3/1/04
When HIM Has 'A Seat at the EHR Table'
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS, and Julie Bryant, RHIA
Thank you to Advance Magazine for permission to use this article

Leslie: Whenever I talk with a health information management (HIM) director lately I can't help but ask the question, "How are you involved in your organization's transition to the electronic health record (EHR)?"

Patty: It's that curious nature of yours!

Leslie: I'm always curious to know what pressing issues HIM directors are facing. It really runs the gamut when it comes to the EHR. I have met HIM professionals who are leading or co-leading the process, and I have met directors who are left out in the cold though they actively lobby their bosses for "a seat at the EHR table." Then of course some directors today are so overwhelmed with the financial challenges of their organizations that the EHR isn't even on their radar screen.

Patty: But fortunately, many of our colleagues are knee deep in helping their organizations forge ahead with the EHR. Perhaps we can describe to our readers an example of a "typical" EHR transformation.

Leslie: While I am starting to see common approaches, health care organizations are all so different. They have different legacy systems, different political systems, different levels of funding available and different priorities. All of these things give every implementation its own special look and feel. But I'm sure our readers would enjoy hearing some stories from the trenches of EHR transformation.

Patty: Let's describe the EHR transition process that Northwes-tern Memorial Hospital in Chicago is experiencing.

Leslie: OK. We'll talk to their HIM Director, Julie Bryant, RHIA.

Patty: Julie, when did your organization start down the road to an EHR?

Julie: We started a repository in 1998. By 2001 it was quite robust. It included reports from laboratory and radiology, pulmonary function, blood flow, nuclear medicine, as well as transcribed operative reports, discharge summaries and some consultation reports.

Leslie: .Once these reports were in the repository, did you stop printing the electronic versions of the reports?

Julie: Not until May 2003 did we stop printing reports. At that time we also implemented online nursing documentation, vital signs, input/output reports on the general med/surg and ob-gyn units. Nurses were also beginning to document pre, intra and postoperative notes online. We describe our record as a hybrid record, part electronic and part paper. All users are now expected to view the electronic parts online.

Patty: How did you get the doctors on board with that decision?

Julie: Our physician services department helped us. It is our customer service department dedicated solely to meeting the needs of our medical staff. They communicated in many different ways the benefits to the physicians to be able to access patient information online. They developed a regular marketing campaign with brochures, pocket aids, graphics, etc. On the day of the policy implementation, they had prepared the nursing personnel with scripts on how to gently, but firmly tell physicians that they could not print the reports for them.

Leslie: Isn't one of the big benefits for the physicians that they now have remote access to patient information?

Julie: Yes, 500 out of our 1,200 physicians have already signed up for remote access. And we also have computers everywhere in the hospital.

Patty: Was training much of an issue?

Julie: There were some training issues. We provided 24/7 support for the first two weeks. And for attending staff members who were not accustomed to using computers, we developed a unique "mentoring or buddy system" in which a resident was matched with each attending who required one-on-one training.

Patty: Julie, how did HIM get involved?

Julie: HIM has just always been very vocal about being involved. The HIM managers have always participated in many hospital committees and task forces. We have long advocated for electronic records and I don't think people here would have even considered not involving us. In fact, I recently have acquired responsibility for the clinical information services teams responsible for the implementation and maintenance of EHR, our paperless medical record, and for PACs, our filmless environment. My new title is director of information services and medical record services.

Leslie: That's fabulous Julie. You are responsible for the electronic and the paper versions of medical records, as well as for the medical record business processes, such as record completion, coding, abstracting, transcription, release of information, cancer registry, etc.

Patty: That seems like such a logical evolutionary path for HIM departments to follow as they transition to eHIM.

Julie: Yes, people here think it makes sense from a functional and operational perspective.

Leslie: What are the professional backgrounds of the employees on the clinical information services team?

Julie: We have clinicians, nurses, pharmacy technicians and biomedical personnel, but the majority of these employees have an information technology (IT) background.

Patty: As an HIM professional, did you feel well prepared to take on responsibility for these new areas?

Julie: Yes, I feel tremendously well prepared. I don't feel out of my element because I was involved in the design and implementation of our EHR system from the very beginning. This organizational model benefits our hospital and the medical record services department, because I am able to involve the medical records staff in evolving the new workflow.

Leslie: Are the two groups still operating as independent departments?

Julie: Yes, for now the medical record services and the information services are two departments, located in two different buildings. In time the departments will become more blended. I meet with people in their own space and bring people from both areas together as necessary.

Patty: Would you tell us exactly how you were involved in the EHR initiative?

Julie: I was a member of our "Impact Directors Group," which along with me, included the directors of patient care, physical therapy, occupational therapy, rehab, outpatient clinics, information systems, quality, admitting/registration and the vice presidents of information systems, professional services and quality. The consultant project manager and the vice president of quality, a nurse who was the executive sponsor of the EHR, led the group. The members of this group had the opportunity to hear the status reports and to discuss with each other how the implementation would affect their areas.

Patty: Were you also involved in some of the design work?

Julie: Yes, I was part of the group that did the initial design, a group of 60 people. It included nursing, every specialty, information systems, HIM and consultants. The group developed a prototype and then worked with individual clinical areas to further refine it.

Patty: What comes next in the transition to EHR for your organization?

Julie: We will focus more on the foundational support. We recently implemented a new pharmacy system, which further integrates with the EHR. Over the spring and summer of 2004 we will bring up the medication administration record, practitioner order entry, physician documentation and further ancillary department documentation.

Leslie: What about other departments?

Julie: The anesthesia department reviews records electronically but they still create them manually. Our laboratory upgrade enables lab orders to be entered so when drawing blood, the technician enters the order and prints a bar code label to put on the specimen. It is the first step in positive patient identification.

Patty: So how has all of this impacted processes in the medical record services department?

Julie: We have had some growing pains. We have not had any problems with the doctors or nurses. But we needed to be more diligent in release of information (ROI). Right now we are going to two places to do ROI. We pull paper and copy and we print from the online system. We will be putting in Cerner's MR Publisher, which will enable us to print the whole chart.

Leslie: Last time we talked you were telling me about all of the work involved in rolling out the documentation process.

Julie: That's right. We had to look at redundant data items, so we would only collect information like allergies once. In the traditional paper record many professionals collected the same information. It was a very tedious process.

Patty: This is where one really starts to impact the clinician's workflow.

Julie: That's right. It is challenging with multidisciplinary tools. Information that is collected by caregivers should carry forward to other parts of the record if need be. For example, if barriers to learning are collected by nursing on admission, that information should carry forward to any forms that address patient teaching. Then, you have the relevant information available and can validate this with the patient instead of asking the same questions again.

Patty: Julie, what did you learn in your incredible journey that you want your colleagues at other organizations to know about implementing the EHR?

Julie: First, I would certainly encourage my HIM colleagues in other health care organizations to ask to have responsibility for the electronic and paper versions of the medical record, whether they are in separate departments or integrated into one HIM department. Second, I must say it is an incredibly exciting, yet exhausting experience. There are definitely challenges in the process, but if you keep an open mind and remember the guiding principles as to why we are embarking on this journey, it is tremendously rewarding.