3/28/05
Strategies for Creating Urgency for EHR Funding and Implementation
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: Despite the economic challenges that health care organizations are facing, quality care and patient safety are really the critical factors leading budget committees to approve funds for electronic health records (EHRs). At the February Healthcare Information and Management Systems Society meeting in Dallas, Dr. David Brailer, National Coordinator for Health Information Technology (HIT) at the U.S. Department of Health and Human Services (HHS) stated, "The important aspect of HIT is not software and computers—it is physicians making better treatment decisions, nurses and pharmacists delivering safer care, and consumers making better choices among treatment options."

Patty: High costs associated with purchasing and implementing an EHR are certainly a key factor that drives the decision-making for funding EHRs. Health care organizations make tough choices in allocating capital budgets as they try to offer the best possible quality care by keeping up-to-date with the advances in medical treatment, surgical and diagnostic equipment.

Leslie: The argument that an EHR will produce a good return on investment is hard to prove and not as persuasive in most organizations as making the case that an EHR will enable the organization to provide safer, better quality care.

Patty: It would be nice to share with our readers a real-life example of how using the impact on patient safety and quality of care helped an HIM director to get EHR funding.

Leslie: Just recently, I interviewed Jean Clark, RHIA, service line director for health information services at Roper St. Francis Healthcare, a two-hospital system in Charleston, SC. Her story is a good example.

Leslie: Jean, when we met last month in Chicago at the American Health Information Management Association sponsored program, Renaissance for the 21st Century: Leading the Change to e-HIM, you told me that your budget committee approved a document management system to finish off the transition to the EHR.

Jean: Yes Leslie, that is correct. We have successfully implemented several components of an EHR over the past several years, but I have always had a vision of a paperless record. I am disappointed that we didn't put in the document management piece sooner.

Leslie: Would you describe for us your organization's journey toward the EHR and how it has impacted quality in your organization?

Jean: We have online nursing and ancillary documentation for our interdisciplinary progress notes, which has improved communications among the clinical staff. We also have a new pharmacy system for medication management that provides excellent alerts to the pharmacists and is building a medication history. In radiology we implemented a Picture Archiving and Communications System (PACS), delivering the images directly to the desktop of the radiologists. They can even read images from home, which has improved turnaround time for reporting. We also made our physicians very happy with access to a physician portal, enabling doctors to have faster access to laboratory results and transcribed reports.

Our operating room (OR) system is live. The pre-, intra- and post-operative records are electronic. Assessments are viewable in the OR, and the "timeout" checklists required for safety by the Joint Commission on Accreditation of Healthcare Organizations are built right into the system. Fields must be completed by the OR nurse for each step the team takes during the timeout to verify the correct patient, procedure, site, laterality, position, X-rays, implants, etc.

On May 1, nursing and physician online documentation will go live in our emergency department (ED). We will scan consents and physicians' orders to have a completely electronic ED record. Finally, next year we will implement the computerized physician order entry (CPOE) component, which will improve patient safety through better legibility, accuracy and timeliness of orders.

Leslie: At that time you will be very close to having a complete EHR.

Jean: Yes, we are closing in on it. About 95 percent of the record will be electronic after we put in the CPOE module next year. However, we still have a paper record in the HIM department. Fortunately the money is now budgeted to implement a document management component to achieve our paperless vision.

Leslie: What is the strategy for using the document management system to get to the paperless state?

Jean: Although some of our systems that generate electronic records are separate, all of the output goes to a repository. We will COLD feed the electronic documents and scan the non-electronic documents into one repository of patient folders.

Leslie: Some organizations implement the document management system needed to get to a paperless state a lot earlier in the journey. Was it your organization's strategy all along to wait until you had the smallest amount of paper possible to scan?

Jean: That was one of our objectives, but I wanted to move more quickly to a paperless environment and requested capital for the past 3 years for document management. It was finally approved this year.

Leslie: What did you do differently this year that got money approved for it?

Jean: I spoke with my colleagues in the information services (IS) department and we decided not to go over the pro forma, talk about saving full-time equivalents or faster retrieval of records. Those arguments had gotten us bumped for clinical requests the past few years. Perhaps the finance people didn't find them credible. A purely financial argument is hard to make when offsite storage is not all that expensive, and HIM staff will still be needed to scan and manage documents and perform HIM roles in the electronic environment.

Leslie: What was your alternative justification?

Jean: We noted that the nursing department had done a good job last year in getting new lifting equipment by doing a survey of all employees about their safety concerns. They reported that their top concern was lifting patients. They feared dropping patients and hurting themselves, clearly two big safety issues. They got their request for new equipment approved immediately.

We concluded that we needed to present the justification for a complete EHR from the clinical perspective. So we decided to examine the patient safety issues created by not having the complete record readily accessible electronically. We were on the agenda for an upcoming patient safety committee meeting. We thought we would try to get their support in making the case that the EHR is a clinical, not a clerical improvement.

Leslie: So what happened?

Jean: Before we even had that meeting, the nursing director of the ED spoke up and opened the door for us. As the ED was preparing for their implementation of electronic documentation, the nurses realized they needed to get rid of all the fragmentation. As they talked about their new processes, it just seemed to dawn on everyone that to be most effective in treating ED patients, they needed to scan the remaining paper documents and get their whole record online.

One of the nurses on the patient safety committee told of the documentation issues that occur because of a hybrid record. She emphasized the need for all caregivers to have the complete record for the most timely documentation and best communication possible, i.e., for quality care. It was the patient safety and quality of care argument that won the day!

Patty: What a great story Jean has to tell. Did she offer any advice for her HIM colleagues who do not yet have a commitment for funds for an EHR?

Leslie: Yes, here is what she had to say.

Jean: I believe that HIM leaders in health care organizations must establish direct communications with all the leaders in the organization. We need to advocate more effectively for a complete EHR, and demonstrate the value of our medical record expertise in leading the way to the EHR. To accomplish that most successfully, we also need to work on expanding and improving our relationships in the organization.

Leslie: It sounds like you have been thinking about some of the topics we discussed at the Renaissance seminar a few weeks ago.

Jean: Yes, the program helped me reflect on my experiences with the EHR during the past few years. The discussion of non-anxious ways to approach people got me thinking that I could have avoided some confrontations and perhaps have achieved some of my goals sooner. We can all improve our skills in communicating our positions in clear and thoughtful ways. And, it is so important to understand where others are coming from as well. If we have a hard time getting along with some of our colleagues in the organization, we shouldn't get our feathers ruffled or be intimidated. We need to learn to improve those relationships.

Leslie: Go on Jean, you are on a roll.

Jean: Another thing, people tend to join with like-minded people. If those are the people that are behind the scenes grumbling, we have to step back and try to be objective. Listen respectfully to everyone's opinions and then reach your own conclusion and say what you think. Learn not to align only with the people you are most comfortable. And, we must learn to avoid the "us vs. them" attitude that sometimes arises between the clinical people and the technical or administrative people in health care organizations.

Leslie: That's right Jean. If people are reactive and sharply critical of what others say during or after team meetings, projects can get derailed very easily.

Jean: I just wanted to say one last thing. As the EHR becomes more common, and the HIM departments morph into e-HIM™ roles and functions, HIM activities will likely become more decentralized. HIM competencies will be required in many hospital departments, and HIM professionals will likely be needed to assume more leadership positions throughout health care organizations. Effective relationship and communication skills must be among our core competencies.

Leslie: Well said Jean. Thank you for relating your interesting journey to the EHR and for your words of wisdom.

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 .