 draft standard for trial use, which was also passed in July 2004.

Patty: It sounds like these are initiatives that health information management (HIM) professionals will be carefully monitoring over the coming months.

Leslie: I hope so Patty, because many of our colleagues working in health care organizations are involved in a number of ways to make EHRs a reality. Understanding the country's broader HIT objectives and how EHRs contribute to meeting those objectives is one more way HIM professionals can communicate their expertise and demonstrate EHR leadership in their organizations.

Patty: I agree that this is a crucial point. As our colleague Gwen Hughes, RHIA, CHP, director of e-HIM™ Services at Care Communications often says to us, "The EHR is not just another IT project."

Leslie: That's for sure. In fact Gwen is moderating a panel with that title at the AHIMA national convention in Washington, DC. She will be presenting with three HIM professionals who have been actively involved in several EHR success stories. It is fascinating to see the breadth of work that HIM professionals are doing with EHR projects.

Patty: Then let's spend a little time talking about what Gwen and our colleagues learned from those experiences.

Leslie: Sure. Maybe we will inspire them to order the CDs!

Patty: Let's start with the experience of Sheila Green Shook, MHA, RHIA, CHP, director of HIM and chief privacy officer at Group Health Cooperative in Seattle, WA. Sheila led the clinical information system (CIS)/HIM team, whose charge it was to create role-based access security matrices for access to their new CIS selected to support ambulatory services provided in the clinics and specialty centers.

Leslie: They started this work in the spring of 2002 and combined it with getting prepared for HIPAA privacy and ensuring "minimum necessary" access to protected health information as appropriate.

Patty: According to their paper, which is to be published in the 2004 AHIMA national convention proceedings, access to patient information was determined by an employee's job description or role. The job descriptions were grouped into types or "flavors" of security. A "flavor" is a unique combination of security profiles, security classes and shared security classes. They wound up with 22 flavors. Each flavor has assigned user identification, department name and business role/job title. The project was a multidisciplinary effort, as the HIM team met with every department that would be accessing the records. They met with department personnel to determine the responsibilities for every role in a department. They also had an HIM professional who represented the IT department on the team, who had to be an active, supportive participant because once the security "flavors" were identified it was up to IT to configure them in the system.

Leslie: So let me recap here. There were HIM department professionals on this team with expertise in HIPAA privacy and security, and an HIM professional from the IT department with expertise in system design and configuration. They worked with the organization's clinical and business departments to assure that employees could access only the patient information that they needed to see in order to perform their jobs.

Patty: That's right. Furthermore, an HIM consultant who was on the team and IS staff manage the security matrices now. This element of designing, implementing and maintaining a secure EHR requires a true multidisciplinary approach and includes important HIM competencies. It's a great example of how successfully HIM professionals are leading EHR change projects.

Leslie: Another member of Gwen's panel is Susan Carey, RHIT, PMP, a division director of HIM, patient access and administrative informatics, at Norton Healthcare in Louisville, KY. Norton Healthcare spans more than 60 locations, including six hospitals, five immediate care centers and 22 physicians' offices. She discusses the implementation of an electronic system designed to move the organization toward an enterprise-wide EHR.

Patty: Susan was the process/change manager on the project, charged with building, testing and leading the change for the nursing, physician and other EHR components of the system. She structured the project around three elements: project management, process redesign and change management.

Leslie: Susan and her team started by implementing the system at two sites that had little systems sophistication. They had more than 4,200 resources to train including physicians, physician office staff and hospital employees. The project management element allowed them to approach the challenge in a very organized way.

Patty: Process design was critical to Norton Healthcare because they did not want to automate broken processes. Their process redesign approach was customer focused and bottom up. They used a "toolkit" approach that allowed for incremental change, the review of many processes with limited resources, and could be accomplished on a short timeline.

Leslie: Susan was also careful not to forget the importance of addressing the human/organizational factors that automatically impact all system implementations. They needed to prepare people for change, communicate accurately and consistently about the change and continually reinforce that change was coming.

Patty: Susan reports that through the management of people, processes and technology, they brought 46 nursing units in two of the hospitals up with administrative and clinical EHR components with solid integration of processes and functions. They went live with 449 patients in house, a full command center in operation, flipping the switch at midnight and never looking back!

Leslie: What a great success story! I look forward to hearing Susan describe more of the details at the convention.

Patty: Gwen has one more HIM professional on her panel: Michelle M. Wieczorek, RN, RHIT, CPHQ, CPUR, director of e-commerce business development at Saint Vincent Health System in Erie, PA. Saint Vincent is a 366-bed nonprofit tertiary-care hospital and regional medical center. It provides a wide range of services through a main medical center, rural clinics, an extensive primary-care medical group and an ambulatory surgery center. The organization was one of the first in the nation to implement document imaging and other electronic data management system (EDMS) components for medical records in 1988. Michelle describes how they expanded that system into the business office, outpatient and ambulatory care settings, and the emergency department (ED) during a 10-year period.

Leslie: Their success in the ED was especially interesting and gratifying as they started out with a reluctant ED staff. However, by listening carefully and addressing the concerns of the ED staff, the HIM department was able to hurdle obstacles. They started with a small pilot study, which ran parallel to the old system, to overcome fears that the system would develop bottlenecks and delay delivery of records. And, they found ways to overcome workspace constraints and worked with the IT department who created a simplified graphical user interface for ED users that decreased the complexity of the search and record access functionality.

Patty: It is inspiring to talk with our colleagues in the field who are proving every day, in the trenches, that HIM professionals are essential to the ultimate success of our national health information infrastructure and the EHR agenda. It demonstrates the role HIM professionals are playing and the critical knowledge and skills required to participate in these initiatives; skills such as leadership, management, project management, change and transition management and technical know how in the areas of HIM, privacy and EHR functionality.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com .